In primary palatoplasty, anatomically oriented, tension-free, atraumatic complete closure is the key in achieving normal speech after a sufficient velopharyngeal closure and in preventing postoperative fistula development. Palatal fistulas are a challenging complication of primary palatoplasty that typically form around the hard palate–soft palate junction. The shortage of local tissues creates significant tension during closure, thus increasing the risk of an oronasal fistula (ONF). Repairing palatal fistulas, particularly wide fistulas, is extremely difficult because the options for closure are limited. However, a few techniques are commonly used to close the remaining fistula after primary palatoplasty. Herein, we report the revision of a palatal fistula using a pedicled buccal fat pad (BFP), palatal lengthening with a buccinator myomucosal flap and sphincter pharyngoplasty to treat a patient with a wide palatal fistula. Tensionfree closure of the palatal fistula was achieved along with correction of velopharyngeal insufficiency (VPI). This surgical method enhanced healing, minimized palatal contracture and shortening, and reduced the risk of infection. The palate healed with mucosalization after 2 weeks, and no complications were noted after 4 years of follow-up. Therefore, these flaps can be considered as an option for closure of large ONFs and VPI correction in young patients with wide palatal defects and VPI.

Palatal fistula is a challenging complication following cleft palate repair [2-4]. Reparative surgery is complex because of inevitable scarring, altered vascularity, and persistent tension after primary palatoplasty [5-7]. However, watertight, tension-free closure of the palate fistula remains the primary treatment of choice, especially for wide fistulas [2]. The rate of postoperative fistula formation differs according to the surgical method, but generally ranges from 2.4% to 35%. Closure of large ONFs in patients with cleft palate is particularly complex for reconstructive surgeons [8,9]. Additionally, children with a wide cleft fistula commonly have reduced VPI, impaired language development, and an impacted quality of life [10]. Therefore, early correction is needed to minimize adverse outcomes. Thus far, aberrant palatal muscle attachment release and radical backward dissection remain the mainstay techniques for favorable surgical results [5,6]. However, a lack of local tissues creates tension during closure and places the patient at risk for an ONF. Facial artery musculomucosal flaps, submental flaps, and temporal and temporoparietal fascial flaps are reparative options. However, these require extraoral skin incisions, and there is a risk of injury to the marginal mandibular branch of the facial nerve [8,11]. These techniques are also exceptionally high risk for pediatric patients [8,10-13].

As described above, we performed a total of four operations to resolve the problem. Operations 1 and 2 focused on repairing the fistula (defect repair), while operations 3 and 4 focused on correcting the VPI. Using a pedicle-based buccinator myomucosal flap has the advantage of replacing the lost tissue with the same type of tissue [8,14]. The myomucosal buccinator flap, first described by Bozola in 1989, has become an essential tool for intraoral defect reconstruction. Various forms of myomucosal cheek flaps have been proposed in the literature, both pedicled and island, based on the buccal or the facial arteries [14]. Cases of myomucosal flaps used for tongue reconstruction have also been reported [13,14]. Furthermore, the use of pharyngoplasty for VPI correction is associated with favorable speech outcomes [15].

This report presents in detail the rare use of a bilateral buccinator myomucosal flap and pedicled BFP transfer in wide cleft palate fistula repair in a pediatric patient. The proximity of the donor site to the palatal region, obviating the need for an extraoral skin incision, and minimal donor-site morbidity are other reasons to consider this surgical technique, especially for pediatric patients [16,17]. Sensibility is expected to return to the flap given its neurovascular axial pattern and the fact that its blood supply comes from the buccal artery (a branch of the maxillary artery) [16,17]. The final speech analysis report indicated that the patient’s VPI had improved extensively.

This report demonstrates a case of a wide palatal fistula wherein a tension-free, watertight closure for both the nasal and oral mucosa was not possible. Instead, the combination of a bilateral buccinator myomucosal flap and pedicled BFP transfer was a feasible and cost-effective technique. The patient required long-term follow-up to monitor his speech development and palate growth. Therefore, a posteriorly based buccinator myomucosal flap might be considered to close large ONFs and improve VPI in young patients with cleft palate.