Open Cancellous Bone Grafting for Recalcitrant Palatal Fistula: Repurposing the Papineau Technique

Cleft palate fistula is defined as a breakdown in the primary surgical repair of the palate resulting in oronasal communication, which can create symptomatic regurgitation for fluids/solids and affect speech, manifested by airflow escape during phonation. With the reported postoperative occurrence rate of 33-37% postfistula repair, it remains a challenging problem. The primary aim of this study was to describe our experience in the management of 7 consecutive cases of recalcitrant palatal fistula, all secondary to primary cleft palate repair. Pure cancellous bone graft was harvested in a standard fashion in sufficient quantity based on size of fistula from the iliac crest and was morselized and was kept mixed with the patient's blood. After flap turnover for nasal closure, the graft was packed over the raw surface on the oral aspect and was secured by placing an oxidized regenerated cellulose sheet fixed to the surrounding mucosa. As per the Papineau technique, no oral closure was performed. Six-month follow-up showed complete epithelization of the oral raw surface in 6 of the 7 patients. In the diverse spectra of cleft surgeries, management of recalcitrant cleft palate fistula remains a surgical challenge. Repurposing Papineau's concept of open cancellous bone grafting in cleft palate fistula is a novel attempt with a sound scientific basis. In our experience, this technique has proved to be very effective in managing recalcitrant palatal fistulae.