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Chapter 83 â€“ Cleft Lip and Palate: Comprehensive Treatment and Technique
Bernard J. Costello
Comprehensive treatment of cleft lip and palate deformities requires thoughtful consideration of the anatomic complexities of the deformity and the delicate balance between intervention and
growth. Comprehensive and coordinated care from infancy through adolescence is essential to achieve an ideal outcome. Surgeons with formal training and experience in all phases of care must
be actively involved in planning and treatment.
Specific goals of surgical care for children born with a cleft lip and palate include:
Normalized aesthetic appearance of the lip and nose
Intact primary and secondary palates
Normalized speech, language, and hearing
Nasal airway patency
Class I occlusion with normal masticatory function
Good dental and periodontal health
Normal psychosocial development
What makes these goals challenging in some children is the wide spectrum of cleft lip, palate, and nasal deformities. The range of manifestations from one affected child to another is highly
variable. An asymptomatic bifid uvula is an example of a clinically inconsequential cleft. A relatively simple deformity may include a submucous cleft palate that causes speech abnormality after an
uneventful adenoidectomy. An occult cleft lip with an intact philtral ridge and symmetrical Cupid's bow and an otherwise normal-looking child with a small notch in the alveolar ridge are other such
examples of minimal deformities. Unfortunately, the other end of the spectrum includes wide bilateral clefts of the lip and palate or facial dysplasia with several associated anomalies (Fig. 83-1).
A cleft surgeon has the tasks of addressing anatomic and functional deficiencies at the initial evaluation and planning for future functional and aesthetic needs. Success in these endeavors is
dependent on many factors, including the severity of disruption of bone, cartilage, and soft tissue. Surgical skill and technique matched to the nature and severity of the deformity are the
fundamental factors in obtaining superior results. Attention to all aspects of care, such as anatomic variants, the biology of scar formation, parent education, and cooperation, is very important in
determining success. A healthy and collaborative team environment is essential in achieving these goals.
This chapter presents a technical overview of the reconstruction of cleft lip and palate deformities. Surgical reconstruction of clefts requires that surgeons undertaking this important work maintain
a cognitive understanding of the complex malformation itself, the varied operative techniques used, facial growth considerations, and the psychosocial health of the patient and family. The
objectives of this chapter are to present the overall staged reconstructive approach for repair of cleft lip and palate from infancy through the time of skeletal maturity, as well as a focused
discussion of the specific surgical procedures involved in primary repair of clefts of the lip and palate.
Because cleft lips come in a variety of configurations, each repair must be individually customized to establish the most normal morphology. A, Microform left unilateral cleft lip only, not requiring repair. B, Minor left incomplete
unilateral cleft lip only. C, Right incomplete unilateral cleft lip and palate with a Simonart band. D, Wide right complete unilateral cleft lip and palate.
CLASSIFICATION OF CLEFTS
Classification of clefts is necessary to describe the deformities, to study causative factors, and to compare results of treatment undertaken. Several classification systems have been
Simple classification systems are valuable for everyday use and are easy to understand; they provide broad groups with large numbers of patients in each group for research and
analysis. However, simple classification systems fail to detail the variations in severity of cleft manifestations. As a consequence, there has been a tendency to use more complex classification
systems, which are more difficult to use clinically but provide better information for research and outcomes analysis.
There is infinite variation in the configuration of clefts, and a compromise between simple and complex classification systems has to be reached. Regardless of complexity, all classification systems
use basic nasal (ala, dome, columella, nostril sill, septum, vomer), labial (vermilion, philtrum, Cupid's bow, Lister's tubercle, red and white lines, prolabium), and palatal (incisive foramen, primary
and secondary palate, hard and soft palate, alveolar process, attachment to septum) landmarks for reporting.
The LAHSHAL system is a basic and useful classification that allows easy compilation of data. Starting from the patient's right side, the cleft status is recorded as C(omplete), I(ncomplete), or X
(absent) for the L(ip), A(lveolus), H(ard palate), S(oft palate), H(ard palate), A(lveolus), and L(ip) (Table 83-1). Craniofacial clefting may be described with Tessier's orbitocentric system of
numbering (Fig. 83-2).
Table 83-1 -- CLASSIFICATION OF CLEFTS
A HS HAL
This example is for a unilateral right incomplete cleft lip (l) with a complete cleft alveolus (A) and hard (H) and soft (S) palates. The vomer is attached to the left side of the hard palate. The
alveolus and lip on the left side are intact.
C, complete; I, incomplete; X, no cleft.
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A and B, Complex facial clefts can be classified according to Tessier's orbitocentric system of numbering. Clefts may involve all tissue planes, including the skin, mucosa, bone, teeth, muscle, brain, peripheral nerve, and other
Successful management of the child born with a cleft lip and palate requires coordinated care provided by individuals from a number of different specialties, including otolaryngology, oral and
maxillofacial surgery, plastic surgery, genetics/dysmorphology, speech/language pathology, orthodontics, prosthodontics, and others.
Because care is provided over the entire course of the
child's development, long-term follow-up is critical to ensure complete and comprehensive care.
Rehabilitation of a patient with a cleft is best performed as an interdisciplinary effort. Most children with clefts have multiple interrelated issues, and several team models are available to address
these issues in an interdisciplinary fashion. Key members of the team are the cleft surgeon or surgeons, orthodontist, and speech-language pathologist. Cleft surgeons may be trained plastic
surgeons, oral and maxillofacial surgeons, or otolaryngologists. Other key persons may include the pediatric dentist, geneticist/dysmorphologist, pediatrician, psychologist, and social worker. The
team director may or may not be a cleft surgeon but should be a nonbiased participant in care. The formation of interdisciplinary cleft teams serves two key objectives of successful cleft care: (1)
coordinated care provided by all the necessary disciplines and (2) continuity of care with close interval follow-up of the patient through-out periods of active growth and ongoing stages of
In a carousel team, patients are seen on the same day by all specialists. Comprehensive evaluation is not performed, at the time of decision making information may be incomplete, and one
practitioner's treatment decision may not reflect the complete status of the patient until all the information can be reviewed by everyone involved. In a triage team, one gatekeeper organizes
outpatient referrals to specialists through multiple visits. This approach is often costly and requires a team meeting of all the practitioners to provide comprehensive care.
Multidisciplinary teams have many specialists, but they may not necessarily be cooperative or interactive. The best organization of care occurs when multidisciplinary teams are also
interdisciplinary. Interdisciplinary teams work together to come up with the best treatment plan for a given patient. In this treatment model, decisions are based on a collaborative process, and
each member is cognizant of other membersâ€™ treatment priorities.
Team involvement ideally starts in the prenatal period.
Prenatal diagnosis by ultrasound presents an opportunity to introduce team members and their roles early in the process and provides
reassurance, familiarity, and a structured approach for the various issues, including counseling, treatment, and feeding approaches. Prenatal sonographic detection of clefts is often dependent on
cleft type and severity. When a cleft is present, the overall detection rate is approximately 65% (isolated cleft palate, 22%; isolated cleft lip, 67%; cleft lip and palate, 93%).
Additional testing may be warranted to evaluate the possibility of associated deformities, syndromes, and sequences that could affect the birthing process. Exceptionally skilled ultrasonographers
can visualize airway development and other abnormalities that may require early intervention with fetal surgery, ex utero intrapartum procedures, extracorporeal membrane oxygenation, or surgical
airway management (tracheotomy) at the time of delivery. Evaluations of any associated malformations are completed via three-dimensional ultrasound, magnetic resonance imaging, and other
genetic evaluations. These detailed evaluations can be very helpful in understanding the nature of various deformities, the likelihood of an uneventful birth, and the need for additional evaluation and
SEQUENCING OF PROCEDURES
Because of many different treatment philosophies, the timing of treatment interventions varies from one cleft center to another. Therefore, it is difficult to produce a timing regimen that everyone
A sample timeline of staged reconstruction of cleft lip and palate deformities is presented in Table 83-2. This is a general timeline and requires an individualized approach based
on aesthetic and functional priorities.
Table 83-2 -- TIMELINE FOR STAGED RECONSTRUCTION OF CLEFT LIP AND PALATE DEFORMITIES
Airway evaluation and intervention
After initial assessment when necessary
Presurgical orthopedics, nasoalveolar molding, lip adhesionBefore lip repair in select cases
Cleft lip/nasal repair
After 10 wk
Cleft palate repair
Myringotomy and tubes
At the time of lip or palate repair, depending on the presence of middle ear effusion and hearing status
Pharyngeal flap or pharyngoplasty
3-5 yr or later, depending on speech development
Maxillary/alveolar reconstruction with bone grafting
6-9 yr, depending on dental development
Cleft orthognathic surgery
14-16 yr in girls, 16-18 yr in boys
After 5 yr of age but preferably at skeletal maturity after orthognathic surgery when possible
Cleft lip revision
Anytime after initial remodeling and scar maturation, but best after 5 yr of age
The timing of cleft lip and palate repair is controversial. Despite a number of meaningful advancements in the care of patients with cleft lip and palate, there is a lack of consensus regarding the
timing and specific techniques used during each stage of cleft reconstruction. Surgeons must continue to carefully balance the functional needs, aesthetic concerns, and the issue of ongoing growth
when deciding how and when to intervene. In no other type of deformity is the effect of early surgery on growth more apparent than in the treatment of cleft lip and palate deformities. The decision
to surgically manipulate the tissues of a growing child should not be made lightly and should take into account the possible growth restriction that can occur with early surgery. Nevertheless, many
patients with congenital deformities will benefit from early surgical intervention for functional or psychosocial reasons. Understanding the growth and development of the craniofacial skeleton is
essential to the treatment planning process.
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MANAGEMENT OF AIRWAY OBSTRUCTION IN PATIENTS WITH CLEFTS
Features of the airway depend on the type of cleft and its severity. An intact palate provides tongue support and prevents glossoptosis. Lacking this support, a child with a wide cleft palate will
have obstruction of the upper airway of varying severity. This obstruction is pronounced in children with associated syndromes and the Robin sequence in which mandibular growth is compromised.
Prone positioning, feeding adaptation, and time may resolve the mild obstruction. In some cases a nasal airway can provide relief for a few weeks to months. Airway evaluation via flexible and rigid
endoscopy is warranted to determine the extent of airway obstruction, as well as additional airway compromise (i.e., choanal atresia, laryngotracheomalacia, subglottic stenosis). In severe cases
of obstruction, surgical options include glossopexy, mandibular distraction osteogenesis, and tracheotomy. Difficult intubation should be anticipated, and additional equipment such as a Bullard
laryngoscope, laryngeal mask airway, or flexible endoscopic intubation devices should be available.
Presurgical orthopedic (PSO) devices are used to mechanically manipulate the position of the alveolar segments before definitive lip and nasal repair. A custom acrylic prosthesis is used to mold
the lip and maxillary dental arch. As the greater segment is pushed into position, space is cut away within the palatal plate to allow the lesser segment to drift into the proper arch form. When the
lip has an incomplete cleft, the alveolar segments are usually molded into a reasonable arch form, and maxillary arch orthopedic devices are not necessary.
Nasoalveolar molding is a technique that combines maxillary arch orthopedics with a PSO device and lip and nasal contour shaping via nasal-vestibular projec- tion (Fig. 83-3).
importance of this technique is emphasized by surgeons who advocate primary nasal repair at the time of lip repair for children with wide clefts and severe nasal deformities, especially those with
a very short columella. Successful use of PSO devices requires a dedicated pediatric dentist or orthodontist, a good laboratory, and diligent parents. Noncompliance can be a problem, so for this
and other reasons, some centers rely on pin-retained prostheses. However, these appliances have been associated with significant midface growth restriction.
A, Frontal and lateral views of the Grayson nasoalveolar molding (NAM) appliance showing the nasal projections that help mold the nasal cartilage and maxillary segments into a more appropriate configuration before repair. B,
Segments before the use of NAM. C, Segments after NAM but before closure.
Some surgeons perform a surgical lip adhesion procedure at about 3 months to mold the alveolar segments into better position before definitive repair. Effective PSO devices may obviate the need
for a lip adhesion procedure and the additional anesthetic required for it.
Although initial results are reportedly good, use of these devices and their efficacy are still controversial because
long-term outcome studies showing improved aesthetics, higher retention of dentition, and better dental arch form are still not available.
In exceptionally wide unilateral or bilateral clefts or in extremely asymmetrical bilateral clefts, it may be helpful to approximate the segments of the cleft lip before definitive lip repair to achieve a
better relationship of both the lip structures and the dental arches. In this technique, which is used by some surgeons, small flaps of tissue are advanced across the cleft site (Fig. 83-4). Care is
taken to not disturb natural landmarks, and a through-and-through horizontal tension suture is placed. When used, lip adhesion is usually completed at 3 months of age. The definitive lip repair is
then completed 3 to 6 months later by excising the scar and reapproximating the remaining lip structures.
Example of the lip adhesion technique used by some surgeons as a first stage in closing wide clefts. A, Flaps are designed to bridge the defect. B, Undermining allows approximation. C, A retention suture may be used before
closure for additional support.
(From Senders CW: Presurgical orthopedics. Facial Plast Surg Clinics North Am 4:333-342, 1996.)
PRIMARY UNILATERAL CLEFT LIP REPAIR
Unilateral clefts of the lip and nose have a high degree of variability, and thus each repair design is unique (see Fig. 83-1). One repair technique preferred by the authors for cleft lip and nasal
deformities is shown in Figurs 83-5 and 83-6 and is usually performed after 10 weeks of age. The goal of the repair is to create a three-layered closure of skin, muscle, and mucosa in which
hypoplastic tissue at the cleft margins is excised and normal tissues are approximated. Critical in the process is reconstruction of the orbicularis oris musculature into a continuous, functional
sphincter. The Millard rotation-advancement technique has the advantage of allowing each of the incision lines to fall within the natural contours of the lip and nose.
This is an advantage
because it is difficult to achieve â€śmirror imageâ€ť symmetry in a unilateral cleft lip and nose with the normal side immediately adjacent to the surgical site. A Z-plasty technique such as the Randall-
Tennison repair may not achieve this level of symmetry because the Z-shaped scar is directly adjacent to the linear nonclefted philtrum. Achieving symmetry is more difficult when the rotation
portion of the cleft is quite short in comparison with the advancement segment. There is a great degree of variability in repair techniques from surgeon to surgeon. Several techniques are
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discussed as examples of unilateral and bilateral lip repair.
A, Key landmarks of a unilateral cleft lip repair are marked with a fine marking instrument. B, Hypoplastic tissue is excised by following the key landmarks, and a variety of backcuts can be made to address symmetry. C, A three-
layered closure is achieved by first reconstructing the oral mucosa and nasal floor and then the orbicularis oris musculature. The skin flaps should be passively closed without tension. D, The rotation and advancement flaps are inset for optimized
symmetry in all three dimensions. E, Limited nasal dissection can be used to reposition the lower lateral cartilage, as well as the lateral alar tissue. These tissues must be released from their abnormal insertions and repositioned for better symmetry.
A nasal bolster or silicone nasal formers may be placed at the end of the procedure.
A, Three-month-old child with a right-sided incomplete unilateral cleft lip. Note the short philtrum near the midline, which must be rotated downward to avoid notching and to improve symmetry. B, Nine-month-old boy after rotation-
advancement repair of his cleft lip and nasal deformities. C, The same child in B 2Â˝ years after his cleft lip and nasal repairs.
All landmarks are carefully marked with the use of operating loupes and surgical calipers (Fig. 83-5A). Marking starts with identification of the low point (midline) (1) and the peak (2) of Cupid's
bow on the noncleft side (NCS). The distance between these two points is used to determine the position of the peak of Cupid's bow on the cleft side (CS) (3). The alar base on the NCS (4), the
columellar base (5), and the commissures (6 and 7) are marked. The lateral peak of Cupid's bow (8) is marked by taking the distance from the CS commissure and the width of the vermilion into
account. The combined vertical height of the wet and dry vermilion at point 8 should match the vertical height of the vermilion at point 3. Therefore, 8 can be placed within 1 to 2 mm of the
measured distance (matching the distance between 2 and 6) from the commissure to match the vermilion in height.
The tip of the advancement flap (9) is marked so that the distance between points 8 and 9 matches the distance between 2 and 5 (see Fig. 83-5A). The surgeon must avoid discolored, hypoplastic
skin with increased vascular patterns when designing the flap. The slightest difference in color here will be highly visible against the contrast provided by the NCS lip and columella skin.
The rotation incision is followed by a very small (<1 mm) releasing cut (y) made high in the lip in a near-perpendicular angle to the rotation incision (see Fig. 83-5B). This should allow the NCS to
drop down without tension and create a symmetrical prolabium with minimal transgression of the upper philtral column.
The orbicularis oris is dissected from the skin along the rotation and advancement flaps (see Fig. 83-5C). The dissection is performed to facilitate layered closure. If feasible, the muscle may be
interdigitated. The mucosal closure is started in the sulcus and extended toward the wet vermilion with 4-0 chromic or polyglycolic acid suture. The skin is closed with 5-0 or 6-0 nylon or with
absorbable suture (see Fig. 83-5D).
Primary nasal reconstruction may be considered at the time of lip repair to reposition the displaced lower lateral cartilage and alar tissue. Several techniques have been advocated, and
considerable variation exists with respect to the exact nasal reconstruction performed by each surgeon.
Primary nasal repair may be achieved by releasing and reshaping the lower lateral
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cartilage and alar base and augmenting the area with allogeneic subdermal grafts or even formal open rhinoplasty. Because lip repair is done at such an early point in growth and development, the
authors prefer minimal surgical dissection because of the effects of scarring on subsequent growth of these tissues. McComb described a technique that has become popular in which the lower
lateral cartilage is dissected free from the alar base and the surrounding attachments through the incision at the alar crease.
The lower lateral cartilage is dissected free of skin (including that between the medial crura and dome) (see Fig. 83-5E) and suspended to the ipsilateral upper lateral cartilage with a looping
suture (see Fig. 83-1D). If necessary, interdomal and suspension sutures (see Fig. 83-1E) may be used to reposition and reorient the nasal tip. This modification requires extended dissection. The
dislocated nasal septum is released, transposed, and secured through the membranous septal incision. The nasal ala is then repositioned to address symmetry in all three dimensions. In most
complete unilateral clefts, the alar base has to be dissociated from the lateral aspect of the lip and piriform aperture by extending the circumalar incision to allow these elements to move
independently. The advancement flap will be advanced more than the ala. The tip of the advancement flap may then be anchored to the membranous septum. The nostril may be stented for
several weeks or longer with silicone nostril retainers or bolsters to prevent distortion in nostril shape.
Parents may feed their child immediately by the same methods that were used preoperatively. Arm restraints are routinely used to protect the lip from trauma for approximately 2 weeks. Antibiotic
ointment may be applied in the first few days, followed by gentle massage several times per day starting 2 weeks after repair to encourage remodeling of the scar.
PRIMARY BILATERAL LIP REPAIR
Bilateral cleft lip repair can be one of the most challenging technical procedures performed. The lack of quality tissue and the widely displaced segments are major challenges to achieving
exceptional results, but superior technique and adequate mobilization of the tissue flaps generally yield excellent aesthetic results (Figs. 83-7 to 83-9). Additionally, the columella may be quite short
in length, and the premaxillary segment may be significantly rotated. Adequate mobilization of the segments and attention to the details of using only appropriately developed tissue will yield
excellent results, even in individuals with significant asymmetry.
A, The bilateral cleft of the lip and maxilla shown here is complete and highlights the nature of hypoplastic tissue along the cleft edges. The importance of the nasal deformity is evident in the shorter columella and disrupted nasal
complexes. B, Markings of the authorsâ€™ preferred repair are shown with an emphasis on excision of hypoplastic tissue and approximating more normal tissue with the advancement flaps. Measurements should be roughly equal in the following
fashion: 1 to 2 = 6 to 10; 5 to 4 = 7 to 11; 1 to 2 = 5 to 4; and 6 to 10 = 7 to 11. C, A new philtrum is created by excising the lateral hypoplastic tissue and elevating the philtrum superiorly. Additionally, the lateral advancement flaps are dissected into
three distinct layers (skin, muscle, and mucosa). Nasal floor reconstruction also occurs in conjunction with these advancement flaps. D, The orbicularis oris musculature is approximated in the midline with multiple interrupted or mattress sutures, or
both. This is a critical step in total reconstruction of a functional lip. There is no musculature present in the premaxillary segment, and it must be brought to the midline from each lateral advancement flap. The nasal floor flaps are sutured at this time
as well. The new vermilion border is reconstructed in the midline with good white roll tissue advanced from the lateral flaps. E, Final approximation of the skin and mucosal tissues is performed in a manner that leaves the healing incision lines in the
natural contours of the lip and nose.
A, Presurgical appearance of a bilateral cleft lip and palate with impressive asymmetry and rotation of the premaxillary segment. Note the significant nasal asymmetry and bunching of the orbicularis oris laterally. B, The same child at
14 months of age. No presurgical orthopedic appliances were used.
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A, Presurgical frontal view of a wide bilateral cleft lip and palate with significant asymmetry and lack of columella length. B, Presurgical left lateral view of a wide bilateral cleft lip and palate with a protrusive premaxillary segment. Note
the short length of the columella. C, The same child after repair of her bilateral cleft lip and palate. No presurgical taping or orthopedic appliances were used.
Although often more challenging than most unilateral repairs, the technique for bilateral cleft lip and nose reconstruction is similar in concept to that for unilateral repair. Markings are made with a
fine marking instrument at key landmarks while being sure to not include any hypoplastic tissue from within the cleft (Fig. 83-7). Points 12 and 13 should be made at the beginning of the good white
roll and vermilion, with a small backcut extending laterally to allow advancement under the prolabial tissue. Points 8 to 12 and 7 to 13 should be equal in length, and the measurement at 2 to 4
should be no longer than 3 mm. This tissue will stretch significantly later as remodeling of the lip occurs. Incisions within the nares should be made carefully so that one does not excise too much
tissue and make the nares quite small. Backcuts around the alar base should be long enough to allow nasal dissection, release of alar tissue from the piriform rim, and advancement medially to
reconstruct the nares.
Some surgeons have used operative techniques involving banked fork flaps to surgically lengthen the columella and preserve hypoplastic tissue. Early and aggressive tissue flaps in the nostril and
columella areas do not look natural after significant growth has occurred and result in abnormal tissue contours. Although surgical attempts at lengthening the columella may look good initially, they
frequently appear abnormally long and excessively angular later in life. Revision of these iatrogenic deformities is difficult, and some of the contour irregularities will not be able to be revised
adequately. Usually, if the hypoplastic tissue is excised and incisions within the medial nasal base and columella are avoided, the long-term aesthetic results are excellent.
The authors prefer a primary nasal reconstruction that can be performed in a fashion similar to the unilateral technique described by McComb.
Other open rhinoplasty techniques involving
either a direct incision on the nasal tip or prolabial unwinding techniques have been suggested.
As with most early maneuvers, aggressive rhinoplasty at this time may result in early scarring that
affects the growth potential of the surrounding tissues and makes revision more difficult and long-term aesthetics less than ideal.
CLEFT LIP REVISION
Despite even the most superb techniques, many patients who undergo cleft lip repair will benefit from at least a minor revision at some point in life. Although revision procedures are often viewed
as optional phases of cleft lip reconstruction, surgeons must advise families of this likelihood. The hard and soft tissues of the maxillofacial complex grow and change as a child grows, and the
repaired lip is affected. Bilateral clefts will benefit from lip revision more often than unilateral clefts will. The majority of lip growth is complete after the age of 5 years, and this may be the best time
to consider revision of the lip because the psychosocial benefits before entering school may be considerable. Alternatively, revision of the lip can be delayed until the teenage years, when most
maxillofacial growth is complete. It is preferable to wait until orthognathic surgery is completed (if this becomes necessary) because these procedures will considerably change the contour and
shape of the nose and lips.
The surgical objectives of cleft lip revision include excision of residual scar, reapproximation of key anatomic landmarks such as the vermilion-cutaneous junction and vermilion-mucosal junction, and
leveling of vertical lip lengths (philtral columns). Repair of the orbicularis oris muscle as a distinct layer is critical to an acceptable outcome. Although small scar revisions may be considered in
some patients, many patients will benefit from a revision that completely reconstructs the area by excision of the scar, dissection of the tissues into three layers (skin, muscle, and mucosa), and a
reconstruction that achieves improved symmetry and form. As with the primary repair, 6-0 or smaller sutures may be used to minimize stitch marks. Postoperative care includes careful early
wound care and avoidance of extended sun exposure, similar to the instructions for primary repairs.
There are two main goals of cleft palate repair during infancy: (1) closure of the oral-nasal communication involving the embryologic secondary palate and (2) anatomic repair of the musculature
within the soft palate, which is important for normal production of speech. The soft palate, or velum, is part of the complex coupling and decoupling of the oral and nasal cavities involved in the
production of speech. When a cleft of the soft palate is present, abnormal muscle insertions are located at the posterior edge of the hard palate. Surgery must not simply be aimed at closing the
palatal defect, but rather at release of abnormal muscle insertions to create muscle continuity with improved orientation so that the velum may serve as a dynamic structure. Despite successful
repair of the palate, a significant number of children who undergo cleft palate repair will still require speech therapy and have difficulty closing the velum for a variety of reasons.
Several techniques of palatoplasty with a substantial number of modifications may be found in the literature. Three popular techniques are discussed, including:
Two-flap palatoplasty with intravelar veloplasty
V-Y pushback with intravelar veloplasty
Before each procedure, the type and severity of the cleft, position of the segments, degree of septum deviation, width of the cleft, length and symmetry of the soft palate, and mobility of the soft
palate and pharyngeal walls have to be considered. It is helpful to measure and record palatal width, length, and other cleft dimensions with calipers.
The patient is placed supine with the neck slightly extended, and a shoulder roll is used. A cleft mouth retractor is used to maximally open the mouth and at the same time secure the endotracheal
tube in a midline position against the tongue. A small throat pack may be fitted in the hypopharynx around the tube. Incisions are marked with a marking pen, gentian violet, or methylene blue.
Lidocaine with epinephrine solution is injected into the submucosal tissue and subperiosteal plane and around the palatine foramen. Subperiosteal injections can facilitate undermining of the
mucoperiosteal flaps and improve hemostasis. The surgeon should avoid injecting into the neurovascular bundle. If vomer flaps are planned, the vomer is injected.
A variety of blades, including nos. 11, 15, and Beaver 6300 blades, are used to dissect the flaps. A small half-circle cutter is helpful when the cleft space is narrow. The PS 5 is a fine all-purpose
â…ś-inch cutter. The PS 4 cutter takes larger bites when required. In careful hands, a cutting needle may be less traumatic than a taper needle. However, if there is any tension on the wound,
tapered needles may be used to avoid mucosal damage.
Two-Flap Palatoplasty with Intravelar Veloplasty
In the authorsâ€™ practice this repair is the most appropriate technique for a complete unilateral cleft palate repair (Fig. 83-10).
The nasal flaps may be designed so that a strip of
mucoperiosteum is left on the medial edge of the hard palate. The wider the cleft, the wider the strip of mucoperiosteum left on the medial edge of flap. The width and angle of the palatal shelves
are also considered when designing the incisions. When these flaps are elevated and mobilized to reconstruct the nasal mucosal layer, they should meet each other without tension. On the soft
palate, the incisions should follow the subtle transition line between the nasal and oral mucosa into the tip of the uvula. In a wide cleft (gaps larger than 15 mm), vomer flaps may be designed to aid
in closure centrally.
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A, A unilateral cleft of the primary and secondary palates is shown with typical involvement from the anterior vestibule to the uvula. B, The Bardach palatoplasty technique requires two large full-thickness mucoperiosteal flaps to be
elevated from each palatal shelf. The anterior portion (anterior to the incisive foramen) of the cleft is not reconstructed until the mixed-dentition stage. C, A layered closure is performed in the Bardach palatoplasty by reapproximating the nasal
mucosa. The muscle bellies of the levator palatini are elevated off their abnormal insertions on the posterior palate. They are then reapproximated in the midline to create a dynamic functional sling for speech purposes. D, Once the nasal mucosa
and musculature of the soft palate are approximated, the oral mucosa is closed in the midline. The lateral releasing incisions are quite easily closed primarily because of the length gained from the depth of the palate. In rare cases, with very wide
clefts, a portion of the lateral incisions may remain open and granulate by secondary intention.
Laterally, the flaps are designed to include oral mucoperiosteum only (see Fig. 83-10B). Gingiva should be avoided. The incision line moves laterally at the junction of the alveolus, and the palatal
shelf recovers its posterior direction quickly once the lateral aspect of the alveolus is reached and may continue 0.5 to 1 cm into the soft palate.
The oral mucosa is separated from the nasal mucosa toward the tip of the uvula with a superficial incision. Mucoperiosteal incisions on the hard palate have to be firm, perpendicular to the palatal
plane, and should reach the palatal shelf with a continuous clean cut. Hemostasis with a fine needle tip electrocautery or bipolar electrocautery at low setting may be performed.
Elevation of mucoperiosteum is started anterolaterally with a Woodson or other small elevator. Gentle subperiosteal elevation of the tip of the flap is performed. After elevation of the tip, a Freer
elevator is used to continue subperiosteal elevation posteriorly to visualize and elevate tissue around the neurovascular bundle. All muscular and tendinous attachments to the hard palate shelf are
detached with a combination of sharp and blunt dissection while leaving the flap attached to the hard palate by the neurovascular bundle and lateral pedicle.
The soft palate is transposed medially by entering the space of Ernst with a blunt instrument (Metzenbaum scissors). To obtain more medial mobilization, infracture of the hamulus may be
performed but is rarely necessary. Veau's muscle inserts into the periosteum on the posterior edge of the hard palate in concert with the tensor aponeurosis after it rounds the hamulus. (Veau's
muscle is a clefted muscle consisting of the levator and the palatopharyngeus.) Some surgeons divide the tendon to mobilize muscles toward the medial aspect.
Gentle traction is used to pull the neurovascular bundle out of the greater palatine foramen (see Fig. 83-10C); the palatine foramen is surrounded by a periosteal cone that can be incised
superficially on either side and posteriorly to allow maximal mobilization of the flap. Additional dissection is necessary to provide maximal mobility of the flap.
Complete dissection of Veau's muscle from the hard palate and nasal mucoperiosteum follows. Attachments are stripped from the nasal mucoperiosteum with sharp scissors and scalpel. Precise
dissection allows lengthening of the palate and posterior/medial transfer of muscles to create a functional muscle sling. This reconstruction is termed an intravelar velarplasty. Dissection of muscle
from the nasal and oral mucosa is more extensive than described in traditional two-flap palatoplasty techniques. Complete dissection with repositioning and tightening of the palatopharyngeus and
levator in a posterior position is, for some, theoretically more physiologic.
Once the flaps are mobilized, closure of the nasal layer begins anteriorly and should be tension free (see Fig. 83-10C). Sutures are tied in knots on the nasal surface. The difference in length
between the two flaps is considered and spacing of the sutures adjusted at this stage. There should be no tension at the hard palateâ€“soft palate junction. The soft palate muscles are
retropositioned (overlapped if necessary) and sutured together with two or three mattress sutures (3-0 to 4-0 resorbable suture). The oral layer is then closed with single resorbable 4-0 or 5-0
interrupted or mattress sutures and knots tied in the oral surface (see Fig. 83-10D).
The combined flaps are anchored (tagged) to the nasal mucoperiosteal closure with a 4-0 resorbable suture at about the midpoint, and the tip is secured to the alveolus with two to four sutures.
These steps prevent dead space between the oral and nasal layers and stabilize the flaps. The same objective can be achieved by using three to four vertical mattress sutures through both the
oral and nasal layers. Exposed bone laterally may be filled with microfibrillar collagen. A tongue suture (3-0 silk/nylon) is applied to aid in tongue advancement acutely in the rare instance of
postoperative obstruction. Surgeons should minimize the time that the mouth gag retractor is activated during the procedure to avoid more severe swelling.
V-Y Pushback with Intravelar Veloplasty
For many surgeons, the V-Y pushback operation is the most appropriate technique for repair of a posterior (soft palate) cleft with limited extension into the hard palate (e.g., Robin-type cleft with
unilateral or bilateral incomplete hard palate involvement). Design principles are similar to those for two-flap palatoplasty but include a V to Y incision design on the hard palate for theoretical
retropositioning of the soft palate. Mucoperiosteum over the primary palate in front of the incisive foramen is left intact, and flaps are designed to leave this area in a V form. For closure, the flaps
slide posteriorly to close the gap, and transposition of this junction into a Y form occurs. (This posterior displacement is limited to the tip of the mucoperiosteal flaps, is minimal, and should not be
confused with what is frequently called a push-back palatoplasty in which posterior displacement aims to reposition the velar muscles.) Intravelar veloplasty and the remaining repair are identical to
those used for the two-flap technique. Generally, a vomer flap is not necessary. The flaps are secured to the anterior mucoperiosteum with several sutures. This technique is not a good choice for
a wide bilateral cleft that involves the incisive foramen area because a residual fistula will remain that is often difficult to close and may affect speech.
The Furlow technique closes the palate by mirror image Z-plasties of the oral and nasal sides of the soft palate (Fig. 83-11A to D).
Palatal muscles are carried in the posteriorly based flaps
of each Z-plasty to construct an overlapping retropositioned palatal muscle sling. In some studies, this technique is associated with a lower frequency of velopharyngeal insufficiency (VPI) than
noted with other palatoplasty techniques and at times is recommended for the treatment of VPI after another type of repair as a secondary procedure.
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A, A complete cleft of the secondary palate (both hard and soft) is shown from the incisive foramen to the uvula. B, The Furlow double-opposing Z-plasty technique requires that separate Z-plasty flaps be developed on the oral and
then the nasal side. Note the cutbacks creating the nasal side flaps, highlighted in blue. C, The flaps are then transposed to theoretically lengthen the soft palate. A nasal side closure is completed in standard fashion anterior to the junction of the
hard and soft palate. Generally, this junction is the highest area of tension and can be difficult to close. This contributes to the higher fistula rate in this type of repair at this location. D, The oral side flaps are then transposed and closed in similar
fashion to complete closure of the palate. E, Lateral view of nasal and palatal anatomy. The lateral extension of incisions in the Furlow palatoplasty sometimes requires that the incision be extended to the torus tubarius region. Care is taken to
reposition the palatal musculature that is abnormally inserted on the posterior palate in conjunction with the double-opposing Z-plasty flaps.
The landmarks that determine the flap angles and flap design include the hamuli, the posterior edge of the hard palate, the base of the uvular halves, and the eustachian tube orifice (torus tubarius)
(see Fig. 83-11E). The hamulus is palpable as a small bony eleva tion of the pterygoid plate just medial and posterior to the maxillary tuberosity. Thus, when marking the flaps, the surgeon should
remember that the Z-plasties are not two dimensional and that the angles do not need to be at 60 degrees each because flap design is based on the anatomy of the palate, not the geometry of
The lateral limbs of the incisions on the oral side and at the level of hamulus are extended to allow advancement of the flaps (see Fig. 83-11B). This incision can be extended around the maxillary
tuberosity as a short backcut when necessary. For limited soft palate clefts, only the soft palate incisions and flaps are elevated without the need for hard palate releasing incisions.
The left myomucosal flap (oral) is posteriorly based. The muscle is dissected from the nasal mucosa with scissors, and the levator muscle is carefully preserved. The palatal muscles are
separated from the aponeurosis and from the medial side of the superior constrictor to mobilize the flap for rotation. Once the oral flaps are raised, the nasal Z flaps are incised. On the left, the
anteriorly based flap (nasal) is elevated as a mucosal flap. On the right, the posteriorly based (nasal) flap is elevated with the muscle. Each lateral limb incision ends just medial to the eustachian
tube orifice (torus).
The left anteriorly based (nasal) mucosal flap is incised from the uvula along the dissected edge of the cleft muscle to the left torus. The right posteriorly based (nasal) mucosal-muscle flap is
created by an incision from the posterior hard palate to near the torus while taking care to include velar cleft muscle in the flap. However, the mucosal incision on this flap is not extended
completely up to the torus to facilitate subsequent closure.
The nasal side is closed by first transposing the left nasal mucosal (anteriorly based) flap transversely to the distal portion of the right nasal incision stepwise from the distal to the proximal aspects
to the posterior hard palate nasal mucoperiosteum until the end of the flap reaches near the right torus. When tension is present, avoidance of the natural inclination to sew the distal tip of the flap
to its ultimate location first helps protect the fragile tip of the flap. Next, the right myomucosal flap is transposed until the tip of the flap reaches the opposite superior constrictor muscle at the torus
(see Fig. 83-11C). This flap is sutured to the nasal mucosal flap anteriorly. The muscle of the posteriorly based oral myomucosal flap on the left side is then secured to the right tonsillar pillar. The
right anteriorly based mucosal flap is sutured in stepwise manner across to the oral mucosa on the opposite side.
Retention sutures through the muscle of the posteriorly based right-sided nasal flap may be placed through the base of the oral flap on the opposite side to relieve tension. Mucoperiosteal flaps
(when present) are brought into the horizontal plane and sutured. Usually, no bone is exposed and no raw nasal area on the soft palate is left to contract and shorten the palate.
Postoperative care includes a liquid diet and placement of arm restraints for approximately 2 weeks to allow adequate mucosal healing. Careful follow-up and regular visits with a speech
pathologist are important.
CLEFT PALATE, MIDDLE EAR, AND SPEECH
Speech characteristics associated with a cleft palate include abnormal nasal resonance, abnormal nasal airflow and altered laryngeal voice quality, nasal or facial grimace, and atypical consonant
production (Table 83-3). In patients with clefts, abnormal nasal resonance is typically manifested as hypernasality secondary to VPI. Inadequate nasal resonance (hyponasality) may also occur as
result of obstruction. Hypernasality and hyponasality can occur together (mixed nasality). Altered laryngeal voice quality commonly includes hoarseness and reduced volume. Nasal or facial
grimace is an unconscious compensation mechanism to inhibit airflow through the nose. As a result of these issues and other factors, there is a risk of articulation disorders and other speech
Table 83-3 -- COMMON SPEECH ABNORMALITIES SEEN IN PATIENTS WITH CLEFT PALATE
Hypernasality: Failure of the palate to separate the oral and nasal cavities during non-nasal consonant production. Oral phonemes substituted by nasal sounds (m, n, ng)
Hyponasality: Reduction of the nasal airflow that occurs with the nasal consonants /m/, /n/, and /ng/. Usually not present with velopharyngeal insufficiency but may be noted when large adenoid or
posterior nasal airway obstruction is present with an incompetent velopharyngeal valve
Cul-de-sac resonance: Air enters the nasal cavity but cannot escape because of anterior nasal blockage.
Muffled sound quality
Nasal emission: Airflow normal with nasal consonants; abnormal with plosives, fricatives, and affricates.
Determined with mirror testing. May be audible or inaudible
Nasal snort,/s/phoneme, and other fricatives: In a patient with an initially closed velopharyngeal valve, as intraoral pressure increases, air escapes from the nose
Stops glottal: Plosive consonant produced by vocal fold valving
Chronic hoarseness: Vocal hyperfunction secondary to compensation at the laryngeal level
Chronic Otitis Media
The cleft palate population has a high incidence of mild to moderate hearing loss. Early onset of otitis media with effusion (OME) is a universal finding in infants with unrepaired cleft palates, and
the pathology is causally related to an inherent defect in the opening mechanism of the eustachian tube that results in persistent collapse of the tubal lumen.
Treatment of this condition
requires evacuation of the effusion and insertion of ventilation tubes. In children with a cleft lip and palate, present and persistent OME should be addressed at the time of lip repair, which usually
takes place at around 3 months of age. In children with a cleft palate only, persistent OME should be addressed when diagnosed, in a separate procedure, and should not wait for palate repair. In
the author's opinion (A.G.), long-term tubes (T tubes) should be used when possible. This option may not be available in a very small ear. In both groups, ears need to be reevaluated shortly
before palate repair and regular tubes replaced with long-term ventilation tubes at the time of palate repair. After successful palate repair, most children with a cleft lip and palate will not be
scheduled for another surgical procedure for several years. The shorter retaining period and high extrusion rate of regular tubes make them less than ideal in many instances. Even after palate
repair, eustachian tube function remains deficient in a large percentage of these children, and ear problems (infections, hearing loss, or both) are most prevalent in the 4- to 6-year-old age group.
Ear problems persist at a substantial level until the age of 12 years, and children with a cleft lip and palate have a prolonged recovery and a substantial incidence of late sequelae.
T tubes are
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retained longer and will therefore obviate the need for repeated tube insertion, which presents additional unnecessary anesthesia risk for the child, as well as increases the cost of care
substantially in the first 5 years of the child's life. Evaluation of the ear and hearing should be undertaken every 6 months.
Submucous Cleft Palate
A submucous cleft palate is a microform or incomplete version of a complete cleft of the embryologic secondary palate. It is characterized by the presence of a bifid uvula, a translucent midline
known as the zona pellucida (caused by diastasis of the soft palate muscles), and lack of a posterior nasal spine causing palpable notching of the posterior hard palate. A submucous cleft palate
may be asymptomatic throughout life or become symptomatic after adenoidectomy, as well as after natural involution of the adenoid tissue. It is important to inspect the uvula carefully and palpate
the posterior hard palate before an adenoidectomy. When considering adenoidectomy in any patient, if the posterior palatal spine cannot be palpated and a midline notch is present, partial
(anterior) adenoidectomy should be considered. In general, submucous cleft palates are repaired only when they cause symptomatic speech abnormalities.
The secondary palate is composed of a hard (bone) palate anteriorly and a soft palate or â€śvelumâ€ť posteriorly. Within the soft palate, the levator veli palatini muscle forms a dynamic sling that
elevates the velum toward the posterior pharyngeal wall during the production of certain sounds. Other muscle groups within the velum, the tonsillar pillar region, and the pharyngeal walls also
affect the quality of resonance during speech formation. The combination of the soft palate and pharyngeal wall musculature jointly forms what is described as the velopharyngeal valve mechanism
(Fig. 83-12). This mechanism functions as a sphincter valve for regulating airflow between the oral and nasal cavities to create a combination of orally based and nasally based sounds.
Anatomy of the palate and velopharyngeal valve mechanism. A, Normal anatomy. B, Unilateral cleft of the primary and secondary palate with associated anatomic abnormalities.
Children born with a cleft palate have, by definition, a malformation that has a dramatic impact on the anatomic components of the velopharyngeal valve mechanism. Specifically, clefting of the
secondary palate causes division of the musculature of the velum into separate muscle bellies with abnormal insertions along the posterior edge of the hard palate (see Fig. 83-12). VPI is a major
functional concern for patients with a cleft. Regardless of the repair type, the incidence of VPI after primary palate repair varies in studies from 5% to higher than 50%.
VPI is defined as inadequate closure of the nasopharyngeal airway port during speech production. The exact cause of VPI after successful cleft palate repair is a complex problem that remains
difficult to define completely. Incomplete surgical repair of the musculature is one cause of VPI, but even muscles that have been appropriately realigned and reconstituted may fail to heal normally
or function properly. In addition, it must be considered that the repaired cleft palate is only one factor contributing to velopharyngeal valve function and that other abnormalities related to
oropharyngeal morphology, nerve innervation, lateral and posterior pharyngeal wall motion, and nasal airway dynamics may all contribute to velopharyngeal valve dysfunction. For example, a short,
scarred soft palate that does not elevate well may be compensated by recruitment and hypertrophy of muscular tissue within the posterior pharyngeal wall (Passavant's ridge).
Approximately 20% of children with VPI after palatoplasty will eventually require management involving additional palatal surgery. Left untreated, nasal air escapeâ€“related resonance problems will
lead to other speech abnormalities, namely, abnormal compensatory articulation. These abnormal, compensatory misarticulations further complicate problems with speech formation and decrease
speech intelligibility in patients with cleft palateâ€“related VPI.
After the initial cleft palate repair, periodic evaluations are important to assess the speech and language development of each child. Typically, this involves a standardized screening examination
performed by a speech and language pathologist as part of an annual visit to the cleft palate team. Detailed studies that include the use of videofluoroscopy and nasopharyngoscopy may be
indicated. Videofluoroscopy is used to radiographically examine the upper airway with the aid of an oral contrast agent. This technique allows dynamic testing of the velopharyngeal valve
mechanism with views of the musculature in action. In addition, details of upper airway anatomy, including residual palatal fistulas, can be visualized and their contribution to speech dysfunction
evaluated during the study. For a videofluoroscopy study to be of diagnostic value it must include multiple views of the velopharyngeal valve mechanism, and a speech pathologist must be present
to administer verbal testing in the radiology suite.
Nasopharyngoscopy allows direct visualization of the upper airway and specifically the velopharyngeal valve mechanism from the nasopharynx. This technique avoids the radiation exposure
associated with videofluoroscopy but requires preparation of the nose with a topical anesthetic, skillful maneuvering of the scope, and a compliant patient. Once the endoscope is inserted,
observations of palatal function, airway morphology, and pharyngeal wall motion are made while the patient is verbally tested by the speech pathologist. The opportunity for direct visualization of
the velopharyngeal valve mechanism in action during speech formation provides information that is critical to clinical decision making related to secondary palatal surgery in cases of confirmed or
With videofluoroscopy and nasoendoscopy, the closure pattern of the palate is documented and should be differentiated. The closure pattern may help determine the success of various secondary
palatal procedures designed to augment anatomic deficiencies.
The most common pattern of closure (55% of the normal population) is coronal closure. It consists of posterior movement of the soft palate to the posterior pharyngeal wall with little
movement from the lateral walls. Approximately 45% of patients with VPI have this pattern of closure.
The sagittal closure pattern is seen in 10% to 15% of the population. Primary closure is by lateral wall movement without significant anterior-to-posterior closure. This pattern is seen in
approximately 10% of children with VPI.
Circular closure includes lateral wall movement and posterior movement of the soft palate. It occurs in approximately 10% of the population and 20% of children with VPI. Circular
closure with Passavant's ridge includes lateral wall and soft palate movement, as well as anterior movement of the posterior pharyngeal wall. This pattern is seen in 20% of the normal
population and in 25% of children with VPI.
Secondary palatal surgery in young children is indicated when VPI is causing hypernasal speech on a consistent basis and is related to the anatomic problem. The exact timing of surgery for VPI
remains controversial, however, with recommendations ranging from 2.5 to older than 5 years. In such a young age group, variables such as the child's language and articulation development and
lack of compliance during speech evaluation compromise the diagnostic accuracy of preoperative assessment. The decision to proceed with additional surgery for VPI is not an isolated surgical
judgment. The authors believe that lack of palatal movement in the anterior-posterior direction benefits most often from a pharyngeal flap, and frequently the lack of lateral wall motion is best
treated by sphincter pharyngoplasty. There is considerable variation in surgical technique for each of these procedures, and each can be customized to fit the particular closure pattern of each
TONSILLECTOMY AND ADENOIDECTOMY IN CHILDREN WITH CLEFTS
The age group of children evaluated for VPI certainly coincides with the period when enlargement of the tonsils and adenoids is most common. This issue is not well addressed in the literature and,
if ignored, has a tendency to disrupt the positive outcome of cleft palate repair.
Severely enlarged tonsils can interfere with elevation and closure of the palate. Careful observation of the tonsilâ€“soft palate relationship during oropharyngeal examination, as well as
nasoendoscopy, will disclose the impact of tonsil enlargement. A repeat speech evaluation should be performed 6 to 8 weeks after tonsillectomy and the presence and severity of VPI reassessed.
Enlarged adenoids aid velopharyngeal closure. After adenoidectomy, occult VPI suddenly becomes overt and decompensated speech patterns can be dramatic. VPI after adenoidectomy in the
general population occurs in less than 1% of cases. Of these, approximately one third can be observed to have findings of mild VPI before adenoidectomy. The risk for VPI after adenoidectomy is
increased in children with developmental delay, generalized hypotonia, mental retardation, submucous cleft palate, family history of VPI, and history of feeding problems in early childhood.
If a subsequent pharyngeal flap is not planned, adenoidectomy in a child with a repaired or submucous cleft palate or in a child with other risk factors as mentioned earlier should be limited to the
anterior one half of the adenoid tissue (closest to the choanae and torus) while leaving the height and posterior one half of the adenoid tissue intact for adequate velar closure. Adenoidectomy in
this age group is frequently indicated for recurrent or chronic sinonasal infections and for recurrent or chronic otitis media. One of the rare causes of VPI is closure of the palate against
asymmetrical adenoid tissue, which can be adequately identified only with nasoendoscopy.
A major cause of obstructive sleep apnea in children is adenotonsillar hypertrophy. Failure to recognize the impact of adenotonsillar hypertrophy in a child with sleep-disordered breathing, snoring,
or mild apnea can lead to severe obstructive sleep apnea after creation of a pharyngeal flap to treat VPI. Performing an adenoidectomy after a pharyngeal flap is in place is difficult and may carry
a higher risk of bleeding. A moderately enlarged mass of adenoid tissue can become severely obstructive after a few months and interfere with the function of a pharyngeal flap. When
adenoidectomy is required before treatment of VPI, appropriate surgical planning may include removal of the obstructive adenoid tissue at least 4 to 6 weeks before creation of a pharyngeal flap.
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Enlarged tonsils obstructing the view of the posterior pillars may interfere with the elongation of flaps for pharyngoplasty. When necessary, conservative tonsillectomy (preservation of both the
anterior and posterior tonsil pillars) is planned before pharyngoplasty. The lateral pharyngeal ports can become obstructed by enlarged tonsils several months after a successful pharyngeal flap
procedure and cause speech disturbance, obstructive sleep apnea, or both. Nasoendoscopy will show this problem and tonsillectomy can alleviate it. It should be noted that adenoidectomy and
tonsillectomy in patients with clefting is a controversial area and that treatment plans must be individualized.
OPERATIVE TECHNIQUES FOR VELOPHARYNGEAL INSUFFICIENCY
Contemporary surgical management of VPI generally involves the use of two types of procedures: a pharyngeal flap and sphincter pharyngoplasty.
The use of autogenous or alloplastic
implants for augmentation of the posterior pharyngeal wall has been described but is not a commonly used procedure. More recently, some surgeons have advocated performance of a second
palatoplasty operation in an attempt at palatal lengthening in a patient with VPI. This may become an alternative in some patients with short gaps posteriorly.
A superiorly based pharyngeal flap remains the standard approach for surgical management of VPI. Using 14F catheters for guidance, the technique advocated by the authors limits the combined
size of the lateral ports to less than 20 mm
, the maximal velopharyngeal port opening during clinically normal speech. Surgical maneuvers are directed at recruiting tissue by developing a
superiorly based soft tissue flap from the posterior pharyngeal wall (Fig. 83-13). The soft palate is then divided along the midsagittal plane from the junction of the hard and soft palate to the uvula,
and the flap from the posterior pharyngeal wall is inset within the nasal layer of the soft palate. A superiorly based flap may be covered with mucosal flaps on both the dorsal and ventral surfaces,
thus increasing the viability of the flap, reducing flap contracture, and expediting mucosal healing. As a result, a large nasopharyngeal opening that cannot be completely closed by the patient's
velopharyngeal valve mechanism is converted into two (right and left) lateral pharyngeal ports. Closure of these ports is easier for the patient to accomplish as long as adequate lateral pharyngeal
wall motion is present.
Superiorly based pharyngeal flap. A, Elevation of a myomucosal flap from the prevertebral fascia and division of the soft palate tissues. B, Dissection of the oral, nasal, and muscular layers for insetting the flap. C, Sagittal view of
soft palatal anatomy in preparation for insetting the pharyngeal flap at the appropriate vertical height. D, Sagittal close-up view indicating the relationship between adenoid tissue and the pharyngeal flap. E, Insertion of the flap with closure of the oral
mucosa over the raw defect to decrease scarring.
The high overall success rate and the flexibility to design the dimensions and position of the flap itself are advantages of the superiorly based pharyngeal flap procedure. Disadvantages of the
pharyngeal flap procedure are primarily related to the possibility of nasal obstruction, resulting in trapping of mucus and the potential for exacerbation of obstructive sleep apnea.
Inferiorly based pharyngeal flaps for the management of VPI are rarely used and tend to cause downward pull on the soft palate after healing and contracture of the flap. The result may be a
tethered palate with decreased ability to elevate during the formation of speech sounds. Moreover, should postoperative hemorrhage occur, an inferiorly based flap obscures the donor site for
access to the bleeding site, and to control the bleeding, the flap may need to be sacrificed in some instances. A superiorly based flap leaves the donor site fully accessible.
Dynamic sphincter pharyngoplasty is another option for the surgical management of VPI. The operative procedure involves the creation of two superiorly based myomucosal flaps that include each
posterior tonsil pillar (Fig. 83-14). Each flap is elevated with care taken to include as much of the palatopharyngeal muscle as possible. It may be difficult to raise flaps in patients with
velocardiofacial syndrome, because the internal carotid arteries may take a median course in the posterior pharynx. The flaps are then attached and inset within a horizontal incision made high on
the posterior pharyngeal wall. These flaps are designed to be anastomosed either end to end (if short) or side to side (overlap) (if long) (see Fig. 83-14).
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