What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review

ObjectiveRecalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes.DesignA systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.SettingAll study designs were included. Non-English articles were excluded.Patients and ParticipantsPatients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula.InterventionsFree tissue transfer for a palatal fistula repair.Main outcomee measuresInformation regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained.ResultsOur search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm² (range 2.54 cm² - 24 cm²). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies.ConclusionsPalatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.