Clinical aspects of cleft palate repair Ahmed Atef Plastic & Reconstructive Surgeon Mataria Teaching Hospital

1. Clinical Aspects of Cleft Palate Repair
Ahmed Atef, Msc, MRCS
Specialist of plastic surgery
Mataria Teaching Hospital

2. Objective
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Incidence
Surgical Anatomy
Embryology
Classification / Cleft Variants
Clinical Effects
Management
Future

4. Cleft Palate / Cleft lip is the the most common
craniofacial malformation
Second most common congenital defect

5. Isolated Cleft palate
• No racial variation
• 1:2000 live birth
• M:F = 1:2
• Left : Right : B/L = 6:3:1

7. Surgical Anatomy
The palate forms a dynamic
boundary between the
oral cavity and the nasal
cavity. It is composed of
the hard palate anteriorly
and the soft palate
posteriorly.

8. Surgical Anatomy
Normal Palate
• Primary Palate
• Secondary Palate
Hard Palate
Soft Palate

9. Surgical Anatomy
The hard palate includes the
palatal processes of the maxilla
and the horizontal plate of the
palatine bone with adherent
mucoperiosteum (attached to
bone by Sharpey’s fibres).

10. Surgical Anatomy
Three pairs of foramina
mark the surface of the
bony palate
• Incisive Foramen
• Greater Palatine Foramen
• Lesser Palatine Foramen

11. The soft palate is a
dynamic structure that
acts as a valve between
the oropharynx and
nasopharynx.
An intact and functioning
soft palate is essential
for normal speech and
feeding.

12. Surgical Anatomy
Soft palate
• Mucosa
• Five paired muscles &
central aponeurosis
Tensor veli palatini
Levator veli palatini
Palatoglossus
Palatopharyngrus
Uvualis
*Veli (Latin) means curtain

13. Surgical Anatomy
Tensor palati
Origin: scaphoid fossa of the medial
pterygoid plate, the lateral part of
the cartilaginous auditory tube
then passes around the pterygoid
hamulus as a tendon
Insertion: broad triangular tendon
at the posterior aspect of the
hard palate as part of the palatine
aponeurosis
Action: tense the soft palate to
form a platform that the other
muscles may elevate or depress.

14. Surgical Anatomy
Levator palati
Origin: petrous bone and the
medial part of the auditory
tube
Insertion: middle third of
upper surface of the soft
palate at upper surface of
the palatine aponeurosis as
far as the midline

15. Surgical Anatomy
Levator palati
The paired muscles form
a ‘V’-shaped sling pulling
the soft palate upwards
and backwards to close
the nasopharynx.

16. Surgical Anatomy
Palatoglossus
Origin: Palatine aponeurosis
Insertion: Side of tongue
Action: Pulls root of tongue
upward and backward,
narrows transverse
diameter of oropharynx

17. Surgical Anatomy
Palatopharyngeus
Origin: Palatine aponeurosis
Insertion: Posterior border of
thyroid cartilage
Action: Elevates wall of
pharynx, pulls
palatopharyngeal folds
medially

18. Surgical Anatomy
Musculus uvulae
Origin: Posterior border of
hard palate
Insertion: Mucous membrane
of uvula
Action: Elevates uvula

19. Surgical Anatomy
The soft palate is raised by the
contraction of the levator palati.
At the same time, the upper fibers
of the superior constrictor muscle
pull the posterior pharyngeal wall
forward.
The palatopharyngeus muscles
contract to pull palatopharyngeal
arches medially, like side curtains.

20. Surgical Anatomy
By this means The intact
palate can
periodically, selectively, an
d completely isolate the
nasopharynx from the
oropharynx during Feeding
& Speech

21. Surgical Anatomy
This harmony in muscular action is necessary for
Velopharyngeal Competence

22. Surgical Anatomy

23. Surgical Anatomy

25. Embryology
Development of the face begins in the fourth week in
utero, when neural cells migrate and fuse with
mesodermal elements to form the facial primordium.

26. Embryology
It results from the fusion
– Two mandibular
processes
– One frontonasal process
– Two maxillary processes

27. Embryology
The palate develops between the 5th and the 12th week
CRITICAL period of palatal development is between the 6th and
the 9th week.
Soft palate development is completed at 12th week

28. Embryology
Primary palate : Median palatine process from the medial nasal
prominences.
Secondary palate : Lateral palatine process from the maxillary
prominence

29. Embryology
6th – 9th week: Initially, the palatine processes are oriented vertically
on either side of the developing tongue.
The tongue is displaced inferiorly as the head grows and the neck
straightens, the lateral palatine processes are elevated and grow
medially to fuse with the septum

30. Embryology
Is Cleft a Deficiency?

31. Embryology
Interference with fusion results in Cleft
Three theories:
i) Failure of fusion of the lateral shelves
ii) Failure of mesodermal penetration of the shelves:
iii) Mechanical interference (the tongue) such as in
Pierre Robbin Sequence

32. Embryology
Gato et al. 2002, expression of chondroitin sulfate proteoglycan is
important in palatal shelf adhesion and is supposed to be
regulated by TGF-b3
Gato A, Martinez ML, Tudela C, Alonso I, Moro JA, Formoso MA, Ferguson MWJ, Martinez-lvarez C (2002) TGF-b3-induced
chrondroitin sulphate proteoglycan mediates palatal shelf adhesion.
Bush et al. 2003; Herr et al. 2003, Expression of T box transcription
factor Tbx22 is found in the inferior nasal septum and the palatal
shelf before fusion.
Bush JO, Lan Y, Maltby KM, Jiang R (2002) Isolation and developmental expression analysis of Tbx22, the mouse homolog of the human x-linked cleft
palate gene. Dev Dyn 225: 322-326
Herr A, Meunier D, Mller I, Rump A, Fundele R, Ropers H-H, Nuber UA (2003) Expression of mouse Tbx22 supports its role in palatogenesis and
glossogenesis. Dev Dyn 226:579–586

34. Classification
Veau Classification 1931
Veau Class I: isolated soft
palate cleft
Veau Class II: isolated hard
and soft palate
Veau Class III: unilateral
CLAP
Veau Class IV: bilateral
CLAP

35. Classification
Striped Y by Kernahan 1971
Millard modification

36. Cleft Variant

37. Cleft Variant

38. Cleft Variant

39. Cleft Variant

40. Syndromatic Cleft
Treacher-Collins syndrome

41. Syndromatic Cleft
Pierre Robin syndrome

42. Syndromatic Cleft
Van der Woude’s syndrome

44. Clinical effects
Patients with cleft deformities experience a multitude of problems
including
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Feeding problems
Speech difficulties
Otologic issues
Midface growth impairment.

45. Clinical effects
Feeding
The infant is usually not able
to suck efficiently due to
inability to achieve negative
pressure.
Nasal regurgitation.
Feeding regimen: includes the
use of squeeze bottles and
holding in a nearly sitting
position during feeding

46. Clinical effects
Speech
Patients are unable to produce
high intra-oral pressure.
Normal velopharyngeal closure is
crucial for production of
intelligible speech; any
abnormalities in this
mechanism can result in
hypernasality, nasal emissions,
imprecise production of
consonants.

47. Hearing
Serous otitis media.
Abnormality of LVP which aids the TVP to dilate ET.
Nasal regurgitation.
Treatment with myringotomy tubes is required pre- and postcleft repair.

49. Management requires a multidisciplinary approach
spanning multiple specialties
• Plastic surgery
• Speech pathology
• Otolaryngology
• Genetics
• Pediatrics
• Orthodontics
• Audiology

50. Goal
Restoring the morphologic form & function
Production of a competent velopharyngeal
sphincter

51. Principles
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Closure of the defect
Correction of the abnormally inserted muscles
Reconstruction of the palatine sling
Tension free repair
2 layer repair of the hard palate & 3 layer repair of the soft
palate

52. Von Langenbeck 1861 pioneered the first bipedicle
mucoperiosteal flaps and relaxing incisions for palate closure
surgery in one stage.
Langenbeck v, B. Uranoplasty by means of raising mucoperiosteal flaps. Arch klin chir. 1861;2:205

53. Veau 1931, The vomer flap and suturing of velar muscles
aiming at lengthening the palate

54. Wardill and Kilner 1937, “pushback” theory V-Y retro
positioning of the palate increases the length further.
By connecting the lateral incisions to the incisions made for the
nasal turn in flaps.
Wardill WEM. The technique of operation for cleft palate. Br J Surg. 1937;25: 117-130

55. A different approach was described by Furlow 1986 with the
double-opposing z-plasty without relaxing incisions
Furlow LT, Jr. Cleft palate repair by double opposing Z-plasty. Plastic and reconstructive
surgery. 1986;78:724-738

56. The Bardach 1991 two-flap palatoplasty uses two large fullthickness hard palate flaps that are mobilized and closed
anteriorly and medially without pushback
Bardach, J. and P. Nosal: Geometry of the two-flap palatoplasty. (2nd). St. Louis,
Mosby-Year Book, 1991

57. Rohrich et al., 2000 & Sommerlad et al., 2002
Closure of the palate can be performed in two stages. This
closing the soft palate early, between 3 and 6 months involves
of age, and delaying the repair of the hard palate.
Sommerlad BC, Mehendale FV, Birch MJ, Sell D, Hattee C, Harland K. Palate rerepair
revisited. Cleft Palate Craniofac J. 2002;39:295-307.
To limit the effect of the hard palate repair on maxillary growth.
It is suggested that the subperiosteal scarring impairs
midfacial growth.

58. Preoperative considerations
• Age: 9-12 month
• Associated anomalies
• Routine Lab. Investigations
• Booking a unit of packed RBCs after G/XM
• Otologic and audiologic assessment

60. Operative preparations
i) RAE tube
ii) Dingman
iii) Shoulder roll
iv) Head Donut
v) Local anesthetic with
1:200,000 epi
vi) Position: supine, neck
Extended, reverse trendlenberg
vii) Throat pack

61. Operative preparations

62. Steps
i) Inject 1 :200 000 epinepherine into the palate.
ii) Don't inject in areas sutures will be placed
iii) Wait 7 minutes for the epinephrine to take effect
iv) Make incision along the medial side of the cleft
v) Make releasing incision to get to bone on both sides
vi) Use freer to elevate mucoperiosteal flap
vii) Dissect nasal mucosa
vii) Strip LVP muscle off abnormal insertion & create palatine
sling
viii) Three layer repair

63. Steps

64. Vomerian flap

65. Postoperative care
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Keep your eye on the airway
AB
Analgesic
Feeding: fluids, soft diet, no bottles for 3w
Arm restraints

66. Complications
Early:
Haemorrhage
Airway obstruction
Dehiscence
Fistula
Late:
Bifid uvula
VPI
Maxillary hypoplasia
Dental malalignment

68. Tissue engineering advancements over the last decade
has provided a plethora of materials that may be
suitable for the healing of craniofacial defects like the
cleft palate.
Future directions with regards to the use of stem cells
especially ASCs in craniofacial repair are
discussed, including possible scaffold for reconstruction
of palatal defect

69. Quiz
Embryogenesis of primary & secondary palate?
Muscles of soft palate?
Velopharyngeal mech?
Clinical effects?
Preoperative preparations?
Principles of repair?
Postoperative care?