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22 Cleft Palate Repair
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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
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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
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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.
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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.
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Special Considerations
In patients with wide clefts (>20mm), primary closure can be achieved with the
previously mentioned palatoplasty techniques. Successful closure can be maximized with the extension of the lateral releasing incisions around the posterior alveolus onto the soft palate toward the retromolar trigone, release of the levator veli
palatini muscles from both the oral and nasal mucosal aps to increase ap mobility, and circumferential dissection and release of the greater palatine neurovascular
pedicle with or without osteotomies. In those cases when excessive tension remains
(primary wide clefts, revision cases with signicant scar tissue), consideration can
be given to the use of acellular dermal matrix. The use of acellular dermal matrix
during palatoplasty when tension-free primary closure cannot be achieved may
reduce stula formation, with an overall stula rate of 5.4% compared to 10.6% in
those who did not undergo non-acellular dermal matrix palatoplasty [14].
A submucous cleft is characterized by dehiscence of the palatal musculature
with intact overlying mucosa, causing difculty in detection. Findings associated
with a submucous cleft include midline notching of the hard palate, bid uvula, and
a zona pellucida (a bluish tint in the soft palate signifying lack of underlying musculature). Management of submucous clefts can include minimally invasive palatopharyngoplasty (MIPP), intravelar veloplasty, Furlow double-opposing Z-plasty,
sphincter pharyngoplasty, and posterior pharyngeal ap. Currently, available data
are mixed, and a Cochrane review on the management of submucous clefts showed
no signicant difference in outcome between MIPP versus MIPP with a pharyngeal
ap or sphincter pharyngoplasty [15]. Calis et al. showed improved speech outcomes in patients undergoing submucous cleft repair with both Furlow doubleopposing Z-plasty and pharyngeal ap combined with intravelar veloplasty;
however, they suggested that pharyngeal ap repair be considered in patients with
severe hypernasality [16].
Postoperative Management
Depending on the surgeon’s preference, a tongue stitch can be placed in the midline
to assist with airway management in the post-anesthesia care unit and on the oor
[17]. This can be removed once the patient is deemed safe from any potential airway
obstruction. Patients are typically admitted for overnight observation to monitor for
airway obstruction and provided liquid pain medication. Soft arm restraints can be
used for those unable to follow commands to avoid disruption of the surgical site.
Under close supervision, these should be released several times a day and range of
motion exercises are encouraged. Patients are discharged once tolerating a pourable/pureed diet. Ideally, no straws or eating utensils are used during the healing
period to prevent possible damage to the suture lines. During hospitalization, caregivers are educated on proper feeding, which is maintained until the rst follow up visit.
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Outcomes
The goals of palatoplasty include complete closure of the oral and nasal mucosa
without the formation of a stula, velopharyngeal competence with normal speech
and feeding, minimal impact on facial skeletal growth, and improved Eustachian
tube function. This is dependent on cleft size and shape, type of repair, and surgeon
experience.
Oronasal Fistula Rate
Oronasal stula is a morbid complication resulting in hypernasality and nasal regurgitation. It is typically located at either the anterior hard palate or at the junction of
the hard and soft palate repair. The incidence of oronasal stula after primary cleft
palate repair is approximately 8.6% [18]. Risk factors for the formation of an oronasal stula include preoperative Veau classication (higher rate of stula with
class III/IV), cleft width (higher rate of stula with cleft width of ~7.75mm and
greater), nutritional status of the patient, and surgeon volume (higher volume protective against stula formation) [19–21]. The surgeon must pay special attention to
the closure by careful development of robust tissue aps and achieving a multilayer,
tension-free closure. Acellular dermal matrix can be used as an adjunct to reduce the
rate of oronasal stula formation [14].
Velopharyngeal Dysfunction
Velopharyngeal dysfunction (VPD) results from the inadequate closure of the velopharynx during speech causing air escape through the nose during oral consonant
production. Symptomatically, patients develop hypernasal speech and nasal regurgitation during feeding. The estimated incidence of VPD following cleft palate
repair has been reported to be between 15 and 30%, with older age at the time of
repair (>2years) being a risk factor for the development of VPD, resulting in poorer
speech outcomes [22–24].
Management of VPD is complex and typically requires a multidisciplinary team,
including a cleft surgeon, speech-language pathologist, and/or maxillofacial prosthodontist. Speech therapy may be used as a primary treatment or adjunct to prosthetic rehabilitation or surgical intervention. Some patients, especially those who
are not surgical candidates, may benet from an obturator or palatal lift fashioned
by a maxillofacial prosthodontist. If surgical intervention is considered, it is individualized based on closure patterns identied on nasopharyngoscopy or uoroscopy; surgical interventions include posterior pharyngeal wall augmentation, palatal
lengthening, and/or alteration of the velopharynx (sphincter pharyngoplasty or posterior pharyngeal ap).
A prospective clinical trial compared the speech of two cohorts of patients with
cleft palate undergoing either Furlow double-opposing Z-plasty or a two-ap
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palatoplasty (von Langenbeck) and found that the Furlow double-opposing Z-plasty
resulted in better velopharyngeal function; however, the Furlow palatoplasty
resulted in higher rate of stula [25]. Intravelar veloplasty has been incorporated
into cleft palate repair and has been shown to signicantly improve postoperative
speech outcomes, resulting in a decrease of secondary velopharyngeal rates from
10.2 to 4.6% [26].
Facial Growth
There has been concern that cleft palate repair may inhibit facial growth, with a
particular focus on the timing of repair. Liao etal. suggested that patients who
underwent late hard palate repair had minimal adverse effects on the growth of the
maxilla [3]. On the other hand, other studies have found late repair resulted in no
impairments in maxillofacial growth, suggesting further research is necessary; however, late cleft palate repair resulted in higher rates of VPD and poorer speech outcomes [5, 24, 27]. Finally, some surgeons suggest less subperiosteal dissection of
the hard palate to prevent maxillary growth impairments and advocate a two-stage
approach to palatoplasty, in which the soft palate is repaired rst, followed by
delayed repair of the hard palate [28]. Ongoing research is needed to further dene
the effects of cleft palate repair on facial growth.
Eustachian Tube Dysfunction
Eustachian tube dysfunction, including chronic otitis media with effusion, affects
nearly all patients with cleft palate and is due to the anatomic disruption of the palatal muscular sling, causing an inability of the tensor veli palatini muscle to dilate the
eustachian tube [29]. The resultant middle ear effusion manifests as conductive
hearing loss, which can be improved with the placement of tympanostomy tubes,
palatoplasty, and/or hearing amplication.
Most patients with cleft palate who undergo palatoplasty will achieve improved
eustachian tube function by age 6years [30]. Smith etal. showed that patients with
cleft palate who underwent Furlow double-opposing Z-plasty had fewer sets of tympanostomy tubes postoperatively (1.8 sets of tympanostomy tubes) compared to
those undergoing traditional two-ap palatoplasty (2.9 sets of tympanostomy tubes)
[31]. In addition, intravelar veloplasty, which restores the palatal muscular sling,
has been shown to improve eustachian tube function [32]. Despite eventual recovery
of eustachian tube function after palatoplasty, patients with cleft palate remain at
high risk for persistent hearing loss and for cholesteatoma, and these patients will
continue to benet from close otologic follow-up [33–35].
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Part VII
Trauma Reconstruction
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