Sommerlad 2003 - PRS - IVVP

Summary

This paper describes a surgical technique for cleft palate repair developed by the author, Brian Sommerlad, over a 24-year period. The goal is to achieve a functional soft palate and reduce the need for secondary velopharyngeal surgery.

The key features of this technique are:

• Repair of the entire palate by 6 months of age.

• Use of an operating microscope for excellent visualisation and illumination.

• Incisions made along the margins of the cleft, avoiding large mucoperiosteal flaps. Lateral releasing incisions are avoided where possible.

• The tensor tendon insertion is exposed by blunt dissection and incised. The oral component of the tensor is also released if needed for tension-free closure. This allows radical retropositioning of the abnormal velar musculature without damaging the neurovascular supply.

• The nasal layer is closed first, then the velar muscles are retropositioned and the oral layer closed. Mucous glands are preserved on the nasal layer near the midline.

• Both the nasal and oral components of the tensor tendon are released from their abnormal insertions.

Results are reported for 442 primary palate repairs by the author, with minimum 10 year follow up. Lateral releasing incisions were avoided in 80% of cases overall. The fistula rate was 15% from 1993-1997.

The rate of secondary velopharyngeal surgery (pharyngoplasty or re-repair) steadily declined over successive 5 year periods, from 10.2% to 4.9% to 4.6%. This suggests improved velopharyngeal function with increased experience and more radical muscle retropositioning compared to historical techniques.

Independent studies of speech outcomes after re-repair and in submucous cleft palate repair also indicate enhanced velar function with this technique.

Potential concerns such as damage to the neurovascular supply or maxillary growth impairment seem unfounded based on the results. Maxillary growth was better compared to Eurocleft centres in one audit.

In summary, this surgical technique combines minimal palatal flap elevation with radical retropositioning of the abnormal velar muscles, tensor tenotomy and microscope visualisation. The goal is a tension-free oral layer closure and reconstitution of normal levator muscle position across the midline.

Results suggest reduced rates of fistulae and velopharyngeal insufficiency compared to historical techniques. However the search continues for further refinements to achieve an even more functional repair. This technique requires surgical experience and skill but shows promising functional outcomes. Further studies directly comparing techniques are warranted.