Article: Cleft Palate Repair and Its Variations

  • In contrast to cleft lip and palate, there is a female predominance of cleft palate. The ratio is approximately 3:2.
  • Passavant’s ridge is a soft tissue prominence which extends into the pharynx. The structure is usually described in association with cleft palate, but has been described in many normal subjects. The soft tissue structure also frequently contributes positively to velopharyngeal closure. The ridge usually forms along the superior border of the superior pharyngeal constrictor muscle, but its exact position on the posterior pharyngeal wall may vary.
  • The von Langenbeck palate repair technique involves the creation of two full thickness mucoperiosteal flaps with care taken to preserve anterior soft tissue pedicles. The theoretical advantage of the anterior soft tissue attachments is additional blood supply for the elevated flaps. During the Bardach (2-flap) and pushback procedures, similar soft tissue flaps are elevated, but no anterior pedicle is maintained. 
  • The Furlow procedure involves the use of double opposing Z-plasties with the musculature elevated with the posteriorly based flaps on the nasal and oral sides. The goals of cleft palate repair are twofold; first, water tight closure of the oral-nasal  communication, and second, the creation of a dynamic soft palate for normal speech production. The most important muscular component of the soft palate is the levator veli palatini muscle which functions to elevate the velum and allow for appropriate speech production. In patients with an unrepaired cleft palate, the levator musculature is clefted and has abnormal insertions along the posterior edge of the hard palate. 
  • Generally, cleft lip repair is carried out when the child is 10 to 12 weeks of age. General guidelines were developed for reduction of anesthetic risk and suggested that the surgery be undertaken when the child is approximately 10 weeks of age, weighs at least 10 lbs, and has a serum hemoglobin of at least 10 mg/dl. This has often been referred to as the “rule of 10’s” for the timing of cleft lip repair.
  • Two-flap palatoplasty techniques involve the elevation of full-thickness mucoperiosteal flaps on each side of the cleft defect for oral side closure. After the nasal mucosa is closed, these soft tissue flaps are sutured together in the midline for closure of the cleft defect. During the initial dissection and elevation of the flaps, the greater palatine neurovascular bundles are identified and protected. The result is that the axial soft tissue flaps are raised based upon the blood supply of the greater palatine arteries bilaterally. If the greater palatine artery is injured or cauterized, then the axial pattern soft tissue flap becomes a random pattern flap (i.e. not based on one specific arterial supply) with perfusion from the palatal soft tissue attachments
  • A superiorly based pharyngeal flap is commonly used for the management of velopharyngeal insufficiency related to cleft palate. A soft tissue flap is developed from the posterior pharyngeal wall. This is done by elevating the posterior pharyngeal wall soft tissues including the superior constrictor muscle off of the prevertebral fascia. This flap is then inset within the soft palate nasal side closure. The superiorly based pharyngeal flap remains the standard approach for surgical management of patients with velopharyngeal insufficiency after cleft palate repair. The procedure involves the creation of a soft tissue flap from the posterior pharyngeal wall which is subsequently inset within the soft palate. The result is that the size of the nasopharyngeal cavity is decreased. The larger nasopharyngeal opening which could not be completely closed by the patient is instead converted into two (right and left) smaller lateral pharyngeal ports. Closure of these ports is easier for the patient to accomplish as long as adequate lateral pharyngeal wall motion is present The goals of bone graft reconstruction in patients with cleft lip and palate include:
    • Providing adequate bony matrix for the developing teeth (e.g. canine and lateral)
    • Closure of any residual oronasal fistula(s)
    • Create alveolar ridge continuity
    • Improve bony support for the nasal base on the cleft side.
  • In patients with bilateral deformities, there is an additional goal of stabilizing the mobile premaxillary segment. Reconstruction of the bilateral cleft defects consolidates the maxillary arch into a continuous bony structure and enhances orthodontic stability.
  • Rule of 10s
    • 10 weeks of age
    • Weighs at least 10 lbs
    • Serum hemoglobin of at least 10mg/dl
  • Secondary bone grafting performed between 6 to 10 years, depending on the child’s dental development – when maxillary canine is ¼ to 2/3 developed
  • Goals of reconstruction include:
  • Providing adequate bony matrix for the developing teeth
  • Closure of any residual oronasal fistulas
  • Create alveolar ridge continuity
  • Improve bony support for the nasal base on the cleft side
  • Bilateral cleft palate – stabilize mobile premaxillary segment
  • Cleft lip with or without cleft palate is a common congenital malformation with an incidence of approximately 1 in 700 live births, but significant variation is encountered when different ethnic/racial populations are examined. African Americans have an incidence which is significantly lower than the general population while Asians and Native-Americans have the highest rates of birth prevalence. By contrast, isolated cleft palate has a lower overall incidence of approximately 1 in 2,000 live births with similar distribution among the different racial and ethnic populations. Of note is that children with isolated cleft palate are almost five-times more likely to also have some other underlying syndromic condition.
  • One stage repair of the secondary palate: Cleft palate repair is generally undertaken between the ages of 10 and 18 months, The choice of timing is a balance between optimizing facial growth and the development of normal speech patterns. Repair prior to this age range has little impact on speech outcomes but does impact negatively on midfacial growth. Repair is then chosen to coincide with the generation of early speech such that a child who is not yet speaking need not undergo palatal repair with any sense of urgency. Delay of palatal repair beyond 18 months is generally felt to be detrimental to speech outcomes.
  • Two-flap palatoplasty techniques involve the elevation of full-thickness mucoperiosteal flaps on each side of the cleft defect for oral side closure. After the nasal mucosa is closed, these soft tissue flaps are sutured together in the midline for closure of the cleft defect. During the initial dissection and elevation of the flaps, the greater palatine neurovascular bundles are identified and protected. The result is that the axial soft tissue flaps are raised based upon the blood supply of the greater palatine arteries bilaterally. If the greater palatine artery is injured or cauterized, surgery may proceed without any modifications. This is because of the abundant blood supply provided by the palatal soft tissue pedicle.Injury to the greater palatine artery simply converts the palatal flap’s blood supply from an “axial” pattern to a “random” pattern (i.e. not based on one specific arterial supply).
  • While a deterioration in velopharyngeal function is a very common manifestation after maxillary advancement surgery in the cleft palate population, the long term incidence is only approximately 18%. Because of the demonstrated recovery potential, it is most prudent to delay any interventions until sufficient time has passed to allow for  spontaneous return of function.  after waiting 6 months to 1 year to allow for spontaneous recovery.
  • Pharyngeal myomucosal flap contains a portion of what muscle? The pharyngeal flap is fashioned on the posterior pharyngeal wall by incising through mucosa and bluntly dissecting through superior constrictor until prevertebral fascia is identified. A superior pedicle is maintained for this finger-like, random pattern flap that is then sewn into the soft palate.
    • The superiorly based pharyngeal flap recruits tissue from the posterior wall of the pharynx and inserts it within the nasals side of the soft palate. The procedure involves the elevation of a superiorly based myomucosal flap (includes mucosa and superior pharyngeal constrictor muscle) off of the underlying pre-vertebral fascia. During the dissection, vertical incisions are made and blunt dissection is utilized to reach a glistening, distinct fascial layer. The soft palate is then split with dissection of the oral, nasal , and muscular layers. The flap is then inset into the nasal side closure and the oral mucosa is closed over the raw surface.
  • Submucosal cleft: 
    • As described by Calnan, the classic clinical findings seen when a patient has a submucous cleft palate are a triad of bifid uvula, hard palate bony notch, and separation along the median raphe of the soft palate especially during elevation of the velum. When a submucous cleft palate is present, the levator muscle is clefted and inserts abnormally into the posterior edge of the hard palate. The primary functional concern related to submucous cleft palate is the possibility that the patient will develop velopharyngeal insufficiency and hypernasal speech as with other cleft palate patients.
    • The lone indication for repair of a submucous cleft palate is the presence of velopharyngeal dysfunction.
  • Phase I orthodontic treatment: Surgical reconstruction of the child with cleft lip and palate requires familiarity with orthodontic management especially when considering sequencing of the procedures. Phase I orthodontic care of the child with bilateral cleft lip and palate should consist of maxillary transverse expansion to reduce cross-bites and align the pre-maxilla for position and symmetry. This will allow proper bone graft placement and consolidation of the premaxilla in the most appropriate position for function and aesthetics.
  • Intravelar veloplasty: The term “intravelar veloplasty” was first used by Kriens in 1969 to describe a muscular reconstruction of the cleft palate. In particular, the levator veli palatini, which lie in an abnormal sagittal orientation and are aberrantly inserted at the posterior edge of the hard palate, are mobilized and re-oriented to lie transversely across the palate in a more normal orientation. The goal is to restore normal palatal function through the restitution of normal palatal functional anatomy. The salpingopharyngeous, palatoglossus and superior constrictor, though part of the velopharyngeal mechanism, are not directly involved in this muscular reconstruction. The tensor veli palatini muscle passes around the hamular process and is not part of the musculature that is re-directed during veloplasty.