Technique of Alveolar Cleft Closure with Reinforcement from Cyanoacrylate to the Mucosal Closure and Cortical Strut Interposition
Fistula leads to regurgitation of oral intake, air escape with speech impediment and cicatrization with multiple repairs. Various techniques using the regional tongue, buccal fat and mucosal flaps and modifications of local advancement have been used to close fistulae. Even non-vascularized bone cartilage, acellular dermis and free tissue have been described. Following palatoplasty an 11 to 34% incidence of fistulae has been reported in literature and recurrence is reported at 50% following repair. Boyne & Sands propose use of suturing a gauze pack in place over the palatal incision aspect follow alveolar cleft closure to serve as a barrier. Application of cyanoacrylate adhesive is an additional effort during palatoplasties to achieve impermeable seal and thus negate the need for gauze covering.
In our proposed technique protocol for the repair of the alveolar cleft, nasal and oral mucosal flaps are elevated. After approximation and suturing of the nasal mucosa, a layer of cyanoacrylate fibrin glue is applied to margins from the oral surface. The nose is irrigated to ensure a water-tight closure. Next a cortical strut from iliac crest bone or allogeneic cortical sheet is positioned by friction adaptation. Following cortical strut placement, particulate cancellous marrow or BMP allogenic particulate mixture is placed to fill the remaining bony alveolar cleft defect. Following advancement and suturing of the flaps, cyanoacrylate glue is applied over the oral mucosal closure.
Surgical principals of suturing and closure have always aimed for positioning the sutured component on a stable anatomical base. We aim to provide this stable base by the placement of cortical strut, which is well contoured and positioned with friction grip into the floor of the nose following elevation of the nasal mucosa. The closure of the nasal floor is critical to the success of alveolar cleft graft survival. Breakdown of nasal mucosal closure will result in contamination and loss of graft with subsequent development of an oronasal fistula. Prior to placement of the cortical piece, the nasal mucosa is sutured and covered with the cyanoacrylate glue for an effective impermeable seal from the nasal environment. The placement of the cyanoacrylate should not interfere with bone healing, since the periosteal blood supply is not affected.
After the bony graft, we isolate our graft from the oral environment, by application of cyanoacrylate fibrin glue around gingival margins of teeth around which flaps were elevated and over buccal and palatal incision approximations. In our observation, this results in decreased breakdown and contamination of the graft with oral flora, which is one of the causes of graft failure in addition to nasal breakdown as mentioned. An additional advantage is that the cyanoacrylate helps secure suture knots from unraveling. At the 2 week follow up, residual glue is usually loose and is removed.
We present the fistula closure technique, composition of cyanoacrylates and method of securing bone graft with the multilayered closure in cleft patients with cyanoacrylates. We find this technique can be easily adopted and accomplished by the individual surgeon. Subjective observation of operative success and postoperative course was favorable using this protocol.
References:
Boyne PJ, Sands NR, Secondary bone grafting of residual alveolar and palatal clefts. Journal of Oral Surgery 1972; 30:87-92
Magee WP, Ajkay N, Githae B, Rosenblum RS. Use of octyl-2-cyanoacrylate in cleft lip repair. Ann Plat Surg 2003; 50:1-5