Operative Technique in Plastic Surgery – Kevin C.Chung

the underside of the oral layer flap to demonstrate the
extent of the dissection laterally, including out toward
the great palatine artery. G. A no. 12 blade is aimed
posteriorly to incise the margin of the uvula and
posterior third of the soft palate.
■ Be careful approaching the posterior nasal spine as the tissues are more
adherent here, and it is easy to tear the oral layer if there is a tethered
salivary gland at this point. Switching between a no. 15 blade and
periosteal elevator is usually necessary (TECH FIG 1E).
■ For wider clefts, a more radical hard palate dissection is required to reduce
the tension when closing.
■ The Warwick-James elevators and dental flat plastic can be alternated to
lift more laterally and, if needed, to free up the periosteal attachments
around the greater palatine artery to improve mobilization (TECH FIG
1F).
■ For incising the margin of the rest of the soft palate and back to the uvula, a
no. 12 blade tends to be easiest (TECH FIG 1G).
■ Depending on the cleft type, it may be necessary to raise vomer flaps to help
close the nasal layer without tension.
■ For wide clefts, it may be useful to incorporate a sphenoid flap in the nasal
layer closure.
■ This is a flag-shaped extension to one of the vomer flaps, which rotates
with insetting to provide additional tissue to the nasal layer around the hard
palate-soft palate junction where it is usually tightest.2
Elevation of the Nasal Layer
■ After raising the vomer flaps, elevate the nasal layer off the hard palate
(again in a subperiosteal plane) with a periosteal elevator or dental flat
plastic.
■ Mobilize the nasal layer off the hard palate bony shelves, taking care not to
damage the nasal layer (TECH FIG 2).

TECH FIG 2 • The stages of dissecting the nasal layer
mucoperiosteal flap from the hard palate bony shelf.
(1) Using a periosteal elevator with the spoon facing
nasally, gently lift the periosteum off the margin of the
bone with small movements. (2) Rotate periosteal
elevator 180 degrees, so spoon faces orally, and
insert it subperiosteally on nasal aspect of posterior
edge of the bony shelf of the hard palate. (3) Wiggle
and rotate spoon across the postnasal spine, the most
adherent point. (Always return to position 2 if the
periosteal elevator slips out of place.) (4) Continue to
make wiggling and rotating movements with the
periosteal elevator from the postnasal spine anteriorly.
■ Start by using a periosteal elevator to gently free the periosteum off the

margin of the bone and postnasal spine.
■ Next, use a periosteal elevator to wriggle beneath the bone shelf in a
subperiosteal plane, working from the area of the tensor aponeurosis,
around the postnasal spine, and then onto the medial margin.
von Langenbeck–Type Releasing Incisions
■ For wide clefts, it may be necessary to use lateral von Langenbeck–type
releasing incisions.
■ This decision may be clear at this point in the operation, in which case
making early incisions can be efficient.
■ When the decision is less obvious, continue with the rest of the dissection,
and the releasing incision can be made immediately prior to oral layer
closure.
■ When a von Langenbeck–type releasing incision is required, mark out a lazy
S incision along the medial aspect of the alveolus and around its posterior
limit to overlie the hamulus (TECH FIG 3A). The incision is kept as short as
possible while allowing good mobilization of the oral layer flaps.
■ Local anesthetic with adrenaline is injected to help with hydrodissection
and vasoconstriction: it is important to have a clear view to reduce the risk
of damage to the greater palatine vessels.
■ The incision is started in the hard palate with a no. 15 blade, incising down
through periosteum at the medial base of the alveolus but ensuring that you
stay lateral to the course of the artery.
■ The incision is extended more superficially around the tubercle and over the
hamulus.
■ A periosteal elevator is used to elevate the flap subperiosteally (TECH FIG
3B). It is often easier to have a second periosteal elevator to elevate
simultaneously the tissues via the previous incision at the medial aspect of
the palate until the two instruments meet.
■ It is then possible to work posteriorly, and one should elevate carefully the
tissues around the greater palatine artery until the oral flap is sufficiently
mobile to meet the opposite flap in the midline.

TECH FIG 3 • A. Marking for the incision of lateral
releasing incision around the posterior aspect of the
alveolus on the left, using a lazy S shape. B.
Following incision of the mucosa, a periosteal elevator
is used to lift under the periosteum and mobilize the
flap.
■ Oral Layer
■ To separate the oral layer from the muscle layer, the periosteal elevator or a
dental flat plastic is swept back from the posterior margin of the palatal bone
shelf (TECH FIG 4).
■ The plane is easier to develop laterally, near the hamulus, so the process
starts here and then moves medially.
■ A no. 12 blade is then used to incise posteriorly along the margin of the cleft
toward the uvula.
TECH FIG 4 • The periosteal elevator is slid off the

back of the hard palate shelf to separate the oral layer
off the muscle fibers. Note the tip of the periosteal
elevator is just reaching the hamulus, as the plane is
easier to develop more laterally.
■ Nasal Layer
■ Use interrupted sutures to close the nasal layer, incorporating vomer flaps
anteriorly if available and needed.
■ A resorbable monofilament suture is used, preferably with a round or
tapercut needle to avoid inadvertent tears of the mucosa. We use 5-0
Monocryl plus on a round-bodied needle for this closure.
■ The bites pick up more of the glandular tissue, with only a small amount of
nasal mucosa, and knots are laid on the nasal aspect. This helps to evert the
edges toward the nasal aspect (TECH FIG 5).
■ If the nasal layer is too tight for closure around the hard palate-soft palate
junction, then leave closure of this section until after the muscle dissection.
TECH FIG 5 • A. Suturing of the nasal layer, with the
knots placed on the nasal aspect. Interrupted sutures
are placed, working posteriorly toward the uvula. B.
Suturing the uvula using horizontal mattress sutures to
pick up the fibrous “core” of the uvula, as the mucosa
tends to become friable in this area.
■ Muscle Dissection of the Nasal layer
■ Applying topical 1:1000 adrenaline on neuro patties for about 5 minutes

before beginning the muscle dissection provides excellent vasoconstriction
and facilitates the subsequent dissection (TECH FIG 6A).
■ To make access easier for the next stage, a stay suture can be used to hold
the oral flaps out of the way (TECH FIG 6B).
■ Closure of the nasal layer has now pulled the soft palate muscles out to
length, with the resultant tension helping with the next stage of dissection.
■ A fresh no. 15 blade is used for each side of the palate. Alternatively, some
surgeons find it easier to use a straight Beaver blade (TECH FIG 6C).
■ Start on each side by incising the posterior border of the muscles; this will
leave behind a triangular block of fibrous/glandular tissue around the base of
the uvula (TECH FIG 6D).
■ Next, incise the medial margin of the muscle (TECH FIG 6E).
■ Finally, incise the tensor aponeurosis anteriorly (TECH FIG 6F), and extend
posterolaterally to divide the tendinous material from the hamulus.
■ Bipolar diathermy is then used sparingly to assist with the lateral
dissection, but the aim is to preserve as much of the vascular supply to the
levator muscle as possible (TECH FIG 6G).
■ A dental flat plastic is then used to slide between the remaining levator and
the nasal layer and particularly to free up any fascial sheath that can sit on the
distal aspect of the muscle and restrict its retropositioning (TECH FIG 6H).
■ When it has been properly dissected, the levator muscle should easily
displaced to the posterior end of the soft palate (TECH FIG 6I,J).

TECH FIG 6 • A. Neurosurgical patties have been
placed in contact with the exposed muscle and topical

adrenaline dripped on with a 1-mL syringe. B. While
the topical adrenaline is taking effect, a stay suture is
inserted in the oral layer of the midsoft palate to help
with retraction for the next stage. C. Using a straight
Beaver blade as an alternative to a no. 15 blade. D.
Diagram showing the dissection of the soft palate
muscles. (Oral layer not shown to allow clearer
visualization.) E. Dissecting the medial extent of the
soft palate muscles. The levator muscle is still not yet
visible at this point in the dissection. F. Incision of the
tensor aponeurosis off the back of the hard palate.
Note how the forceps are used to tension the muscle
toward the midline, which helps the dissection and
reduces the chance of “buttonholing” the nasal layer.
The sharp incision continues laterally to free the
muscle from the hamulus. G. Key landmarks when
freeing to muscle and of bipolar dissection. H. A dental
flat plastic is slid between the levator (just visible as
the slightly bluish muscle fibers under the brighter pink
pharyngeus muscle fibers) and the nasal layer to
complete the dissection. Before (I) and after (J) views
of the muscles on the right side of the soft palate to
show the extent of retropositioning after dissection is
complete.
■ Closure
■ The nasal layer closure can now be completed if necessary.
■ If the nasal layer has no holes, drainage holes can be incised laterally if
required.
■ The two sides of the muscle are now sutured across the midline (TECH FIG
7A,B).
■ We use a nonabsorbable monofilament suture such as 5-0 nylon to place
reliable knots, minimize trauma to the muscle, and avoid inflammatory

reaction from resorption.
■ There is also the potential benefit that the sutures act as a useful marker of
the levator position if it becomes necessary to re-explore the palate in the
future. A locked mattress suture (similar to a Kessler stitch) is used.
■ It is important to avoid tying the suture too tightly as this would strangulate
the muscle with any postoperative swelling.
■ It is also essential to cut the suture extremely short, right on the knot, so the
knots can be laid flat as reef knots.
■ The oral layer is closed with looped mattress sutures using a resorbable
monofilament suture such as 4-0 Monocryl.
■ Modifying the mattress suture that sits just anterior to the muscle can close
off the dead space between the oral and nasal flaps in the soft palate
(TECH FIG 7C).
■ By picking up a bite of the fibrous/glandular tissue that was left behind on
the nasal layer as the muscle was dissected, the mattress suture closes the
two layers together (TECH FIG 7D).
■ Finally, after closure is complete, the mouth is rinsed out, a nasal suction
catheter is used to ensure there is no blood clot in the postnasal space, and if
a throat pack was used, this is removed (TECH FIG 7E).

TECH FIG 7 • A. The mattress suture is placed in the
muscle, aiming with each transverse bite to pick up
the levator fibers (on the underside) as well as the
aponeurosis tissue for a more reliable closure. B. The
muscles on each side sitting at the posterior extent of
the soft palate after suturing. C. Illustration (oral layer
omitted) of the suture to appose the muscles on the
two sides, just prior to tying. Locked mattress sutures
pick up both keratin fibers (underneath) and tough
tender aponeurosis tissue (anteriorly and on top) with
each bite. D. The needle picks up a bite of the
fibrous/glandular tissue that has been left attached to
the nasal layer. E. The looped mattress suture,
including the bite of the nasal layer, just prior to tying.

PEARLS AND PITFALLS
Timing of
surgery
■ Careful optimization of the baby prior to surgery is important,
progressive gain in length and weight as documented in a growth
chart is a useful indicator—a thriving baby at the time of surgery is
more important than a specific age.
Shared
airway
■ As with all “shared airway” surgery, it is important for the
anesthetist and surgeon to communicate well with each other—the
WHO checklist and team brief are very useful for this.
Protecting
the mouth
and
commissures
■ Steri-Strips are placed to protect the corners of the mouth from
abrasion by instruments.
Operative
microscope
■ The routine use of the operative microscope for palate repair gives
excellent lighting and visualization of the operative field. It is also
very helpful for giving trainees a better view and involvement, as
well as reducing the strain on the surgeon’s neck.
Muscle
dissection
■ The key to dissecting the muscles (without putting holes in the
nasal layer) is to place tension on the tissues by using a skin hook
or forceps to draw the muscle bulk toward the midline and then to
stroke the curve of the blade to get a neat division. The vascular
plexus that is seen immediately superficial to the nasal layer is a
useful marker.
Draping the
patient
■ We use a clear plastic drape over the trunk, which allows the
anesthetist to see the endotracheal tube and circuit without
disturbing the surgical field. We avoid any adhesive drapes near
the endotracheal tube because these have the potential to catch and
dislodge the airway.
Postoperative
elevation
■ Nursing the baby “head-up” in the recovery room and on the ward
after surgery is very helpful for reducing postoperative swelling—
cuddling the baby over the parent’s shoulder tends to give ideal
positioning.
POSTOPERATIVE CARE
■ Topping up the local anesthesia with a long-acting agent at the very end of the

operation is useful for postoperative comfort and feeding.
■ Nurse the baby with the head elevated.
■ Babies can be offered feeds straight away once they are awake.
■ Monitor airway and oxygen saturation, especially during the first night after
surgery.
OUTCOMES
■ The main outcome measures for cleft palate repair are fistula rate, structural
speech problem rate, and impact on maxillary growth.3
■ Negative outcomes in any of these parameters can lead to the need for
secondary surgery for their correction.
■ Sommerlad reported approximately 5% secondary surgery rates for VPI with a
10-year follow-up.4
■ He reported fistula rates that vary considerably by cleft type—35% in
bilateral cleft lip and palate but an average of 12% in other cleft types.
COMPLICATIONS
■ Infection, significant bleeding, and transfusion are all rare after palate surgery.
■ Airway compromise is a potential risk, especially in babies with Pierre Robin
sequence and in younger or smaller babies.
■ Fistula is often reported around the hard palate-soft palate junction, but there is
wide variation between series and the extent and width of the cleft palate can
be a major factor in the fistula rate.
■ Speech problems may occur for a variety of reasons, to include VPI and/or
articulatory errors characteristic of cleft type.
REFERENCES
1. Kriens OB. An anatomical approach to veloplasty. Plast Reconstr Surg.
1969;43:29-41.
2. Khan K, Hardwicke J, Seselgyte R, et al. Use of the sphenoid flap in repair of
the wide cleft palate. Cleft Palate Craniofac J. 2018;55:437-441.
3. Sitzman TJ, Allori AC, Thorburn G. Measuring outcomes in cleft lip and
palate treatment. Clin Plast Surg. 2014;41:311-319.
4. Sommerlad BC. A technique for cleft palate repair. Plastic Reconstr Surg.
2003;112:1542-1548.

11
CHAPTERTwo-Flap Palatoplasty
David K. Chong, Kathryn V. Isaac, and Kenneth E. Salyer
DEFINITION
■ Cleft palate is the failure of fusion of the palatal shelves during embryological
development.
■ Cleft palate may occur in isolation or in combination with a cleft lip. It may
occur as part of a syndrome or in the absence of associated anomalies.
■ A cleft of the palate may lead to feeding difficulties, speech impairment,
chronic Eustachian tube dysfunction, hearing loss, and altered facial growth.
■ Varying surgical approaches for cleft palate repair are utilized depending on
the type of cleft palate and beliefs regarding facial growth and speech
repercussions.
ANATOMY
■ Embryologically, the cleft may affect the primary or/and secondary palate.
■ Anatomically, the cleft is defined according to the involvement of the hard and
soft palate.
■ The hard palate is the bony palate, and surgical anatomy involves
■ Palatine process of maxilla
■ Horizontal plate of palatine bone
■ Hook of hamulus and pterygoid plates of sphenoid bone
■ Vomer/septum
■ Greater palatine foramina
■ Soft palate is the mobile part of the palate, and surgical anatomy involves
■ Levator veli palatini
■ Tensor veli palatini aponeurosis
■ Palatopharyngeus

■ Palatoglossus
■ The Veau classification provides a clinically useful description of the cleft type
according to the involvement of the alveolus, the hard palate, and the soft
palate. It guides selection of the surgical treatment.
■ The two-flap palatoplasty is most commonly performed for clefts of the hard
and soft palate. It is not commonly used for isolated clefts of the soft palate
and is not used for submucous clefts.
PATHOGENESIS
■ The etiology of cleft palate is multifactorial: environment, teratogen exposure
(alcohol, anticonvulsants, steroids, diazepam), nutrition, maternal infections
(rubella, toxoplasmosis), and genetics.
■ Cleft palate repair restores anatomical closure between the oral and nasal
cavities.
■ An unrepaired cleft palate may result in impaired:
■ Breathing
■ Feeding
■ Speech
■ Hearing
NATURAL HISTORY
■ Orofacial clefting is the most common craniofacial birth defect, occurring in
1:750 live births.
■ The incidence of cleft palate alone is 1:2000, with a female-to-male ratio of
2:1.
■ The incidence of cleft palate in combination with cleft lip is greater,
estimated at 1:1000 with a reverse gender ratio.
■ In the population of children with cleft lip and/or cleft palate (CL+/−P),
approximately 50% will have CLP, 30% to 35% CP, and 15% to 20% CL.
■ Approximately 40% of CP patients will have a syndrome, and 15% of CLP
will have a syndrome.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The diagnosis of a cleft palate is made by prenatal ultrasonography or by
physical examination at birth and in early infancy. A detailed assessment is
made of the child’s breathing, feeding, growth, and development.
■ Airway assessment must exclude presence of sleep apnea and micro-

/retrognathia.
■ Assessment of growth and weight is key to identify and monitor feeding
difficulty, gastroesophageal reflux, and use of feeding aids (Haberman/Pigeon
teat).
■ Hearing and middle ear function must be assessed and treated early by an
otolaryngologist.
■ The plastic surgeon should define the cleft palate type according to the
anatomic structures involved, the laterality, width of the palate, and
presence/absence of a cleft lip.
■ Also, the child should be assessed for associated anomalies suggestive of a
syndrome: craniofacial dysmorphism, airway compromise, cardiac defects,
ocular and auricular abnormalities, and musculoskeletal anomalies. A genetics
referral is suggested if suspicious of syndromic cleft palate.1
DIFFERENTIAL DIAGNOSIS
■ Syndromic cleft palate
■ van der Woude syndrome
■ Stickler syndrome
■ Robin sequence
■ 22q11.2 deletion syndrome
■ Treacher Collins syndrome
■ Nager syndrome
■ Ectrodactyly-ectodermal dysplasia
■ Klippel-Feil syndrome
NONOPERATIVE MANAGEMENT
■ It is very uncommon not to repair a cleft palate.
■ If the child is unable to undergo surgical treatment secondary to airway
concerns or medical fitness, a palatal obturator may be considered.
SURGICAL MANAGEMENT
■ Cleft palate repair is ideally performed between 9 and 12 months of age,2 with
the infant weighing greater than 8 kg.
■ Airway and middle ear disease assessment is performed and treated prior to or
simultaneously with cleft palate repair.
■ Risks of the procedure are hemorrhage/hematoma, airway compromise, wound
dehiscence, infection, oronasal fistula, flap necrosis, velopharyngeal

insufficiency, and reduced midfacial growth.
■ The main objectives of the cleft palate repair are as follows:
■ To separate the oral and nasal cavities
■ To reposition to the velar musculature for restoration of the velopharyngeal
sphincter, in particular the reconstruction of the levator muscular sling
■ To improve Eustachian tube function
■ To minimize detrimental effects on subsequent maxillary growth
■ The main steps of the procedure are (a) marking and elevation of
mucoperiosteal flaps off the hard palate; (b) isolation and lengthening of
pedicles (greater palatine artery) for mobilization of the oral mucoperiosteal
flaps; (c) dissection and separation of the nasal mucosa, velar musculature, and
oral mucosa; (d) tension-free closure of nasal mucosal layer; (e) reconstruction
of the velopharyngeal sphincter with repositioning of the levator sling; (f)
recreation of the uvula; and (g) closure of the oral mucosal layer.
Preoperative Planning
■ Active or passive dentofacial orthopedics is utilized for aligning the cleft
maxillary arches by many teams today and is applied in the first few weeks of
infancy. The orthopedic device is discontinued once the maxillary arches have
been satisfactorily repositioned.
■ With the patient anesthetized, the width of the cleft is measured at the junction
of the soft palate and hard palate. The width of the cleft is important to predict
difficulty of the cleft palate repair and anticipated amount of dissection
required for closure. A cleft gap of:
■ Less than 11 mm closes with ease
■ 12 to 16 mm will require more extensive dissection to mobilize the greater
palatine vessel and achieve nasal lining mobilization
■ Greater than 17 mm will require special maneuvers detailed below to achieve
tension-free closure (greater palatine foramina osteotomy)
Positioning
■ The patient is positioned supine with shoulder roll to allow neck extension. A
south-facing oral RAE tube is carefully taped centrally with a mesentery.
Corneas are protected with eye tapping.
■ Access and visualization of the entire palate is very important and cannot be
understated. It is especially important to ensure visualization from the uvuli to
the anterior extent of the palate.

■ It is essential for the surgeon to ensure that positioning is correct prior to
scrubbing. This will facilitate the procedure.
■ The surgeon should have a headlight or lighted instruments for optimizing
visualization in the confined space and a skilled attentive assistant. It is also
advantageous to have a bed that allows for Trendelenburg positioning. Some
surgeons stand to perform palate surgery from below but having the baby’s
head supported with the surgeon seated operating upside down provides the
best exposure and is the preferred position by many surgeons.
Approach
■ The aim of cleft palate surgery is tension-free closure of the palate oral and
nasal mucosal layers and restoration of the velopharyngeal muscular sphincter.
■ Difficulties anticipated include the following:
■ Access
■ Lighting
■ Unforgiving tissue
■ Bleeding obscuring visualization
■ Surgical approaches differ with regard to the amount of dissection performed
to achieve tension-free closure and muscle repositioning.
■ Importance lies in adequate exposure and dissection of tissues to allow
comfort for the operating surgeon to achieve tension-free closure.
■ Oral layer mobilization is largely dependent on careful mobilization of the
greater palatine artery from its periosteal sleeve.
■ Nasal layer mobilization is largely dependent on careful mobilization of the
mucosa as a sheet from its dense bony attachments.
T E C H N I Q U E S
■ Two-Flap Palatoplasty for a Unilateral Complete
Cleft Palate
Markings
■ Carefully insert an intraoral gag and a throat pack (it is the surgeon’s
responsibility to insert and remove).

■ Mark the incision lines:
■ Along the medial edges of the cleft from the uvuli to the anterior junction
of the hard palate and alveolus
■ Laterally at the junction of the hard palate and maxillary alveolus,
extending from the posterior maxillary tubercle to the anterior medial
marking (TECH FIG 1)
■ Inject local anesthetic with adrenaline into the hard palate and soft palate
(average of 8 mL). The vasoconstrictive properties reduce blood loss and
obstruction of the visual field. Local anesthetic also allows for
hydrodissection of the mucoperiosteal flaps off of the hard palate and tissue
expansion for ease of layer dissection in the soft palate.
■ Wait 8 minutes or until injection sites stop bleeding.
Elevation of Oral Mucoperiosteal Flaps
■ Perform incisions with needle tip cautery to reduce bleeding. Use a skin
hook on the uvula or stay sutures for countertraction.
■ Incisions, flap elevation, and pedicle dissection are done similarly on both
the greater and lesser segments.
■ Begin with lateral incisions: from the retromolar trigone along the junction
of the alveolus and palate with diathermy down to bone and slightly angled
medially to avoid injury of developing teeth.
■ For the medial incisions, palpate the posteromedial edge of the hard palate
before incising to ensure that the incision medially will be onto the bone
(hard palate) as you can inadvertently cut into the nasal layer and do a
“double cut” that reduces the available tissue for nasal layer closure. The
incision medially is made with a scalpel.

TECH FIG 1 • Markings of a two-flap palatoplasty for a
unilateral complete cleft palate.
■ Oral palatal mucosa is susceptible to tearing, so dissect continuously along
the entire length of the lateral incision toward the cleft to elevate the
mucoperiosteal flaps. Avoid “tunneling” as this can cause tearing of the hard
palate mucosa due to dense periosteal attachments.
■ Use a periosteal elevator to raise the mucoperiosteal flaps from lateral to
medial (TECH FIG 2A).
■ Then, use a skin hook at the leading anterior edge of the flap and dissect
from anterior to posterior along the hard palate in sweeping motions toward
the greater palatine foramina and posterior limit of the hard palate (TECH
FIG 2B).
Isolation of Greater Palatine Vessels
■ As you approach the greater palatine artery at the posterolateral edge of the
hard palate, the vessel becomes visible on the undersurface of the flap.

TECH FIG 2 • A. Dissection of the oral mucoperiosteal
flaps. B. Elevation of the oral mucoperiosteal flap
toward the pedicle, located posteriorly in the greater
palatine foramina.
■ The palatine artery has a circle of dense periosteal attachments around it.
■ Carefully dissect starting anterior and then working circumferentially
around the foramina, staying on bone and taking care not to dissect into the
artery or the leash of veins surrounding it.
■ To completely release the pedicle from its periosteal sleeve, careful and
complete release of the periosteal attachments must be achieved by
dissecting the flap directly off the posterior edge of the palatine bone.
■ Staying on bone during pedicle dissection is very important and rewarding
as there are tethering ligaments that insert into the oral mucosa.
■ Dissection directly off bone facilitates the circumferential release of these
ligaments, which otherwise make it exceedingly easy to tear the oral
mucosa and injure the pedicle.
■ Previous hydrodissection during local anesthetic injection will also aid in
finding the bloodless plane between the oral layer mucosal glands and the
muscular layer.
■ Complete circumferential pedicle dissection is achieved once the periosteal
sleeve is released behind the greater palatine foramina and velar muscle

attachments to the posterior edge of the hard palate are visualized (TECH
FIG 3).
■ It is critical for the surgeon to approach the release of the periosteal sleeve
patiently with gentle dissection and successive wider approach, which will
allow the palatine artery to finally be freed without tearing the mucosa or
creating excessive bleeding.
■ Once pedicle dissection is achieved, use gentle traction with scissors to tease
the vessel free out of the foramina. This will create enough freedom to close
most palatal clefts.
■ Very occasionally in the widest of clefts (>16 mm), osteotomy of the
posterior wall of the foramina is required.
■ Once sufficiently mobilized, retract the flaps out of the surgical field with
stay sutures and secure to the intraoral gag/retractor.
TECH FIG 3 • Oral mucoperiosteal flap elevation is
completed: pedicles are mobilized and velar
musculature is visualized attached along the posterior

hard palate.
■ Under magnification, dissect in the plane between oral mucosal glands and
the muscle layer posteriorly in the soft palate from the edge of the bony
palate to the uvula.
Dissection of the Nasal Mucoperiosteum
■ Mobilize the nasal mucoperiosteal layer with care, beginning on the lesser
segment of the cleft. This requires the gradual and wide dissection of this
continuous sheet of nasal mucosa, which is firmly attached to the hard palate
along its medial and posterior edges, along the nasal surface of the bony
palate and the medial surface of the medial pterygoid plate. The elevation of
the nasal layer anteriorly on the greater segment will necessitate elevation off
of the vomer.
■ The nasal mucosa is even more unforgiving than the oral mucosa, and once
a tear occurs, it is very easy to propagate. Resist the temptation to tunnel
before a whole edge has been liberated.
■ Use a Mitchell’s trimmer or similar blunt-edged instrument, starting at the
cleft margin, and scrape the oral surface of the bone until the edge of the
nasal mucosa starts to be defined and liberate the dense attachments to the
medial hard palate. As the edge becomes apparent, elevate the nasal
mucoperiosteum widely off the entire extent of the medial hard palate.
■ Judicious use of needlepoint diathermy on low setting can help to elevate
firmly attached areas that are not easily released with the Mitchell’s
trimmer.
■ Once the edge of the nasal mucoperiosteal flap is defined, slide the trimmer
around the corner of the hard palate onto the nasal surface of the bone staying
right on bone. If the edge is sufficiently liberated, then sweep anteriorly and
posteriorly to liberate the entire sheet off of the nasal surface (TECH FIG
4A).
■ If a portion of the edge is still attached, resist further sweeping until
releasing the portion that remains tethered to prevent a tear.
■ This dissection is continued to the posterior nasal spine. At this juncture,
there are always muscle attachments. Release these aberrant velar muscle
attachments with needlepoint diathermy.
■ Continue dissection along the nasal surface following the posterior edge of

the bone cephalad and lateral toward the medial surface of the medial
pterygoid plate (TECH FIG 4B).
■ Release the nasal mucoperiosteum directly off the bony surface of the medial
surface of the medial pterygoid plate with careful dissection of the fibrous
attachments here. Be patient and careful during the release of this densely
adherent portion of the nasal mucosa working posteriorly and cephalad along
the pterygoid plate and palatine bone. Confirm complete release by directly
visualizing the plane of the medial surface of the medial pterygoid plate. If
further release is required, the origin of the tensor veli palatini (TVP) along
the medial pterygoid plate may be severed to improve mobilization.
■ The sheet of mucosa should now be freely mobile as one continuous sheet
posteriorly and along the anterior medial hard palate. When extensive
dissection is required for a wide cleft, there may be a noticeable reduction in
the circumference of the oropharynx as the sheet mobilizes medially.
TECH FIG 4 • A. Elevation of nasal mucoperiosteal
flaps. B. Nasal flap dissection toward the medial
surface of the medial pterygoid plate.
■ Attention is then turned to the greater segment.

■ The dissection of the nasal mucoperiosteal flap is identical posteriorly
along the hard palate cleft margin.
■ Anteriorly, at the bony junction of the vomer and bony palate, the nasal
mucoperiosteum is raised in continuity with the vomerine periosteum.
■ This vomerine flap is raised cephalad directly off bone and in continuity
with the periosteum of the nasal surface of the hard palate.
Nasal Closure
■ Nasal layer closure is then commenced once there is assurance that the repair
is tension free by checking that both sides are sufficiently liberated.
■ Meticulous closure with knots tied on the nasal side
■ Small wedges are excised out at the base of the oral surface of the uvula to
assist closure. Place eversion sutures during the closure of the uvuli to
prevent notching or bifidity.
Dissection and Reconstruction of the Velar Musculature
■ With the nasal layer completely closed, proceed with the muscle dissection
and reconstruction of the velopharyngeal sphincter.
■ Three steps are critical for muscle repositioning:3
• Identification and separation of levator veli palatini (LVP)
• Velar musculature dissection and release from its attachments to the cleft
margin and hard palate shelf
• Velar musculature repositioning and repair
■ Deep to the muscles inserted into the back of the bony hard palate, the LVP
inserts abnormally at the cleft margin in the anterior half of the velum.
■ Using a scalpel, sharply dissect the velar muscle layer off of the nasal
mucosa along the cleft margin. This is done with a paramedian incision
lateral to the nasal mucosal closure line through muscle until the nasal
mucosal surface is identified.
■ It is easiest to separate the muscle layer once the nasal mucosa has been
repaired to give a “trampoline” effect, providing tactile feedback and
countertraction during this careful dissection.
■ Also, it is important to note that the bulk and breadth of the muscle widen
as you dissect laterally. This is analogous to the changing depth of a
swimming pool, with a shallow end (paramedian) becoming deeper as one
progressively dissects laterally.
■ The velar musculature is raised off the nasal mucosa and separated from the

tendinous fibers of the TVP. This separation is done laterally along the hard
palate shelf at the junction of “salmon pink” velar muscle fibers and
tendinous fibers of the TVP.
■ The velar musculature is further dissected until it can be freely mobilized to
lie parallel to the posterior hard palate margin and overlying the contralateral
velar muscle bundle.
■ You have completed the levator dissection when the “salmon pink”-colored
longitudinal fibers of the levator are identified emerging from the skull base
and the entire dissected muscle is free to be reoriented to a more functionally
effective position in the posterior half of the soft palate.
■ The dissection of the velar musculature is performed on both sides.
■ Repair the muscles and reconstruct the levator muscular sling by suturing the
muscles and securing with multiple sutures, knots facing the nasal surface.
■ Ensure proper hemostasis is achieved.
Oral Closure
■ Close the oral layer beginning with stay sutures placed anteriorly and
progressing posteriorly toward the uvuli with horizontal mattress sutures.
■ There is no attempt of push-back of the flaps for lengthening with a V-Y
closure.
■ During oral layer closure, place some full-thickness sutures through both the
oral and nasal layers just posterior to the hard palate shelf (anterior to muscle
repair) to help obliterate the dead space and position the muscle repair.
■ Place interrupted simple sutures between each of the mattress sutures.
■ Attempt to minimize raw bone exposure by closing palatal flaps to alveolus
wherever possible.
■ Recheck for adequate hemostasis, irrigate, and remove throat pack.
■ If concerned for airway during postoperative period, consider
nasopharyngeal tube insertion and a tongue stitch.
■ Two-Flap Palatoplasty—Bilateral Complete Cleft
Palate
■ In a bilateral cleft palate, the operative steps are similar to those outlined
above except for the flap elevation and closure anteriorly along the junction
of the primary and secondary palate.

■ The oral and mucosal nasal incisions and dissections on the lesser segment
are performed as outlined above.
■ Bilateral vomerine flaps are raised from the premaxilla in continuity with the
nasal mucoperiosteal flaps (TECH FIG 5).
■ The anterior closure of the nasal and oral layers requires meticulous
approximation and closure to eliminate the risk of an oronasal fistula at the
junction of the primary and secondary palate.
■ Careful and patient dissection is required to the dense attachments of
mucoperiosteum to the posterior surface of the premaxilla to which the
palatal flaps will be anchored.
TECH FIG 5 • Markings of a two-flap palatoplasty for a
bilateral complete cleft palate.
PEARLS AND PITFALLS

Headlight and
positioning
■ Good lighting and access paramount importance
Loupe magnification
■ Especially helpful for dissection around palatine
foramina and muscle when surgeon is less
experienced
Hemostasis
■ Ensure meticulous hemostasis throughout case to
optimize visualization.
■ Judicious use of needlepoint diathermy
■ Failure to do so may result in airway compromise,
flap necrosis, and wound dehiscence.
Use needlepoint
diathermy to make hard
palate incisions.
■ Controls bleeding and persisting ooze
Work on broad front.
■ Avoid tunneling during dissection.
Patience and precision
during dissection
especially around
palatine foramina
■ Bleeding obscures view, and careless dissection risks
injury to pedicle and vascularity of the flap.
Handle tissues with
care.
■ Nasal mucosa is especially susceptible to tears.
Inset palatal flaps with
stay sutures to help
control closure.
■ Helps to put the most difficult sutures anteriorly with
stay sutures to judge closure and maintains good
exposure
Do not attempt closure
until all layers are
sufficiently mobilized.
■ Prevents tearing
■ If sutures are prematurely placed, further attempts to
mobilize tissue are more likely to result in tears.
Prematurely suturing may also result in tears if
tension is still present.
Oronasal fistula
■ Critical to achieve adequate tissue dissection, perfect
approximation, and apposition of tissue layers with
meticulous suture technique to prevent fistulae.
POSTOPERATIVE CARE
■ Nasopharyngeal tube as required

■ Remove tongue stitch in recovery if used.
■ Analgesia to reduce blood pressure and distress (24 hours of intravenous
opioids)
■ Encourage feeding.
■ Postoperative visit in 4 weeks
OUTCOMES
■ Two-flap palatoplasty yields excellent speech outcomes with minimal surgical
morbidity.
■ In a 20-year long-term follow-up, the authors have recorded a 7% to 11%
incidence of velopharyngeal insufficiency with no significant difference
between cleft subtypes.4
■ Speech results were normal to mildly impaired resonance (92%), no or
inaudible nasal air emission (80%), and no compensatory articulation errors
(98%).
■ The fistula rate of a cleft palate repair with a unipedicled flap technique is
6.2% (95% CI, 4.3%–8.4%) according to a systematic review of international
data.5
■ The effect of palatoplasty on maxillary facial retrusion is controversial.
Inherent maxillary growth deficiency, secondary scarring from palatal flap
elevation, and timing of repair are all contributing factors to midfacial
retrusion.6 Deleterious growth has been shown to be greatest in patients treated
by Veau push-back technique. Further long-term studies are required to
compare the effect of palatal flap technique on maxillary growth restriction.
COMPLICATIONS
■ Bleeding is a feared complication as it may lead to an emergency with airway
obstruction and respiratory compromise. Additionally, hematoma may lead to
compression of the pedicle or flap, with resultant flap necrosis, wound
dehiscence, and oronasal fistulae. To prevent this complication, vigilant
hemostasis is an absolute and adequate postoperative analgesia is necessary.
■ Airway obstruction may occur in the absence of hemorrhage, and a tongue
stitch or nasopharyngeal tube may assist in prevention of obstruction in infants
at risk. Airway obstruction can also occur if a throat pack is utilized and the
surgeon overlooks removal of the throat pack prior to extubation.
■ Flap necrosis is rare and avoidable with careful dissection and release of the
periosteal sleeve of the greater palatine pedicle.

■ Infection and wound dehiscence leading to oronasal fistulae are detrimental. A
small fistula secondary to delayed wound healing may heal with conservative
measures. Failure of closure may necessitate reoperation with re-elevation and
closure of oral and nasal flaps as well as possible augmentation using local
flaps and/or biologic adjuncts.
REFERENCES
1. van Aalst JA, Kolappa KK, Sadove M. MOC-PS CME article: non-syndromic
cleft palate. Plast Reconstr Surg. 2008;121:1-14.
2. Rohrich RJ, Love EJ, Byrd HS, Johns DF. Optimal timing of cleft palate
closure. Plast Reconstr Surg. 2000;106:413-422.
3. Kriens OB. An anatomical approach to veloplasty. Plast Reconstr Surg.
1969;43:29-41.
4. Salyer KE, Sng KW, Sperry EE. Two flap palatoplasty: 20-year experience
and evolution of surgical technique. Plast Reconstr Surg. 2006;118:193-204.
5. Hardwicke JT, Landini G, Richard BM. Fistula incidence after primary cleft
palate repair: a systematic review of the literature. Plast Reconstr Surg.
2014;134:618e-627e.
6. Lee YH, Liao YF. Hard palate repair technique and facial growth in patients
with cleft lip and palate: a systematic review. Br J Oral Maxillofac Surg.
2013;51:851-857.

12
CHAPTER
Tongue-Lip Adhesion/Floor
of Mouth Muscle Release
for Pierre Robin Sequence
Chad A. Purnell and Arun K. Gosain
DEFINITION
■ Pierre Robin sequence (PRS) is a clinical triad of glossoptosis, retrognathia,
and airway obstruction.
■ Cleft palate is present in approximately 50% of cases.
■ PRS is associated with an identified syndrome in 30% to 60% of cases.1
■ The most common syndromes associated with PRS are Stickler syndrome
(11%–20%) and 22q11.2 deletion (velocardiofacial) syndrome (11%).2
ANATOMY
■ The tongue in PRS is posteriorly displaced due to retrognathia. This results in
an airway obstruction at the tongue base (FIG 1).
■ Airway obstruction may also result from lesions lower than the tongue, such as
laryngomalacia. Synchronous airway lesions are present in up to 28% of
patients.3
■ Cleft palate may be U- or V-shaped; a U-shaped palatal cleft is classically
associated with PRS.
PATHOGENESIS
■ Pathogenesis of PRS is incompletely understood and likely multifactorial.

FIG 1 • Micrognathia results in a more posterior position
of the mandible and tongue in PRS (solid lines)
compared to a normal patient (dotted lines).
■ Theorized mechanisms of PRS include mechanical obstruction to mandibular
growth, delay in neuromuscular development of the tongue and oropharynx,
connective tissue dysplasia, and teratogen exposure.4,5
NATURAL HISTORY
■ PRS occurs on a spectrum that ranges from mild asymptomatic hypoplasia to
critical airway obstruction requiring emergent endotracheal intubation at birth.
■ In more severe phenotypes, PRS is often associated with feeding issues such
as gastroesophageal reflux, failure to thrive, and abnormal oroesophageal
motility.6,7
■ Mortality has decreased dramatically with improved awareness and care.
Mortality in 1946 was greater than 50% and has decreased to 16%, with all
deaths occurring in syndromic patients.8,9

PATIENT HISTORY AND PHYSICAL FINDINGS
■ A full birth history and physical examination should be performed. A key point
of examination should be documenting the maxillomandibular discrepancy
with the child upright and the mandible closed.
■ A careful examination for syndromic features should include hearing and
ocular exam to evaluate for Stickler syndrome.10
■ Evaluation and treatment of any patient with PRS should be performed by a
multidisciplinary team, which includes craniofacial surgery, otolaryngology,
speech and feeding therapy, critical care/anesthesiology, and genetics.
IMAGING
■ If the child is not intubated, a polysomnogram should be performed, including
a portion with a nasopharyngeal airway in place in order to determine whether
there is ongoing sleep apnea if upper airway obstruction is removed.
■ Fiberoptic nasendoscopy is performed to evaluate whether the airway
obstruction is isolated to the tongue base or whether there are additional
sources of supraglottic airway obstruction, including laryngomalacia.
■ Prior to any surgical intervention, bronchoscopy should be performed to
evaluate for subglottic synchronous airway lesions.
NONOPERATIVE MANAGEMENT
■ The majority of patients can be treated nonoperatively.
■ Initial airway management is prone positioning to displace the mandible
anteriorly.
■ Supplemental oxygen may be added as well.
■ A nasopharyngeal airway should be placed if desaturations continue. This
airway has been utilized successfully as end-treatment at home by several
centers.11
■ If a nasopharyngeal airway does not resolve airway obstruction, emergent
endotracheal intubation is indicated.
■ Continuous positive airway pressure masks and palatal appliances have also
been described for treatment.12,13
SURGICAL MANAGEMENT
Preoperative Planning
■ Prior to any surgical treatment, bronchoscopy should be performed. In the

presence of significant subglottic obstruction, tracheostomy is likely the only
treatment option.
■ Prior to performing a tongue-lip adhesion, a GILLS score should be
calculated. One point is given for each of the following: gastroesophageal
reflux, intubation preoperatively, late operation (greater than 2 weeks of age),
low birth weight (less than 2500 g), and syndromic diagnosis. A score of 3 or
more is predictive of failure of tongue-lip adhesion, and another option such as
mandibular distraction osteogenesis or tracheostomy should be considered.14,15
Positioning
■ The procedure is performed supine.
■ Endotracheal intubation may be nasotracheal or orotracheal, with the tube
taped to the side out of the operative field.
Approach
■ Soft tissue procedures for PRS include tongue-lip adhesion, subperiosteal
release of the floor of mouth, or both procedures performed concomitantly.16,17
■ Subperiosteal release of the floor of mouth is an ideal addition to tongue-lip
adhesion if the patient has a fixed, immobile tongue (ankyloglossia) and a
tongue-based airway obstruction. This procedure is also performed in isolation
for airway obstruction at some centers.
■ Mandibular distraction osteogenesis is a skeletal technique to treat mandibular
hypoplasia that may have more repeatable resolution of airway obstruction in a
broader range of patients with PRS, with potentially higher complication
rates.18–20
T E C H N I Q U E S

Video p8-c012
■ Subperiosteal Release of the Floor of the Mouth
Creation of Tongue and Lip Flaps
■ 0.5% lidocaine with epinephrine is injected into all planned incisions for
hemostasis.
■ A transverse incision is made 1.5 cm in length in the lower lip (TECH FIG
1A).
■ Incision is carried obliquely posterior into the muscle of the lip to create a
superiorly based flap approximately 1.5 × 1 cm in area.
■ A 1.5-cm transverse incision is made in the undersurface of the tongue
approximately 2 mm inferior to the rugae (TECH FIG 1B).
■ An inferiorly based 1.5- × 1-cm musculomucosal flap is elevated (TECH
FIG 1C).
00:00 / 00:00

TECH FIG 1 • A. A 1.5- × 1-cm flap is marked in the
mucosa of the inferior lip. B. A 1.5- ×1-cm inferiorly
based flap is marked on the inferior tongue. C. See
TECH FIG 4. Tongue musculomucosal flap after
elevation.

TECH FIG 2 • A. A V-shaped incision is placed on
either side of the tongue frenulum for subperiosteal
release of the tongue. B. Area of periosteal elevation
of the lingual surface of the mandible.
Subperiosteal Release of the Floor of the Mouth
■ A separate V-shaped incision is made around the base of the frenulum of the
tongue (TECH FIG 2A).
■ Dissection is carried anteriorly until the lingual surface of the mandible is
reached. The periosteum of the mandible is incised.
■ A periosteal elevator is used to completely elevate the periosteum of the
lingual surface of the symphysis, parasymphyses, and bilateral mandible
bodies (TECH FIG 2B).
■ Incision is closed in a V-to-Y advancement fashion with 4-0 Vicryl in the
muscle layer and 5-0 Monocryl for the mucosal layer.
Placement of Tongue Suspension Suture
■ A loop of 4-0 silk suture is tied through one hole of a surgical button and left

long as an emergency pullout suture.
■ The button is placed on a backer of adhesive foam to help prevent pressure
sores (TECH FIG 3A).
■ 2-0 polypropylene suture on a long, curved taper needle (2-0 Prolene on a
CT-1 needle; Ethicon, Somerville, NJ) is used after straightening the needle
slightly to allow the needle to capture the anterior tongue mass.
■ This suture is passed through the raw area created by the tongue flap,
through the mass of the anterior tongue musculature, and out the posterior
tongue mucosa at a point where the tongue starts to curve toward the
oropharynx in a more vertical orientation.
■ The needle is then passed through the button, then back through the tongue
in a mattress fashion (TECH FIG 3B).
■ The suspension suture is pulled forward to assess anterior movement of the
tongue mass as the suture is brought under tension.
■ If tongue movement is acceptable, the suture is brought through the incision
in the lower labial sulcus, staying anterior to the mandible, to exit the skin in
a submandibular crease.
■ The loose end of the suture can be threaded through a Keith needle and
passed parallel to the first end to complete the mattress suture.
■ Before removing the needles, both suture ends are passed through a foam-
backed button, over which the suture will be tied. Foam should be firm and
can be fashioned from the foam backing within an empty needle pack.
■ The button overlying the tongue mass does not require foam backing,
whereas the submandibular button does require foam backing to avoid
ulceration of the facial skin.
Closure and Tensioning of Tongue
■ The posterior mucosa of the tongue is approximated to the inferior aspect of
the labial sulcus incision using interrupted 5-0 Monocryl suture (Ethicon,
Somerville, NJ).
■ Sutures are placed sequentially from one side of the incision to the other,
taking care to place the knots such that they lie on the mucosal side of the
closure (TECH FIG 4A).

TECH FIG 3 • A. A backer of adhesive foam is placed
on the back of the surgical buttons to prevent pressure
sores from the buttons. B. Path of 2-0 polypropylene
suspension suture through the tongue and surgical
button and out the skin.
■ The muscle of the tongue and the lip are approximated on either side and in
the center of the limbs of the suspension suture using 4-0 Vicryl suture
(Ethicon, Somerville, NJ). Three such sutures are usually sufficient.
■ The anterior mucosa of the tongue is approximated to the superior aspect of
the labial sulcus incision using interrupted 5-0 Monocryl suture. Sutures are
placed sequentially from one side of the incision to the other, taking care to
place the knots such that they lie on the mucosal side of the closure.
■ Tension on the tongue suspension suture is determined by gently securing
the first knot over the submandibular foam-backed button until the tongue
mass just begins to move forward. No further tension should be placed so as
minimize pressure on the skin. Subsequent knots are placed to secure the
suture (TECH FIG 4B).
■ The purpose of the suspension suture is simply to take pressure off of the
mucosal and muscular layers of the closure for the first 7 to 10 days, and
sequelae such as tongue edema or skin ulceration can be minimized by
placing the least amount of tension on the suture required to move the
tongue mass forward.

■ The safety silk suture tied to the button in the mouth is taped to the cheek.
■ A nasogastric tube is placed to facilitate feeding.
TECH FIG 4 • A. Posterior layer of mucosal flaps is
closed with 5-0 Monocryl sutures. B. Suspension
suture is tied over a button under the chin. Note the
safety silk suture used to retrieve the intraoral button.
PEARLS AND PITFALLS
Preoperative
screening
■ Nasendoscopy and bronchoscopy are essential prior to tongue-lip
adhesion. The procedure should not be performed if there are any
synchronous airway lesions.
Suspension
suture
■ The suspension suture should be tensioned to pull the base of the
tongue forward but should not be pulled maximally as to cause
tissue necrosis and increased tongue edema.
Postoperative
care
■ The adhesion should NOT be left in place until repair of cleft
palate. This jeopardizes oromotor development and mobility of the
tongue.
POSTOPERATIVE CARE
■ Extubation is carried out when deemed appropriate by anesthesiology or
critical care. A nasopharyngeal airway is left in place for several days to
manage the airway while surgical edema is present.

■ The suspension suture is left in place for 7 to 10 days.
■ The child is monitored carefully for resolution of airway obstruction.
Postoperative polysomnography is performed.
■ If airway obstruction resolves, the patient is evaluated every 1 to 2 months.
The tongue is monitored for active motion in response to touch, a sign of
maturing tongue function.
■ If tongue motion has matured and MMD has decreased to 3 mm or less, the
adhesion is taken down, usually by 6 to 7 months of age.
■ Early takedown of the tongue-lip adhesion is preferable so as to avoid
oromotor delay in tongue function. Prior reports left the adhesion in place until
the time of palate repair, often close to or later than 1 year of age. We believe
that this can contribute to oromotor retardation. In addition, it is preferable to
take down the tongue-lip adhesion well before the palate repair so as to assess
adequacy of airway prior to further airway restriction that accompanies cleft
palate repair.
OUTCOMES
■ Resolution of airway obstruction is variable in studies of tongue-lip adhesion,
ranging from 43% to 89%.15,21
■ Complete resolution of feeding difficulties also is variable, but many authors
report an approximately 60% rate of ability to oral feed without any tube-
feeding supplementation. Variabilities may exist due to institution-based
protocols for surgical feeding tube placement.22,23
■ Few studies comprehensively assess polysomnographic findings after tongue-
lip adhesion. Sedaghat et al.24 describe improvement in sleep study findings in
7/8 patients after adhesion, but only 3 patients had reduction to mild or no
sleep apnea. Flores et al.18 describe improvement in apnea-hypopnea index in
15 patients after adhesion, but improvement was significantly less compared to
mandibular distraction patients.
■ Tongue-lip adhesion has minimal effects on long-term speech development.25
COMPLICATIONS
■ Dehiscence (greatly reduced in techniques that utilize a suspension suture)
■ Failure to completely resolve airway obstruction
■ In these cases, the airway should be reassessed for sites of synchronous
airway lesions that may not have been appreciated, paying particular attention
to supraglottic airway compromise and laryngomalacia.

■ If the only other site of airway compromise is some element of
laryngomalacia, the multidisciplinary team should be consulted regarding
potential role for mandibular distraction osteogenesis with or without
supraglottoplasty.
■ If the patient is found to have laryngomalacia and is not felt to be a candidate
for mandibular distraction osteogenesis with or without supraglottoplasty, or
if synchronous subglottic airway compromise is identified (eg,
tracheomalacia), then tracheostomy is recommended.
■ Requirement for prolonged nasogastric feeds or gastrostomy tube
REFERENCES
1. Izumi K, Konczal LL, Mitchell AL, Jones MC. Underlying genetic diagnosis
of Pierre Robin sequence: retrospective chart review at two children’s hospitals
and a systematic literature review. J Pediatr. 2012;160(4):645.e2-650.e2.
2. van den Elzen AP, Semmekrot BA, Bongers EM, et al. Diagnosis and
treatment of the Pierre Robin sequence: results of a retrospective clinical study
and review of the literature. Eur J Pediatr. 2001;160(1):47-53.
3. Andrews BT, Fan KL, Roostaeian J, et al. Incidence of concomitant airway
anomalies when using the University of California, Los Angeles, protocol for
neonatal mandibular distraction. Plast Reconstr Surg. 2013;131(5):1116-1123.
4. Cohen M. Robin sequences and complexes: causal heterogeneity and
pathogenetic/phenotypic variability. Am J Med Genet. 1999;84:311-315.
5. Chiriac A, Dawson A, Krapp M, et al. Pierre Robin syndrome: a case report.
Arch Gynecol Obstet. 2008;277:95-98.
6. Daniel M, Bailey S, Walker K, et al. Airway, feeding and growth in infants
with Robin sequence and sleep apnoea. Int J Pediatr Otorhinolaryngol.
2013;77(4):499-503.
7. Baudon JJ, Renault F, Goutet JM, et al. Motor dysfunction of the upper
digestive tract in Pierre Robin sequence as assessed by sucking-swallowing
electromyography and esophageal manometry. J Pediatr. 2002;140(6):719-723.
8. Douglas D. The treatment of micrognathia associated with obstruction by a
plastic procedure. Plast Reconstr Surg. 1946;1:300.
9. Costa MA, Tu MM, Murage KP, et al. Robin sequence: mortality, causes of
death, and clinical outcomes. Plast Reconstr Surg. 2014;134(4):738-745.
10. Antunes RB, Alonso N, Paula RG. Importance of early diagnosis of Stickler
syndrome in newborns. J Plast Reconstr Aesthet Surg. 2012;65(8):1029-1034.
11. Abel F, Bajaj Y, Wyatt M, Wallis C. The successful use of the nasopharyngeal

airway in Pierre Robin sequence: an 11-year experience. Arch Dis Child.
2012;97(4):331-334.
12. Leboulanger N, Picard A, Soupre V, et al. Physiologic and clinical benefits of
noninvasive ventilation in infants with Pierre Robin sequence. Pediatrics.
2010;126(5):e1056-e1063.
13. Butow KW, Hoogendijk CF, Zwahlen RA. Pierre Robin sequence:
appearances and 25 years of experience with an innovative treatment protocol.
J Pediatr Surg. 2009;44(11):2112-2118.
14. Abramowicz S, Bacic JD, Mulliken JB, Rogers GF. Validation of the GILLS
score for tongue-lip adhesion in Robin sequence patients. J Craniofac Surg.
2012;23(2):382-386.
15. Rogers GF, Murthy AS, LaBrie RA, Mulliken JB. The GILLS score: part I.
Patient selection for tongue-lip adhesion in Robin sequence. Plast Reconstr
Surg. 2011;128(1):243-251.
16. Argamaso RV. Glossopexy for upper airway obstruction in Robin sequence.
Cleft Palate Craniofac J. 1992;29(3):232-238.
17. Caouette-Laberge L, Borsuk DE, Bortoluzzi PA. Subperiosteal release of the
floor of the mouth to correct airway obstruction in pierre robin sequence:
review of 31 cases. Cleft Palate Craniofac J. 2012;49(1):14-20.
18. Flores RL, Tholpady SS, Sati S, et al. The surgical correction of Pierre Robin
sequence: mandibular distraction osteogenesis versus tongue-lip adhesion.
Plast Reconstr Surg. 2014;133(6):1433-1439.
19. Master D, Hanson P, Gosain A. Complications of mandibular distraction
osteogenesis. J Craniofac Surg. 2010;21:1565-1570.
20. Paes EC, Bittermann GK, Bittermann D, et al. Long-term results of
mandibular distraction osteogenesis with a resorbable device in infants with
Robin sequence: effects on developing molars and mandibular growth. Plast
Reconstr Surg. 2016;137(2):375e-385e.
21. Li HY, Lo LJ, Chen KS, et al. Robin sequence: review of treatment
modalities for airway obstruction in 110 cases. Int J Pediatr Otorhinolaryngol.
2002;65(1):45-51.
22. Kirschner R, Low D, Randall P, et al. Surgical airway management in Pierre
Robin sequence: is there a role for tongue-lip adhesion? Cleft Palate Craniofac
J. 2003;29:239.
23. Hoffman W. Outcome of tongue-lip plication in patients with severe Pierre
Robin sequence. J Craniofac Surg. 2003;14(5):602-608.
24. Sedaghat AR, Anderson IC, McGinley BM, et al. Characterization of

obstructive sleep apnea before and after tongue-lip adhesion in children with
micrognathia. Cleft Palate Craniofac J. 2012;49(1):21-26.
25. LeBlanc SM, Golding-Kushner KJ. Effect of glossopexy on speech sound
production in Robin sequence. Cleft Palate Craniofac J. 1992;29(3):239-245.

13
CHAPTERPalatal Fistula
Gregory D. Pearson
DEFINITION
■ A fistula is defined as an epithelialized tract between two cavities that are not
meant to be communicating.
■ A palatal fistula is an abnormal communication between the oral and nasal
cavities.
■ Palatal fistula can be intentional or unintentional.
■ Intentional fistulas are fistulas not repaired at the time of initial operation.
Examples include:
• The alveolar cleft with a Veau III or Veau IV (unless the surgeon elects to
perform a gingivoperiosteoplasty)
• A Veau IV with a “locked out” premaxilla
■ Unintentional fistula after palatoplasty1–3:
• These fistulas are unwanted and not planned for during the initial operation.
• Veau IV clefts are associated with the highest fistula rate.
• No difference in risk for palatal fistula related to gender, age at time of
repair, and race.
• The difference in fistula rate between straight line repairs and Furlow-type
repairs appears to be surgeon/institution dependent with no clear lower risk
between the two types of repair.
■ Palatal fistula repair can be an extremely challenging problem to solve and
prevention is the best option.
ANATOMY
■ The Pittsburgh fistula classification system classifies fistulas as I to VII, from

a posterior to anterior location on the palate4 (FIG 1).
■ Type I involves only the uvula (consisting of a bifid uvula).
■ Type II involves the soft palate.
■ Type III occurs at the junction of the hard/soft palate.
■ Type IV arises within the hard palate.
FIG 1 • Pittsburgh fistula classification system.
■ Type V is located at the incisive foramen (reserved for Veau IV clefts).
■ Type VI is a lingual alveolar communication on the alveolus.
■ Type VII is located on the labial side of the alveolus.
PATHOGENESIS
■ Occurrence rates of palatal fistula vary from 0% to 60% in reported
literature.1–3
■ Several factors have been associated with the prevention of palatal fistula:
■ Tension-free and watertight closure
• Relaxing incisions advocated by von Langenbeck for tension-free closure.
• Jackson et al. proposed “CHOP modification” of Furlow palatoplasty for
soft palate repair.2
■ Complete two-layer closure of nasal and oral flaps
• LaRossa promoted liberal use of vomer flaps for closure of the nasal floor.5
■ Infection prevention
• The use of perioperative antibiotics is debated in the literature.

NATURAL HISTORY
■ Palatal fistula will remain patent until the time of closure.
■ A fistula can be symptomatic or asymptomatic
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Palatal fistula can occur after cleft palate repair, oncologic resection, trauma,
or illicit drug use.
■ Patients may report that the fistula is symptomatic.
■ Nasal escape of food or liquids
• May be intermittent
• Typically, viscous liquids like yogurt
■ Nasal escape of air
• May be noted by patient as change in voice
■ May be noted by speech pathologist as nasal turbulence or hypernasality
■ Physical examination will demonstrate a hole or communication from the oral
to nasal cavity.
■ Fistulas can range from small to large and vary in location on the palate.
■ Small fistulas can be difficult to see, but the patient can typically state/point
to the location.
• An examination under anesthesia with a lacrimal probe can be useful to
determine the location, size, and orientation of a fistula.
■ A dental mirror can be useful in evaluating anterior fistulas.
■ Deep crevasses or folds of mucoperiosteal tissue can simulate a fistula.
■ Palatal expansion may open an occult fistula that was already present.
IMAGING
■ Radiographic fistulograms (such as those performed for an enterocutaneous
fistula evaluation) are not necessary.
■ Physical examination should determine whether a fistula is present.
■ Nasopharyngoscopy or video fluoroscopy should be employed to determine
velopharyngeal gap size in patients with fistula and velopharyngeal
dysfunction.
DIFFERENTIAL DIAGNOSIS
■ Hypernasality from velopharyngeal dysfunction (VPD)
■ Nasal escape of liquids/food secondary to poor oral motor planning/retrograde

oronasal reflux
NONOPERATIVE MANAGEMENT
■ Obturators/dental retainers can be fabricated by dentists or orthodontists to
provide symptomatic relief (FIG 2).
■ Obtaining patient compliance for wearing the retainer can be difficult.
■ The dental brackets on the retainer may loosen and require retightening or
fabrication of a new splint.
■ The patient must have enough teeth to properly support a retainer.
SURGICAL MANAGEMENT
■ Surgical management and operative options are largely dictated by the location
of the palatal fistula based upon the Pittsburgh classification system.
■ When determining whether to repair a fistula, the surgeon should strongly
consider and assess whether the fistula is symptomatic.
■ Nasal escape of fluids or foods, hypernasality, and preventing further surgical
or orthodontic interventions (eg, bone grafting or orthognathic surgery) are all
reasons for attempted fistula repair.
■ Pittsburgh type I
■ Bifid uvula rate ranges from 1.34% to 19% of selected populations, but the
true fistula rate is probably underestimated in the literature.
■ Because these fistulas tend to be asymptomatic as well as concerns about
anesthesia on pediatric brain development, these fistulas are the least likely to
be repaired as a primary objective for an operation.
■ Pittsburgh type II
■ When determining the type of reconstruction choice for a soft palatal fistula
repair, a surgeon should also make a determination related to a child’s
resonance (specifically if VPD is present) and the type of previous repair
performed.
• If the child has VPD, the fistula may be fixed but hypernasality will likely
persist unless addressed with the repair.
■ If a child has normal resonance regardless of the type of primary palatoplasty
performed, augmentation/reinforcement with acellular dermal matrix (ADM)
can be used.6
■ For patients with a fistula after straight-line repair and concurrent VPD,
addressing the VPD with either a palatal lengthening procedure or VPD
surgery should be strongly considered.

• A conversion to a Furlow double opposing Z-plasty typically allows repair
of a type II fistula while addressing VPD in children with small
velopharyngeal gaps on imaging.7
• The CHOP modification with bilateral relaxing incisions can facilitate
tension-free closure.
■ For larger velopharyngeal gaps and fistula or very large fistula (dehiscence),
a superiorly based posterior pharyngeal flap may be necessary as conversion
to Furlow may not lengthen the palatal sufficiently.
■ Pittsburgh type III
■ Traditional teaching reports that the junction of the hard palate and soft palate
remains the most common site of fistula, particularly when employing a
Furlow palatoplasty.
■ As for type II fistula, the patient’s resonance and type of previous repair
should influence the operation considered for fistula repair.
■ Pittsburgh type IV
■ There is significant overlap for techniques used to repair type III and IV
palatal fistulas.
■ The mucoperiosteal flaps tend to scar, become stiffer, and have less mobility
compared to flaps used in a primary palatoplasty, thus limiting their
advancement or rotation potential.
■ Pittsburgh type V
■ This is the second most common location of fistula as well as the most
challenging to repair given the relative lack of palatal tissue in this area.
■ These fistulas are often the result of either poor inset of the lateral palatal
mucoperiosteal flaps into the premaxillary segment or more commonly a
premaxillary segment that is so anteriorly displaced out of the arch (a “locked
out” premaxilla and intentional fistula) that closure at the time of initial
palatoplasty is not possible.

FIG 2 • Palatal fistula (A) covered with an obturator (B).
■ Pittsburgh type VI and VII fistulas pertain to the alveolar arch and labial
sulcus and are addressed in the chapter on alveolar cleft repair.
Preoperative Planning
■ The surgeon must discuss the possibility of palatal fistula recurrence after
attempted closure with the patient and family.
■ Assuring proper patient compliance with postoperative instructions prior to
embarking upon repair is imperative.
■ Depending on the type of repair technique used, a surgeon may consider
having orthodontist fashion of a postsurgical retainer to protect repair while
healing, particularly for type IV and V fistulas.
■ It is important to ensure the retainer does not put pressure on flaps or area of
repair while still protecting the surgical site from tongue and food particulate.
■ As previously stated, in rare instances, an examination under anesthesia with a
lacrimal probe can be useful to determine the location, size, and orientation of
a fistula.
■ If a local flap is used, it must be protected from masticatory trauma during
healing.
Positioning
■ The patient should be orally intubated.
■ May use a regular endotracheal tube or oral RAE endotracheal tube
depending upon surgeon and anesthesiologist’s preferences.
■ The endotracheal tube may be positioned in the midline or laterally
depending on the repair technique chosen.