Salvage Reconstruction of a Traumatic Oronasal Fistula Following Complex Panfacial Trauma: Durable 2-Layer Mucoperiosteal Repair.

INTRODUCTION: Oronasal fistula is an uncommon but functionally significant complication following severe palatal fractures. While fistula repair is well described in cleft populations, traumatic fistulas after complex panfacial reconstruction are less frequently reported and may present unique reconstructive challenges due to prior fracture displacement and surgical manipulation. CASE REPORT: A 48-year-old male sustained extensive facial trauma after a tractor rollover, resulting in bilateral Le Fort III fractures with additional Le Fort I and II components, a displaced hard palate fracture with mucosal laceration, and associated zygomaticomaxillary and orbital injuries. He underwent open reduction internal fixation of midfacial fractures with external fixation of the palate and occlusal splinting. Five weeks later, palatal hardware was removed due to concern for mucosal compromise. A small palatal defect subsequently progressed to a persistent 0.5×1 cm symptomatic oronasal fistula. Four months after injury, the patient reported nasal regurgitation and speech changes without evidence of infection or bony instability. Given the persistence of symptoms and lack of spontaneous closure, operative intervention was recommended. At surgery, a 2-layer mucoperiosteal repair was performed. Bilateral hinge flaps were elevated in the mucoperiosteal plane and inverted to reconstruct the nasal lining. A right-sided palatal mucoperiosteal flap based on the greater palatine pedicle was then transposed to restore the oral lining. Tension-free layered closure was achieved. Six weeks postoperatively, the repair remained intact with complete resolution of nasal regurgitation. Follow-up is ongoing, with a 5-month evaluation scheduled. CONCLUSION: Traumatic palatal fistula following complex panfacial reconstruction represents a challenging complication in previously operated tissue. Two-layer mucoperiosteal closure provides a reliable, tissue-sparing salvage strategy that restores oral-nasal separation. Timely recognition and layered repair can achieve favorable functional outcomes.