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References
Chibbaro P, Barzilai J, Breen M. Nursing care of the patient
with cleft lip and palate. Losee JE, Kirschner RE.
Comprehensive cleft care. McGraw-Hill: New York; 2009.
Cooper-Brown L, Copeland S, Dailey S. Feeding and
swallowing dysfunction in genetic syndromes. Dev Disabil
Res Rev. 2008;14:147–157.
Dailey S. Feeding and swallowing management in infants with
cleft and craniofacial anomalies. SIG5 Perspect Speech Sci
Orofac Disord. 2013;23:62–72.
Kael BA, Basile P, Kol PF, et al. Current surgical practices in
cleft care: cleft palate repair techniques and postoperative
care. Plast Reconstr Surg. 2009;124:899–906.
Nassar E, Marques IL, Trindade AS, Beiol H. Feeding-
facilitating techniques for the nursing infant with Robin
sequence. Cleft Palate Craniofac J. 2006;43:55–60.
Reid J, Kilpatrick N, Reilly S. A prospective, longitudinal study
of feeding skills in a cohort of babies with cleft conditions.
Cleft Palate Craniofac J. 2006;43:702–709.
Shprinen RJ, Higgins AM, Lipton A. Growth, weight gain,
and feeding. Plural Publishing: San Diego; 2008. Shprinen
RJ, Golding-Kushner KJ. Velo-cardio-facial syndrome. vol 1.
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Physical Management of Clefts
Primary
Physical management of clefts is surgical, prosthetic, or both. The child
with a cleft lip and palate will likely undergo several surgical
procedures to create (1) a lip and nose that are aesthetically pleasing
and functional, (2) an intact palate, and (3) an intact alveolar ridge that
provides good bony support for the lip and nasal base. Prosthetic
treatment is now used much less often than in the mid-twentieth
century, but it still plays a role.
Typically, two operations are performed on the nose in childhood: (1)
the initial repair of the lip and nose in infancy and (2) a nasal revision a
few years later, after the nose has grown. These are in addition to (3)
initial palatoplasty and (4) alveolar ridge repair. Hence the count of
four procedures.
Speech-language pathologists (SLPs) are well aware that “cleft palate
speech” can occur in speakers who have neither an overt cleft nor a
submucous cleft. This condition is generically referred to as noncleft
velopharyngeal inadequacy (VPI) and has many diverse causes.
Surgical or prosthetic treatment is often needed to treat noncleft VPI.
The details regarding characteristics of cleft-related speech are
discussed in Chapter 5, perceptual speech assessment and diagnosis in
Chapter 8, and secondary physical management in Chapter 10.
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Perspective on Lip and Palate Surgery
Surgery always results in scar tissue, and scar tissue does not move or
grow (Box 3-1). Too much scar tissue inhibits both growth and
muscular function. This is why surgeons try to minimize the number of
operations performed on any one structure. Parents often want a lip
scar completely “erased.” But this outcome is not truly achievable, and
each additional surgical procedure has the potential of adding more
scar tissue.
Box 3-1
Glossary of Terms Relevant to Lip and Palate
Surgery
augmentation pharyngoplasty: alteration of the configuration of the
posterior pharyngeal wall either by the surgical transplantation of
soft tissue or cartilage or by the injection of a variety of organic or
inorganic substances; injectable substances have included fat,
collagen, calcium hydroxyapatite, and Teflon
Bardach two-flap palatoplasty: a currently popular method of closing a
cleft palate
buccal flap: use of tissue from the inside of the cheek to repair the
palate
buccinator myomucosal island flap: another term for buccal flap
Furlow Z-plasty: a popular technique for use both in repairing the cleft
of the velum and in adding length to a previously repaired velum;
can be done only one time
palatal pushback: a surgical technique for closing the palate; sometimes
used as a technique for obtaining more length for the palate; involves
substantial dissections that leave a considerable amount of raw bony
surface and thus tends to result in excessive scar tissue in the palatal
vault; dates back to 1925
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palatoplasty: surgery of the palate; usually refers to the initial operative
procedure
periosteum: a fibrous vascular membrane covering bone that is
permeated with the nerves and blood vessels that innervate and
nourish underlying bone; in repairs of the hard palate, flaps of
mucoperiosteum (the combined layer of the periosteum together with
its overlying mucosa) are moved toward the midline
pharyngeal flap: historically, surgery that creates a central bridge of
tissue between the posterior pharyngeal wall and the velum; the
bridge is a static tissue obturator, not a moving muscular force;
pharyngeal flaps were originally created with the base low in the
pharynx (inferiorly based), but beer speech results were reported
with superiorly based flaps; good speech results are dependent on
inward movement of the lateral pharyngeal walls; asymmetrical flaps
are possible when the velopharynx is asymmetrical in shape or there
is asymmetrical velopharyngeal muscle movement in speech
(Mehendale and Sommerlad, 2003)
pharyngoplasty: a generic term for any surgery altering the
configuration of the pharynx
primary pharyngeal flap: a pharyngeal flap performed as the first
corrective surgery for someone with an incompetent repaired palate,
a submucous cleft, or a congenitally short or hypotonic velum
rotation-advancement: one technique for surgical repair of the lip
sphincter pharyngoplasty: any of a group of closely related surgical
procedures that create a small, central sphincter between surgically
repositioned posterior faucial pillars; improvement in speech is
dependent on muscular action closing the sphincter
triangular flap: one technique for surgical repair of the lip
V-Y pushback: another form of palate repair dating back to the 1920s;
still used by some surgeons
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Veau-Wardill-Kilner technique: a technique for repair of the hard and
soft palate dating from the mid-twentieth century; largely replaced by
techniques using minimal incisions (e.g., Mendoza et al., 1994)
vomer flap: surgery for hard palate repair in which a flap of tissue is
dissected from the vomer bone and switched into a horizontal
position to help fill in the cleft
von Langenbeck repair: a technique for palate repair dating back to
1861; basically a straight-line repair; modified von Langenbeck
repairs are still often done on the hard palate
Historically, the flaened midface associated with cleft lip and palate
was the result of two factors: (1) deficiency of tissue and of growth
potential in the midfacial structures, and (2) overly aggressive surgery
(too many procedures, too early) on the nose. The nose is a major
growth center for the face. Surgery to repair the nose must be very
delicate and not repeated time after time in early childhood.
Timing of lip and palate surgery is not necessarily the same across
treatment centers. In most centers in the United States, surgical closure
of the lip precedes that of the palate. The lip is usually closed in the first
few months of life (e.g., 3 months). When the cleft is bilateral, the two
sides of the lip may be closed either simultaneously or in two stages.
Age at palatal surgery is highly controversial. SLPs would like to see
the palate closed at the time of the onset of canonical babbling, and
orthodontists would prefer to see the palate untouched for several
years. The SLP is concerned about the child's early phonological
development; specifically, a child who has no way to seal off the nasal
airway from the oral airway could develop maladaptive compensatory
articulations instead of normal pressure consonants. The orthodontist is
concerned that early surgery on the palate will inhibit growth of the
maxilla. Thus, age at palatal surgery is somewhat of a compromise. For
many years, the most frequently reported ages at surgery were between
9 and 18 months. However, a survey of more than 300 U.S. surgeons
that was completed by Kael et al. in 2009 showed a strong preference
for closing palates between the ages of 6 and 12 months.
In some treatment centers in the United States, Japan, and Europe, the
soft palate is closed at the time of lip closure and the hard palate is left
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p p p
open until the child is approximately of school age. This treatment
regimen is known as primary veloplasty. The theory is that leaving the
hard palate open allows for beer growth of the maxilla and midface.
Interestingly, use of a prosthesis to close the hard palate until surgery is
done is not consistent across patients or across centers using this
regimen. Although the growth results such as demonstrated by Friede
et al. (2012) are very impressive, the concern about speech persists.
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Specifics of Lip and Nose Surgery
Lip closure is not just a maer of sewing the two sides of the cleft
together. The surgeon is careful to create a Cupid's bow (aligning the
vermilion border from each side) and to provide enough length to the
lip. Doing so requires some zig-zag dissections and redirection then
reconnection of tissue, including the muscle fibers of the orbicularis
oris. It is very important that the continuity of all the muscles involved
in the cleft lip, including the perinasal and perioral muscles, be
reestablished. Figures 3-1, 3-2, and 3-3 illustrate unilateral cleft lip
repair. Other examples of lip repair may be found in the Web-based
audiovisual material associated with this book.
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FIGURE 3-1 Fisher's 25-point repair for unilateral cleft lip. In
this case, the patient had an incomplete cleft lip. Note the
amount of detail involved in the preplanning for the repair,
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despite the fact that the cleft was incomplete. (From Fisher DM:
Unilateral cleft lip repair: an anatomical subunit approximation technique. J Plast
Reconstr Surg 116:61-71, 2005.)
FIGURE 3-2 Triangular flap repair for a unilateral cleft lip. (From
Randall P: Long-term results with the triangular flap technique for unilateral cleft lip
repair. In Bardach J, Morris HL [eds]: Multidisciplinary management of cleft lip and
palate. Philadelphia: Saunders, 1990, p 225.)
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