A Technique for Cleft Palate Repair Brian C. Sommerlad, M.B., B.S., F.R.C.S. London and Essex, United Kingdom The author has developed a technique of palate repair that combines minimal hard palate dissection with radical retropositioning of the velar musculature and tensor teno- tomy. The repair is performed under the operating mi- croscope. Results are reported for 442 primary palate repairs performed between 1978 and 1992 inclusive, with follow-up of at least 10 years. In 80 percent of these palate repairs, repair was carried out through incisions at the margins of the cleft and without any mucoperiosteal flap elevation or lateral incisions. Secondary velopharyngeal rates have decreased from 10.2 to 4.9 to 4.6 percent in successive 5-year periods within this 15-year period. Evi- dence from independent assessment of speech results in palate re-repair and submucous cleft palate repair sug- gests that this more radical muscle dissection improves velar function. (Plast. Reconstr. Surg. 112: 1542, 2003.) The abnormal musculature of the cleft pal- ate was described by Fergusson 1 and then by Veau, 2,3 who described the abnormal tensor veli palatini (the tensor) and the “cleft mus- cle.” The first description of correction of this abnormal musculature during palate repair was by Braithwaite, 4 while Kriens 5 coined the term “intravelar veloplasty.” The detailed anat- omy of the muscles in the normal velum was described by Boorman and Sommerlad, 6 who demonstrated that the levator veli palatini mus- cle (the levator) occupied the middle 40 per- cent of the velum. Interest in the tensor was related to tech- niques to release its tension to facilitate palate closure. Liston 7 in London described tensor tenotomy, and Billroth 8 in Vienna described fracture of the hamulus, both designed to make closure of the palate easier. Anatomical dissections of the normal tensor tendon have shown that it is at least partially attached to the hamulus and that division of the tensor tendon medial to the hamulus should not affect the role of the muscle in eustachian function. The tensor tendon normally fans out to form the relatively elastic aponeurosis, which occupies the anterior third of the velum. In the cleft, the tensor tendon is in two parts. Its most nasal component forms a dense fibrous triangular structure, close to the nasal mucosa, passing from the hamulus and attached to the poste- rior border of the hard palate laterally. A more oral component passes toward the oral mucosa immediately behind the greater palatine neu- rovascular bundle and is well seen when lateral releasing incisions are made. The normal levator is not significantly at- tached to the tensor aponeurosis, but it reaches the midline in the middle 40 percent of the velum. The levator muscle in the cleft is, however, closely related to the tensor tendon– like aponeurosis and is inserted mainly at the margins of the cleft in the anterior half to two thirds of the velum. Cutting et al. 9 have independently evolved a technique of radical reconstruction of the pal- atal musculature, which has much in common with the technique to be described but some differences. In particular, the author’s tech- nique does not require mucoperiosteal palatal flap elevation, the velar musculature is exposed by raising the oral mucosa in a plane between the mucous glands and the muscles, the nasal layer is closed before muscle retropositioning, mucous glands are left attached to the nasal mucosa near the midline, and both the oral and the nasal components of the tensor ten- don are divided from their insertions. The op- eration is carried out under the operating mi- croscope and with knife rather than scissor From the Great Ormond Street Hospital for Children and St. Andrew’s Centre for Plastic Surgery, Broomfield Hospital. Received for publication August 21, 2002; revised January 9, 2003. DOI: 10.1097/01.PRS.0000085599.84458.D2 1542
Transcript
A Technique for Cleft Palate RepairBrian C. Sommerlad, M.B., B.S., F.R.C.S.London and Essex, United Kingdom
The author has developed a technique of palate repairthat combines minimal hard palate dissection with radicalretropositioning of the velar musculature and tensor teno-tomy. The repair is performed under the operating mi-croscope. Results are reported for 442 primary palaterepairs performed between 1978 and 1992 inclusive, withfollow-up of at least 10 years. In 80 percent of these palaterepairs, repair was carried out through incisions at themargins of the cleft and without any mucoperiosteal flapelevation or lateral incisions. Secondary velopharyngealrates have decreased from 10.2 to 4.9 to 4.6 percent insuccessive 5-year periods within this 15-year period. Evi-dence from independent assessment of speech results inpalate re-repair and submucous cleft palate repair sug-gests that this more radical muscle dissection improvesvelar function. (Plast. Reconstr. Surg. 112: 1542, 2003.)
The abnormal musculature of the cleft pal-ate was described by Fergusson1 and then byVeau,2,3 who described the abnormal tensorveli palatini (the tensor) and the “cleft mus-cle.” The first description of correction of thisabnormal musculature during palate repairwas by Braithwaite,4 while Kriens5 coined theterm “intravelar veloplasty.” The detailed anat-omy of the muscles in the normal velum wasdescribed by Boorman and Sommerlad,6 whodemonstrated that the levator veli palatini mus-cle (the levator) occupied the middle 40 per-cent of the velum.
Interest in the tensor was related to tech-niques to release its tension to facilitate palateclosure. Liston7 in London described tensortenotomy, and Billroth8 in Vienna describedfracture of the hamulus, both designed tomake closure of the palate easier. Anatomicaldissections of the normal tensor tendon haveshown that it is at least partially attached to thehamulus and that division of the tensor tendonmedial to the hamulus should not affect the
role of the muscle in eustachian function. Thetensor tendon normally fans out to form therelatively elastic aponeurosis, which occupiesthe anterior third of the velum. In the cleft, thetensor tendon is in two parts. Its most nasalcomponent forms a dense fibrous triangularstructure, close to the nasal mucosa, passingfrom the hamulus and attached to the poste-rior border of the hard palate laterally. A moreoral component passes toward the oral mucosaimmediately behind the greater palatine neu-rovascular bundle and is well seen when lateralreleasing incisions are made.
The normal levator is not significantly at-tached to the tensor aponeurosis, but itreaches the midline in the middle 40 percentof the velum. The levator muscle in the cleft is,however, closely related to the tensor tendon–like aponeurosis and is inserted mainly at themargins of the cleft in the anterior half to twothirds of the velum.
Cutting et al.9 have independently evolved atechnique of radical reconstruction of the pal-atal musculature, which has much in commonwith the technique to be described but somedifferences. In particular, the author’s tech-nique does not require mucoperiosteal palatalflap elevation, the velar musculature is exposedby raising the oral mucosa in a plane betweenthe mucous glands and the muscles, the nasallayer is closed before muscle retropositioning,mucous glands are left attached to the nasalmucosa near the midline, and both the oraland the nasal components of the tensor ten-don are divided from their insertions. The op-eration is carried out under the operating mi-croscope and with knife rather than scissor
From the Great Ormond Street Hospital for Children and St. Andrew’s Centre for Plastic Surgery, Broomfield Hospital. Received forpublication August 21, 2002; revised January 9, 2003.
DOI: 10.1097/01.PRS.0000085599.84458.D2
1542
dissection. However, the philosophy of radicalmuscle correction is similar.
TECHNIQUE
The aim is to repair the entire palate at 6months. The author has used the operatingmicroscope for all palate repairs since 1991.The microscope gives excellent magnificationand illumination (Fig. 1) and with practicebecomes very easy to use and comfortable forthe surgeon.10
After infiltration with lignocaine and adren-aline, an incision is made along the margins ofthe cleft at the junction between oral and nasalmucosa (usually on the oral side of the edge ofthe cleft). Even in clefts of the soft palate, themidline incision is extended onto the posteriorhard palate and a posterior mucoperiostealflap is elevated to expose the posterior borderof the hard palate. This dissection is extendedbackward by a combination of knife dissection
(particularly where there are dimples in thepalatal mucosa) and blunt dissection with adental scaler. Laterally, the scaler passes be-hind the greater palatine vessels and posteri-orly beyond the posterior edge of the hardpalate, raising mucous glands to expose thewhite triangular nasal insertion of the tensortendon (Fig. 2). It is possible to pass a bluntinstrument around the greater palatine neuro-vascular bundle to lift it out of its foramen andto gently incise the periosteal sheath around it,to allow mobilization if necessary to achieveclosure of the oral layer. The oral componentof the tensor tendon can be visualized and feltbehind the greater palatine vessels and incisedif closure of the oral layer is expected to betight. These maneuvers help to make lateralreleasing incisions unnecessary in the majorityof cases, but if required, they may be per-formed before exposure of the tensor tendonor at closure and are kept as small as possible.
FIG. 2. (Above) A close-up view and (below) line drawing ofthe right side, showing the cleft margin of the nasal mucosavertically on the left, a hook elevating the oral mucosa on theright, and the triangular insertion at the cleft tensor palatitendon in the center, inserting onto the back of the hardpalate.
FIG. 1. (Above) A surgeon’s eye view and (below) line draw-ing of a cleft involving most of the soft palate, with incisionsmarked. The upper alveolus (held in the mouth gag) is below,the tongue blade of the mouth gag is above, and the over-lapping cleft uvula is in the center of the photograph.
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The oral mucosa of the velum, with attachedmucous glands, is then dissected off the mus-culature by knife and blunt dissection to theposterior border of the velum and laterally tothe pterygoid hamulus. The nasal mucosa isthen mobilized if necessary off the palatalshelves and sutured in the midline. Suturing ofthe nasal layer before muscle dissection makesthe dissection easier by providing the tensionnecessary for sharp knife dissection. Using suc-tion for exposure and gentle retraction, anincision is made on each side of the midline.Posteriorly, this incision is about 3 mm fromthe midline and it passes closer to the midlineanteriorly, just lateral to the nasal layer sutures.This knife dissection extends deeply to the na-sal mucosa (which appears almost blue), leav-ing mucous glands centrally. Knife dissectionthen continues laterally in a plane betweennasal mucosa and musculature for 5 mm to 10mm, leaving small vessels on the nasal mucosa.The head is turned, the microscope adjusted,
and with a skin hook in the musculatureand/or the tensor tendon, the muscle and thetendon are divided from the posterior hardpalate by an incision parallel to it. This knifedissection continues until the nasal mucosa isseen (Fig. 3). It is important to identify the“blue” nasal mucosa and to be sure that allmuscle and tendon has been divided. An occa-sional small hole in the nasal mucosa does notseem to cause problems, and in fact, stab inci-sions are made intentionally in the nasal layerto minimize the risk of hematoma.
The incision then passes backward at 90 de-grees to the posterior border of the hard pal-ate, alongside the pterygoid hamulus, with di-vision of the tensor tendon medial to thehamulus. With tension maintained on the de-veloping muscle bundles, the muscle is furtherseparated from its insertions into the nasal mu-cosa by a combination of knife and blunt dis-section. When the posterior fibers of the tensorhave been divided, a noticeable retroposition-
FIG. 3. (Above) A high-power view and (below) line drawingof the right side, showing the tensor tendon being divided bya scalpel (center inferiorly) from the back of the hard palate.
FIG. 4. In the (above) photograph and (below) line draw-ing, after dissection of the musculature, the retro-displacedright levator muscle is seen as an almost transverse discretebundle close to the center of the screen. A hole in the nasalmucosa is seen below the levator.
1544 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2003
ing of the muscles occurs and it is usually pos-sible at this stage to elevate and split the moreoral palatoglossus and palatopharyngeus fibersto expose the levator palati. The levator is seenas a discrete cylindrical muscle within a thinfascial envelope (Fig. 4) with neurovascularstructures lying on its anterior and oral surface.Sharp and blunt dissection continues until themuscle bundle is felt to be freely mobile, butcare must be taken to leave as many neurovas-cular structures as possible undamaged, to en-sure that neither devascularization nor dener-vation of the muscle occurs.
The muscle is then united, usually in theposterior half of the velum (Fig. 5), with non-absorbable 4-0 or 5-0 nylon sutures, with theanterior suture usually picking up a segment ofthe retrodisplaced tensor tendon to providestrength to the repair. The first suture in theoral mucosa is inserted just in front of themuscle and picks up the nasal mucous glandswith a loop mattress suture11,12 (Fig. 6). One ortwo further absorbable oral/nasal layer loopmattress sutures are inserted anteriorly to oc-
clude dead space and to keep the muscle in itsposterior position. The loop mattress suturedecreases tension. For the nasal layer, the au-thor uses 4-0 or 5-0 monofilament absorbablesuture, [currently 5-0 Monocryl on a 16-mm 3⁄8curve reverse cutting needle (W3204), or on a16-mm compound curve reverse cutting needle(Special NP0127) for more difficult areas]. Forthe oral layer, 3-0 or 4-0 monofilament absorb-able suture is used on a 5⁄8 curve needle [cur-rently 4-0 Monocryl on a 17-mm 5⁄8 curve taper-cut needle (Special NP0128), or on a 16-mmcompound curve reverse cutting needle (Spe-cial NP0126) for more difficult areas, especiallyanteriorly]. The Special sutures NP0126,NP0127, and NP0128 are being developed forthe author’s use by Ethicon (Edinburgh,Scotland).
The baby is allowed to bottle feed soon afterthe repair. The baby’s arms are not splinted.13
RESULTS
In a 5-year period (from 1993 to 1997 inclu-sive), only cleft marginal incisions with no lat-eral incisions (Langenbeck flaps) were made in
FIG. 5. (Above) A lower-power view and (below) line draw-ing show the sutured nasal mucosa with the posterior borderof the velum above. A nonabsorbable suture is being insertedto oppose the retro-displaced muscle. The needle holder is inthe top left corner of the photograph, inserting the needle intothe left levator. Stay sutures retract the oral mucosa.
FIG. 6. In the (above) photograph and (below) line draw-ing, a loop mattress suture is being inserted from oral to nasalmucosa in front of the repaired muscle.
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80 percent of all palate repairs (Table I). Morespecifically, no lateral incisions were made in80 percent of unilateral cleft lip and palatecases (92 percent if vomerine flaps had beenused for single-layer closure of the hard palateat lip repair; Table II) or in 84 percent of cleftsof the secondary palate (ranging from 59 per-cent in complete clefts to 100 percent in cleftsof the soft palate alone; Table III.)
In the 5-year period from 1993 to 1997 in-clusive (Tables I, II, and III), the rate of fistulasrequiring repair has been 14 percent in unilat-eral cleft lip and palate, 35 percent in bilateralcleft lip and palate, and 12 percent in clefts ofthe secondary palate. The overall fistula rate inthese 285 palate repairs has been 15 percentand 12 percent if bilateral cleft lip and palate isexcluded.
On the basis of a 10-year follow-up, of allthose patients whose palates had been person-ally repaired by the author (usually at 6 monthsand all before 12 months), with no exclusions(for example, for syndromes), secondary velo-pharyngeal surgery had been performed innine of 88 palate repairs (10.2 percent) per-formed from 1978 to 1982 inclusive, eight of162 repairs (4.9 percent) performed from 1983to 1987 inclusive, and nine of 192 repairs (4.6percent) performed from 1988 to 1992 inclu-sive (Table IV).
An independent review of 40 patients under-going surgical treatment for varying degrees ofsubmucous cleft palate showed encouragingresults.14
Palate re-repair, using a similar technique(as a secondary procedure), was reported in 33patients, most of whom had had little or noprimary muscle correction,15 and in a morerecent study in an additional 85 patients, mostof whom had had some attempt at correctionof the cleft muscle deformity elsewhere.16 Bothstudies confirm the benefits of this radical mus-cle correction, performed as a secondary pro-cedure, enabling a pharyngoplasty to beavoided in about 80 percent of cases.
DISCUSSION
Many surgeons have felt it necessary to raiselong palatal flaps based on the greater palatinevessels (Veau,3 Wardill,17 and Kilner18) on theprobably mistaken hypothesis that theselengthen the palate. Others have also usedthese flaps or longer oral mucoperiostealflaps19 as a means of access to the soft palatemusculature. The author approaches the softpalate muscles through the cleft marginal inci-sions. If necessary, von Langenbeck lateral re-leasing incisions are made. In a 5-year period,this was only necessary in 20 percent of allpalate repairs (20 percent of unilateral cleft lip
TABLE ILangenbeck Flaps from 1993 to 1997 Inclusive*
* Early in this period, the author changed protocol to include vomerineflaps nasal layer closure of the hard palate at the time of cleft lip repair at 3months.
TABLE IIILangenbeck Flaps for Patients with Clefts of the Secondary
* Data shown are number of patients requiring secondary velopharyngealsurgery within 10 years of cleft palate repair. However, as indicated in Table V,it is likely that in those cases with longer follow-up, these figures have increasedand the final secondary velopharyngeal surgery roles will therefore be higherif patients are followed to maturity and beyond.
1546 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2003
and palate and 8 percent if vomerine flaps hadbeen used, and 16 percent of clefts of thesecondary palate).
A little breakdown at the junction of hardand soft palate, which heals spontaneously, isnot uncommon. In the 5-year period from1993 to 1997 inclusive (Tables I, II, and III),the rate of fistula repair has been 15 percent(and 12 percent if bilateral cleft lip and palatecases are excluded). This rate may have moreto do with attempts to avoid lateral releasingincisions than with muscle dissection, but it isregarded as a price worth paying for fewer scarsand the hope that this will result in less cross-bite and maxillary retrusion.
No cases of loss of levator function havebeen identified, which suggests that the neuro-vascular supply—at least of the levator—is notdamaged by this procedure. Studies of exten-sibility following secondary repairs (re-repairs)using this technique have shown an increase inthe resting and extended length of the velum,implying that fibrosis is not a major problem.
The fear that this dissection may impair max-illary growth seems to be unfounded in that anindependently conducted audit of 20 childrenwith complete unilateral cleft lip and palate20
fulfilling the Eurocleft Study criteria21 showedbetter maxillary growth than in any of the orig-inal six centers at the age of 8 to 11 years.
Rates for secondary velopharyngeal surgeryare difficult to compare. They depend on in-clusions and exclusions, the threshold of thecleft team to perform operations such as pha-ryngoplasty, the patient’s and/or parents’wishes, and the length and completeness offollow-up. Follow-up in most series has beenrelatively short. Cutting et al.9 report pharyn-goplasty flap rates by the age of 6 years. How-ever, the author’s experience is that secondaryvelopharyngeal surgery may be performed atany age up to maturity (Table V). With a min-imum of 10 years of follow-up, the author’ssecondary velopharyngeal surgery rate de-creased from 10.2 to 4.9 to 4.6 percent insuccessive 5-year periods (Table IV).
The technique has evolved over a 24-yearperiod. There appears to be a significant re-duction in velopharyngeal incompetence asso-ciated with increasingly radical surgery and, ofcourse, increased experience of the operator.More radical muscle dissection and retroposi-tioning than have been generally described ap-pear to improve palatal function, but thesearch continues for an even more functionalpalate repair.
Brian C. Sommerlad, M.B., B.S., F.R.C.S.The Old Vicarage17 Lodge RoadWrittle, ChelmsfordEssex, CM1 3HYUnited [email protected]
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TABLE VSecondary Velopharyngeal Surgery in Successive 5-Year Periods after Palate Repair*
Palate Repairs 0 to �5 Years 5 to �10 Years 10 to �15 Years 15 to �20 Years 20 to �25 Years
* Data are expressed as number of patients. These data suggest that the follow-up period quoted in most articles is inadequate. All cases were personal repairswhere the palate was repaired before the patient reached the age of 12 months. There were no exclusions (for example, for syndromic diagnoses).
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cous cleft palate: A system of grading and a review ofa consecutive series of 40 submucous cleft palate re-pairs. Cleft Palate Craniofac. J. (in press).
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16. Sommerlad, B. C., Mehendale, F. V., Birch, M. J., Sell, D.,Hattee, C., and Harland, K. Palate re-repair revis-ited. Cleft Palate Craniofac. J. 39: 295, 2002.
17. Wardill, W. E. M. Technique of operation for cleft pal-ate. Br. J. Surg. 25: 97, 1937.
18. Kilner, T. P. Cleft lip and palate repair technique. In R.Maingot (Ed.), Postgraduate Surgery, Vol. 3. London:Medical Publishers, 1937.
19. Bardach, J., and Salyer, K. E. Cleft palate repair. In J.Bardach and K. E. Salyer (Eds.), Surgical Techniques inCleft Lip and Palate. St. Louis: Mosby Year Book, 1991.Pp. 224–273.
20. Chate, R., DiBiase, D., Ball, J., et al. A comparison of thedental occlusions from a United Kingdom sample ofcomplete unilateral cleft lip and palate patients, withthose from the Eurocleft Study. Transactions of The 8thInternational Congress on Cleft Palate and Related Cranio-facial Anomalies, Singapore, 1997.
21. Mars, M., Asher-McDade, C., Brattstrom, V., et al. Asix-center international study of treatment outcome inpatients with clefts of the lip and palate: Part 3. Dentalarch relationships. Cleft Palate J. 29: 405, 1992.
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