A technique for cleft palate repair

The author has developed a technique of palate repair that combines minimal hard palate dissection with radical retropositioning of the velar musculature and tensor tenotomy. The repair is performed under the operating microscope. 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. Evidence from independent assessment of speech results in palate re-repair and submucous cleft palate repair suggests that this more radical muscle dissection improves velar function.     

Management and timing of cleft palate fistula repair

This study reviewed 199 cleft palate repairs resulting in 22 percent fistula formation. Of these, 49 percent were judged to be symptomatic. Of 44 fistulas, 21 required treatment, of which 14 had conventional type surgical closure with an overall success rate of 35 percent. Good surgical technique and good surgical judgment were felt to be important factors both in preventing postoperative fistula and in the success of their repair. Conventional methods of surgical repair of hard palate fistulas were seen to result in a very poor success rate. Orthodontic movement of maxillary segments was seen to contribute to late postoperative fistula formation. Therefore, orthodontic movement should be completed before undertaking surgical repair of anterior palatal fistulas. Finally, the success rate of anterior fistula repair has been dramatically improved by the addition of free periosteal grafts and cancellous bone grafts.     

Experience with the Furlow double-reversing Z-plasty for cleft palate repair

One-hundred and six cases of soft palate closure using the Furlow double-reversing Z-plasty technique have been reported. Most of these patients have been done in the past 2 years. There seem to be a number of worthwhile advantages to this procedure, with few disadvantages or complications. The operation is adaptable for use in early soft palate closure (3 to 6 months) as well as late closure (12 to 14 months), in submucosal clefts, as well as in secondary palatal repair where lengthening and repositioning of the levator muscle is desired. With this type of palatoplasty, the need for raising or shifting large mucoperiosteal flaps from the hard palate has been completely avoided. The operation can be combined with a primary posterior pharyngeal flap if desired, although this is not advised if early palatal closure (3 to 6 months) is used because of a high incidence of sleep apnea. Preliminary speech results are very encouraging.     

The use of the operating microscope for cleft palate repair and pharyngoplasty

Since 1991, the author has used the operating microscope for all palate and pharyngeal operations. There are benefits for the surgeon, who operates in a more comfortable position with reliable lighting and variable magnification; for trainees and operating room staff, who have the same view as the surgeon, either through a teaching arm or on a video screen; and, it is hoped, for the patient, as the anatomy is more clearly displayed and potentially, therefore, more accurately reconstructed.     

A model for fetal cleft lip repair in lambs.

Fetal wounds heal without inflammation and scar formation. This phenomenon may, in the future, be applicable to human cleft lip and palate repair. However, extensive experimental work must first be done to document the benefits of in utero repair. We developed a large animal model for creation and repair of a complete cleft lip and alveolus using fetal lambs. The cleft lip and alveolus deformity was created in eight 75-day-gestation fetuses (term = 145 days) and either repaired in three layers or left unrepaired. There were four sham-operated fetuses, and all animals were alive at harvest. Repaired, unrepaired, and control fetuses were harvested at 7, 14, 21, and 70 days following surgery. The unrepaired fetuses demonstrated a complete cleft lip and alveolus with an oronasal fistula. The maxilla was asymmetrical, with the greater segment deviated toward the cleft and with decreased anterior maxillary width. In contrast, repaired cleft lip and alveolus animals showed no scar, normal thickness of the lip, and a symmetrical maxilla. Histologic analysis of the repaired wounds showed evidence of tissue regeneration without scar formation. The results of this preliminary study indicate that the fetal lamb cleft lip and alveolus model is technically feasible with an excellent survival rate. Healing occurs without scar formation. In the repaired animals, the maxilla was symmetrical. This model will be used to document facial growth following in utero repair of a cleft lip and alveolus.     

Uvular transposition: a new method of cleft palate repair

This prospective study was done to determine whether a new cleft palate repair utilizing uvular transposition improved speech outcome as measured objectively by a speech pathologist. In the uvular transposition procedure, the palate was lengthened with tissue from the uvula by a double-opposing Z-plasty; an intravelar veloplasty was performed, and two-thirds of the mass of the uvula was transposed to the nasal surface of the soft palate. This procedure facilitates velopharyngeal closure by significantly lengthening the palate, anatomically reconstructing the muscles of the palate, and decreasing the palatal excursion necessary to achieve closure. Sixty-two children with a cleft palate were treated with this procedure performed by the senior surgeon between the years of 1988 and 1995. These children were then enrolled in cleft lip and palate clinic at age 2 to 3 years and blindly evaluated yearly by a single speech pathologist who specialized in pediatric speech pathology. Postoperative clinical follow-up ranged from 36 to 112 months (mean, 56.8 months). Perceptual nasal emission was found to be normal in 59 of the 62 patients (95 percent). Nasometry was performed in all 62 of these patients, and the mean score was 15.7 percent, well within the accepted normal range of 25 or less at our institution. Only two of these children (3 percent) required a pharyngeal flap for velopharyngeal insufficiency. These findings suggest that the uvula transposition cleft palate repair may result in good normalization of speech with negligible rates of velopharyngeal insufficiency.