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21 Unilateral Cleft Lip Repair
6. LeMESURIER AB. A method of cutting and suturing the lip in the treatment of complete
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A. Namin and R. F. Brown
Cleft Palate Repair
22
AdrianA.Ong, RyanF.Brown, andFiyinSokoya
Introduction
Cleft lip and/or palate is a common congenital malformation within the head and
neck; the incidence of isolated cleft palate is ~1:2500 [1]. These orofacial clefts are
most often an isolated nding but can be associated with syndromes or other comorbidities in 30–50% of cases [2]. Untreated, these patients may experience otologic
diseases, speech and language problems, difculty with oral feeding, velopharyngeal dysfunction, and psychosocial issues. Many surgical techniques have been
developed and rened to address the various types of cleft palate, and surgical intervention is often tailored to the individual patient. Ultimately, the goal of cleft palate
repair is to restore separation between the nasal and oral cavities to allow for oral
feeding and improve verbal communication. Determining candidacy and the timing
of repair for return to normal feeding, speech, and Eustachian tube function is then
balanced with the impact of surgical intervention on maxillary growth [3].
Anatomy
Understanding the normal anatomy of the palate is important to the repair of palatal
clefts, which helps to separate the oral and nasal cavities (Fig.22.1). The incisive
foramen is an important landmark, and divides the primary palate consisting of the
A. A. Ong
Fort Worth, TX, USA
R. F. Brown
Department of Head and Neck Surgery/Facial Plastic and Reconstructive Surgery,
Denver, CO, USA
F. Sokoya (*)
Wellstar Health Systems, Atlanta, GA, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_22
289
290
Palatine foramen
Fig. 22.1 Normal
anatomy of the palate
A. A. Ong et al.
Dental arch
Premaxilla
Incisive foramen
Palatine process
of maxilla
Palatine bone
Posterior nasal
spine
Hamulus
Tensor palatini
muscle
Levator palatini
muscle
premaxilla anteriorly from the secondary palate consisting of the remainder of the
hard palate and soft palate posteriorly.
The soft palate plays a key role in speech and swallowing function. The levator
veli palatini muscle is the most signicant structure within the soft palate. It is a
paired muscle, which forms a sling from its origin at the base of the temporal bone
to the midline. Together with its contralateral component, they elevate the soft palate to the posterior pharyngeal wall. In addition, the palatopharyngeus muscle aids
in the elevation and posterior movement of the soft palate. The tensor veli palatini
muscle originates from the medial pterygoid and inserts onto the palatine aponeurosis. It assists the levator veli palatini muscle in the elevation of the palate and helps
maintain the normal function of the Eustachian tube. Finally, the uvularis muscle is
a small muscle that originates from the palatine aponeurosis and inserts into the
mucosa of the uvula. It shortens the uvula; however, it does not appear to play a
signicant role in speech.
The blood supply of the palate consists of the greater and lesser palatine arteries,
which are distal branches of the maxillary artery. The greater palatine arteries are
especially important as these contribute the main blood supply to the aps used during cleft palate repair.
Clefts of the palate can consist of a combination of bony and soft-tissue abnormalities. Clefts of the secondary palate are typically midline, while clefts of the
primary palate are asymmetric. In clefts of the secondary palate, the velar musculature is affected, with the levator veli palatini muscle oriented in a longitudinal direction with an anomalous insertion onto the bony cleft margin.
The most popular classication system for cleft palate is the Veau classication
(Fig.22.2), which describes cleft palates in four groups: Group I, defect of the soft
palate only; Group II, defect involving both the hard and soft palate; Group III,
ab
cd
22 Cleft Palate Repair
Fig. 22.2 Veau
classication. (a)
Incomplete cleft involving
the soft palate only; (b)
cleft involving the hard and
soft palate; (c) complete
unilateral cleft involving
the lip and palate; (d)
complete bilateral cleft
291
defect involving the hard and soft palate and alveolus; and Group IV, bilateral complete cleft palate [4]. This classication can provide a framework for the appropriate
type of repair.
Indications/Contraindications
Nearly all patients will benet from the repair of the cleft palate, and the question is
not if but when. Repair of the cleft palate may have an effect on craniofacial skeletal
growth, but this should be balanced with the development of proper speech and
language [5]. The American Cleft Palate-Craniofacial Association currently recommends that the palate be closed by age of 18months and preferably earlier when
possible [6]. At most institutions, the cleft palate is repaired at 10–12months of
age [7, 8].
As many patients may have an associated syndrome and/or comorbidities, contraindications to cleft palate repair are related to those conditions and not the cleft
palate itself. Life-threatening comorbidities, such as complex congenital heart disease, may require specialized care involving pediatric cardiology and pediatric
anesthesiology to determine the safety of general anesthesia. In addition, surgery on
patients with severe neurodevelopmental delay who are nonverbal and
292
gastrostomy- tube dependent should be balanced with prognostic factors that portend improvement or worsening of their neurodevelopmental delay. In the immediate preoperative period, patients who have recently had an upper respiratory illness
or hospitalization may benet from postponing surgical intervention to decrease
perioperative risks.
A. A. Ong et al.
Preoperative Planning
As stated earlier, patients with cleft palates may have signicant comorbid conditions and preoperative assessment by the primary care provider with or without
cardiology involvement is an important step before proceeding with surgical intervention. Any recent upper respiratory illnesses or hospitalizations are identied, as
these may affect the timing of surgery.
Patients undergoing cleft palate repair are orotracheally intubated, and this may
be challenging in patients with craniofacial anomalies. Cleft surgeons should communicate with anesthesia colleagues prior to induction, and discuss any signicant
physical examination or exible laryngoscopy ndings to maximize intubation success. An oral RAE endotracheal tube, which has a preformed bend, can be used to
direct the circuit away from the surgical eld.
Depending on the comorbid conditions of the patient, arrangements may be
made for a bed in the intensive care unit, if close monitoring is required
postoperatively.
Caregiver education is initiated during the preoperative visit to avoid any postoperative pitfalls. This is especially important for diet maintenance with options
including squeeze bottles with tubing, traditional cups, syringe with tubings or
spoon feeding with the goal of minimizing negative pressure in the oral cavity during feeding in the postoperative period [9].
Instruments/Equipment Set
A head pad (either donut or horseshoe) is used to stabilize the patient’s head and
minimize movement throughout the duration of the case. A shoulder roll can also be
placed if there are no contraindications to further cervical extension. Having the
head and neck extended provides an easier view of the anterior palate, which can
facilitate repair. The Dingman mouth retractor is commonly used during cleft palate
repair. The teeth hooks can be adjusted during the case depending on the portion of
the palate that requires exposure, and the lateral cheek retractors provide additional
visualization. The use of a surgical headlight and loupe magnication are important
for improved intraoperative visualization.
Periosteal elevation of the palatal aps can be facilitated with a Joseph elevator
or a #9 periosteal elevator. If additional pedicle length is required, the greater palatine artery can be carefully osteotomized. The authors nd that a curved or 90-degree
Beaver blade can help remove the fascia around the vascular pedicle if added
22 Cleft Palate Repair
293
freedom is needed of the ap. A curved elevator, such as a Woodson elevator, is
needed to free off the nasal mucosa under the hard palate. The authors nd that having ne- tipped dissecting scissors, such as longer tenotomy scissors, is helpful
when freeing up the muscle from the hard palate and isolating the layers of the soft
palate. During the closure, sutures with various types of suture needles may allow
for improved placement intraorally, and it is up to the surgeon’s preference.
Typically, rounded tapered needles are helpful for the closure of the delicate and
various palate aps. Either monopolar or bipolar cautery can be used for hemostasis, with care taken to not over-cauterize the tissue aps or endanger the vascular
pedicle.
Flap Design/Surgical Technique/Pearls
The type of palatoplasty is dependent on many factors, including the width of the
hard and soft palatal clefts, width of the alveolar cleft, approximation of the soft
palate cleft with the posterior pharyngeal wall, and presence of comorbidities [10].
The principles of an ideal palatoplasty include a separation of the nasal and oral
cavities, tension-free and multilayer closure, establishing the correct anatomical orientation of the levator sling, and retro-positioning of the soft palate for appropriate
velopharyngeal closure. The main palatoplasty techniques include (1) von
Langenbeck palatoplasty, (2) two-ap palatoplasty (Bardach), (3) Furlow doubleopposing Z-palatoplasty, and (4) the Children’s Hospital of Philadelphia (CHOP)
modication of the Furlow palatoplasty (Fig.22.3).
To begin all palatoplasty techniques, the patient is placed supine on the operating
room table in cervical extension if there are no contraindications. After orotracheal
intubation, the mouth retractor is placed to expose the palate. Local anesthetic is
inltrated in the palate and assists in hydro-dissection in the region of the hard palate. It is important to give several minutes for the epinephrine component of the
local anesthetic to work before making incisions so as to minimize bleeding. Care
should be taken at every point in this process to avoid damage to the neurovascular
bundle. Finally, an intravelar veloplasty is advised, which repositions the abnormally attached levator veli palatini muscles from the posterior edge of the hard palate to recreate the palatal muscular sling as it has been shown to improve speech
outcomes in those undergoing palatoplasty [11].
Von Langenbeck Palatoplasty
The palate is marked along the alveolar ridge and the medial aspect of the cleft edge.
The lateral-releasing incisions near the alveolar ridge are performed rst to create
the anteriorly- and posteriorly-based ap. This incision can be carried laterally
around the posterior extent of the alveolus if further mobilization is necessary. Next,
the incisions of the medial cleft edge at the oral/nasal mucosal junction are brought
294
e
A. A. Ong et al.
a
b
c
d
Fig. 22.3 Types of cleft palate repair. (a) von Langenbeck palatoplasty; (b) two-ap palatoplasty
(Bardach); (c) Furlow double-opposing Z-palatoplasty; (d) Children’s Hospital of Philadelphia
(CHOP) modication of the Furlow palatoplasty (e) Combined two-ap palatoplasty with Furlow
doupole-opposing Z-palatoplasty at the soft palate
22 Cleft Palate Repair
295
to the apex of the uvula. The mucosa overlying the vomer is incised and can provide
additional aps to achieve a tension-free closure.
Once all incisions are made, a subperiosteal dissection is carried from the lateralreleasing incision to the medial cleft edge. Blunt dissection to the posterior edge of
the palate is carefully performed, and the greater palatine neurovascular bundle is
identied. The greater palatine neurovascular bundle is circumferentially released,
and additional length can be gained by releasing the pedicle using osteotomies in
the bony canal.
Elevation of the nasal aps is performed and can be carried to the lateral nasal
wall as needed to provide tension-free closure. Once all aps are elevated, attention
is turned to the velar musculature to start the intravelar veloplasty. The levator veli
palatini is released from its anomalous insertion onto the posterior edge of the hard
palate. This can be elevated behind the greater palatine neurovascular bundle to
provide additional length for the mucosal and muscle layers.
Nasal closure is performed with sutures placed in a mucosal-to-submucosal fashion such that the knots are along the nasal mucosal surface. The vomer aps can be
incorporated anteriorly to provide tension-free closure. Next, the intravelar veloplasty is completed. Interrupted or horizontal mattress sutures are used to reorient
the levator veli palatini muscles and recreate the levator sling. Finally, the oral
mucosa is closed with interrupted or running sutures in a posterior-to-anterior fashion. Sutures may be placed in the lateral-release incision for stabilization, but this is
not often necessary.
Two-Flap Palatoplasty (Bardach)
The two-ap palatoplasty is typically used in cases of complete cleft palate with
adequate soft palate length. Similar to the von Langenbeck palatoplasty, the lateralreleasing incisions are marked; however, when incised, they are taken to the medial
cleft margin edge. This connects the medial and alveolar incisions anteriorly creating a posteriorly based ap on the greater palatine neurovascular bundle. During
subperiosteal dissection, the oral hard palate mucosa can be reected posteriorly to
identify and skeletonize the greater palatine neurovascular bundle. The vomer and
nasal aps are created. If the patient has a bilateral cleft palate, then bilateral vomer
aps can be used to help close the anterior nasal oor. Multilayer closure and
intravelar veloplasty are performed similarly to the von Langenbeck palatoplasty. It
is very common to have some gaps between the lateral and anterior alveolar ridge.
It is important to place tacking sutures to hold the sutures in place and then surgical
is placed over exposed bone. The cleft will be covered by the closure, and these new
areas of exposed bone will re-mucosalize in a matter of days to weeks.
296
A. A. Ong et al.
Furlow Double-Opposing Z-Palatoplasty andChildren’s Hospital
ofPhiladelphia Modification
The purpose of the double-opposing Z-palatoplasty is to reorient the levator veli
palatini muscles into a horizontal sling position and to lengthen the soft palate [12].
The nasal and oral incisions do not overlap and theoretically decrease the risk of
stula formation. The hard palate is closed with vomer and nasal aps for the nasal
surface and oral mucoperiosteal aps for the oral surface.
In the CHOP modication, the double-opposing Z-palatoplasty is used to treat
the soft palate and hard palate, and lateral-releasing incisions or bipedicled aps
(von Langenbeck) are developed to treat the hard palatal defect [13]. The
Z-palatoplasty incisions are shortened such that there is no intersection with the
lateral-releasing incisions.
In the traditional Furlow repair, the hard palate mucoperiosteal ap is elevated
from medial to lateral without lateral-releasing incisions. The greater palatine neurovascular bundle is identied, released circumferentially, and preserved. Next, the
soft palate is dissected.
On the left, the mucosa is incised along the medial cleft edge and the planned
Z-plasty incision to create a posteriorly based myomucosal ap. The anomalous
bers of the levator veli palatini muscle are released from the posterior edge of the
hard palate and incorporated into the ap. This is dissected away from the undersurface of the nasal mucosa. A suture is placed at the apex of the left myomucosal ap
to allow for retraction and access for nasal ap mobilization. On the right, an anteriorly based oral mucosal ap is elevated toward the hamulus and dissected in a
submucoperiosteal plane once the lateral palatal shelf is reached.
On the right, a nasal myomucosal ap is then developed by incising the ap at
the base of the oral mucosal ap and carried to the hamulus in an anterior-toposterior direction. On the left, a nasal mucosal ap is created, beginning posteriorly and raised in an anterolateral direction toward the hamulus.
Once all aps are developed, the nasal surface is closed by placing the right nasal
posteriorly based myomucosal ap in its posteriorly transposed site. Sutures are
placed initially at the base to allow for greater advancement of the ap and decreased
tension in the closure. The left nasal anteriorly based mucosal ap is inset similarly.
The left oral posteriorly based myomucosal ap is then overlayed onto its nasal
compliment and sutured to reconstitute the levator sling. At this point, closure of the
nasal surface of the hard palate is closed similar to the other types of palatoplasty.
After nasal surface closure and reorientation of the levator muscles, the right oral
anteriorly based mucosal ap is then transposed and inset. The oral hard palate
mucosal closure is then performed in a posterior-to-anterior fashion.
The Furlow palatoplasty is commonly used to repair either a submucous cleft,
isolated soft palate cleft, or velopharyngeal insufciency caused by a short soft palate after primary cleft palate repair, as discussed below.