Cleft palate: Part II – The concept and techniques

Partha Sadhu; Neelam Chauhan

doi:10.4103/jclpca.jclpca_25_22

CME ARTICLE

Year : 2023 | Volume : 10 | Issue : 1 | Page : 48-53

Cleft palate: Part II – The concept and techniques

Partha Sadhu¹, Neelam Chauhan²
¹ Durgapur Cleft Centre, Operation Smile, Siliguri, West Bengal, India
² Department of Plastic and Reconstructive Surgery, King George's Medical College, Lucknow, Uttar Pradesh, India

Date of Submission	22-Nov-2022
Date of Acceptance	10-Jan-2023
Date of Web Publication	14-Mar-2023

Correspondence Address:
Dr. Neelam Chauhan
Department of Plastic and Reconstructive Surgery, King George's Medical College, Lucknow, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jclpca.jclpca_25_22

Abstract

Cleft palate is the most common craniofacial anomaly with multiple surgical options in the armamentarium of a surgeon. Following the principles and right surgical techniques can yield excellent functional results. The various techniques have gradually developed over time and each has their own peculiarities along with specific advantages and disadvantages. Here, in this article, we will be discussing a few palatoplasty techniques which have stood the test of time and are commonly performed.

Keywords: Cleft palate, palatoplasty, techniques

How to cite this article:
Sadhu P, Chauhan N. Cleft palate: Part II – The concept and techniques. J Cleft Lip Palate Craniofac Anomal 2023;10:48-53

How to cite this URL:
Sadhu P, Chauhan N. Cleft palate: Part II – The concept and techniques. J Cleft Lip Palate Craniofac Anomal [serial online] 2023 [cited 2023 Mar 30];10:48-53. Available from: https://www.jclpca.org/text.asp?2023/10/1/48/371643

Introduction

The cleft palate child needs a multidisciplinary approach for its management. Along with plastic surgeon, the need of a pediatrician, a speech pathologist, an otolaryngologist, and orthodontics is equally important. As the condition affects an individual at multiple stages of life, so does its management which is hence planned at different times of life. The importance of cleft repair is to create the functional separation between the oropharynx and nasopharynx.

Objectives Of Palatoplasty

The most important objective in the management of cleft palate is to have a normal speech which is well articulated and has a normal resonance and requires normal effort. The aim of the surgery should be to construct a palatal sphincter which provides velopharyngeal closure as well as has a good mobility to provide a normal relaxed speech. However, due importance is also to be given to dentofacial growth. The timing of surgery thus has a great importance in determining the functional and esthetic outcome. The objectives of the cleft palate repair can be enumerated as follows:^[1]

To produce anatomical closure of the defect
To create an apparatus for the development and production of normal speech
To minimize the maxillary growth disturbances and dentoalveolar deformities.

Principles Of Palatoplasty

The principles of palatoplasty can be defined as follows:^[1]

Closure of the defect
Correction of the abnormal position of the muscles of the soft palate, especially levator palate
Reconstruction of the muscle sling
Retropositioning of the soft palate so much so that during speech the posterior part of the soft palate comes in contact with the posterior pharyngeal wall during speech
Minimal or no raw area should be left on the nasal side or the oral surface
Tension-free suturing
Two-layer closure in the hard palate region and a three-layer closure of the soft palate.

Timing of Repair

The timing of repair of palate is determined mainly on the basis of the following two factors.

Speech outcome

The primary aim of the development of normal speech requires cleft palate surgery as early as possible. An infant with a cleft palate either starts substituting the consonants that he cannot speak with those that he can or starts omitting them, leading to a pattern of substitution and omission in his speech. This pattern when once develops in the mind, its then difficult to change through speech therapy. The development of babbling can be hence considered the ideal time for surgery.

Veau^[2] earliest noted the correlation between the timing of surgery and the speech outcome in 1931, that repairs done before 12 months of age had the best speech outcome compared to those done at 2–4 years of age. The speech outcome is however affected by the timing of surgery as well as by the type of surgery. Certain surgical techniques are found to have better speech outcomes compared to others. There is also a high incidence of recurrent otitis media in untreated cleft patients. Repair of cleft helps at least partially in restoring Eustachian tube ^{More Details} competence.

However, the surgical scarring as a result of the procedure affects the facial growth. Hence, a balance needs to be sought between the need for a good speech and a better facial growth.

Conventionally, the cleft palate used to be closed at 18–24 months but now its closed at 9–12 months of age.^[3],[4] 6–12 months are accepted as the ideal time for surgery at most of the centers, though the majority perform at 12–18 months.

Maxillary growth

The maxillary growth is significantly affected in operated cleft patients. They are found to have a transverse maxillary deficiency which requires orthodontic maxillary widening at a later stage of life. This transverse deficiency of arch is also responsible for crowding of teeth, lateral cross bite, and open bite.^[5],[6] The narrowed arch and maxillary growth inhibition could be due to either cicatrix postpalate repair^[7],[8] or intrinsic maxillary underdevelopment or due to both. Hence, the timing of repair is highly important factor wherein one needs to seek balance between the speech and facial growth. However, maldeveloped speech is difficult to correct in older children, whereas facial development and malocclusion can be corrected later using the orthodontic treatment and orthognathic surgery, hence palate repair cannot be delayed much.

Muscle Repair

The proper development of speech requires the correction of abnormal attachment of muscles along the cleft. The levator veli sling needs to be created to allow for adequate velum movement. Kriens had highlighted the same point by emphasizing the need to free the levator muscle from its abnormal insertion on the posterior border of hard palate. The muscle after freeing should be overlapped in the midline to create a sling. Hence, intravelar veloplasty is an essential step of cleft palate surgeries.

Antibiotics

Palatoplasty is a clean-contaminated surgery. These patients may have a preexisting otitis media. The surgery also requires intubation for a considerable amount of time; hence, these patients are at a risk of postoperative respiratory tract infection. Therefore, the perioperative use of antibiotics is justified in these patients.

Surgical Techniques

There are various techniques described for palatoplasty, here, we describe the most commonly followed techniques. Each technique has its own differences; however, there are certain steps that are the same in all these techniques.

Intubation – Patients are intubated using South pole Ring-Adair-Elwyn tube which is fixed in the midline. The use of this tube prevents the kinking due to the tongue blades of the mouth gag
Position – Patient is laid with neck in extension which is maintained by placing pillows under the shoulder. The head is stabilized by placing pillows on either side of the head
Exposure – Dingman retractor is placed to achieve the exposure. It has a slot in the tongue blade for the tube to avoid any kinking
Oral packing – Peri-tube oral packing is done to prevent leakage of anesthetic gases, reduce bubbling and to prevent aspiration
Infiltration – Injection adrenaline 1:1000 is diluted with 200 ml saline to create 1:200,000 concentration which is then infiltrated along the cleft margin in a dose of 0.3–0.5 ml/kg with a maximum of 1 ml/kg to provide vasoconstriction and hemostasis. One must wait for 7–8 min for adequate vasoconstriction before giving incision
Perioperative antibiotics may be administered
While dissecting, care needs to be taken to save the greater palatine vessels. Lateral incisions on the alveolar side are made using contralateral hands so that the incision is beveled away from the pedicle
The palate needs to be circumferentially freed from all its attachments around the pedicle, along with stretching of the pedicle out of the foramen, to ensure tension-free closure
The most difficult site for closure is the hard and soft palate junction, which is hence the most common site for fistula also
Emphasis while soft palate closure should be on correcting the abnormal position of levator muscle.

Furlow's palatoplasty

It is a double opposing Z-plasty which comprises one Z on the oral mucosa and another Z in a reverse pattern on the nasal mucosa. The levator muscle is included in the posteriorly based flaps, oral mucosa flap on one side, and nasal mucosa flap on the other side [Figure 1]. For a right-handed surgeon, it is easier to raise posteriorly based oral mucomuscular flap on the left side and nasal mucomuscular flap on the right side. A left-handed surgeon may prefer otherwise. As in any other Z-plasty, the gain in length is at the expense of the width, hence with wide clefts it is not possible to raise large flaps. The hard palate can be closed using vomer flap or by raising mucoperiosteal flaps.

Figure 1: Furlows double opposing Z plasty. (a) Marking of Insicion; (b) Raising of the anteriorly based oral mucosal flap and posteriorly based oral mucomuscular flap; (c) Closure of nasal Z plasty flaps; (d) Oral layer closure (Image courtesy- Dr. Neelam Chauhan)

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The advantages of this technique are as follows:

Lengthens the soft palate
Avoids raising large mucoperiosteal flaps which may cause retardation of mid-facial growth
Restores the correct orientation of levator muscle
Reduces muscle dissection
Avoids straight line closure of soft palate which could contract later
It can be done together with a primary pharyngeal flap
It can be done as a secondary procedure for palatal lengthening.

Technique

After proper positioning and infiltration, the incision is made longitudinally along the cleft margin. Uvula margin may be excised to achieve a broader approximation of the cleft margin
First, the anteriorly based oral mucosal flap on the right side is raised by dissecting between the mucosa and levator muscle. The dissection is continued till the posterior border of hard palate. Further anteriorly the dissection is continued along the cleft margin. Using dental elevators, mucoperiosteal flaps are raised over the hard palate for some distance laterally
Similarly, dissection is done on the left side from anterior to posterior, raising the mucoperiosteal flaps. The nasal mucosa is then elevated off the hard palate on the left side, thus creating a plane for dissection between the muscle and nasal mucosa. The levator muscle is then freed from its attachment on the posterior border of hard palate
The posteriorly based oral mucomuscular flap is then raised on the left side by carefully dissecting the muscle off the nasal mucosa
The anteriorly based nasal mucosa flap on the left side can be then raised from posterior to anterior using scissors. Laterally, the flap should be raised close to the eustachian tube
The posteriorly based nasal mucomuscular flap is then raised on the right side. The levator muscle is freed from its attachment to hard palate by cutting the nasal mucosa
Wide and superiorly based nasal flaps are raised from the vomer for hard palate closure. In case of bilateral clefts, it is raised from both sides of vomer. This avoids the need of raising large mucoperiosteal flaps and hence helps in reducing the maxillary growth disturbances
Furlows did not recommend lateral relaxing incisions; however, they can be given if the closure of flaps is too tight. These relaxing incisions are given laterally in the soft palate starting anterior to the anterior tonsillar pillar and continue to pass around the maxillary tubercle anteriorly into the mucoperiosteum of hard palate.

von Langenbeck palatoplasty

This technique involves the raising of large bipedicle mucoperiosteal flaps off the hard palate, along with the detachment of levator muscle from its abnormal insertion along the posterior border of hard palate.[Figure 2].

Figure 2: Von Langenbeck palatoplasty (a) Incision; (b) Raising of mucoperiosteal flaps; (c) Nasal layer closure; (d) Oral layer closure (Image courtesy- Dr. Neelam Chauhan)

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Technique

After proper positioning and infiltration, incision is made longitudinally along the cleft margin extending from the alveolus till uvula. Uvular margin is preferably excised. The incision site can be varied to include more or less of oral mucosa to turn down for nasal lining closure as per the width of the cleft
Lateral relaxing incisions are made starting from the anterior tonsillar pillar posteriorly and extending anteriorly just lateral to the posterior maxillary tubercle. The incision passes around the posterior maxillary tubercle and extends between the gingiva and palatine vessels reaching till the premolar level. The incision is made deep to the periosteum level
Mucoperiosteal flaps are raised from the hard palate bilaterally between the cleft margin and lateral relaxing incision using a blunt elevator. Blunt dissection is done using scissors along the posterior edge of hard palate and into the soft palate through medial cleft incision and lateral relaxing incisions. Care needs to be taken while dissecting around the palatine vessels
Vomer flap may be used to help in two-layer palatal closure
The levator muscle is detached from its abnormal insertion on the posterior border of hard palate
Palatal closure is done in layers using 4–0 or 5–0 absorbable sutures starting with the nasal layer, followed by the muscle layer and oral mucosa. Mattress sutures are applied on the oral mucosa to prevent inversion of margins.

Bardach's palatoplasty

The originally described surgery by Bardach involves the mobilization of mucoperiosteal flaps from cleft margin incision only. The more commonly performed Two flap palatoplasty is a modification of the von Langenbeck palatoplasty, in which the lateral relaxing incision extends along the alveolar margin to join the cleft margin incision and then raising large mucoperiosteal flaps from hard palate, which are posteriorly based on greater palatine vessels [Figure 3]. The rest of the procedure is similar to von Langenbeck palatoplasty.

Figure 3: Two flap palatoplasty. (a) Marking of incision; (b) Mucoperiosteal flaps raised and nasal mucosa mobilised; (c) Nasal layer closed along with intra velar veloplasty; (d) Oral layer closure(Image courtesy- Dr. Neelam Chauhan)

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Veau-Wardill-Kilner palatoplasty

It is performed in incomplete cleft palate. Inadequate velum movement and inadequate palatal length are common reasons for velopharyngeal incompetence. Veau-Wardill-Kilner palatoplasty aims to increase the palatal length by doing a V-Y lengthening of the hard palate mucoperiosteal flaps [Figure 4]. This maintains the palate length, however, nasal mucosa lengthening may also be done by Z-plasty as described by Stark.^[9] This surgery however creates raw areas in the hard palate laterally which heal by scarring and can cause disturbance in maxillary growth and dental occlusion.

Figure 4: (a) Marking of incision; (b) Mucoperiosteal flaps raised; (c) Nasal layer closure along with intravelar veloplasty; (d) Oral mucosa closure and remaining lateral raw areas (Image courtesy- Dr. Neelam Chauhan)

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This technique was developed and evolved by contributions of multiple surgeons. Victor Veau^[10] advocated nasal mucoperiosteal closure and used metallic suture to close the palatal muscles. Wardill advocated fracture of hamulus and division of greater palatine vessels to increase the mobility of the flaps. He also performed pharyngoplasty in all patients routinely.^[11] Kilner later instead of dividing the vessels, described freeing of the vessels all around the foramen, osteotomy of the posterior border of greater palatine foramen, periosteal stripping, and stretching of the vessels to increase the length of the palate.^[12],[13]

Technique

The patient is positioned as previously described and adrenaline infiltration is given
Incision is made medially along the cleft margin from uvula till the apex of cleft and then extended laterally over the hard palate till gingiva of canine tooth forming a “V”
Lateral incisions are made similar to other procedures, anteriorly meeting the hard palate incision as described above
Mucoperiosteal flaps are raised from the hard palate using a blunt elevator. Dissection is continued in soft palate to elevate the oral mucosa followed by dissection of levator muscles. The nasal mucosa is also mobilized to achieve tension-free closure. Vomer flap may also be used
The closure is done in layers using 4–0, 5–0 absorbable sutures. The oral mucoperiosteal flaps are pushed back and closed in “Y” pattern to achieve palatal lengthening
The lateral raw areas are usually left as such but can be covered with a buccal fat pad as well.

Postoperative Care

Patients are kept under observation in the postanesthesia recovery rooms for at least an hour. The child needs to be monitored for oxygenation, airway difficulty, respiration, and bleeding. Intravenous fluid supplementation is given initially, followed by oral liquids in the evening of surgery. Initially, clear liquids are given and soft diet can be started from the 3^rd postoperative day. Parents are advised to give water after every feed to clear the palate of any food particles to keep the stitch line clean.

Complications

Airway compromise – Infants are obligate nose breathers and may develop some respiratory difficulty in postoperative due to reorganization of their airway postpalatoplasty. Some amount of bleeding along with soft palate edema may also cause partial airway obstruction. The use of the nasopharyngeal airway or a traction suture on the tongue can be done in such a case
Bleeding – It can occur due to oozing from the raw surfaces when the effect of adrenaline fades away. Applying some pressure on the hard palate postrepair can help in reducing the bleed
Dehiscence – It can occur due to tight closure or due to infection
Oronasal fistula – It is a late complication that may occur.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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11.	Millard DR Jr. Cleft Craft: The Evolution of Its Surgery. III: Alveolar and Palatal Deformities. Boston, MA: Little, Brown; 1980. p. 240.
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