A Technique for Cleft Palate Repair - Intravelar veloplasty

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 Fergusson1 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 Kriens5 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. Liston7 in London described tensor tenotomy, and Billroth8 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 dissection. However, the philosophy of radical muscle correction is similar. TECHNIQUE The aim is to repair the entire palate at 6 months. The author has used the operating microscope for all palate repairs since 1991. The microscope gives excellent magnification and illumination (Fig. 1) and with practice becomes very easy to use and comfortable for the surgeon.10 After infiltration with lignocaine and adren- aline, an incision is made along the margins of the cleft at the junction between oral and nasal mucosa (usually on the oral side of the edge of the cleft). Even in clefts of the soft palate, the midline incision is extended onto the posterior hard palate and a posterior mucoperiosteal flap is elevated to expose the posterior border of the hard palate. This dissection is extended backward by a combination of knife dissection (particularly where there are dimples in the palatal mucosa) and blunt dissection with a dental scaler. Laterally, the scaler passes be- hind the greater palatine vessels and posteri- orly beyond the posterior edge of the hard palate, raising mucous glands to expose the white triangular nasal insertion of the tensor tendon (Fig. 2). It is possible to pass a blunt instrument around the greater palatine neuro- vascular bundle to lift it out of its foramen and to gently incise the periosteal sheath around it, to allow mobilization if necessary to achieve closure of the oral layer. The oral component of the tensor tendon can be visualized and felt behind the greater palatine vessels and incised if closure of the oral layer is expected to be tight. These maneuvers help to make lateral releasing incisions unnecessary in the majority of cases, but if required, they may be per- formed before exposure of the tensor tendon or at closure and are kept as small as possible. F IG . 2. (Above) A close-up view and (below) line drawing of the right side, showing the cleft margin of the nasal mucosa vertically on the left, a hook elevating the oral mucosa on the right, and the triangular insertion at the cleft tensor palati tendon in the center, inserting onto the back of the hard palate. F IG . 1. (Above) A surgeon’s eye view and (below) line draw- ing of a cleft involving most of the soft palate, with incisions marked. 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. Vol. 112, No. 6 / CLEFT PALATE REPAIR 1543 80 percent of all palate repairs (Table I). More specifically, no lateral incisions were made in 80 percent of unilateral cleft lip and palate cases (92 percent if vomerine flaps had been used for single-layer closure of the hard palate at lip repair; Table II) or in 84 percent of clefts of the secondary palate (ranging from 59 per- cent in complete clefts to 100 percent in clefts of 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 fistulas requiring repair has been 14 percent in unilat- eral cleft lip and palate, 35 percent in bilateral cleft lip and palate, and 12 percent in clefts of the secondary palate. The overall fistula rate in these 285 palate repairs has been 15 percent and 12 percent if bilateral cleft lip and palate is excluded. On the basis of a 10-year follow-up, of all those patients whose palates had been person- ally repaired by the author (usually at 6 months and all before 12 months), with no exclusions (for example, for syndromes), secondary velo- pharyngeal surgery had been performed in nine of 88 palate repairs (10.2 percent) per- formed from 1978 to 1982 inclusive, eight of 162 repairs (4.9 percent) performed from 1983 to 1987 inclusive, and nine of 192 repairs (4.6 percent) performed from 1988 to 1992 inclu- sive (Table IV). An independent review of 40 patients under- going surgical treatment for varying degrees of submucous cleft palate showed encouraging results.14 Palate re-repair, using a similar technique (as a secondary procedure), was reported in 33 patients, most of whom had had little or no primary muscle correction,15 and in a more recent study in an additional 85 patients, most of whom had had some attempt at correction of the cleft muscle deformity elsewhere.16 Both studies confirm the benefits of this radical mus- cle correction, performed as a secondary pro- cedure, enabling a pharyngoplasty to be avoided in about 80 percent of cases. D ISCUSSION Many surgeons have felt it necessary to raise long palatal flaps based on the greater palatine vessels (Veau,3 Wardill,17 and Kilner18 ) on the probably mistaken hypothesis that these lengthen the palate. Others have also used these flaps or longer oral mucoperiosteal flaps 19 as a means of access to the soft palate musculature. The author approaches the soft palate 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 all palate repairs (20 percent of unilateral cleft lip TABLE I Langenbeck Flaps from 1993 to 1997 Inclusive* Flaps No Flaps No. % No. % UCLP (n
80) 16 20 64 80 BCLP (n
28) 20 71 8 29 CP (n
177) 29 16 148 84 UCLP, unilateral cleft lip and palate; BCLP, bilateral cleft lip and palate; CP, clefts of the secondary palate. The numbers of patients requiring lateral releasing incisions in each main cleft palate subgroup in a 5-year period from 1993 to 1997 inclusive. TABLE II Langenbeck Flaps for Patients with Unilateral Cleft Lip and Palate (n
80), from 1993 to 1997 Inclusive Flaps No Flaps No. % No. % Complete (n
65) Vomerine (n
48) 4 8 44 92 No vomerine (n
17) 10 59 7 41 Incomplete (n
15) 2 13 Early in this period, the author changed protocol to include vomerine flaps nasal layer closure of the hard palate at the time of cleft lip repair at 3 months. TABLE III Langenbeck Flaps for Patients with Clefts of the Secondary Palate (n
177), from 1993 to 1997 Inclusive Flaps No Flaps No. % No. % HP 3/3 (n
29) 12 41 17 59 HP 2/3 (n
35) 11 31 24 69 HP 1/3 (n
52) 6 12 46 88 HP 0/3 (n
61) 0 0 61 100 Data show the decreasing requirement for lateral releasing incisions with decreasing extent of the cleft. TABLE IV Secondary Velopharyngeal Surgery within 10 Years of Cleft Palate Repair Palate Repairs Re-Repairs First Pharyngoplasty Total 1978–1982 88 4 5 9 (10.2%) 1983–1987 162 4 4 8 (4.9%) 1988–1992 192 2 7 9 (4.6%) * Data shown are number of patients requiring secondary velopharyngeal surgery 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 increased and the final secondary velopharyngeal surgery roles will therefore be higher if patients are followed to maturity and beyond. 1546 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2003 and palate and 8 percent if vomerine flaps had been used, and 16 percent of clefts of the secondary palate). A little breakdown at the junction of hard and soft palate, which heals spontaneously, is not uncommon. In the 5-year period from 1993 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 palate cases are excluded). This rate may have more to do with attempts to avoid lateral releasing incisions than with muscle dissection, but it is regarded as a price worth paying for fewer scars and the hope that this will result in less cross- bite and maxillary retrusion. No cases of loss of levator function have been identified, which suggests that the neuro- vascular supply—at least of the levator—is not damaged by this procedure. Studies of exten- sibility following secondary repairs (re-repairs) using this technique have shown an increase in the 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 an independently conducted audit of 20 children with complete unilateral cleft lip and palate20 fulfilling the Eurocleft Study criteria21 showed better maxillary growth than in any of the orig- inal six centers at the age of 8 to 11 years. Rates for secondary velopharyngeal surgery are difficult to compare. They depend on in- clusions and exclusions, the threshold of the cleft team to perform operations such as pha- ryngoplasty, the patient’s and/or parents’ wishes, and the length and completeness of follow-up. Follow-up in most series has been relatively short. Cutting et al.9 report pharyn- goplasty flap rates by the age of 6 years. How- ever, the author’s experience is that secondary velopharyngeal surgery may be performed at any age up to maturity (Table V). With a min- imum of 10 years of follow-up, the author’s secondary velopharyngeal surgery rate de- creased from 10.2 to 4.9 to 4.6 percent in successive 5-year periods (Table IV). The technique has evolved over a 24-year period. There appears to be a significant re- duction in velopharyngeal incompetence asso- ciated with increasingly radical surgery and, of course, increased experience of the operator. More radical muscle dissection and retroposi- tioning than have been generally described ap- pear to improve palatal function, but the search continues for an even more functional palate repair.