Bucket-Handle Vestibular Mucosal Flap to Anterior Palate

EDITORIAL COMMENT

This technique certainly accomplishes its task; however, the buccal sulcus, which is very difficult to recreate at a later time, is sacrificed unless the patient is committed to an Abbé flap.

The problem of minor residual fistulas and clefts adjacent to the premaxilla or in the palate has received little attention in the literature compared with other aspects of clefting. The reason may be that these fistulas are often symptomless, and surgical correction may be difficult and disappointing. Also, prosthetic covering of these fistulas is sometimes successful, although the long-term effect of any partial prosthetic appliance on the remaining dentition must be taken into account.

ANATOMY

As Figure 186.1 demonstrates, the pedicle of the flap is situated laterally, and the base is well vascularized (1), unlike the base of the vestibular flap, which can be used most successfully in unilateral clefts and is situated medially in the region of the cleft. The vessels involved are branches of the labial and infraorbital arteries. The midpart of the flap, however, is composed partly of scar tissue, a condition that must be noted.

FLAP DESIGN AND DIMENSIONS

In unilateral clefts, the average fistula can be closed with a vestibular flap (2). In major openings, the tongue flap (see Chapter 185) can be used advantageously (3). In bilateral cleft patients in whom a Y-shaped opening around the premaxilla exists, bilateral vestibular flaps can be used, but the failure rate seems fairly high. Because the base of the vestibular pedicle is usually scarred by previous operations, the blood supply must be assumed to be marginal, and where the two flaps meet, tip necrosis occurs frequently.

OPERATIVE TECHNIQUE

Two parallel incisions are made in the vestibulum (Fig. 186.1A). The width of the flap is between 0.4 and 1 cm, depending largely on the local anatomy and the depth of the vestibular sulcus. Exact measurements cannot be given, because irregularities in the scarred area are considerable. If the vestibulum is quite shallow, the surgeon should be careful not to remove too much tissue from the inner aspect of the lip unless correction with an Abbé flap is planned.

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