|Year : 2014 | Volume
| Issue : 1 | Page : 19-25
Complications of cleft palate repair and how to avoid them
Department of Plastic Surgery, Sri Ramachandra University, Chennai, Tamil Nadu, India
|Date of Web Publication||5-Feb-2014|
Department of Plastic Surgery, Sri Ramachandra University, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: The cleft palate repair is commonly performed procedure in plastic surgery practices. In addition, this is also procedure done by trainees to the senior most surgeons. One of common procedure for trainee who are introduced to cleft lip and palate surgeries. Literature is flooded with articles on complication of cleft palate repair and probable factors influencing it till the latest one, which suggest that we are far from getting desirable results in cleft palate repair. Review: The common complications of cleft palate repair are fistulae, velopharyngeal insufficiency and detrimental effect on maxillary growth. Palatal fistula is commonly stated in literature with variable incidence ranging from 3-40% 1 , with an average of 7-10%. Other complications are poor speech outcome and poor growth potential of maxillary bone due to scars following palate repair. Every attempt needs to be made to avoid complications or reduce the rate of complications. This article reviews the factors and pitfalls that are likely to increase the chances of complication following palate repair. Conclusion: As surgeon we are duty bound to reduce the avoidable complication, specially related to judgment and techniques. However, the complication due to inherent deficiency of tissue like hypoplastic soft palate muscles and poor scarring tendencies leading to complications are not avoidable.
Keywords: Cleft palate, palatal fistula, velopharyngeal insufficiency
|How to cite this article:|
Murthy J. Complications of cleft palate repair and how to avoid them. J Cleft Lip Palate Craniofac Anomal 2014;1:19-25
| Introduction|| |
To err is human however, we need to understand that our error may cause grief to our patients and therefore we should strive to avoid inordinate errors. Pare's philosophy of "I dress and God heals" will bear fruit only if we have followed the basic principles of cleft surgery and not gone against them.
We should strive to do our best to avoid complications due to surgical technique and human errors. Often when parents bring a child with cleft palate fistula, if inquired how the "whole appeared", the answer likely that child cried post-operatively or child had severe vomiting, as explained by the surgeon. The ignorant and naοve parents buy this deceitful explanation. Introspection and looking at our fallacies and shortcoming are demanded from a dutiful surgeon. We need to be aware of the subtle surgical issues that lead to complications and need to recognize the potential risk factors and avoid them.
| Literature|| |
Studying the history of cleft palate repair is an important step in the prevention of complications. Johann Friedrich Dieffenbach in 1816 was the first to elevate soft-tissue flaps instead of paring the edges only. However, he used lateral palatine osteotomy to move the palate medially which was a rather radical surgical procedure. von Langenbeck was the first to raise pedicled mucoperiosteal flaps based on the sound knowledge of anatomy which is till in use today.  Veau in 1927 described the importance of nasal layer repair, which is being practiced until date. He also described breaking of the hamulus and push back procedure, which probably has lost its importance in the present day. 
Independently, Wardill and Kilner  developed the more radical push back procedure in 1937, which was becoming popular in UK. Of course, with time this technique has proved to be disastrous due to the extensive scarring and the raw bony surface that it leaves after surgery. With these disastrous results and knowledge of early surgery and scarring causing growth problems, the pendulum - swung to the Schweckendiek and Doz  technique of two-stage repair where in the hard palate is closed later than 5-7 years of age. A study by Bardach et al.  presented his two flap technique suitable for wide cleft in the presence of alveolar cleft and with less incidence of fistula. Later, superiorly based vomer flap was used to close hard palate as a single layer with the expectation of better growth outcome.  The latest addition to the cleft palate operation is "Radical Muscle Mobilization" developed simultaneously by, Sommerlad and Cutting et al. However, while Sommerlad uses the operating microscope for the muscle dissection and sling formation, Cutting et al. uses the magnifying loupes. The authors claim better speech outcomes following radical muscle dissection and veloplasty. ,
| Principles for Cleft Palate Repair|| |
There are certain basic principles, established by various-studies, which are necessary for better results and for avoiding complications following palate repair. These are:
1. Water-tight closure of oral flaps
2. Competent velopharyngeal port
3. Minimal raw areas to avoid detrimental effect on growth
4. Proper creation of a muscular sling.
| Factors Influencing Unfavourable Outcome Following Cleft Palate Repair|| |
There are guidelines and principles that help to avoid complications of palate repair.
General clinical history
Gold standard of clinical history and examination should not be compromised. It may reveal factors such as malnutrition, associated anomalies, poor oral hygiene and others which may affect the general well-being and unfavorable local conditions.
Anatomy of the cleft
Understanding the details of the anatomy in each cleft is essential to choose the appropriate method for surgical repair.
Type of cleft
Bilateral cleft lip and palate has more chances of having a fistula compared to the unilateral cleft and this is mainly due to technical difficulty in bilateral cleft palate repair; especially in the post-alveolar region. With a flexed premaxilla following cleft lip repair, approach to this area becomes difficult. Therefore, it is often prudent to do the anterior palate repair during lip repair to give one layer closer in peri-alveolar region.
Width of cleft
There are many studies, including our clinical study,  which have proved that cleft width does not influence the speech outcome. However, the wider clefts that are more difficult to close and may need skilled hands and these clefts are also more likely to have a residual fistula. 
Length of palate
Randall et al.  classified cleft palate in four types based on the examination findings under general anesthesia. Type IV is more likely to have unfavorable result as far as speech is concerned but do not affect the fistula formation.
- Type I, the distal tips of both uvulae reach the posterior pharyngeal wall
- Type II, one or both uvulae only reach the posterior half of the adenoid pad
- Type III, one or both sides of the uvulae reach anterior half of the adenoids
- Type IV, one or both sides do not even reach as far as the adenoids.
Age of repair
Many studies have confirmed that palate repair before 18 months of age is necessary for better speech outcome.  Intact palate and adequate musculature at the time of speech development are prerequisite for good speech. It was also reported to have lower incidence of otitis media following early surgery. 
Hypoplasia of palatal tissue
Any tissue deficiency in cleft palate or submucous cleft patients with hypoplastic muscles will result in compensatory articulation and poor speech outcome [Figure 1].
Associated anomalies like cyanotic heart disease with low oxygen level or genetic defect like epidermal dysplasia with poor skin quality are likely to pose problems of healing. There may be associated syndromes especially with isolated cleft palate, like thymus dysfunction or Ca 2+ deficiency which may interfere with tissue healing.
Feeding problems and low birth weight is not uncommon in cleft children. General low weight without any major nutritional deficiency may not pose any specific problem, however, severe protein deficiency adversely affects normal healing of tissues. Though throat swabs are not necessary, palate surgery with active throat infection is more likely to have post-operative infection and increase rate of fistula formation.
Technique and general surgical skills
Atraumatic technique incorporating good tissue handling and completion of procedure in appropriate time duration influence the final outcome. Magnifying loupes or microscope certainly help to improve precision and have become almost a necessity for cleft lip and palate surgery.
Protocols and selection of procedure
The most important factor is to select appropriate technique to suit the type and anatomy of cleft palate. Establishing and following protocol in management of the cleft definitely improves the outcome and reduces unfavorable results. There is no single protocol which can be claimed to be the best and there is no one technique which is good for all clefts. The priority in soft palate repair is good muscle dissection as described by Sommerlad and creating sling in posterior half of the soft palate. A similar result can be achieved by Furlow's Z plasty,  but adds additional scars on the soft palate. General consensus for suitable technique (type of incision) when cleft extends on hard palate are the following.
Only paring incision
Palate is repaired by only paring cleft edges with mucoperiosteal flaps dissection with good muscle repair. This is suitable for very narrow cleft or sub-mucous cleft.
This is best suitable for cleft of secondary palate or unilateral cleft palate with no alveolar gap. Lateral releasing incisions and raising of mucoperiosteal flaps on vascular pedicle allow adequate medial mobilization to avoid tension on suture line of palate. This technique has shown better growth results than two flaps technique [Figure 2].
|Figure 2: Von Langenbeck incision for cleft of secondary palate with lateral releasing incision|
Click here to view
Two flaps technique
It is an easy technique with a minimal fistula rate but has poor growth outcome. The mucoperiosteal flaps are raised on greater palatine vessel pedicles and mobilized medially. However, as shown in [Figure 3], the anterior alveolar defect is common and a potential place for large fistulas. This can be reduced by repairing anterior palate (in a single nasal layer) during lip repair. This technique is more suitable for older patients having unilateral or bilateral complete cleft lip and palate.
|Figure 3: Two fl ap technique used mainly when there is alveolar cleft with cleft lip and palate. Please note perialveolar defect, which likely to result into fi stula after lip repair|
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Alveolar extended palatoplasty
This is a modification of two flap technique when palatal flaps include lingual gingival of incisor and premolar region. This incision is more along the embryogenic line and possible only when teeth are present. It is an excellent method to avoid fistula in post-alveolar region.  This technique also useful for closing anterior palatal fistula [Figure 4].
|Figure 4: Alveolar extension palatoplasty (AEP) flaps extending into alveolar defect prevent perioalveolar fistula. AEP also used for closing anterior palatal fistula|
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Vomer flap or one layer repair
In this protocol the hard palate is repaired by single layer of superiorly based vomer flap. This procedure is often combined with primary lip repair or at later date when cleft becomes narrow following lip and soft palate repair. Vomer flap for hard palate repair avoids lateral incision and raw areas and some studies have shown that it results in better growth outcomes. 
Tension free closure
No technique is good if it does not allow closure of palate without tension. Any tension especially at junctional area will cause tear in mucoperiosteum when one tries to tighten knots. At any moment, if one feels that closure is under tension and needs to hold first knot before second knot, it is an indication that some manoeuvre is necessary to reduce the tension. Often surgeons hesitates to give lateral incision which is blamed for poor growth. However, with tension at suture line it is highly possible that it will result in fistula formation which will demand second surgery, probably with more extensive dissection and lateral releasing incision. There are many manoeuvres which can reduce tension at suture line which are as follows:
a. Releasing lateral incision like in von Langenbeck [Figure 2] may be restricted to molar region. Mucoperiosteal flaps are raised on vascular pedicle and mobilized medially to avoid tension on central palatal suture line
b. Releasing pedicle from foramen: After lateral incision, if there is still tension, pedicle needs to be teased from surrounding tissue and periosteal sleeve. This is done by blunt dissection rather than sharp instrument. Restricting fibers are located all around the pedicle and need to be released circumferentially. Small gentle jerks will help to break these fibers, which may need occasionally sharp cutting instrument
c. Separating pedicle from flap: This is rarely necessary especially in very wide cleft in syndromic children. Sharp dissection is needed under magnification without damaging the pedicle. This maneuver may not increase mobility to a great extent
d. Breaking of hamulus or posterior wall of foramina: Breaking of hamulus has been described and practiced till today. However, it has not scientifically proved to be useful.  More radical procedure of breaking posterior wall of foramina has been described in literature but not practiced in present day. Greater palatine vessels pass through a long canal and breaking the bone at the mouth will not release the pedicle from the canal. We have never performed this manoeuvre to mobilize the pedicle.
Repair of nasal layer
This is a controversial topic and there are reports suggesting that it is not necessary at all  to repair nasal mucoperiosteum, while other reiterate that it is a very critical step in cleft palate repair. We believe that a good nasal layer repair is critical in reducing the incidence of post-operative fistula. However, there is no study, which suggests that raising nasal layer leads to growth disturbance. Nasal mucoperiosteum can be recruited from lateral nasal wall up to inferior turbinate to reduce the tension.
Addition of tissue to reduce velopharyngeal insufficiency (VPI)
This is another controversial topic and many procedures have been described with addition of tissue like buccal myomucosal flap,  or the superiorly based pharyngeal flap during primary palate repair to reduce VPI.  The first argument is that in primary palate repair, the soft palate mucosa is highly stretchable and additional mucosa will not be of much value to increase length. Secondly when there is a short palate and tissue deficiency, it is likely that there will be deficiency of muscles as well. With weak and hypoplastic muscles, any addition of mucosa to lengthen the soft palate will not be helpful because weak muscle will not be able to stretch the mucosa. A good reason for adding tissue is for the secondary palate procedures where scarring prevent stretching of mucosa with good muscle repair. Similarly, addition of buccal pad of fat in lateral raw areas of palate to reduce the growth disturbances are also not proved scientifically.
Hemostasis and bleeding
Palate is a highly vascular structure with multiple vessels crisscrossing its length and breadth. Dissection in a proper plane is necessary to avoid bleeding. Dissection in a plane superficial to mucoperiosteal level leads to more bleeding and should be avoided. In older children and adults, occasionally large blood vessels come out of palatine bone anterior to greater palatine foramen, which need to be tackled appropriately. Direct trauma to pedicle or accidental coagulation of the artery while trying to stop bleeding near pedicle is no unlikely event. In such eventuality, one should avoid dissecting soft palate muscle and also try to retain anterior attachment of mucoperiosteum. Bipolar cautery is the necessity to avoid direct damage to the pedicle.
Post-operative care and infection
A few reports suggest that the cause of fistula is infection.  However, infection is unlikely in younger babies, unless they are compromised either immunologically or nutritionally. In older children, infection is seen especially with poor dental and oral hygiene. In addition, the dissection is difficult in older children and adults due to adherent mucoperiosteal flaps, probably due to repeated oral infection. Due to these adhesions and difficulty of dissection in proper plane, the flaps often become thin mucosal flaps rather than mucoperiosteal flaps. These mucosal flaps in presence of infection are likely to breakdown
| Potential Areas of Risk|| |
There are potential areas about which one needs to be careful to avoid unfavorable results.
This is the most common site for fistula  probably due to high tension and thin mucoperiosteum, especially if not dissected with mucous glands situated deeper to junctional mucoperiosteum.
This is often a technically difficult area, especially in a palate with collapsed arches and in bilateral cleft lip and palate patients with flexed premaxilla. Alveolar extended palatoplasty [Figure 4] is a good solution for older children even in presence of protruding premaxilla and collapsed arches, though technically difficult. In younger children one should repair the anterior palate using the vomer flap with primary lip repair to avoid fistula in alveolar and post-alveolar region.  Once fistula occurs in post-alveolar region with flexed premaxilla and shortage of tissue, it is likely to need import of tissue like tongue flap [Figure 5].
Hypoplastic palate and scarring
In syndromic children especially in cleft of secondary palate only, the muscle bulk and soft-tissue is very hypoplastic in soft palate and junctional areas. Even with good muscle repair, there is likely to be some tension on the suture line. Therefore, these palate repairs are likely to result in velopharygeal insufficiency and have higher chances of palatal fistula formation [Figure 1]. This is one of the conditions where addition of tissue either informs of buccal flap may be indicated in primary palate repair. In badly repaired palate with scarring and shortage of tissue, addition of tissue is more critical and necessary to get closure of palate [Figure 6].
|Figure 6: Shortage of tissue in hard and soft palate, repaired with simultaneous pharyngeal flap and tongue flap|
Click here to view
Submucous cleft palate
Often in submucous cleft palate, the central translucent area is wide. It is very tempting to put suture in this thin mucosa rather than excising it and creating wider cleft defect. However, it is very likely that suture in this thin mucosa would give way, resulting in fistula formation [Figure 7] and [Figure 8]. Therefore, it is advisable to excise this mucosa creating wider cleft and if necessary making lateral incision to mobilize thicker mucoperiosteal flaps medially to achieve stronger suture line.
|Figure 8: Central hypoplastic tissue need to excise and suture to be put in normal tissue|
Click here to view
| Pragmatism and Practicality|| |
The best protocol is one which works the best in your hands.
1. Can we get all cleft palate patients speaking normally? No, because in addition to good surgical technique, we need many prerequisites in cleft palate likes a long palate with good muscle bulk. Soft palate muscles are one of components which close the pharyngeal port and therefore the other component of pharyngeal muscles also should be adequate with good functional capabilities. In addition, speech is an evolutionary higher function with complex brain activities, involving many different parts of cortex. And therefore deficiency or dysfunctional problems of higher function can also affect the speech outcome.
2. Can we get all cleft palate repairs without fistula? No, because in addition to skills and experience of surgeon, there are a few rare occasions of anatomical complexities which may make it nearly impossible to provide complete cleft palate repair. In some rare syndromes and patients with cyanotic heart diseases healing is an issue, which may lead to fistula. Nevertheless, the lowest fistula rate achievable is 2-3% as presented by many authors. And therefore, one should not accept fistula as common consequence of palate repair. It is complication but an avoidable one. 
3. Can we avoid detrimental effect on growth of maxilla? No. Any surgery will have detrimental effect on the growth of maxilla. However, atraumatic technique and careful handling of tissue will reduce the growth disturbances. Proper protocol and appropriate technique like vomer flap and von Langenbeck technique have shown to reduce growth disturbances.
| Conclusion|| |
There are few randomized control trials and other evidence based studies available currently that can suggest the best protocols and techniques for cleft palate repair. It may be safe to suggest that the technique that works best for the surgeon and the patient is indeed "a good one." One must carefully choose a technique, master it and follow-up the cases for a reasonably long period of time and be ready to learn from mistakes. This is the only sure way forgetting past the unfavorable results.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]