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FIGURE 3-3 Millard rotation-advancement technique for lip
repair. (From Salyer KE. Unilateral cleft lip and cleft lip nasal reconstruction. In
Bardach J, Morris HL [eds]: Multidisciplinary management of cleft lip and palate.
Philadelphia: Saunders, 1990, pp 176-179.)
Most clefts of the lip extend into the nasal base, and the initial repair
of the nose is done together with the first lip repair. As stressed earlier,
surgeons try to produce the best-looking nose they can. But they also
try to minimize the amount of surgical trauma, because the nose is a
major growth site for the midface. Aggressive surgery on the nose
interferes with its forward growth. Salyer (1986, 1994) demonstrated the
aesthetic benefits of careful reconstruction of the nose.
Patients with bilateral clefts of the lip typically have lile to no nasal
columella, so the nasal dome appears to be directly aached to the
philtrum of the lip. The foreshortening or absence of the columella
flaens the nasal alae, thus displacing the alar rims outward. Before the
initial lip and nose repair, the structures that should have formed the
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middle section of the lip and alveolus (referred to as the premaxilla) are
aached directly to the septum, and the premaxilla is often very
protrusive (Fig. 3-4). Various techniques are used to move this segment
back into a more desirable position in preparation for surgery,
including lip taping, nasoalveolar molding, and the use of an
orthodontic plate with a lightweight elastic chain placed over the
prolabium (the lip portion of the premaxilla) (Reisberg, 2004). Repair of
the lip and nose in bilateral clefts requires minute “architectural” plans
for freeing up enough tissue to put the lip together on both sides and to
bring the nasal alae inward and upward. Depending on the regimen of
the individual surgeon or team, a separate surgical procedure may be
performed when the child is approximately 18 months of age to
construct or lengthen the columella (Byrd et al., 2008).
Before the 1980s, treatment of the protrusive premaxilla in bilateral
clefts included external traction, oral pinning, surgical setback, and
even excision (see Reisberg, 2004). All these procedures carried the
potential for disastrous results with regard to facial growth.
FIGURE 3-4 The straight vomer bone and very protuberant
premaxilla, with the palatal shelves collapsed medially in an
infant with a complete bilateral cleft.
It is common for a subsequent procedure to be carried out on the lip
and nose at approximately 6 years of age to improve appearance,
especially if the results of the initial procedure are less than satisfactory.
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This age is chosen because much of the growth of the nose has taken
place by the age of 6. A final lip or nose revision is common toward the
end of teenage facial growth (16 years for girls, 18 years for boys) (Byrd
et al., 2007). In addition, if the profile is not satisfactory (e.g., if it is
relatively flat and if the upper dental arch is posterior to the lower
dental arch [class III malocclusion]), the teenager may undergo
maxillary distraction osteogenesis, as discussed in Chapter 6.
Although parents and the surgeon from the treating team may
encourage a teenager to have a “definitive” lip/nose revision, teenagers
are old enough to insist that they do not want or need another
operation.
Outcomes of Initial Lip and Nose Surgery
Poor surgical results on the lip include excessive scar tissue,
foreshortening of the lip, and lack of muscular continuity across the lip.
In the last case, the lip musculature “bunches up” when the individual
aempts to purse the lips because the fibers of the orbicularis oris have
not been aligned properly (Fig. 3-5). A straight-line repair, with no
aempt to interconnect the muscles, also usually results in a prominent,
red-line vertical scar. A step-off in the vermilion border (the term
surgeons use when the upper edge of the vermilion border does not
match between the left and right sides of the repaired lip) is also a sign
of a less than optimal lip repair.
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FIGURE 3-5 When the fibers of the orbicularis oris have not
been properly aligned in the surgical closure of the lip, protruding
the lip may result in an irregular appearance of the upper lip
vermillion and adjacent skin.
When the primary repair of a bilateral cleft lip results in a
foreshortened lip, often called a “whistle deformity,” the surgeon may
aempt to lengthen the lip by using tissue from the lower lip. In this
procedure, known as an Abbe flap, a central portion of the lower lip is
partially dissected out of the lip and sutured temporarily to the upper
lip. This is a rather complex procedure, because the upper and lower
lips are partially sewn together until the flap has gained an adequate
blood supply from the upper lip. The flap is fully severed from the
lower lip after blood supply is established and it is clear that the flap
will survive.
The nose in unilateral and bilateral clefts of the lip lacks normal
cartilage support. Also, the alar rim droops to some extent, even if it
looks quite good immediately after the initial repair (or immediately
after nasoalveolar molding). The appearance can be improved when the
child is older and the nose has completed most of its growth.
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In unilateral clefts of the lip and alveolus (with or without a cleft of
the palate), the septum deviates toward the affected side. Nasoseptal
revisions are common, but again it is best if they are timed so as not to
interfere with nasal growth. In bilateral clefts, the vomer bone and
septum are usually straight, but both alar rims are flaened until they
are properly reconstructed (Fig. 3-6).
FIGURE 3-6 A and B, The initial repair of a complete bilateral
cleft lip in this little boy has resulted in a nice lip, but the alar rims
are flattened. This defect will be corrected when he is a little
older, giving the nose time to grow.
Effects of the Repaired Lip on Speech
Most repaired lips have no effect on speech. Bilateral lip repairs that
leave a “whistle-deformity” rarely prevent bilabial closure. Even an
overly scarred and stiff upper lip rarely affects speech, because most of
the labial movement for speech is provided by the lower lip. A severely
foreshortened lip will likely lead to incomplete bilabial closure for /p, b,
m/, but the perceptual effect will probably be more visual than auditory.
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Specifics of Palate Surgery
Overview of Palate Repair
Many different techniques are used for surgical closure of the palatal
cleft. Here are some basic points about palate surgery, without going
into individual operative techniques:
1. The hard and soft palate may be closed in one or two procedures.
Most commonly, they are closed in a single operation (Kael et al.,
2009).
2. When the hard palate and soft palate are closed in two operations, the
hard palate may be closed first and the soft palate later. Treatment
centers that use this approach usually have both parts of the palate
closed no later than 18 months of age. Closing the soft palate first and
the hard palate several years later is known as primary veloplasty.
3. Most treatment centers leave the alveolar cleft open (unoperated)
when the hard palate is initially closed. Closure of the alveolar cleft in
infancy (known as primary bone grafting) is unpopular because it
inhibits forward growth of the midface and also prevents later
orthodontic expansion of the maxilla. In addition, alveolar bone grafting
in infancy places the tooth buds in the vicinity of the cleft at risk.
An open alveolar cleft rarely causes a speech problem because the soft
tissue of the operated lip prevents the air stream from escaping into the
nose. Occasionally, one sees a child in whom the space in the alveolar
bone leads to a puffing-out of the lip on /p/ and /b/.
4. Secondary bone grafting to close the alveolar cleft is usually done
after orthodontic expansion of the maxilla, when the maxillary and
mandibular teeth are in a good occlusal relationship. Autogenous bone
(meaning bone generated within the body of the patient, often bone
from the upper rim of the hip) is preferred, particularly if further tooth
movement in the region of the graft is likely.
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The current version of the Parameters of Care document of the
American Cleft Palate Association contains the following statement
regarding secondary bone grafting: “The timing of bone grafting of the
alveolar cleft should be determined by the stage of dental development.
The graft should be placed before the eruption of the permanent
maxillary teeth in the region of the cleft, although in late-presenting
patients bone grafting may necessarily take place after full eruption of
the permanent teeth. The timing of the operative procedure should be
determined in collaboration with the orthodontist. Autogenous bone
should be used when tooth movement through the graft is anticipated.
The occlusion should be stabilized before materials that have potential
to impede tooth movement are used.”
Palate repairs are performed in layers. Hard palate repairs are
accomplished by moving the nasal mucosa and the periosteum
(together called the mucoperiosteum layers) toward the midline (Fig. 3-
7). The surgeon decides whether each layer requires lateral releasing
incisions (just inside the alveolar arch) to facilitate the inward
movement of the layers. Multiple surgical techniques are used for hard
palate repairs (shown in the illustrative material on the website that
accompanies this book). Whether enough oral mucoperiosteum is
present to cover the repaired cleft varies from case to case. The width of
the cleft and the preferred operative approach of the surgeon determine
which procedure is used.
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FIGURE 3-7 Bardach two-flap procedure for the repair of
palatal clefts. (Adapted from Bardach J, Salyer K: Surgical techniques in cleft lip
and palate. Chicago: Year Book Medical Publishers, 1987.)
The soft palate is repaired by moving the nasal mucosa, the muscle
fibers of the levator veli palatini, and then the oral mucosa to the
midline. The most important part of this process is geing the muscle
fibers properly aligned and interdigitated to form a good “sling.”
Again, there are several different operative techniques for
accomplishing this goal while obtaining adequate length of the velum at
the same time. The survey by Kael et al. (2009) indicated a popular
preference for the two-flap palatal closure (which closes both the hard
and soft palate [Bardach, 1990], Fig. 3-7) and the Furlow Z-plasty
(Furlow, 1986, Fig. 3-8).
Several palatal surgery techniques are used in both primary (initial)
palatoplasties and secondary procedures when the initial palatoplasty
has not provided the desired speech result. Preferred procedures for
primary and secondary repairs have historically included the
“pushback” (also known as the V-Y pushback). The popularity of this
technique seems to have declined over time for two reasons: (1)
surgeons questioned whether the palatal length gained during surgery
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was actually sustained following surgery, and (2) clinical research
confirmed that the procedure was associated with poorer facial growth
results. In addition, because the procedure involved denuding of what
had been healthy tissue of the palatal shelves, it led to large
accumulations of scar tissue in the middle of the palatal vault. Surgeons
now have other techniques available, such as the Furlow Z-plasty, that
both lengthen the palate and minimize interference with facial growth
The Furlow Z-plasty and the intravelar veloplasty are also popular for
closing the velar portion of a cleft that extends all the way through the
hard and soft palate.
FIGURE 3-8 A, Two mirror-image Z-plasties are drawn with the
cleft as their central limbs. B, The oral-side Z-plasty flaps are
elevated with the levator-palatopharyngeus muscle in the
posteriorly based flap. Only mucosa is elevated in the anteriorly
based flap. C, The nasal flaps are elevated with the remaining
muscle in the posteriorly based flap. D and E, Transposing the
two sets of flaps overlaps the palatal muscles and lengthens the
soft palate. (From Furlow LT: Cleft palate repair by double opposing Z-plasty. Plast
Reconstr Surg 78:724-736, 1986.)
For the most part, palate repairs do not involve using tissue from
other parts of the body. Two exceptions are (1) bone from the hip or
sometimes from a rib that is used in secondary bone grafting of the
alveolar cleft and (2) the occasional use of a flap of tongue tissue to
repair oronasal fistulas.
Surgical Management of Overt or Covert (Occult)
Submucous Clefts
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If a submucous cleft is actually causing VPI, surgical intervention is
usually required. Typically this intervention involves creating a beerfunctioning levator veli palatini sling. (In submucous clefts, the paired
muscles of the levator run forward, alongside each other, instead of
interdigitating in the middle of the soft palate.) Often only one surgical
procedure is needed. Either a Z-plasty (Furlow, 1986) or an intravelar
veloplasty (Kriens, 1969; Marsh et al., 1989) can be done to create a wellfunctioning soft palate.
Several decades ago, primary pharyngeal flaps (pharyngeal flaps
performed as the first procedure) were very popular for the treatment of
submucous clefts and other forms of VPI. However, these operations
have grown less popular with the advent of effective palatal
lengthening techniques and muscular repositioning procedures.
Pharyngeal flaps remain, however, as secondary surgical options if the
primary muscle reconstruction procedure does not work. Other options
include sphincter pharyngoplasties and pharyngeal augmentation
procedures, discussed in Chapter 10.
Outcomes of Palatal Surgery
The optimum outcome of palatal surgery is a complete, intact palate
with no oronasal fistulas and a velum that is long enough and
functionally adequate to accomplish velopharyngeal closure for speech.
The goal is normal speech sound production in terms of both
articulation and resonance.
Bad outcomes of palatal surgery include oronasal fistulas, a velum
that lacks sufficient length or mobility to reach the pharyngeal walls for
speech, or a palate repair in which the fragile palatal tissue was so
aggressively managed during surgery that the repair dehisces (comes
apart). All three of these outcomes result in the perceptual
characteristics of VPI in speech, and all three require secondary
management, as discussed in Chapter 10.
A surgical outcome of a velum that is just too short is not necessarily
the result of poor surgical technique. Quite often, too lile palatal tissue
is available to obtain an adequately long (and intact) velum.
How Often Are Palatoplasties Successful?
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