Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 257 - файл
.pdf
Lateral relaxing incisions are also
shown. The dotted lines anteriorly
would be incised to convert this
bipedicled technique to a
unipedicled island flap (Bardach)
repair. In the soft palate, a straight-
line repair (IVV) is planned. B.
Appearance of palate after closure
of oral mucosa, muscle, and nasal
mucosa. Cellulose material has
been placed into the lateral defects
for hemostasis. (Photos courtesy of
Dr. Craig Birgfeld.)
MANAGEMENT
GOALS
Closure of Cleft
Separate oral and nasal cavities.
Prevent nasal regurgitation of oral contents.
Normalization of Speech
Requires competent VP mechanism
Operative goals: close cleft, reposition LVP, increase
length
Prevent maladaptive compensatory misarticulations
Perform repair by 1 year of age
Timing of speech milestone (first words)
Prelinguistic testing may indicate need for earlier
surgery
https://t.me/medicina_free
Hearing
Recurrent otitis media commonly occurs in patients with CP
Eustachian tube dysfunction: abnormal LVP insertion
impairs “milking” action, which leads to poor venting of
middle ear
Permanent impairment results with recurrent infection
Myringotomy tubes often placed at time of CP repair
Some surgeons advocate for tensor tenopexy during
palatoplasty to improve eustachian tube function
postoperatively
Restoration of velar anatomy improves eustachian tube
function
Maintenance of Facial Growth
*Palate repair in early childhood may adversely affect
maxillary growth, but this drawback is outweighed by
the improvements in speech achieved by early
correction.
Early soft palate and delayed hard palate repair has been
advocated (controversial two-stage approach) by some
European cleft centers to maximize midfacial growth.
Variable speech outcomes.
Nearly 90% of U.S. surgeons perform single-stage
repair.
*Around 25% of patients will require orthognathic
surgery in adolescence (Le Fort I advancement; see
Chapter 18: Orthognathic Surgery) for midface
hypoplasia and class III malocclusion.
REPAIR TECHNIQUES
In CLP (Veau III or IV), both the primary and secondary
palates require repair
The entire hard palate mucoperiosteum must be elevated
for oral sided closure
Nasal mucosa elevated off bony cleft margins to provide
two-layer closure
Vomer flaps utilized for nasal layer closure
https://t.me/medicina_free
Soft palate dissection allows for nasal, oral, and muscle
repair
In isolated CP, only the secondary palate requires repair
Veau I—soft palate repair only with closure of nasal,
muscle, and oral layers
Veau II—soft palate repair and posterior hard palate repair
that may require lateral relaxing incisions or bipedicled
mucoperiosteal flaps if cleft is wide
Soft Palate Repair Techniques
Straight-line repair with intravelar veloplasty (IVV) (Fig.
14-3)
IVV first described by Kriens in 1967
Useful in wide clefts
Three-layered closure (nasal mucosa, muscle, oral
mucosa)
Correct aberrant insertion of LVP from hard palate and
rotate posteriorly into transverse orientation IVV:
complete LVP dissection from nasal and oral mucosa,
disinsertion from posterior hard palate, and muscle
repair in the midline
Adverse sequelae: potential for short palate and
subsequent VPI
Furlow palatoplasty or double-opposing Z-plasty (Fig. 14-4)
https://t.me/medicina_free
Figure 14-4 Furlow double-opposing
Z-plasty. The procedure is not that
different from primary cleft palate
repair. Above, left: the posteriorly
based oral musculomucosal flap is
elevated first. The clefted levator
muscle is detached from its hard palate
attachment and nasal mucosa. When
the lateral extent of the dissection
nears the hamulus, the levator as a
distinct muscle bundle coming into the
flap. Above, center: The lateral limb
incision is made from the base of the
uvula to just lateral to the hamulus. As
the flap is elevated, care is taken to
https://t.me/medicina_free
separate the mucosa from the
underlying muscle. The plane should
be deepened to the back of the hard
palate and carefully detached from it,
without damaging the greater palatine
vessels. Above, right: The anteriorly
based nasal mucosal flap is incised
from the base of the uvula to the
superior constrictor. Below, left: The
posteriorly based nasal
musculomucosal flap is created by
incising the nasal mucosa 3 to 4 mm
from the posterior edge of the hard
palate toward the eustachian orifice for
~1 cm. With the tip of the flap pulled
transversely, the levator muscle is
released carefully from the new free
margin of the nasal mucosal incision,
and the lateral limb incision is
extended until the tip of the flap will
reach the end of the contralateral nasal
mucosal flap lateral limb incision. This
brings the distal end of the levator
muscle against the contralateral
superior constrictor and immediately
under the contralateral levator. Below,
center: Flaps are then inset, beginning
https://t.me/medicina_free
with the nasal musculomucosal flap,
bringing the tip of the levator muscle to
the contralateral superior constrictor.
Below, right: The tip of the oral
musculomucosal flap is positioned at
the point along the lateral limb incision
over the contralateral levator muscle
belly, just posterior to the hamulus,
orienting the levator transversely to
complete the overlapping levator sling.
(Reprinted with permission from Naran
S, Ford M, Losee JE. What’s new in
cleft palate and velopharyngeal
dysfunction management? Plast
Reconstr Surg. 2017;139(6):1343e-
1355e. Figure 4.)
Opposing Z-plasty flaps for both oral and nasal closure
Posteriorly based oral myomucosal flap is on the
patient’s left
Conventional technique
Remember: easier for right-handed surgeon
to elevate the left-sided myomucosal triangle
first
Posteriorly based nasal myomucosal flap is on the
patient’s right
Rotation of triangles will “automatically” bring LVP
muscles into anatomic alignment (recall: anomalous
LVP insertion)
Lengthens soft palate
https://t.me/medicina_free
Offsets the nasal and oral suture lines (decreasing risk
for fistulas)
Adverse sequelae: sacrifice of width in order to gain
length; may not be possible in wide clefts (consider
IVV)
Hard Palate Repair Techniques
Von Langenbeck repair (Fig. 14-3)
Bipedicled mucoperiosteal flaps
Anterior pedicle: blood supply via sphenopalatine
a.
Posterior pedicle: blood supply via greater palatine
a.
Parallel incisions are made along cleft margin.
Lateral relaxing incisions along lingual side of alveolus
left open to heal secondarily.
Nasal and oral mucosal flaps are mobilized to midline
and sutured in two layers.
Adverse sequelae: potential for maxillary growth
restriction; high tension repair, which may lead to
dehiscence.
V-Y pushback (Veau-Wardill-Kilner)
Unipedicled flaps
V-Y advancement of mucoperiosteal flaps
Lengthens palate for speech
Adverse sequelae: significant potential for maxillary
growth restriction
Two-flap palatoplasty (Bardach repair)
Requires elevation of entire palatal mucosa: island flap
based on greater palatine a.
May be used in wide cases of isolated CP to gain extra
mucosa for closure
Most common repair in Veau III and IV
Adverse sequelae: anterior areas heal secondarily
causing maxillary growth restriction
Additional Maneuvers for Wide Clefts
Infracture of the hamulus can bring lateral elements toward
midline
https://t.me/medicina_free
Osteotomy of greater palatine foramen for increased
pedicle length
The periosteal sheath around pedicle can be released with
meticulous dissection to gain additional pedicle length
ADJUNCTIVE TECHNIQUES
Buccal Fat Pad Flaps
Used to cover raw surfaces of hard palate laterally to
minimize scarring and secondary growth restriction or to fill
in dead space at areas of high tension (hard-soft palate
junction) to decrease risk of fistula
Small incision made just lateral to maxillary tuberosity
Fat “teased” from buccal space with gentle spreading
motion
Can be spread to cover surprisingly large surface area
Will mucosalize secondarily
Vomer Flaps
Based superiorly
Used for nasal mucosal closure anteriorly in all Veau III/IV
repairs
Facial Artery Myomucosal Flap
Intraoral mucosal flap based on facial artery.
Often used to repair palatal fistulae secondarily
Gingivoperiosteoplasty
Can obviate the need for secondary bone grafting during
mixed dentition
May be indicated at time of lip repair to close alveolar
segments
Only feasible if greater and lesser segments are within ∼1
mm of each other
Performed frequently at cleft centers that utilize
nasoalveolar molding or Latham devices
https://t.me/medicina_free
POTENTIAL COMPLICATIONS OF CP
REPAIR
Acute Airway Obstruction
Bleeding/aspiration/laryngospasm.
Tongue swelling due to reperfusion injury from Dingman
mouth gag.
Reintubation in immediate perioperative period is ~1%.
Some patients require ICU admission for closer monitoring.
Place tongue stitch and nasopharyngeal airway
postoperatively.
Pulse oximetry overnight.
Dehiscence of Palatal Flaps
Undue tension
Poor flap vascularity
Poor tissue handling
Palatal Fistula
Reported rates range from 5% to 50%.
More common in Veau III/IV than Veau I/II.
*Hard/soft palate junction is the most common location.
Requires repair if causes nasal regurgitation of food or
hypernasality.
Midfacial Growth Restriction
Intrinsic midface growth problems are present in children
with CP or CLP.
Scarring/secondary healing from palate repair exacerbates
maxillary growth restriction.
May be reduced by avoiding secondary intention healing.
Limit undermining when possible.
Use buccal fat pad flaps to close lateral open areas.
Timing of palate repair: as late as possible to allow maximal
growth, but before the emergence of speech.
Hyponasality: much less common than VPI; related to
overaggressive closure of velopharynx
https://t.me/medicina_free
VPI (Please see Chapter 15: Velopharyngeal Insufficiency for
details)
Incomplete closure of velum
Air escape through nasopharynx
Hypernasal speech
Secondary to inadequate palatal length or poor muscle
function
20% incidence following palatoplasty
Patient develops maladaptive compensatory
substitutions of abnormal for normal sounds in order to be
understood
Pharyngeal fricatives
Glottal stops
Treatment
Obturator (prosthesis) to fill areas of tissue deficit
Posterior pharyngeal flap (PPF)
Static, nonphysiologic technique
Myomucosal flap from posterior pharynx
Mucosa and superior pharyngeal constrictor
m.
Superiorly based and sutured to soft palate
Appears as a tissue “bridge” with two lateral ports
Requires the patient to have movement of lateral
walls
Dynamic Sphincter Pharyngoplasty (DSP)
Dynamic technique
*Superiorly based myomucosal flaps from
posterior tonsillar pillar flaps
(palatopharyngeus m.)
Crossed and overlapped (to variable degrees) in
midline
Indicated with absent or minimal medial excursion
of lateral walls
Appears as a single port
Buccal myomucosal flaps
Myomucosal flaps elevated intraorally from buccal
mucosa
https://t.me/medicina_free
Соседние файлы в папке @xirurgi_2025