Primary intravelar vestibuloplasty--adaptation of surgical modification of the anatomical defect

Oro-nasal fistulae often occur after the primary closure of the hard and soft palate cleft and in particular at the junction between the hard and soft palate. This is the area where maximal tension is exerted during the intravelar veloplasty closure procedure. Six surgical modifications of the primary intravelar veloplasty technique are described and each is specifically adapted according to the existing anatomical form and defect of the cleft soft palate, so that the occurrence of an oro-nasal fistula may be prevented. The surgical procedures may be divided into two main groups, namely those which are based on a localized swivel flap and those where remote flaps are used.     

Asymmetrical soft palate cleft repair: Preliminary results

The reconstructions of the asymmetrical soft palate cleft is a surgical challenge when it comes to achieving symmetry and optimal soft palate muscular function. Three different versions of the intravelar veloplasty have been used: the intravelar veloplasty (1969) (type I), the modification according to anatomical defects (1991) (type II), and the modification using part of Sommerlad's technique and part of Ivanov's technique (2008) (type III). The perioperative outcomes of the type II and type III intravelar veloplasty were assessed and compared in asymmetrical cleft cases. Two hundred and seventy-seven soft palate clefts were reconstructed: 153 type II and 124 type III. Of these, 49 were asymmetrical (17.7%); 23 underwent the type II procedure and 26 the type III procedure. Of the type II procedure cases, 30.4% remained asymmetrical postoperatively compared to 3.8% of the type III cases. The uvula appeared subjectively atrophic in 47.8% of the type II cases and in 7.7% of type III cases. Oro-nasal fistula occurred in 13.0% of the type II cases and 3.8% of the type III cases. Speech results will only be assessed after 4 years of age. The type III modified intravelar veloplasty has had a major beneficial impact on patients who had an asymmetrical soft palate cleft.     

Veloplasty using the wave-line technique versus classic intravelar veloplasty.

Objective: A well-known problem in primary surgery of the soft palate is its shortness and the deficit of local soft tissue. This article introduces a modification of the primary intravelar veloplasty, allowing lengthening of the soft palate, and compares this alternative technique to the classic intravelar veloplasty.Method: The soft palate wave-line technique adds a wavy incision at the velar cleft margins to the intravelar veloplasty. In 24 patients with complete clefts of the palate, either the newly developed or classic technique was performed. Four years following primary surgery, speech performance and type of breathing were analyzed.Results: Even in wide clefts of the soft palate, repair was easily accomplished using the wave-line technique. Complete closure of the nasal, muscular, and oral layers was achieved, and no postoperative fistula was observed. An average lengthening of the soft palate of 56% (range 24% to 83%) was observed immediately following velar repair with the wave-line technique. Speech was significantly better in the wave-line group (p <.05). Furthermore, physiological breathing was observed more often in these patients.Conclusion: Primary repair of clefts of the soft palate using the wave-line technique is straightforward, safe, and easy. On the basis of the present results, this technique seems superior to the classic intravelar veloplasty.     

Modifying the two-stage cleft palate surgical correction.

OBJECTIVE: This paper reports the experience with a two-stage approach to surgical correction of the complete cleft palate, wherein timing of the second stage is dependent on the judgment of the speech pathologist and the orthodontist together with the surgeon. PATIENTS: Of a total of 35 patients having complete unilateral clefts a sample of 22 were available for postsurgical assessment. The first-stage repair of the palate was carried out at an average age of 10.7 months (range 6 to 17 months), and the second-stage repair of the residual cleft was completed at an average age of 32.7 months (range 26 to 34 months). INTERVENTIONS: The first-stage repair of the soft palate defect involved mobilizing two short posteriorly based flaps, which extend onto the posterior quarter of the hard palate thus including up to 1 cm of mucoperiosteum. Careful freeing of the muscle is followed by an intravelar veloplasty. The later closure of the residual cleft involved turnover hinge flaps and small mucoperiosteal flaps. RESULTS: Eighty-seven percent of the sample had good to excellent speech as assessed by the Great Ormond Street screening method. Only two patients showed evidence of recessive maxillae with Class III malocclusions. CONCLUSIONS: A two-stage surgical closure of the palate using this procedure would appear to confer several valuable advantages to the patient. These include favorable outcomes for speech in the large majority of cases and minimal adverse effects on the growth of the midface region.     

Comparison of speech outcomes using type 2b intravelar veloplasty or furlow double-opposing Z plasty for soft palate repair of patients with unilateral cleft lip and palate

BackgroundThe aim of this study is to compare speech outcomes, fistula rates, and rates of secondary speech surgeries after palatoplasty using Furlow palatoplasty or type 2b intravelar veloplasty for soft palate repair.Patients and methodsPatients with unilateral cleft lip and palate who had either Furlow palatoplasty or intravelar veloplasty for soft palate repair were retrospectively evaluated for demographic and perioperative variables and speech outcomes. Fistula rate, secondary surgical intervention for improved speech results, and findings of speech assessment were further reviewed for the patients who met the inclusion criteria.ResultsA total of 76 patients, 36 in the Furlow palatoplasty group and 40 in the intravelar veloplasty group, were included in the study. In the speech assessment, nasalance values were statistically similar between the two groups. Also, there was no statistically significant difference between the groups in velopharyngeal motility (p = 0.103). The total rates of secondary surgeries and fistula were statistically similar between the groups (p = 0.347 and 0.105, respectively).ConclusionThe similar outcomes of speech and surgical evaluation between the two groups make the surgeon's preference determinant in the selection of the surgical technique for soft palate repair.     

Tensor veli palatini muscle tension sling for eustachian tube function in cleft palate. Surgical technique and audiometric examination

The high incidence of middle ear effusion in cleft lip and/or palate infants and children led to the development of a tension sling for the tensor veli palatini muscle for better Eustachian tube function after intravelar veloplasty.--The surgical technique is outlined in this paper and an audiometric examination was conducted to determine the influence of this surgical modification, performed in the same procedure as the intravelar veloplasty, on the Eustachian tube function. The intra- and intergroup comparisons indicate that this surgical technique has a positive influence on the tube function.     

Speech outcomes of early palatal repair with or without intravelar veloplasty in children with complete unilateral cleft lip and palate

We compared the early speech outcomes of 40 consecutive children with complete unilateral cleft lip and palate (UCLP) who had been treated according to different 2-stage protocols: the Malek protocol (soft palate closure without intravelar veloplasty at 3 months; lip and hard palate repair at 6 months) (n = 20), and the Talmant protocol (cheilorhinoplasty and soft palate repair with intravelar veloplasty at 6 months; hard palate closure at 18 months) (n = 20). We compared the speech assessments obtained at a mean (SD) age of 3.3 (0.35) years after treatment by the same surgeon. The main outcome measures evaluated were acquisition and intelligibility of speech, velopharyngeal insufficiency, and incidence of complications. A delay in speech articulation of one year or more was seen more often in patients treated by the Malek protocol (11/20) than in those treated according to the Talmant protocol (3/20, p = 0.019). Good intelligibility was noted in 15/20 in the Talmant group compared with 6/20 in the Malek group (p = 0.010). Assessment with an aerophonoscope showed that nasal air emission was most pronounced in patients in the Malek group (p = 0.007). Velopharyngeal insufficiency was present in 11/20 in the Malek group, and in 3/20 in the Talmant group (p = 0.019). No patients in the Talmant group had an oronasal fistula (p < 0.001). All other outcomes were similar. Despite later closure of the soft and hard palate, early speech outcomes were better in the Talmant group because intravelar veloplasty was successful and there were no fistulas after closure of the hard palate in 2 layers.     

Impact of early intravelar veloplasty at six months on mandibular growth in patients with Pierre Robin Sequence

Pierre Robin Sequence (PRS) combines mandible microretrognathia, asynchronism of the pharynx and tongue, glossoptosis and, in some cases, cleft palate. Its principal functional consequences are respiratory and feeding problems during the neonatal period.In this study, we focused on the impact of early closure of the cleft at six months on mandibular growth in patients with PRS.We performed a retrospective study of 15 patients followed for PRS and undergoing surgery performed by the same senior surgeon (HB) at our cleft center between 2005 and 2012. These patients underwent early closure of the cleft (at a mean age of 5.87 months) by intravelar veloplasty, as described by Sommerlad.Only one article with exploitable data analyzing facial and mandibular growth in a cephalometric study of children with PRS has been published. The children in this series, constituting the control group for our study, underwent veloplasty between the ages of 12 and 18 months, often accompanied by labioglossoplasty, and the cephalometric study was carried out between the ages of four and seven years. We compared this control group in which surgery was performed at 12–18 months with our series of children undergoing surgery at six months, in a cephalometric study based on teleradiographic profile measurements performed between the ages of four and seven years.We found that early closure of the cleft soft palate yielded results identical to those for the control group in terms of mandibular growth, without the need for labioglossopexy. Finally, early intravelar veloplasty led to early functional improvement in terms of speech and phonation.     

A three-in-one surgical approach for unilateral cleft lip and palate

A single stage surgical procedure, combining the Le Fort I osteotomy, oro-nasal fistula closure and secondary osteoplasty, for the treatment of adolescents and adults with both an orthognathic deformity and a persistent oro-nasal fistula is described. During the same procedure the cleft alveolar ridge is fused by means of a bone transplantation. This three-in-one surgical procedure is intended for the unilateral cleft lip and palate case.     

The effect of intravelar veloplasty on velopharyngeal competence following pharyngeal flap surgery

Clinical experience from primary palatoplasty and studies of velopharyngeal valving suggest that intravelar veloplasty (IVVP) could increase the achievement of velopharyngeal competence in patients undergoing pharyngeal flap surgery. In order to test this hypothesis, a group of 91 patients undergoing superiorly based, high-attached, lined pharyngeal flaps along with intravelar veloplasty were compared retrospectively with 39 patients who underwent the same procedure without intravelar veloplasty. Comparison of speech evaluation and pressure-flow data demonstrated no difference in attainment of velopharyngeal competence between the two groups. Though theoretically sound, intravelar veloplasty did not appear to improve the results of pharyngeal flap surgery. The high incidence of postoperative hyponasality in both the study and control groups suggests a possible need for increased lateral port size in performing the procedure.     

Cleft palate repair using a marginal musculo-mucosal flap.

OBJECTIVE: To describe a modified procedure consisting of a mucoso-periosteal flap palatoplasty with a marginal musculo-mucosal flap (3M flap). This is also the first report of a primary repair for complete cleft palate using the 3M flap. We describe the lengthening effect of the nasal mucous layer of the soft palate and evaluate the fistula formation rate associated with this method. METHODS: This procedure has been performed on 21 patients with unilateral complete clefts and on 27 patients with incomplete clefts. A mucoso-periosteal flap raised from the hard palate was used mainly for closure of the cleft and not for the push-back. The 3M flap repaired the deficit of the nasal mucosa, making sure that the soft palate was lengthened. Intravelar veloplasty was performed also. RESULTS: The dimension of the nasal mucosal defect that can be filled with the 3M flap is 10 to 12 mm in length, oriented anterior-posterior, and 15 to 20 mm wide. Oronasal fistula formation was recognized in only 3 of 48 cases (2 of 21 complete clefts, 1 of 27 incomplete clefts) and were located at the hard-soft palate junction at the anterior portion of the 3M flap. CONCLUSIONS: This method has the theoretical advantages of (1) preventing fistula formation by filling the tissue deficiency with the 3M flap; (2) achieving better velopharyngeal function due to elongation of the soft palate and retropulsion of the muscular bundle, utilizing the 3M flap; and (3) minimizing maxillary growth retardation by adopting a non-push-back method of hard palate repair.     

Closure of palatal fistula with a local mucoperiosteal flap lined with buccal mucosal graft.

OBJECTIVE: Oro-nasal fistula is a common complication of palatoplasty. Current methods for fistula repair utilize mucoperiosteal flaps or pedicled flaps. These procedures are often cumbersome and leave a raw nasal surface, which may increase the incidence of postoperative risks and problems. In addition, the recurrence rate of the fistula is as high as 34%. We propose a simple two-layer method of fistula repair to avoid recurrences. DESIGN: A standard mucoperiosteal flap is raised on the oral side. A buccal mucosal graft is harvested from the cheeks and sutured to the nasal side of the flap that is then inset into the fistula. SETTING: Patients were either referred to the senior author's private practice (four patients) or were patients who had previously been operated on by the senior author himself (three patients). SUBJECTS: Study subjects consisted of seven patients, four males and three females, ages 14 months to 8 years. All patients had previously undergone cleft palate repair, complicated by subsequent oro-nasal fistula formation. INTERVENTIONS: All patients underwent oro-nasal fistula repair under general anesthesia with a local mucoperiosteal flap lined with buccal mucosal grafts placed on the nasal side of the flap. RESULTS: In all cases, the fistula was completely closed at first attempt without complications. Patients were followed for a minimum of 2 years, without evidence of recurrence. CONCLUSIONS: Our proposed surgical procedure for fistula closure using a standard mucoperiosteal flap lined with a buccal mucosal graft is a suitable alternative for the repair of postpalatoplasty oro-nasal fistulas. Further study and long-term follow-up is needed to establish this method as a new standard form of repair.     

Primary palatorraphy in the adult cleft palate patient. Surgical, prosthetic and logopaedic aspects

The treatment of 8 adults with untreated cleft palates is retrospectively discussed. A palatorraphy, consisting of a palatoplasty with pedicled palatal mucoperiosteal flaps and an intravelar veloplasty, is performed. A rib graft between the nasal and oral layer and a partial vestibuloplasty are used in a few patients to create a more favourable anatomical situation for the prosthetic appliance. The palatorraphy contributes to improved speech intelligibility however, combined with a pharyngeal flap as performed in 5 patients, an even better result can be achieved. According to the results, a surgical procedure in the adult still seems to be worthwhile.     

The use of decellularized dermal grafting (AlloDerm) in persistent oro-nasal fistulas after tertiary cleft palate repair

To assess the efficacy of decellularized dermal grafting as an adjunct to the closure of recurrent oro-nasal fistulas. Five consecutive patients with recurrent oro-nasal fistulas were repaired with decellularized dermal grafting sandwiched between oral and nasal flaps of a von Langenbeck palatal repair. All patients had previously undergone a minimum of three prior palatal repairs with the recurrence of their oro-nasal fistula in the post-alveolar area. Decellularized dermal graft was placed between the nasal mucosa and the levator veli palatine muscle. Patients were followed postoperatively and assessed for infection, dehiscence, signs of rejection, and fistula recurrence. All patients were followed for an average of three months. Clinical examination revealed no recurrence of their oro-nasal fistula nor associated symptoms of nasal reflux. Decellularized dermal grafts were not rejected nor extruded from the site of surgical repair. Decellularized dermal graft should be considered for use in the treatment of recurrent oro-nasal fistula after cleft palate repair. We would also like to encourage further clinical study.     

Primary veloplasty: long-term results without maxillary deformity. a twenty-five year report.

Primary veloplasty during the first year of life enables normal growth of the upper jaw and of the facial skeleton in patients with clefts. In spite of the remaining cleft in the hard palate, intelligible speech can be learned. The closure of the residual cleft of the hard palate is generally postponed until the age of 12 to 14 years, when the normal growth of the jaw is virtually completed. This method has been used in the clinic by the author and his father for thirty years. The results after primary veloplasty for some hundred adult patients show normal maxillary and cranial growth both clinically and radiologically. Primary veloplasty operations constitute acceptable restorative surgical treatment of the maxilla. Various problems of timing and methods of cleft palate treatment are discussed. The author's cases are summarized.     

可吸收医用生物膜修复硬腭裂隙的临床应用

目的　探讨使用可吸收医用膜修复硬腭裂隙的可行性及评价其近期临床效果。方法　68例腭裂患者随机分为实验组和对照组。实验组34例患者在软腭及悬雍垂裂修复的同时剖开硬腭裂隙,植入可吸收医用膜修复; 对照组34例采用常规腭裂修复术。结果　实验组所有患者其软腭及悬雍垂创口愈合良好,无穿孔与裂开;硬腭部创口一期愈合30例,二期愈合3例,1例遗留永久性的口鼻瘘,3例存在口腔前庭瘘。与对照组相比较,其出血量及口腔前庭瘘发生率减少,手术时间无明显延长,术后出血、呼吸困难等并发症无明显增加;术后体温多波动在 37·5℃以下,且逐渐降低,7 d后复查血常规与对照组相比无显著异常。结论　可吸收医用膜用于硬腭裂隙修复, 临床效果肯定且手术操作简单、可行,同时因避免了常规腭裂修复术时在硬腭部掀起粘骨膜瓣的缺点,可减少对颌骨发育的影响。     

Intravelar veloplasty in cleft lip, alveolus and palate and outcome of speech and language acquisition: a prospective study

Background: Speech and language acquisition are major, important criteria in the treatment outcomes of cleft lip and palate patients. A generally accepted and definitive treatment protocol regarding surgical techniques and the time schedule does not yet exist. In the world literature, there are reports of velo-pharyngeal insufficiency rates between 7 and 30%.Purpose: In a prospective study, all children aged months with cleft lip, alveolus and palate, or cleft palate only, underwent an intravelar veloplasty. Follow-up monitoring consisted of frequent clinical linguistic checks and supervision of language development without a planned intention of articulation therapy before the age of about 5 years.Results: Three hundred and ninety-seven children with non-syndromic clefts were included in this study, the youngest being 8-year old. Sixty children (15%) showed deviations in language and speech acquisition. From these, 56 (14%) had received articulation therapy after the 5th birthday. From these 56 children, 45 had overcome their problems with speech therapy alone whereas 11 (3%) needed a velo-pharyngeoplasty.Discussion: Although these results are much better than those reported in other cohorts, some children still have velo-pharyngeal incompetence for no apparent reason. One possible explanation might be surgical, since on occasions, the intravelar muscle bundle is divided into two parts and the palato-pharyngeal part runs isolated more laterally and can be missed during reconstruction and retropositioning.     

Anterior pillarplasty: a modification in cleft palate repair

After the primary repair of cleft palate, surgeons are frequently confronted with a short soft palate and a wide velopharyngeal space, both of which are known to diminish the quality of speech. We introduce a new modification of the primary repair of cleft palate that lengthens the soft palate and helps to reduce the volume of the velopharyngeal space. Ten patients younger than 12 months with nonsyndromic cleft palate were operated on with this technique. The incision at the cleft margin extended behind the uvula as a modification to the classic design of mucoperiosteal flaps. The sagittally divided mucosal layers of each anterior tonsillar pillar are sutured at the midline 1 cm posterior to the new uvula. The rate of postoperative fistula formation and other complications were evaluated postoperatively. One patient had a uvular and partly pillar detachment at the postoperative period. All other clefts healed without complication. The primary repair of the cleft palate with the anterior pillarplasty technique is a safe and easy-to-perform procedure. This modification can effectively reduce the transverse diameter of the velopharyngeal space and increase the anteroposterior length of the palate.     

聚-DL-乳酸可吸收医用生物膜修复硬腭裂隙的临床观察

目的 :修复硬腭裂隙 ,观察由聚 DL 乳酸 (PDLLA)制成的可吸收医用膜植入硬腭裂隙后的局部变化及临床效果 ,为进一步的临床应用提供依据。方法 :选择 2 .67～ 12 .83岁的腭裂患者 3 2例 ,于软腭及悬雍垂裂修复同期剖开硬腭裂隙、植入可吸收医用膜并予以固定 ,术后定期随访 ,了解手术时间、术后并发症、可吸收医用膜色泽、质地的变化、局部组织生长及创口愈合情况。结果 :所有手术均顺利完成 ,术后患者软腭及悬雍垂创口愈合良好 ,无穿孔与裂开 ;硬腭部植膜区创口周围组织沿医用膜向中心生长 ,创口逐步缩小 ,术后 12周完全由新生软组织关闭。追踪观察 6个月 ,局部组织较为平滑 ,与周围正常组织色泽基本相同 ,形态相近。结论 :可吸收医用膜用于硬腭裂隙修复 ,手术操作简单、实用、可行 ,临床效果肯定 ,可选择性推广应用。     

单侧完全性唇腭裂患儿唇裂修复同期硬腭裂隙封闭的临床观察

目的　探讨单侧完全性唇腭裂患儿时唇裂修复同期硬腭裂隙封闭的可行性及临床效果。方法　47例年龄为3·0~7·5月龄的单侧唇腭裂患儿在唇裂修复同期行硬腭裂隙封闭,分析手术时间、术中出血、术后恢复、创口愈合及腭部裂隙变化情况。结果　所有患儿的手术均顺利完成。手术时间与单纯唇裂修复术相比平均延长13 min , 术中出血平均增加5 ml,术后恢复好,无创口感染及裂开。至患儿9~18月龄二期手术时腭部裂隙比行单纯唇裂修复术平均小0·28 cm,使二期手术时软腭后退充分,腭咽闭合良好。结论　单侧完全性唇腭裂患儿唇裂修复同期行硬腭裂隙封闭是安全和可行的。