[Downloaded free from http://www.jclpca.org on Tuesday, January 05, 2016, IP: 36.80.189.
136]
Founder’s Lecture 2014
Repair of cleft palate: Evolution and current
trends
Chona Thomas
ABSTRACT
The management of a patient with cleft palate is
complex. Various prevalent surgical techniques are
presented, but no universal agreement exists on the
appropriate treatment strategy. There is a consensus
of opinion that normal speech should be the most
important consideration in the therapeutic plan.
Growth disturbance should be minimized, but not at
the expense of speech impairment because facial
distortion can be satisfactorily managed by surgery,
whereas speech impairment can often be irreversible.
There is a need for well-controlled, prospective studies
to establish the validity of the widely different claims of
superior results from various techniques. Cleft patients
should be managed in a center with a multidisciplinary
team. Cleft palate remains a significant and interesting
challenge for current and future plastic surgeons.
Key words: Cleft Palate, current trends,
palatoplasty, palate repair, present trend
HISTORY OF THE PROCEDURE
In 1552, Dr. Houlier proposed suturing of the palatal
clefts. Dr. Ambroise Pare in 1564, used obturators for
palatal perforations. Dr. Von Graefe was the person
to perform the velar repair of the cleft. In 1828,
Dr. Dieffenbach reflected the hard palatal mucosa for
the closure of the hard palatal cleft. In 1859, Dr. von
Langenbeck performed the bipedicled mucoperiosteal
flap for the repair of a cleft palate.[1]
With the ability to successfully close the palate, concern
about palatal function was raised. It was evident by
this time that the short and immobile palate impaired
Senior Consultant Plastic Surgeon, Muscat, Oman
Address for correspondence:
Dr. Chona Thomas, P. O. Box 180 Mina Al Fahal,
Postal Code 116, Muscat, Oman.
E-mail: chonathomas@gmail.com
6 January-June 2015 / Vol 2 / Issue 1
Access this article online
Website:
www.jclpca.org
DOI:
10.4103/2348-2125.150704
Quick Response Code:
the speech capability of patients with cleft palate. Veau
(1931), Wardill (1937) and Kilner (1937) described the
unipedicle mucoperiosteal flap based posteriorly on the
greater palatine artery that pushed the flap posteriorly to
lengthen the palate. The scarring of the denuded bone
areas anteriorly and laterally was suspected as the cause
of facial growth retardation. In 1944, Dr. Schweckendiek
advocated the use of a 2-stage cleft palate closure. The
soft palate was closed early (4-6 months), with the
closure of the hard palate delayed until 4-5 years later
(sometimes even at age 14-15 years). The rationale
for the 2-stage procedure was to provide improved
velopharyngeal function during the initial speech
development and to accomplish the closure of the hard
palate after the cleft narrows with facial growth thus
causing less facial growth retardation.[2]
Now, it is proved beyond doubt that the anatomic muscle
realignment is essential in improving postoperative
velopharyngeal function.[3,4]
A cleft palate has tremendous esthetic and functional
implications for patients in their social interactions,
particularly on their ability to communicate effectively
and on their facial appearance. Hence, the treatment
focuses on two areas:
1. Speech development.
2. Facial growth.
Speech development is foremost in the appropriate
management of cleft palate.
Still there are controversial issues in the repair of a
cleft palate, such as timing of surgical intervention,
speech development after various surgical procedures
and effects of surgery on facial growth.
PATHOPHYSIOLOGY
A child with cleft palate has feeding difficulties, liable
to get recurrent ear infection leading to hearing loss,
Journal of Cleft Lip Palate and Craniofacial Anomalies
[Downloaded free from http://www.jclpca.org on Tuesday, January 05, 2016, IP: 36.80.189.136]
Thomas: Palatoplasty: Evolution and current trends
abnormal speech development, and facial growth
distortion.
The goals of the surgical repair should be focused to
separate the oral and nasal cavities, the repositioning
of the soft palate musculature to anatomical position to
establish normal speech and to minimize the retardation
of growth of the maxilla.
Anatomical considerations
Based on the embryonic origin, the bony portion of the
palate is divided into primary and secondary palates.
The primary palate consists of premaxilla, alveolus,
and lip, which are anterior to the incisive foramen. The
secondary palate includes structures posterior to the
incisive foramen, and these are paired maxilla, palatine
bones and pterygoid plates.
The following six muscles have attachment to the palate.
They are levator veli palatini, superior constrictor
pharyngeus, musculus uvulus, palatopharyngeus,
palatoglossus and tensor veli palatini. Among these
muscles, three muscles that appear to have the greatest
contribution to the velopharyngeal function are levator
veli palatini, superior constrictor pharyngeus and
musculus uvulus.
The uvulae muscle acts by increasing the bulk of the
velum during muscular contraction. The levator veli
palatini pulls the velum superiorly and posteriorly
to oppose the velum against the posterior pharyngeal
wall. The medial movement of the pharyngeal wall,
attributed to superior constrictor pharyngeus, adds
in the opposition of the velum against the posterior
pharyngeal wall to form the competent sphincter
[Figures 1 and 2].
Figure 1: Normal anatomy of the soft palate, the levator palatini muscle is
seen as a sling across the posterior soft palate. (After Millard Dr. Jr. Cleft
Craft, vol iii. Boston, Little, Brown, 1989:19, 30)
Journal of Cleft Lip Palate and Craniofacial Anomalies
The tensor veli palatini does not contribute to the
movement of the velum. The function of the tensor veli
palatini, similar to tensor tympani with which it shares
a similar innervation, is to improve the ventilation and
drainage of the auditory tubes.
Timing of palatal closure
The ultimate outcome to be aimed for the repair of a
cleft palate is the development of normal speech. The
speech outcome depends on the surgical technique and
the timing of the palate repair. Most surgeons operate
between the age of 9-18 months.
Choice of operation includes single stage palatal closure,
palatal closure with palatal lengthening and either of the first
techniques with direct palatal muscle re-approximation.
Techniques of palate repair
von Langenbeck procedure
The bipedicle mucoperiosteal flaps by incising along
the oral side of the cleft edges and along the posterior
alveolar ridge. Mobilize the flaps medially with
preservation of the greater palatine arteries and closed
in layers. The hamulus may need to be fractured to ease
the closure [Figure 3a and b].[2]
Even though, it is a simple procedure, the speech
outcome is poor because of inadequate retroposition.
Palatal lengthening-V-Y pushback-Veau-Wardill-Kilner
technique
The essence of the push back repair is the V to Y
incision and closure on the hard palate. The hamulus
Figure 2: Cleft palate anatomy. The levator palatini muscle is displaced
longitudinally, almost parallel to the cleft. The tendon of the tensor palatini
muscle can be seen coming around the hamulus to join the aponeurosis
of the levator, division of this tendon is important to rotate the levator
back into a posterior position. Note the position of the vascular pedicles,
exiting through the palatine foramina. (After Millard Dr. Jr. Cleft Craft, vol
iii. Boston, Little, Brown, 1989:19, 30)
January-June 2015 / Vol 2 / Issue 1 7
[Downloaded free from http://www.jclpca.org on Tuesday, January 05, 2016, IP: 36.80.189.136]

Thomas: Palatoplasty: Evolution and current trends

is fractured,[3,4] and the muscle closure is affected as a

separate layer. The velopharyngeal function is improved
since there is an increased palatal length. However,
this technique creates a larger area of denuded palatal
bone anterolaterally and also associated with a higher
incidence of fistula formation [Figure 4].

Intravelar veloplasty
Careful dissection and freeing of the abnormal
attachment of levator palatini muscles from the posterior
part of the palatine bone and also from the aponeurosis
and rarely from the hamulus and re-approximation as a
midline layer has shown excellent speech outcomes. In a b
addition, it lengthens the palate and restores the normal Figure 3: (a) Operative marking of the technique. (b) Post-operative
appearance. (From Randall P LaRossa D: Cleft palate in McCarthy JG, ed:
muscular sling of the levator veli palatini.[3,5] Plastic Surgery, Philadelphia. WB Saunders. 1990: 2743)

Double-opposing Z-plasties-Furlow’s technique

There is a different lengthening of the palate as a
consequence of the new position of the velar and
pharyngeal tissues. [6,7] Speech development was
excellent in Furlow’s study. The Furlow’s technique
a b
appears to be quite successful in clefts of limited size.
In moderate-size clefts, lateral-relaxing incisions may
still be required to obtain closure. But in wide clefts,
this type of closure may not be possible [Figure 5a-d].
c d
Two-flap palatoplasty - (Bardach
and Salyer-1984)
The main goals are complete closure of the entire cleft
without tension at an early age with minimal exposure e f
of raw bony surfaces [Figure 6].[8] Figure 4: (a and b) Operative markings and the reflection of the oral and
nasal layers. (c and d) Hamulus is fractured and levator veli palatini is
identified. (e and f) Closure of the layers as nasal layer, muscle layer and
The intravelar veloplasty is an essential part of
oral layer (From Randall P LaRossa D: Cleft palate in McCarthy JG, ed:
this closure; hence this technique developed Plastic Surgery, Philadelphia. WB Saunders. 1990: 2744)
velopharyngeal function within normal limits and
also eliminates fistulas in the anterior hard palate
[Figures 7-9].

Postoperative management
Child is given nothing by mouth until 6 post-operative
hours or the next day. Hydration is maintained
during this time with intravenous fluid. Oximetry is a b
continuously monitored for 24-48 h. Arm splints are
also applied to prevent a child from disrupting the
wound by placing his fingers in his mouth. Oral feeding
is initiated by spoon or drinking from cups. The liquid
diet is continued for 7-10 days with solid food to follow.

Complications
Immediate complications are bleeding and respiratory
distress. Respiratory compromise secondary to
obstruction from the palate lengthening or sedation can
be life threatening. The wound dehiscence may happen
c d
Figure 5: (a) Operative markings of Z-plasties on both sides of the cleft
palate. (b) Reflection of the flaps by keeping the muscles in the opposing
flaps. (c) Nasal layer closure. (d) Oral layer closure (From Randall P
LaRossa D: Cleft palate in McCarthy JG, ed: Plastic Surgery, Philadelphia.
WB Saunders. 1990: 2740)

8 January-June 2015 / Vol 2 / Issue 1 Journal of Cleft Lip Palate and Craniofacial Anomalies
[Downloaded free from http://www.jclpca.org on Tuesday, January 05, 2016, IP: 36.80.189.136]
Thomas: Palatoplasty: Evolution and current trends
a b
c d
Figure 6: (a) Operative markings with reflection of the flaps. (b) Vomerine
flap closure in the anterior palate in wide cleft palate. (c) Nasal layer closure
with intravelar veloplasty. (d) Oral layer closure with the elimination of the
lateral raw areas by few interrupted stitches (From Randall P, LaRossa
D: Cleft palate in McCarthy JG, ed: Plastic Surgery, Philadelphia. WB
Saunders. 1990: 2740)
a b
c
Figure 8: (a) Pre-operative appearance of a complete wide left unilateral cleft
lip and palate. (b) Appearance after the repair of the cleft lip with primary
rhinoplasty by open approach along with the repair of the anterior palate at
3 months. (c) Appearance after the Repair of the Cleft Palate at 12 months
as a result of poor tissue quality and excessive wound
tension. This may lead to oro-nasal fistula. The main
long term sequelae is the palatal fistula, the incidence,
reported as 5-29%.
There are several contributory factors for the palatal
fistula such as type of cleft, type of the surgical repair,
wound tension, dead space below the mucoperiosteal
flaps and rapid maxillary arch expansion. The usual
strategy of the management of palatal fistula is the
closure of the fistula after completion of the arch
expansion. In general, the palatal fistulas may be
repaired with local flaps, tongue flaps and rarely needs
microvascular free flaps if the fistula is very large.
Velopharyngeal incompetence
The analysis of velopharyngeal competence after various
techniques is difficult to interpret in the different
studies. Morris reported Velopharyngeal competence of
Journal of Cleft Lip Palate and Craniofacial Anomalies
a b
c d
Figure 7: (a) Pre-operative markings of a complete cleft palate. (b) Reflection
of the palatal flaps based on the greater palatine neurovascular pedicles
after tenotomy of the tensor tympani and detachment of the abnormal
attachments of levator palatini muscles. (c) Intravelar Veloplasty after the
closure of the nasal layer. (d) Closure of the oral layer. Lateral raw areas
are covered with gel foam without any stitches
a
b
Figure 9: (a) Appearance of a post alveolar cleft palate. (b) Appearance of
the repair of the cleft palate at twelve months of age
75% (No differentiation was made on the type of cleft
or the technique of repair). Peterson-Falzone (1991)
reported 83.4% competence based on the same criteria.
Growth and morphology
Graber was the first to document disturbance of facial
growth as a result of palatal surgery. This compromised
the facial bone growth in all directions, but principally
in the horizontal dimension. The effect was most
pronounced at the level of the palate and slightly less
so in height of the mid face. The noticeable changes are
collapse of the dental arch, contraction of the arch and
hypoplasia of the maxilla.[9]
Submucous cleft palate
Submucous cleft palate occurs when the palate
has mucosal continuity but the underlying levator
palatini muscle is discontinuous across the mid-
January-June 2015 / Vol 2 / Issue 1 9
[Downloaded free from http://www.jclpca.org on Tuesday, January 05, 2016, IP: 36.80.189.136]
Thomas: Palatoplasty: Evolution and current trends
line and longitudinally oriented. Diagnosis usually
will be delayed till the child starts speaking with a
nasal sound. The diagnosis is to be confirmed with
speech evaluation and endoscopy. Corrective surgical
technique for submucous cleft palate is focused on
anatomic corrections of the velar muscle diastasis.
The Furlow’s double-opposing Z-Plasty maybe an ideal
procedure for these patients because there is no width
discrepancy to overcome.[6,7]
Author’s protocol
The child with cleft is often referred to the author as a
newborn or infant. Emphasis will be given to reassure
the parents and care to be taken for the nutritional status
of the child. Pediatric evaluation with immunization
status is ascertained, correct feeding advice is given to
the mother and the child is followed up periodically.
The timing of the operation is usually between 9 and
18 months when the child is free of infections and
general health is suitable for general anesthesia. Pre-
operative investigations such as complete blood counts,
coagulation profile, blood grouping and cross matching,
throat and nasal swabs for culture and sensitivity are
done usually. Clinical photographs are taken in every
stage. Magnification by loupe or operative microscope
is always helpful during the operation in identifying
the anatomical structures and detaching the abnormal
attachments of the levator palatini muscles (Author
always use a panoramic high magnification loupe).[4]
The operative technique is a modified two-flap
technique. Two mucoperiosteal palatal flaps based
on the greater palatine neurovascular pedicles are
reflected. Tenotomy of the tensor palatini is done
(no need to fracture the hamulus). The abnormal
attachment of levator palatini muscles is detached
from the posterior part of the palatine bone and also
from the aponeurosis and rarely from the hamulus.
The intravelar veloplasty is effectively done and a
layered closure using suitable sized vicryl sutures.
Lateral raw areas are covered with gel foam instead of
interrupted stitches, which may create tension at the
midline sutures and may lead to fistula formation. At
operation; ENT evaluation, myringotomy and grommet
insertions are always done. Routine post-operative
management will be done keeping the child during
first 24 h, either in ICU or high dependency room.
10 January-June 2015 / Vol 2 / Issue 1
Liquid diet for the first 5 days, followed by soft diet
and normal diet after 10 days. Subsequent follow-up
will be done at the multidisciplinary cleft lip and palate
clinic. Plastic Surgeon, Orthodontist, ENT Surgeon,
Pediatrician, Speech therapist, clinical photographer,
specialized nurses and social worker are the members
of this multidisciplinary cleft lip and palate clinic.
Future and controversies
The management of a patient with cleft palate is
complex. At present, no universal agreement exists
on the appropriate treatment strategy. Normal speech
should be the most important consideration in the
therapeutic plan. Growth disturbance should be
minimized, but not at the expense of speech impairment
because facial distortion can be satisfactorily managed
by surgery, whereas speech impairment can often
be irreversible. There is a need for well-controlled,
prospective studies to establish the validity of the
widely different claims of superior results from various
techniques. Cleft patients should be managed in a center
with a multidisciplinary team. Cleft palate remains a
significant and interesting challenge for current and
future plastic surgeons.
REFERENCES
1. Rogers BO. History of the cleft lip and cleft palate treatment. In:
Grabb WC, editor. Cleft Lip and Palate. Boston, Little: Brown; 1971.
2. Hoffman WY, Mount DL. Cleft palate repair. In: Mathes SJ, editor.
Plastic Surgery. 2nd Ed. Vol 4. Philadelphia: Saunders Elsevier,
2006; p. 249-69.
3. Cutting C, Rosenbaum I, Rovati L. The technique of muscle repair
in the soft palate. Oper Tech Plast Surg 1995;2:215-22.
4. Sommerlad BC, Henley M, Birch M, Harland K, Moiemen N,
Boorman JG. Cleft palate re-repair - a clinical and radiographic study
of 32 consecutive cases. Br J Plast Surg 1994;47:406-10.
5. Bardach J, Salyer K. Surgical Techniques in Cleft Lip and Palate.
Chicago: Year Book; 1987.
6. Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast
Reconstr Surg 1986;78:724-38.
7. Furlow L. Cleft palate repair by double opposing Z-plasty. Oper
Tech Plast Surg 1995;2:223-32.
8. Bardach J. Two-flap palatoplasty: Bardach’s technique. Oper Tech
Plast Surg 1995;2:211-4.
9. Millard DR Jr, Latham RA. Improved primary surgical and dental
treatment of clefts. Plast Reconstr Surg 1990;86:856-71.
Cite this article as: Thomas C. Repair of cleft palate: Evolution and current
trends. J Cleft Lip Palate Craniofac Anomal 2015;2:6-10.
Source of Support: Nil. Conflict of Interest: None declared.
Journal of Cleft Lip Palate and Craniofacial Anomalies