|FOUNDERíS LECTURE 2014
|Year : 2015 | Volume
| Issue : 1 | Page : 6-10
Repair of cleft palate: Evolution and current trends
Senior Consultant Plastic Surgeon, Muscat, Oman
|Date of Web Publication||4-Feb-2015|
Dr. Chona Thomas
P. O. Box 180 Mina Al Fahal, Postal Code 116, Muscat
Source of Support: None, Conflict of Interest: None
The management of a patient with cleft palate is complex. Various prevalent surgical techniques are presented, but no universal agreement exists on the appropriate treatment strategy. There is a consensus of opinion that normal speech should be the most important consideration in the therapeutic plan. Growth disturbance should be minimized, but not at the expense of speech impairment because facial distortion can be satisfactorily managed by surgery, whereas speech impairment can often be irreversible. There is a need for well-controlled, prospective studies to establish the validity of the widely different claims of superior results from various techniques. Cleft patients should be managed in a center with a multidisciplinary team. Cleft palate remains a significant and interesting challenge for current and future plastic surgeons.
Keywords: Cleft Palate, current trends, palatoplasty, palate repair, present trend
|How to cite this article:|
Thomas C. Repair of cleft palate: Evolution and current trends. J Cleft Lip Palate Craniofac Anomal 2015;2:6-10
| History of The Procedure|| |
In 1552, Dr. Houlier proposed suturing of the palatal clefts. Dr. Ambroise Pare in 1564, used obturators for palatal perforations. Dr. Von Graefe was the person to perform the velar repair of the cleft. In 1828, Dr. Dieffenbach reflected the hard palatal mucosa for the closure of the hard palatal cleft. In 1859, Dr. von Langenbeck performed the bipedicled mucoperiosteal flap for the repair of a cleft palate. 
With the ability to successfully close the palate, concern about palatal function was raised. It was evident by this time that the short and immobile palate impaired the speech capability of patients with cleft palate. Veau (1931), Wardill (1937) and Kilner (1937) described the unipedicle mucoperiosteal flap based posteriorly on the greater palatine artery that pushed the flap posteriorly to lengthen the palate. The scarring of the denuded bone areas anteriorly and laterally was suspected as the cause of facial growth retardation. In 1944, Dr. Schweckendiek advocated the use of a 2-stage cleft palate closure. The soft palate was closed early (4-6 months), with the closure of the hard palate delayed until 4-5 years later (sometimes even at age 14-15 years). The rationale for the 2-stage procedure was to provide improved velopharyngeal function during the initial speech development and to accomplish the closure of the hard palate after the cleft narrows with facial growth thus causing less facial growth retardation. 
Now, it is proved beyond doubt that the anatomic muscle realignment is essential in improving postoperative velopharyngeal function. ,
A cleft palate has tremendous esthetic and functional implications for patients in their social interactions, particularly on their ability to communicate effectively and on their facial appearance. Hence, the treatment focuses on two areas:
- Speech development.
- Facial growth.
Speech development is foremost in the appropriate management of cleft palate.
Still there are controversial issues in the repair of a cleft palate, such as timing of surgical intervention, speech development after various surgical procedures and effects of surgery on facial growth.
| Pathophysiology|| |
A child with cleft palate has feeding difficulties, liable to get recurrent ear infection leading to hearing loss, abnormal speech development, and facial growth distortion.
The goals of the surgical repair should be focused to separate the oral and nasal cavities, the repositioning of the soft palate musculature to anatomical position to establish normal speech and to minimize the retardation of growth of the maxilla.
Based on the embryonic origin, the bony portion of the palate is divided into primary and secondary palates. The primary palate consists of premaxilla, alveolus, and lip, which are anterior to the incisive foramen. The secondary palate includes structures posterior to the incisive foramen, and these are paired maxilla, palatine bones and pterygoid plates.
The following six muscles have attachment to the palate. They are levator veli palatini, superior constrictor pharyngeus, musculus uvulus, palatopharyngeus, palatoglossus and tensor veli palatini. Among these muscles, three muscles that appear to have the greatest contribution to the velopharyngeal function are levator veli palatini, superior constrictor pharyngeus and musculus uvulus.
The uvulae muscle acts by increasing the bulk of the velum during muscular contraction. The levator veli palatini pulls the velum superiorly and posteriorly to oppose the velum against the posterior pharyngeal wall. The medial movement of the pharyngeal wall, attributed to superior constrictor pharyngeus, adds in the opposition of the velum against the posterior pharyngeal wall to form the competent sphincter [Figure 1] and [Figure 2].
|Figure 1: Normal anatomy of the soft palate, the levator palatini muscle is seen as a sling across the posterior soft palate. (After Millard Dr. Jr. Cleft Craft, vol iii. Boston, Little, Brown, 1989:19, 30)|
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|Figure 2: Cleft palate anatomy. The levator palatini muscle is displaced longitudinally, almost parallel to the cleft. The tendon of the tensor palatini muscle can be seen coming around the hamulus to join the aponeurosis of the levator, division of this tendon is important to rotate the levator back into a posterior position. Note the position of the vascular pedicles, exiting through the palatine foramina. (After Millard Dr. Jr. Cleft Craft, vol iii. Boston, Little, Brown, 1989:19, 30)|
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The tensor veli palatini does not contribute to the movement of the velum. The function of the tensor veli palatini, similar to tensor tympani with which it shares a similar innervation, is to improve the ventilation and drainage of the auditory tubes.
Timing of palatal closure
The ultimate outcome to be aimed for the repair of a cleft palate is the development of normal speech. The speech outcome depends on the surgical technique and the timing of the palate repair. Most surgeons operate between the age of 9-18 months.
Choice of operation includes single stage palatal closure, palatal closure with palatal lengthening and either of the first techniques with direct palatal muscle re-approximation.
Techniques of palate repair
von Langenbeck procedure
The bipedicle mucoperiosteal flaps by incising along the oral side of the cleft edges and along the posterior alveolar ridge. Mobilize the flaps medially with preservation of the greater palatine arteries and closed in layers. The hamulus may need to be fractured to ease the closure [[Figure 3]a and b]. 
|Figure 3: (a) Operative marking of the technique. (b) Post-operative appearance. (From Randall P LaRossa D: Cleft palate in McCarthy JG, ed: Plastic Surgery, Philadelphia. WB Saunders. 1990: 2743)|
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Even though, it is a simple procedure, the speech outcome is poor because of inadequate retroposition.
Palatal lengthening-V-Y pushback-Veau-Wardill-Kilner technique
The essence of the push back repair is the V to Y incision and closure on the hard palate. The hamulus is fractured, , and the muscle closure is affected as a separate layer. The velopharyngeal function is improved since there is an increased palatal length. However, this technique creates a larger area of denuded palatal bone anterolaterally and also associated with a higher incidence of fistula formation [Figure 4].
|Figure 4: (a and b) Operative markings and the reflection of the oral and nasal layers. (c and d) Hamulus is fractured and levator veli palatini is identifi ed. (e and f) Closure of the layers as nasal layer, muscle layer and oral layer (From Randall P LaRossa D: Cleft palate in McCarthy JG, ed: Plastic Surgery, Philadelphia. WB Saunders. 1990: 2744)|
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Careful dissection and freeing of the abnormal attachment of levator palatini muscles from the posterior part of the palatine bone and also from the aponeurosis and rarely from the hamulus and re-approximation as a midline layer has shown excellent speech outcomes. In addition, it lengthens the palate and restores the normal muscular sling of the levator veli palatini. ,
Double-opposing Z-plasties-Furlow's technique
There is a different lengthening of the palate as a consequence of the new position of the velar and pharyngeal tissues. , Speech development was excellent in Furlow's study. The Furlow's technique appears to be quite successful in clefts of limited size. In moderate-size clefts, lateral-relaxing incisions may still be required to obtain closure. But in wide clefts, this type of closure may not be possible [[Figure 5]a-d].
|Figure 5: (a) Operative markings of Z-plasties on both sides of the cleft palate. (b) Refl ection of the flaps by keeping the muscles in the opposing flaps. (c) Nasal layer closure. (d) Oral layer closure (From Randall P LaRossa D: Cleft palate in McCarthy JG, ed: Plastic Surgery, Philadelphia. WB Saunders. 1990: 2740)|
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Two-flap palatoplasty - (Bardach and Salyer-1984)
The main goals are complete closure of the entire cleft without tension at an early age with minimal exposure of raw bony surfaces [Figure 6]. 
|Figure 6: (a) Operative markings with reflection of the flaps. (b) Vomerine flap closure in the anterior palate in wide cleft palate. (c) Nasal layer closure with intravelar veloplasty. (d) Oral layer closure with the elimination of the lateral raw areas by few interrupted stitches (From Randall P, LaRossa D: Cleft palate in McCarthy JG, ed: Plastic Surgery, Philadelphia. WB Saunders. 1990: 2740)|
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The intravelar veloplasty is an essential part of this closure; hence this technique developed velopharyngeal function within normal limits and also eliminates fistulas in the anterior hard palate [Figure 7], [Figure 8], [Figure 9].
|Figure 7: (a) Pre-operative markings of a complete cleft palate. (b) Reflection of the palatal flaps based on the greater palatine neurovascular pedicles after tenotomy of the tensor tympani and detachment of the abnormal attachments of levator palatini muscles. (c) Intravelar Veloplasty after the closure of the nasal layer. (d) Closure of the oral layer. Lateral raw areas are covered with gel foam without any stitches|
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|Figure 8: (a) Pre-operative appearance of a complete wide left unilateral cleft lip and palate. (b) Appearance after the repair of the cleft lip with primary rhinoplasty by open approach along with the repair of the anterior palate at 3 months. (c) Appearance after the Repair of the Cleft Palate at 12 months|
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|Figure 9: (a) Appearance of a post alveolar cleft palate. (b) Appearance of the repair of the cleft palate at twelve months of age|
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Child is given nothing by mouth until 6 post-operative hours or the next day. Hydration is maintained during this time with intravenous fluid. Oximetry is continuously monitored for 24-48 h. Arm splints are also applied to prevent a child from disrupting the wound by placing his fingers in his mouth. Oral feeding is initiated by spoon or drinking from cups. The liquid diet is continued for 7-10 days with solid food to follow.
Immediate complications are bleeding and respiratory distress. Respiratory compromise secondary to obstruction from the palate lengthening or sedation can be life threatening. The wound dehiscence may happen as a result of poor tissue quality and excessive wound tension. This may lead to oro-nasal fistula. The main long term sequelae is the palatal fistula, the incidence, reported as 5-29%.
There are several contributory factors for the palatal fistula such as type of cleft, type of the surgical repair, wound tension, dead space below the mucoperiosteal flaps and rapid maxillary arch expansion. The usual strategy of the management of palatal fistula is the closure of the fistula after completion of the arch expansion. In general, the palatal fistulas may be repaired with local flaps, tongue flaps and rarely needs microvascular free flaps if the fistula is very large.
The analysis of velopharyngeal competence after various techniques is difficult to interpret in the different studies. Morris reported Velopharyngeal competence of 75% (No differentiation was made on the type of cleft or the technique of repair). Peterson-Falzone (1991) reported 83.4% competence based on the same criteria.
Growth and morphology
Graber was the first to document disturbance of facial growth as a result of palatal surgery. This compromised the facial bone growth in all directions, but principally in the horizontal dimension. The effect was most pronounced at the level of the palate and slightly less so in height of the mid face. The noticeable changes are collapse of the dental arch, contraction of the arch and hypoplasia of the maxilla. 
Submucous cleft palate
Submucous cleft palate occurs when the palate has mucosal continuity but the underlying levator palatini muscle is discontinuous across the mid-line and longitudinally oriented. Diagnosis usually will be delayed till the child starts speaking with a nasal sound. The diagnosis is to be confirmed with speech evaluation and endoscopy. Corrective surgical technique for submucous cleft palate is focused on anatomic corrections of the velar muscle diastasis. The Furlow's double-opposing Z-Plasty maybe an ideal procedure for these patients because there is no width discrepancy to overcome. ,
The child with cleft is often referred to the author as a newborn or infant. Emphasis will be given to reassure the parents and care to be taken for the nutritional status of the child. Pediatric evaluation with immunization status is ascertained, correct feeding advice is given to the mother and the child is followed up periodically.
The timing of the operation is usually between 9 and 18 months when the child is free of infections and general health is suitable for general anesthesia. Pre-operative investigations such as complete blood counts, coagulation profile, blood grouping and cross matching, throat and nasal swabs for culture and sensitivity are done usually. Clinical photographs are taken in every stage. Magnification by loupe or operative microscope is always helpful during the operation in identifying the anatomical structures and detaching the abnormal attachments of the levator palatini muscles (Author always use a panoramic high magnification loupe). 
The operative technique is a modified two-flap technique. Two mucoperiosteal palatal flaps based on the greater palatine neurovascular pedicles are reflected. Tenotomy of the tensor palatini is done (no need to fracture the hamulus). The abnormal attachment of levator palatini muscles is detached from the posterior part of the palatine bone and also from the aponeurosis and rarely from the hamulus. The intravelar veloplasty is effectively done and a layered closure using suitable sized vicryl sutures. Lateral raw areas are covered with gel foam instead of interrupted stitches, which may create tension at the midline sutures and may lead to fistula formation. At operation; ENT evaluation, myringotomy and grommet insertions are always done. Routine post-operative management will be done keeping the child during first 24 h, either in ICU or high dependency room. Liquid diet for the first 5 days, followed by soft diet and normal diet after 10 days. Subsequent follow-up will be done at the multidisciplinary cleft lip and palate clinic. Plastic Surgeon, Orthodontist, ENT Surgeon, Pediatrician, Speech therapist, clinical photographer, specialized nurses and social worker are the members of this multidisciplinary cleft lip and palate clinic.
Future and controversies
The management of a patient with cleft palate is complex. At present, no universal agreement exists on the appropriate treatment strategy. Normal speech should be the most important consideration in the therapeutic plan. Growth disturbance should be minimized, but not at the expense of speech impairment because facial distortion can be satisfactorily managed by surgery, whereas speech impairment can often be irreversible. There is a need for well-controlled, prospective studies to establish the validity of the widely different claims of superior results from various techniques. Cleft patients should be managed in a center with a multidisciplinary team. Cleft palate remains a significant and interesting challenge for current and future plastic surgeons.
| References|| |
Rogers BO. History of the cleft lip and cleft palate treatment. In: Grabb WC, editor. Cleft Lip and Palate. Boston, Little: Brown; 1971.
Hoffman WY, Mount DL. Cleft palate repair. In: Mathes SJ, editor. Plastic Surgery. 2 nd
Ed. Vol 4. Philadelphia: Saunders Elsevier, 2006; p. 249-69.
Cutting C, Rosenbaum I, Rovati L. The technique of muscle repair in the soft palate. Oper Tech Plast Surg 1995;2:215-22.
Sommerlad BC, Henley M, Birch M, Harland K, Moiemen N, Boorman JG. Cleft palate re-repair - a clinical and radiographic study of 32 consecutive cases. Br J Plast Surg 1994;47:406-10.
Bardach J, Salyer K. Surgical Techniques in Cleft Lip and Palate. Chicago: Year Book; 1987.
Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg 1986;78:724-38.
Furlow L. Cleft palate repair by double opposing Z-plasty. Oper Tech Plast Surg 1995;2:223-32.
Bardach J. Two-flap palatoplasty: Bardach's technique. Oper Tech Plast Surg 1995;2:211-4.
Millard DR Jr, Latham RA. Improved primary surgical and dental treatment of clefts. Plast Reconstr Surg 1990;86:856-71.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]