14

Sommerlad’s Technique of Cleft Palate Repair

Brian C. Sommerlad1, Sheng Li2

1
The Great Ormond Street Hospital for Children and St. Andrew’s, Centre for
Plastic Surgery, Broomfield Hospital, London and Essex, United Kingdom,
brian@sommerlad.co.uk
2
Jiangsu Provincial Stomatological Hospital, Stomatological College of Nanjing
Medical University, Nanjing, 210029, China, lisheng1812@163.com

14.1 Introduction

The aims of palatoplasty are to improve feeding, to achieve normal speech, and to
minimize maxillary growth restriction. The technique of palate repair may also have
an impact on middle ear function and hearing. Cleft palate repair is the most important
component of cleft surgery, not only in that it determines the outcome as far as speech
and communication is concerned, but also in that it potentially has the greatest impact
on maxillary growth and the dental arch relationship. But the evolution of palatoplasty
has been relatively slower than cheiloplasty. Most of the frequently used techniques
nowadays are derived from the early 1900s [1-5]. Though surgeons have started to
highlight the reconstruction of the levator veli palatine (LVP) the anatomic restoration
has never been accomplished [6-8]. On the other hand, the success of velopharyngeal
closure (VPC) can be influenced by a number of factors, such as patient age [9, 10],
the surgeon’s expertise and width of cleft [11]. Therefore, it is difficult currently to
assess the significance of velo palatine levator reconstruction in palatoplasty. In
addition, VPC is the result of multiple factors, and muscular reconstruction is only
a technique affecting the soft palate. However, the operative anatomic restoration
of LVP is definitely an ideal worth pursuing. The authors have persisted in practising
this technique in different countries during the past decades and have achieved
better results than traditional techniques [12]. The better results include both a
higher post-operative VPC ratio and maximizing development of the maxilla and
maxillary dental arch [13], since there is less use of releasing incisions and therefore

B. Shi et al. (eds.), Cleft Lip and Palate Primary Repair
© Zhejiang University Press, Hangzhou and Springer-Verlag Berlin Heidelberg 2013
266 14 Sommerlad’s Technique of Cleft Palate Repair

reduced scarring [14]. These results make us firmly convinced that complete
anatomic reconstruction of the LVP is a promising technique, which has radically
changed the techniques and conceptualization of palatoplasty.

14.2 Design

The complete cleft palate became narrower after vomer flap repair of the hard
palate during primary cheiloplasty. The hard palate was covered by new epithelial
tissue, leaving only the soft palate to be closed [15] (Fig. 14.1).

Fig. 14.1 Only left soft cleft palate is left after vomer flap repair

The incision is designed along the cleft, and nasal mucosa should be conserved
a little more. The uvula will be reconstructed respecting the parents’ requirements
though it is of no use for phonation. In front of the cleft, a triangular flap is
designed comprising new epithelial tissue which will be turned over to help close
the nasal mucosa (Fig. 14.2).

Fig. 14.2 Design of incision

 14.3 Closure of Nasal Mucosa 267

Injection of  200,000 adrenaline normal saline in the operative area helps to

minimize bleeding (Fig. 14.3).

Fig. 14.3 Injection of 1 200000 adrenaline NS

14.3 Closure of Nasal Mucosa

Cutting mucosa along the design line: the triangular flap should be carefully
prepared and turned over to join the nasal mucosa. The muscle and gland layer
will be separated using the elevator (Fig. 14.4).

Fig. 14.4 Cutting mucosa along the design line

268 14 Sommerlad’s Technique of Cleft Palate Repair

Using a single hook, the oral mucosa and gland layer is separated from the
muscle layer. The muscle should be kept intact (Fig. 14.5).

Fig. 14.5 Separating mucosa from muscle on left side

Separating around the greater palatine nerve-vessel bundle reveals the white
bone around the root of the bundle. The periosteum here should be cut to release
the palatal flap. There is a little hard connective tissue that restricts the flap from
moving the bundle and this tissue can be seen through the releasing incision
outside the bundle (Fig. 14.6).

Fig. 14.6 Separation around the greater palatine nerve-vessel bundle

Dissection of the greater palatine nerve-vessel bundle: the degree of dissection

depends on the cleft width. It should not be too thorough in the narrower cases
(Fig. 14.7).
 14.3 Closure of Nasal Mucosa 269

Fig. 14.7 Dissection of the greater palatine nerve-vessel bundle

The anterior triangular flap is prepared to be turned over to close the cleft
together with nasal mucosa (Fig. 14.8).

Fig. 14.8 Preparing the triangular flap

The same technique is used on both sides. Here the muscle is attached to the
nasal mucosa (Fig. 14.9).

Fig. 14.9 Separating mucosa from muscle on right side

270 14 Sommerlad’s Technique of Cleft Palate Repair

The anterior palatal flap is raised by a curved elevator, which makes suturing
the cleft easier (Fig. 14.10).

Fig. 14.10 Elevating the palate flap

Stent suturing is used on both sides, and the nasal mucosa and muscle is
exposed and prepared to be closed (Fig. 14.11).

Fig. 14.11 Exposure of the nasal mucosa and muscle

The closure of the nasal mucosa and muscle is completed. Note that the
triangular flap has been turned over. The wider the cleft is, the larger the flap
required. There is still considerable tension here, so the suture of the flap is
important [16] (Fig. 14.12).
The muscle can be seen clearly after nasal closure (Fig. 14.13).
 14.4 Dissection of Velo Palatine Levator 271

Fig. 14.12 Closure of nasal mucosa Fig. 14.13 The fiber of muscle

14.4 Dissection of Velo Palatine Levator

Dissection begins from the posterior rim of muscle and 5 mm from the midline.
One must take care to keep the nasal mucosa intact. From back to front, the
incision is made from far to near (Fig. 14.14).
The LVP does not attach to the back boundary of the hard palate but goes into
the cleft rim in front of the middle part of soft palate. The rear boundary of the
hard palate is attached to the palatopharyngeus muscle (Fig. 14.15).

Fig. 14.14 Beginning of dissection of muscle Fig. 14.15 Fiber of levatorveli palatine

Separate the LVP and nasal mucosa as far as the Eustachian tube. Mark the
position of the LVP on the nasal mucosa. This should be done on both sides
(Fig. 14.16).
The white tissue that becomes apparent is the palatine aponeurosis, which
attaches to the posterior boundary and should be separated (Fig. 14.17).
272 14 Sommerlad’s Technique of Cleft Palate Repair

Fig. 14.16 Mark the position of levator veli Fig. 14.17 Palatine aponeurosis
palatine on nasal mucosa

After separation of the palatine aponeurosis, the incision turns backwards to

separate the tensor veli palatine from the hamulus. The palatopharyngeal muscle
should be separated from the nasal mucosa at the same time. The inner side of the
hamulus can be seen when the tendon of tensor veli palatine moves backwards
(Fig. 14.18).
A small horizontal vessel can be seen during dissection of the LVP, and this
vessel should be conserved (Fig. 14.19).

Fig. 14.18 The inner side of hamulus Fig. 14.19 Small horizontal vessel

Muscle dissection completed: the nasal mucosa can be seen from this angle
together with the relaxed LVP (Fig. 14.20).
Forceps can help to show the LVP on the left side (Fig. 14.21) and on the right
side (Fig. 14.22).
4-0 or 5-0 nylon is used to suture the muscle. This kind is not absorbable so
the suture can be kept for a long time. Both the LVP and the palatopharyngeus
should be sutured. The knot should be put on the nasal side to minimize
discomfort or exposure (Fig. 14.23).
 14.4 Dissection of Velo Palatine Levator 273

Fig. 14.20 Muscle dissection finished Fig. 14.21 Levator veli palatine on left side

Fig. 14.22 Levator veli palatine on right side Fig. 14.23 Suture the muscle

Finally, close by suture the anterior part of the LVP and make it protrude
downwards. The reconstructed muscle sling now clearly moves to the posterior
part of soft palate (Fig. 14.24).

Fig. 14.24 Last suture of muscle

274 14 Sommerlad’s Technique of Cleft Palate Repair

14.5 Closure of Oral Mucosa

Closure of the oral mucosa requires simple mattress suturing. Note that nasal and
oral mucosa should be sutured together to stabilize the muscle position and, at the
same time, close the dead space. This kind of suture should be used two or three
times (Fig. 14.25).
The subsequent sutures are placed in the same way and a part of the muscle
tissue should be closed together with mucosa (Fig. 14.26).

Fig. 14.25 Closure of oral mucosa Fig. 14.26 Following suturesof oral mucosa

Suture of uvula: the uvula will turn upwards to the nasal side and facilitate
phonation (Fig. 14.27).
Gradual closure of the cleft from back to front (Fig. 14.28).

Fig. 14.27 Suture of uvula Fig. 14.28 Posterior part of cleft closed

Closure of the cleft without releasing incisions: closing the hard palate cleft by
a vomer flap during primary cheiloplasty makes the operation more complicated
but makes palatoplasty easier [17]. Our research has shown that of all 36 cases, only
3 needed releasing incisions. Furthermore, there is no evidence that the vomer flap
 14.6 Conclusion 275

technique has any negative influence on maxillary development (Fig. 14.29).

Fig. 14.29 The cleft closed without releasing incision

14.6 Conclusion

Cleft palate repair is essential as it is fundamental not only for vocal

communication but also for maxillary growth and appearance. Further exploration
of palate repair techniques is required to ensure minimal maxillary growth
hindrance and optimal speech outcome.

References

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