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Anatomical Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip Repairs Reduce Fistulas at the Alveolus

Mittermiller, Paul A., M.D.; Sethi, Harleen, B.S.; Morbia, Roshan P., M.D.; Johns, Dana, M.D.; Baylan, Joseph, M.D.; Lorenz, H. Peter, M.D.; Khosla, Rohit K., M.D.

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 1549–1556
doi: 10.1097/PRS.0000000000004986
Pediatric/Craniofacial: Original Articles
Cover Article

Background: Techniques vary for addressing the nasal floor during cleft lip repair in patients with a cleft lip and palate. Sometimes, no closure is performed, leaving a symptomatic alveolar fistula until the time of alveolar bone grafting. Often, medial and lateral skin flaps are used, but these are often thin and unreliable. Anatomical nasal lining flaps are used to improve closure with robust, well-vascularized flaps that anatomically close the nasal floor.

Methods: A retrospective chart review was performed to identify patients with a unilateral or bilateral cleft lip and palate who underwent primary cleft lip repair with nasal lining flaps or with medial and lateral flaps. The primary outcome was presence of a symptomatic and/or visible oronasal fistula.

Results: Sixty-four patients were included. Thirty-seven underwent closure with nasal lining flaps, whereas 27 underwent closure using Millard medial and lateral flaps. The rate of symptomatic/visible fistulas after cleft palate repair was 19 percent (seven of 37) for patients with nasal lining flaps and 44 percent (12 of 27) for patients with medial and lateral flaps (p = 0.0509, Fisher’s exact test). The alveolar fistula rate was 3 percent (one of 37) for patients with nasal lining flaps and 30 percent (eight of 27) for patients with medial and lateral flaps (p = 0.0032, Fisher’s exact test).

Conclusions: Nasal lining flaps at the time of cleft lip repair effectively close the anterior nasal floor in patients with a unilateral or bilateral cleft lip and palate. Decreasing the presence of alveolar fistulas after cleft palate repair improves the quality of life for patients with cleft deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Palo Alto, Calif.; and Mesa, Ariz.

From the Division of Plastic and Reconstructive Surgery, Lucile Packard Children’s Hospital, Stanford University Medical Center; and A. T. Still University, School of Osteopathic Medicine.

Received for publication December 6, 2017; accepted April 19, 2018.

Presented in part at the 66th California Society of Plastic Surgeons Annual Meeting, in Santa Monica, California, May 27 through 30, 2016; the 55th Northwest Society of Plastic Surgeons Annual Meeting, in Big Sky, Montana, February 12 through 22, 2017; the 67th California Society of Plastic Surgeons Annual Meeting, in San Francisco, California, May 26 through 29, 2017; and Plastic Surgery The Meeting, Annual Meeting of the American Society of Plastic Surgeons, in Orlando, Florida, October 6 through 10, 2017.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Rohit K. Khosla, M.D., Division of Plastic and Reconstructive Surgery, Stanford University, 770 Welch Road, Suite 400, Palo Alto, Calif. 94304–5715, rkhosla@stanford.edu

©2018American Society of Plastic Surgeons
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