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This one is about: Fistulas: A Hole in the Whole Healing Process
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FISTULAS: A Hole in the Whole Healing Process
by John Canady, MD
Despite the best of intentions and techniques, occasionally the healing process after cleft repair is disrupted by the formation of a fistula. A fistula is a hole that allows air and fluids to pass from one space to another and is named after the spaces it connects. Using this system, an oronasal fistula connects the mouth (oro) and nose (nasal); a nasolabial fistula connects the nasal cavity (naso) and the space under the upper lip (labial); and the oro-antral fistula connects the mouth (oro) with the maxillary sinus (the sinus cavity under the eye, which is also referred to
as the antrum).
There are many reasons that fistulas can form, but the most common causes seem to be infection, trauma from eating the wrong foods, blood clots under flaps of the closure, and tension at the sutured edge of the wound. Some of these, such as tension, may be unavoidable in extremely wide clefts or other circumstances where tissue flaps are moved a long way to achieve closure.
After surgery, the patient may unintentionally put the closure under tension by crying and causing the suture line to stretch before it has had a chance to develop enough strength to resist separating.
The fact that the scar at the closure line is weak right after surgery is the reason that it is common to require the patient's diet to be restricted to liquids or soft foods for some period of time after surgery. Not only do these foods not seem to irritate the freshly closed cleft, but they are easy to clean off the surgical site with rinses, and this decreases the chances of infection. Food that is trapped in the nooks and crannies around the sutures provides an ideal place for germs to develop and grow.
If blood clots are present in the wound they also can provide an environment where it is easy for infections to develop. Also, as the blood clots are resorbed by the body, certain types of substances are released which may be extremely harmful to nearby tissue. This may cause the newly formed, weak scar to break down in the post-operative period.
Finally, it is not unheard of for the patients to disrupt their own wound if they get their arms out of their restraints. It may seem overly cruel to keep these restraints on after surgery, but any cleft surgeon in business for very long will have had personal experience with a wound which has been torn apart when the restraints were off for "just a second". It is very important that the parents follow the doctor's instructions after surgery because these rules have usually been developed on past experiences which do not need to be repeated!
Methods of dealing with fistulae vary among surgeons and depend on factors such as location, condition of surrounding tissue, and the size of the fistula. Your surgeon will explain what needs to be done. But do not become alarmed if surgery to repair the hole is not immediately scheduled. Depending on the individual case, it may be best to allow some time for the scars around the fistula to soften and regain some of their stretch. This process naturally occurs very slowly in some people but if it is patiently allowed to happen, the chances of secondary closure of the fistula may improve. Also, there is always a chance that the hole may close on its own if it is given enough time. The reasons for this are not always apparent, but no one ever argues when it happens.
In summary, fistulas are a problem which will likely continue to haunt cleft surgeons, patients and families. Good cooperation with post-operative instructions will help keep fistula occurrence low and will also help the wound heal in a way which will maximize the chances for secondary closure if they do occur.
---------------------------------------John Canady, MD is a Plastic Surgeon and director of the University of Iowa Hospitals and Clinics, Cleft Palate Program. He is also the Medical/Surgical consultant for WIDE SMILES Magazine.