Reoperative Aesthetic & Reconstructive Plastic Surgery

1026
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Patient Examples
This patient presented for repair of a right secondary cleft lip deformity and alve-
olar cleft defect with stula.The lip is opened to reveal the alveolar defect and the
extent of the stula. Alveolar mucoperiosteal aps were elevated to close the nasal
oor. The hemipalatal ap was raised and used to close the oral defect. The nasal
oor was reconstructed with turned-up mucoperiosteal aps from the cancellous
bone graft placed in the cleft and on the anterior maxilla. The buccal mucope-
riosteal ap was elevated and used to close the alveolar defect, and to cover the
bone graft. Note how the mucosa of the ap was used to lengthen the central lip
mucosa (arrow).

The 3-month postoperative result is shown.
1027
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
This patient had an alveolar bony defect that was bone grafted.
The radiographs show the progression of tooth eruption after
stula closure and bone grafting. Orthodontic management was
initiated after canines erupted through the bone grafted area.

1028
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This patient’s appearance is typical after treatment of left unilateral cleft deformity.
She underwent one-stage correction, lip revision, nasal revision, maxillary onlay
bone grafting, stula closure, and alveolar bone grafting.The patient is shown post-
operatively. Note the correction of nasal tip asymmetry.
CORRECTION OF MAXILLARY/ MANDIBULAR DEFORMITY
The number of patients who have a retruded maxilla after primary cleft repair is,
hopefully, decreasing. However, when this occurs its outcome is an indication for a
LeFort I advancement osteotomy. Although stula closure and grafting can be per-
formed at the same time as the advancement, it is probably safer to perform this
procedure rst. The stula closure and grafting will be carried out later. If indi-
cated, a mandibular osteotomy can be performed at the same time as the maxillary
advancement. Planning an osteotomy should be performed in concert with the or-
thodontist who will prepare the dental occlusion for the surgery. Frequently onlay

1029
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
bone grafting will be necessary to correct maxillary hypoplasia. With good plan-
ning, secure xation, and the correct choice of surgery, the results can be very good.
If necessary, lip repair and rhinoplasty are included in the procedure. In cases with
signi cant soft tissue scarring and severe jaw disproportion, maxillary distraction is
a wiser course.20
Patient Examples
This patient had a unilateral cleft lip and palate with bimaxillary retrusion. Correc-
tion involved bimaxillary osteotomies, rhinoplasty, and onlay bone grafting. Pre-
operative and postoperative photos of the patient, including her dental occlusion,
are shown.

1030
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This patient presented with left unilateral cleft lip and palate with maxillary retru-
sion and mandibular protrusion. He is shown after LeFort advancement of the max-
illa, a sagittal split, set back of the mandible, rhinoplasty, and onlay bone grafting.
Preoperative and postoperative lateral cephalograms are also shown.
BILATERAL DEFORMITY
Correction of bilateral deformities is a signi cant challenge in almost all but Asian
patients, in whom the relatively at nose and short columella are aesthetically ac-
ceptable characteristics. However, in Caucasian patients, the columella provides pos-
sibly the greatest surgical challenge. Grayson and Santiago21 recently described a
promising technique for lengthening the columella that uses a traction system. It is
unusual to see an older patient with a bilateral cleft who does not require correc-

tive surgery. Fortunately, both our understanding of the problems associated with a
bilateral cleft deformity as well as surgical techniques for treatment are improving.
As a result, outcomes are better.
Reconstructing the bilateral deformity is a tall order. It involves closing the palate,
incorporating the premaxilla within the dental arch, reconstructing the lip, length-
ening the columella, reconstructing the nose and, at some point, grafting the bilat-
eral alveolar defects.
Early presurgical orthodontic management is performed to align the lateral seg-
ments and the premaxilla. At this point, if the alveolar defect can be widened, s-
tula repair is easier and bone grafting is more secure. The surgical correction per-
formed in our department is different than the standard approach. The alveolar
defects are closed at 3 months, and the lip and palate at 6 months. This regimen
eliminates stulas, which are a considerable and sometimes impossible problem to
deal with in the secondary case. Columellar lengthening is performed before the
child goes to school. Bone grafting will be performed, as indicated, at a later date.
Early and secure closure of the alveolar defects allows this to be accomplished with-
out problems.
Frequently the patients with repaired bilateral deformities who are referred to us
have bilateral stulas, maxillary hypoplasia and/or retrusion, a poor lip repair with
a nonfunctional central lip unit, and a poor nasal reconstruction with a short col-
umella. As with all cases of secondary cleft deformity, there is a team assessment—
radiographs, dental impressions, and models are studied, and orthodontic manage-
ment is instituted, if necessary.
After this assessment, the management is similar to management of the patient with
unilateral cleft deformity—the stula is closed with up-turned mucoperiosteal aps
for the nasal layer and a buccal myomucosal ap for oral closure. For long defects,
bilateral palatal aps will also be used in the repair along with bone grafting, max-
illary advancement, and nasal and soft tissue surgery, as indicated. The therapeutic
and technical challenges of managing patients with bilateral cleft problems are
much more signi cant than for unilateral cases.
LIP
When assessing patients with bilateral lip deformities who present for secondary
surgery, it is commonly found that no attempt at muscle reconstruction has been
made, the scars are often unsatisfactory, and the center of the lip is square instead of
the triangular form of the normal lip.The result is an unattractive lip that is too big
and resembles an immobile curtain.
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1032
PART III
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Patient Examples
This patient presented with a maxillary retrusion, nasal deformity, poor lip repair,
and anterior stulas. He was treated with LeFort I advancement osteotomy, stula
closure with bone grafting and lip revision, cranial bone grafting to the nose, and
an iliac crest bone graft to the maxilla and alveolus.The patient is shown preoper-
atively and postoperatively.
A careful orthodontic assessment is performed with cephalograms, dental impres-
sions, and Panorex lms, as indicated.The following aspects must be examined:the
presence of stulas;lip function, volume, and muscle position;the width and length
of scars;and the relationship of the lip to the nose area.The lip scars are excised in
a full-thickness elliptical fashion to create a central lip segment of normal size and
shape. The central skin segment is elevated based on the columella. Attention is
now turned to the lateral segments. Hooks are placed on the skin edges and the or-
bicularis muscle is dissected out bilaterally and extensively. The muscle dissection
must be extensive to ensure satisfactory, functional lip reconstruction, and the nerve
supply should be observed and preserved. The muscles are approximated in the
midline under the skin and stabilized to the subcutaneous tissue with long-lasting

sutures.The muscles are interdigitated to provide the correct height in the central
portion of the lip and,ideally,to provide central lip function,which must be achieved
without tension.The prolabial segment should now be redesigned.This procedure
is easy because the segment is based on the columellar base.The prolabial skin,which
has been trimmed to the correct size and shape for the prolabium, is brought back
down and sutured in position.The mucosa on the lateral segments is trimmed and
placed in a way that provides central lip bulk.This anatomic feature is often lost in
bilateral lip reconstruction.The result is a normally functioning lip without the dis-
agreeable lateral bulges, and a prolabium of the correct size and shape.
1033
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
This patient presented with a bilateral cleft with loss of premaxilla, and a large cen-
tral alveolar palatal stula. The muscles of the upper lip were dissected out very
carefully, realigned, and sutured with nonabsorbable material.The stula was closed
with upturned aps, iliac crest bone graft, and bilateral buccal mucoperiosteal aps
together with hard palate re-repair.
The same patient is shown postoperatively at 18 years of age.

This case provides an excellent example of columellar lengthening.This 5-year-old
patient presented with bilateral cleft deformities. A attened nose and short col-
umella were evident. The central lip ap was outlined in the center of the pro-
labium.
1034
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
COLUMELLAR R ECONSTRUCTION
Many methods of reconstruction have been used to correct the columella.We have
used the central portion of the prolabium.This area is usually hairless;if it is not, the
hairs can be removed by laser before or after the reconstruction. (This has not been
necessary in any case.) The ap is designed centrally and vertically, based on the
nasal columella and tip. The prolabium is usually left too wide in the primary re-
pair by design. The width of the ap is determined by assessing the width of the
columella.The ap is designed with a point at the lower end to give some central
lip lengthening on closure of the donor defect. An incision is made vertically on
both sides of the present columella and the planned columella and the skin of the
nasal tip is dissected upward.The lower lateral cartilages can be isolated by dissec-
tion and are sutured in the midline. Further cartilage grafts from the ears can form
a more satisfactory tip, usually in a pyramid shape. Alternatively, the cartilage may
be placed in Surgicel and molded into a tip. The alar bases can be dissected out
and approximated into the midline with nonabsorbable suture.There are no inci-
sions around the alar bases. The complete central lip segment now forms the ex-
tended columella.The central lip defect is closed to form a central lip groove.
Patient Examples

1035
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
The prolabial ap was elevated and sutured in position.The ap defect was closed,
lengthening the prolabium.The postoperative result is seen after 5 years.
This patient presented with an asymmetrical primary bilateral cleft lip and palate.
The columella was reconstructed using the method described for the patient in
the previous example (p. 1034).The patient is shown immediately postoperatively
and at 16 years of age.

1036
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
If there is concern about the lip ap, a 10- to 14-day delay is recommended;how-
ever, this situation is unusual.This reconstruction technique has provided the best
results in bilateral cleft revisions. In some cases a cartilage graft has been placed
along the whole length of the columella, in the midline, before suturing the ap in
place.There has been no loss of skin or other soft tissue.There should be no con-
cerns about a scar, because midline scars heal very well.22
This case provides an example of the management of the lip and nose in a patient
with an old bilateral cleft deformity. The shortness of the central portion of the
upper lip and the de cient mucosa are clearly shown.The patient underwent a re-
constructive regimen with (1) addition of mucosa to the midline by a VY mucosal
advancement and elevation of the skin segment of the lip (see p. 1033), (2) recre-
ation of the underlying orbicularis musculature with replacement of the central lip
skin and subcutaneous tissue, (3) and rhinoplasty. The patient is shown 10 years
postoperatively.

1037
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
ABBÉ FLAP
The Abbé ap is a time-honored technique for correction and reconstruction of
the tight upper lip, especially in secondary bilateral cleft cases. It is especially use-
ful for correcting multiply operated and badly scarred lips. Although this method
provides an excellent correction, it is static, and frequently, the end result is not sat-
isfactory.The classic technique offers little or no movement in this reconstructed lip
segment. As a result, a “sandwich” Abbé ap has been designed to provide a nor-
mally mobile central lip.23
We customarily dissect out the lip muscles in all bilateral cleft cases and join them
in the midline to provide a functional lip with the creation of an oral sphincter;
however, most surgeons do not do this. Therefore, in most secondary cases that
present in our clinic, there is an unreconstructed sphincter waiting to be recon-
structed. Because of this problem, the lip is tight and the central position may be
nonfunctional. In addition, in many cases there is scarring in the midline at the
skin mucosal junction, and the overall appearance in that area is unsatisfactory.
The central area of the lip (that is, the prolabium) is incised through-and-through
the full thickness of the lip. In most cases, the incisions continue up on both sides
of the columella, and the nasal tip is dissected upward. As mentioned previously, ear
cartilage is placed on the tip after approximating the domes of the lower lateral
cartilages. The central skin segment of the lip is now raised, and the remainder of
the lip segment is discarded; the central segment provides cover for the elongated
columella. The patient in the next example underwent reconstruction with this
technique.
The muscles of the upper lip, which are always “locked” in the lateral segments, are
now dissected out, paying particular attention to nerves and their preservation.The
muscles are advanced and reconstructed in the midline; they are usually interdigi-
tated to give some extra vertical length.
On the lower lip the Abbé ap design is drawn, always triangular and related to the
anatomy of the normal philtrum. The skin is then dissected up to the mucocuta-
neous margin and the mucosa is elevated in the same fashion. The intervening
muscle and nerve supply of the lip is left intact.The mucosa is incised through and
through on one side, allowing the labial vessels to be visualized and divided. With
this information on the position of the vessels, the contralateral side can be incised,
leaving the supplying vessels with a surrounding cuff of soft tissue.The lower lip is
closed in layers. The ap is now turned into the upper lip; the mucosal portion
provides cover for the inner aspect of the lip, and the skin provides external cover.
The upper lip muscles provide the functional “meat” in the sandwich. The ap is
now sutured in position.The pedicle is divided in approximately 15 days.

1038
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The muscles of the upper lip were dissected out very carefully, realigned, and su-
tured with nonabsorbable material. The defect in the upper lip was created, and
the ap was lifted virtually as an island on the labial vessels. There was no muscle
in the ap, only mucosa and skin. The defect in the lower lip was closed in layers,
and the sandwich was inserted by rotation on its very narrow pedicle.The skin and
mucosa cover the reconstructed upper lip muscles.
The contour of the upper lip in this patient was extremely tight, but the columel-
lar bulk was satisfactory.The plan for the ap was drawn.

The preoperative and postoperative results are shown, as well as the reconstructed
lips at rest and when functioning.
The advantages of this technique are (1) the upper lip is truly functional—it has
been augmented but not overaugmented, which was frequently the case in the past,
and (2) the aesthetics of the face are preserved with the ap in position. Because the
scars follow the lines of the philtrum, patients have been delighted with this re-
construction. Most importantly, there have been no ap losses. The functional as-
pect of the lower lip is left intact and the impression is that this has been an aesthetic
and functional advantage.
1039
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity

1040
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
BONY DEFICIENCY
Bony de ciency may be a volume problem related to hypoplasia of the lesser seg-
ment. Alternatively, it may be a functional problem caused by a segmental bony
alveolar defect (often with malocclusion), a stula, or absence of teeth. Another
factor influencing function is malocclusion resulting from alveolar collapse or a
retruded maxilla.
Unilateral hypoplasia causing nasal and cheek asymmetry can be corrected by on-
lay bone grafting. The best material for bone replacement is undoubtedly cancel-
lous bone from the iliac crest.This bone can be obtained through a small skin in-
cision, followed by the creation of a defect on the medial aspect of the ileum.The
required amount of bone is curetted out. Other sites have been used, but the me-
dial aspect of the ileum is undoubtedly the best location for both adults and chil-
dren.The iliac crest defect is closed with bone wax followed by insertion of a suc-
tion drain, if necessary.
ALVEOLAR GRAFTING
The most important aspect of alveolar grafting is secure soft tissue closure, without
which the bone graft will fail and a stula will form or recur. In some cases the graft
will simply be an onlay to improve contour and alar base support.When there is a
stula present, the bone graft supports the soft tissue repair. The graft provides a
nasal oor in the correct position, and establishes alveolar continuity. A tooth or
teeth may erupt through the grafted area. The graft supports the nasal oor and
improves nasal function, and when positioned as an onlay, hypoplasia and conse-
quently asymmetry of the maxilla can be corrected. When maxillary continuity
has been established and is solid, maxillary osteotomies can be performed to im-
prove the facial pro le, and to establish a normal occlusion.These conditions could
not be obtained without a one-piece maxilla.The orthodontist greatly appreciates
a bone grafted alveolus because it allows the teeth to be moved into areas that were
previously de cient. Dental bridges can be manufactured, obviating the need for
dentures.This information is always well-received by patients.

The corrections that apply to patients with unilateral complete clefts are also used
for patients with bilateral clefts. Surgery is ideally performed when the patient is 16
to 17 years old. Older patients can also undergo rehabilitation. In some situations,
earlier grafting will be performed at the request of the orthodontist.
In patients with bilateral clefts and stulas, the techniques of stula closure and
bone grafting are the same techniques used to correct unilateral deformities. Flaps
consisting of mucosa and periosteum based superiorly are formed by incising both
sides of the alveolar and palatal defect.They are dissected at the subperiosteal level,
turned upward, and sutured to form the nasal oor. Bilateral buccal-periosteal aps
are then elevated and used to close the defects in the alveolus, and for oral repair.
To support the reconstruction and to provide bone for tooth eruptions, cancellous
iliac crest bone is used to reconstruct the bony defect.
Patient Example
1041
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
This patient provides an example of a secondary bilateral lip correction. Preopera-
tively the position of the nose, the tight upper lip, and a retruded mandible were
noted. A collapsed upper arch, bilateral stulas, and velopharyngeal incompetence
were also present.

1042
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The collapsed upper arch can be seen clearly on both the left and right. An intra-
oral view is shown after expansion, bone grafting, and coverage with bilateral mu-
coperiosteal aps.
The patient is shown after undergoing LeFort I osteotomy, lip revision with an
asymmetrical Abbé ap, and correction of nasal deformity.The velopharyngeal in-
competence was corrected after healing had matured.
MAXILLARY AND MANDIBULAR DISTRACTION
If there is a great deal of scarring, an osteotomy with distraction may be a more sat-
isfactory and a more stable procedure for adolescents and older patients.When dis-
traction is performed, the required osteotomies are carried out and an external or
intraoral device can be used. The face is advanced at the LeFort I level or higher,
as indicated. The latter situation is usually a syndromic situation in which the up-
per face is involved and a larger area of the face is being advanced (for example,
LeFort III).

Patient Examples
1043
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity
This patient presented with a bilateral cleft lip and palate deformity, midface retru-
sion, and a relative prognathism. This deformity was corrected by performing a
LeFort III osteotomy and distraction using a “Blue Distractor,” as shown. Rhino-
plasty, columellar lengthening, onlay bone grafting, and lip revision with an Abbé
ap were performed when the distraction was completed.

1044
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Some patients with cleft deformities will develop velopharyngeal incompetence as
a result of distraction.These patients will require appropriate assessment and the in-
dicated corrective procedure. Secure xation is obtained with plates and screws. In
the case of mandibular retrusion, distraction can be performed using an osteotomy
at the junction of the ascending ramus and the body of the mandible.
Examples of distraction devices are shown above.

This patient presented with a left unilateral cleft and a retruded mandible. He is
shown after mandibular distraction, lip revision, and rhinoplasty were performed.
THE NOSE
Appearance and/or function are the usual problems with the nose. Function is fre-
quently a concern.
Bilateral Cleft Nose
In some ways a bilateral cleft nose is easier to deal with than a unilateral cleft nose.
There may be a shortage of material with the bilateral cleft nose (for example, col-
umella), but the deformity is usually symmetrical. The situation requires careful
analysis that should include the following questions: What did the previous sur-
gery consist of? This can be quite variable.What is the extent of the support mech-
1045
Chapter 29
Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity

1046
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
anism? Is there any asymmetry? How wide is the bridgeline and the interalar base
distance? Can a satisfactory bridgeline be achieved without an onlay graft? Is the
nose functional? Although careful clinical, endoscopic, and radiographic examina-
tions can provide information that will help to answer these questions, the true
complexity of the problem is often appreciated only during surgery.
The following rule must be emphasized and obeyed when performing primary or
secondary correction of the bilateral cleft nose.
It is never necessary to make an incision around the alar base. This
structure is a normal anatomic part of the face; if it is incised, a defor-
mity is created that can never be totally corrected.
The columella may be the key to obtaining a satisfactory result.This is determined
by placing or attempting to place the tip of the nose in its correct anteroposterior
position. Augmentation at the tip will suf ce if the tip can be corrected without in-
ducing a significant amount of ischemia at (1) the base of the columella when
pulling it forward, or (2) the tip when it is being pushed forward by an instrument.
This method is well described. If there is ischemia at the tip, a columellar length-
ening procedure should be performed.
Surgical Correction of the Bilateral Cleft Nose
Before any correction of the nose is done, the lip should be inspected and assessed.
Frequently lip surgery is performed concurrently with nasal correction. As men-
tioned above, assessment of the tip projection, interalar width, prolabial segment
width, and overall laxity of the upper lip is key to a successful nasal reconstruction.
At this point a useful maneuver is to hold the nasal tip up with a double hook to
determine the anteroposterior shortness of the columellar lip area.
In the case of the bilateral cleft nose, it is better to perform the nasal bone infrac-
tion rst.This procedure requires careful preparation with vasoconstrictors, head el-
evation, and anesthetic cooperation to provide as bloodless a eld as possible. Per-
forming the infracture loosens up the skin envelope and allows easier assessment of
the tip and alar base positioning. After soft tissue dissection, the tip is placed in its
ideal position. This placement allows four assessments to be made—the required
length of the columella, the required medial movement of the alar bases, the ideal
position of the tip, and whether alar base, columellar base, and nostril sill will require
support. In many cases a subperiosteal freeing from a small upper buccal sulcus in-
cision will be necessary to bring the whole lower nose forward; this maneuver re-
sults in a signi cant subperiosteal dead space. If necessary, a bone graft will be in-
serted at this time. Subperiosteal tunnels are made either from the intraoral
approach or from just inside the alar bases. Nasal bone osteotomy is performed fol-
lowed by an infracture. The forces on the soft tissue envelope have now been de-
creased and the nose can be repositioned more satisfactorily using appropriately

placed hooks and fingers to mold and position the nose correctly. The surgeon
now has an idea as to what must be done to keep the nose in this position.
If there is a subperiosteal defect on the maxilla, a bilateral cancellous bone graft is
placed. If there is a bridgeline defect, a cranial bone graft of the correct shape for
the nose is harvested. The shape required will determine from which part of the
skull the bone is taken. This graft is inserted through a vertical incision in the
glabella. A slot is cut with an edge being left inferiorly;this acts as a fulcrum. As the
graft is being stabilized with a screw, the tip of the inferior graft comes forward
until the ideal nasal tip, shape, size, and position are achieved. Preferably, the graft tip
is covered by the lower lateral cartilages.24,25
The nose now has a base and a tip.The nasal bones may or may not have to be in-
fracted.The surgeon will determine whether this is necessary.
The lower lateral cartilages are inspected and rearranged as required.The alar bases
are now in their correct position in many cases and frequently do not require any
further manipulation. Medial positioning can be performed using a hook to display
the soft tissue dissection previously carried out. Nonabsorbable sutures taken from
side to side and tightened gently in the midline will provide the small amount of
medial movement of the bases to give a satisfactory result. Occasionally a small
amount of nostril sill, lateral to where the columella has been lifted, will be re-
sected and the defect closed to obtain optimal results.
The domes of the lower lateral cartilages are brought together and sometimes tip
grafting is performed to achieve as near to an ideal tip as possible. If this plan is
followed, it is possible to produce acceptable correction in the secondary bilateral
nasal deformity.
One of the problems of the bilateral cleft nose, both primarily and secondarily, is the
shortness of the columella. When the nose is corrected as outlined above, there is
some lengthening but this is not always suf cient to provide a satisfactory nasal tip.
The ideal length of the columella should be determined early in the procedure.The
amount of soft tissue required to achieve lengthening is determined and taken from
the lip.Two parallel lines are taken vertically downward from the columella base and
end in a V shape. The central ap based superiorly is raised and two incisions are
made on either side of the columella.The nasal tip is pulled upward with a double
hook, the ap is inserted into the columella, and the nasal tip is grafted with carti-
lage, if indicated.The lip incision is carefully closed, the inferior closure is V-to-Y.
The lip scar never causes any problems because it is on the midline.This simple ma-
neuver has solved the problem of the bilateral cleft nose when required.
With careful analysis and replacement of missing bony support, together with re-
arrangement of nasal soft and hard tissue, good aesthetic and functional results can
be accomplished in both unilateral and bilateral deformities.
1047
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1048
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Bony Disproportion in Patients With Cleft Deformities
There is still a considerable amount of controversy as to when and how problems
of bony disproportion should be addressed. It was customary to wait until growth
was complete, probably because the bone graft was considered as a defect ller. An
alternative point of view is that the soft tissue must be placed in its correct position
to obtain a satisfactory result. The soft tissue should be repositioned to the level
that produces the least scarring—the subperiosteal level. At this level, bone is
formed, not scar tissue as with subcutaneous mobilization.
Another concern regarding bony disproportion has been the tightness of the peri-
osteal envelope. This tightness is easily corrected by incising the periosteum in an
area distant from the region to be corrected. Soft tissue including the periosteum
can now be repositioned appropriately, without tension. A bone graft, usually can-
cellous, is then inserted.There is no tension. Many bene ts have been obtained by
relieving the tightness of the periosteal envelope.
OSTEOINTEGRATION
Osteointegration has been a most useful addition to our armamentarium of cleft re-
construction, but it necessitates secure alveolar bone grafting.When this grafting is
solid, an endosseous implant is placed and a dental implant is applied.
Patient Example
In this illustration, an endosseous implant has been placed in a bone graft. A radio-
graph of the implant in position is shown.
Antrum
Endosseous
implant
Dental prosthesis

Osteointegration is demonstrated in this patient. Bone grafting has been performed
on the upper arch and an orthodontic device has been implanted.The upper arch
is shown after expansion and integration.The patient demonstrates excellent den-
tal occlusion.
CONCLUSION
I acknowledge that many of the ideas presented in this chapter may be controver-
sial; however, their indications and applications are the result of many years of ex-
perience correcting secondary cleft deformities in patients of all ages.This experi-
ence has been applied to patients with primary clefts and has eliminated many of
the deformities previously seen. In no case has a technique been described that has
caused any patient a long-term disability. All techniques have been performed, in-
vestigated, and found to be satisfactory over a long-term follow-up.
References—With Annotated Key References
1. McComb H. Primary correction of unilateral cleft lip nasal deformity:A 10-year review. Plast
Reconstr Surg 75:791-799, 1985.
A 10-year follow-up of patients who underwent primary correction of their cleft lip nasal deformity
is presented.These are the rst 10 consecutive patients who were treated following a change in treat-
ment plan in 1973. Primary correction of the cleft lip nasal deformity essentially consists in elevat-
ing the displaced alar cartilage at the time of lip repair.There has been no interference with nasal
growth, and the position of the alar cartilages and nasal tip has been maintained.
1049
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1050
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
2. Bearn D, Mildinhall S, Murphy T, et al. Cleft lip and palate care in the United Kingdom—the
Clinical Standards Advisory Group (CSAG) study. Part 4:Outcome comparisons, training, and
conclusions. Cleft Palate Craniofac J 38:38-43, 2001.
3. Friede H, Enemark M, Semb G, et al. Craniofacial and occlusal characteristics in unilateral
cleft lip and palate patients from four Scandinavian centres. Scand J Plast Reconstr Hand Surg
25:269-276, 1991.
4. Shaw WC, Semb G, Nelson P, et al.The Eurocleft project 1996-2000:Overview. J Craniomax-
illofac Surg 29:131-140, 2001.
The original Eurocleft project, a European intercenter comparison study, revealed dramatic differences
in outcome, which were a powerful stimulus for improvement in the services of respective teams.The
study developed a preliminary methodology to compare practices and the potential for wider European
collaboration including opportunities for the promotion of clinical trials and intercenter comparison was
recognized by the European Commission.The project,“Standards of Care for Cleft Lip and Palate
in Europe: Eurocleft,”which ran between 1996 and 2000, aimed to promote a broad uplift in the
quality of care and research in the area of cleft lip and palate.The results of the 1996-2000 project
include a register of services in Europe, with details of professionals and teams involved in cleft care,
service organization, clinical protocols, and special facilities for research;a set of common policy state-
ments governing clinical practice for European cleft teams, practice guidelines describing minimum rec-
ommendations for care that all European children with clefts should be entitled to and recommenda-
tions for documentation governing minimum records that cleft teams should maintain;and encouraging
initial efforts to compare outcomes (results) of care between centers.
5. Jackson IT. Closure of secondary palatal stulae with intra-oral tissue and bone grafting. Br J
Plast Surg 25:93-105, 1972.
6. Henderson D, Jackson IT. Combined cleft lip revision, anterior stula closure and maxillary os-
teotomy: A one-stage procedure. Br J Oral Surg 13:33-39, 1975.
The syndrome of defects that characterize the cleft lip and palate patient undergoing secondary sur-
gery is discussed, and the traditional system of multiple sequential operations for its correction is chal-
lenged. A single-stage combined procedure is described that permits the correction of maxillary collapse
and hypoplasia to be combined with closure of an anterior palatal stula and lip revision, together with
some improvement of abnormal nasal appearance.
7. Latham RA. Orthopedic advancement of the maxillary segment: A preliminary report. Cleft
Palate J 17:227-233, 1980.
8. Millard DR Jr, Latham RA. Improved surgical and dental treatment of clefts. Plast Reconstr
Surg 86:856-871, 1990.
9. Matsuo K, Hirose T, Otagiri T, et al. Repair of cleft lip with nonsurgical correction of nasal de-
formity in the early neonatal period. Plast Reconstr Surg 93:22-31, 1989.
10. Spolyar J. Comparison of different methods of repair. J Craniofac Surg 17:468-473, 2006.
11. Randall P, Whitaker LA, LaRosa D.The importance of muscle reconstruction in primary and
secondary cleft lip repair. Plast Reconstr Surg 54:316-323, 1974.
12. Jackson IT, Vandervord JG, McLennan JG, et al. Bone grafting of the secondary cleft lip and
palate deformity. Br J Plast Surg 35:345-353, 1982.
13. Bello G, Jackson IT, Keskin M, et al.The use of polyacrylamide gel in soft tissue augmentation:
An experimental assessment. Plast Reconstr Surg 2006 (accepted for publication).
14. Golding-Kushner KF, Argamaso RV, Cotton RT, et al. Standardization for the reporting of
nasopharyngoscopy and multiview video uoroscopy:A report from an international working
group. Cleft Palate J 27:337-347, 1990.
A multidisciplinary International Working Group of scientists was assembled to address the question
of standardizing reporting techniques for multiview video uoroscopy and nasopharyngoscopy, the gen-
erally accepted standards for direct observation of the velopharyngeal valve.This report is a rst attempt
to propose standards while seeking feedback from the readership to further develop a common method-
ology.

15. Elahi MM, Jackson IT, Moreira-Gonzalez A, et al. Nasal augmentation with Surgicel-wrapped
diced cartilage: A review of 67 consecutive cases. Plast Reconstr Surg 111:1309-1318; discus-
sion 1319-1321, 2003.
Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the
nasal framework.The technique described by Erol uses Surgicel-wrapped diced cartilage grafts in
rhinoplasties. A retrospective case review of patients who were treated with a Surgicel-wrapped diced
cartilage graft as part of an aesthetic and/or functional rhinoplasty between 1995 and 2000 was
performed in this study.The technique of using Surgicel-wrapped diced cartilage proved to be effective
for the augmentation of various areas of the nose.This technique is recommended for nasal augmen-
tation and contouring for selected rhinoplasty patients.
16. Rachmiel A, Jackson IT, Clayman L, et al. Midface advancement by gradual distraction:A fol-
low-up study. Monasterio FO, ed. J Craniofac Surg 4:269-273, 1993. In Proceedings of the
Fifth International Congress of the International Society of Craniofacial Surgery, Oaxaca,
Mexico. Bologna: Mondizzi Editore, 1993.
17. Hall DJ,Turvey TA,Warren DW. Changes in nasal airway resistance associated with rapid max-
illary expansion. Am J Orthod Dentofacial Orthop 85:109-114, 1984.
18. Warren DW, Hershey HG,Turvey TA, et al.The nasal airway following rapid maxillary expan-
sion. Am J Orthod Dentofacial Orthop 91:111-116, 1987.
19. Wertz RA. Changes in nasal airflow incident to rapid maxillary expansion. Angle Orthod
38:1-11, 1968.
20. Potpari´c Z, Jackson IT, Rachmeil A. The application of the Ilizarov technique on the facial
skeleton. In Jackson IT, Sommerlad B, eds. Recent Advances in Plastic Surgery, 5th ed. London:
Churchill Livingstone, 1996, pp 71-80.
21. Grayson B, Santiago P. Presurgical orthodontics for cleft lip and palate. In Aston S, Beasley R,
Thorne C, eds. Orthodontic Management of the Nose in Newborns. Grabb and Smith’s Plas-
tic Surgery. Philadelphia: Lippincott-Raven, 1997, pp 237-244.
22. Yavuser R, Jackson IT, Kelly CP, et al.The central lip ap and nasal mucosal rotation advance-
ment: Important aspects of composite correction of the bilateral cleft lip nose deformity. J
Craniofac Surg 16:255-262; 2005.
23. Jackson IT, Smith J, Mixter RC. Nasal bone grafting using split skull grafts. Ann Plast Surg
11:533-540, 1983.
The nose has been reconstructed with bone grafts, cartilage, and silicone. Each of these methods has dis-
advantages, but the bone graft is most trouble free. It is possible to take a split skull graft with a high-
speed drill and an osteotome. Several grafts may be used to build up the nasal dorsum further.This
method has been used in patients with acute trauma and deformities resulting from previous trauma,
rhinoplasty, congenital anomalies, and after cancer resection.
24. Jackson IT, Soutar DS.The sandwich Abbé ap in secondary lip deformity. Plast Reconstr Surg
66:38-44, 1980.
The history and use of the Abbé ap in the correction of secondary cleft lip deformity is outlined. A
modi cation, the sandwich Abbé ap, is presented and its advantages are described from a cosmetic and
functional standpoint. An extension of this method is also used in the revision of unsatisfactory con-
ventional Abbé ap results.
25. Demirtas Y,Yavuser R, Findikcioglu K, Atabay K, Jackson IT. Fixation of the split cranial bone
graft in nasal reconstruction. J Craniofac Surg 17:131-138, 2006.
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1. What is the main advantage of the sandwich Abbé ap?
a. It can be used to reconstruct large defects
b. It may become sensate
c. It is less bulky
d. It allows a functional upper lip to be reconstructed
e. The color match is better
2. What is not advised at the time of a LeFort I advancement?
a. Dental extractions
b. Mandibular correction
c. Ear tube insertion
d. Rhinoplasty
e. Onlay bone grafting
3. What type of bone is the best and easiest to use in secondary bone grafting for
the patient with a cleft?
a. Cranial
b. Homologous (stored)
c. Olecranon
d. Cancellous iliac crest
e. Cortical iliac crest
4. What is the best approach for a severe secondary cleft nasal deformity?
a. Open
b. Intranasal
c. Alveolar (central)
d. Glabellar
e. Alveolar (bilateral)
5. In a patient with secondary unilateral cleft lip, all of the following can be pres-
ent in relation to the abnormality except:
a. Maxillary retrusion
b. Airway blockage
c. Maxillary asymmetry
d. Mandibular prognathism
e. Alveolar stula
R EVIEW QUESTIONS

1053
The two main concerns in cleft palate repair are speech and maxillary growth. For
each patient these concerns cannot be answered until long after the act of surgery.
For those of us who live in a part of the world where speech-language and dental
colleagues reside, the answers will come in large part from our cohorts on the team,
who have different viewpoints, backgrounds, and technical languages;therefore the
best decisions for our patients will be arrived at by committee.To take a valid part
in those treatment decisions, we must understand at least the basics of their elds.
Secondary Cleft Palate Surgery
Leonard T. Furlow, Jr.
C ha pter 3 0
Reoperative Problems
Airway obstruction
Still dysfunctional velopharyngeal mechanism
Bleeding
Velopharyngeal incompetence
Fistula
(VPI): Nasal escape, hypernasality
Flap dehiscence
Hyponasality
Inhibition of maxillary
Compensatory articulation errors
growth
Obstructive sleep apnea (OSA)
The human body experiences a powerful gravitational pull in the
direction of hope.That is why the patient’s hopes are the physician’s
secret weapon.They are the hidden ingredients in any prescription.
Norman Cousins

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SPECIFIC PROBLEMS
EARLY POSTOPERATIVE PROBLEMS
Three problems may mandate reoperation in the early postoperative period after
cleft palate repair. Fortunately the need rarely arises.
Airway Obstruction
A much higher incidence of perioperative airway obstruction has been reported in
patients with other congenital anomalies.1 This most immediate problem can, on
occasion, result from poor planning.The use of a pharyngeal ap should be avoided
unless it is really necessary, for example, in infants, especially those with small
mandibles such as patients with Pierre Robin sequence, Stickler syndrome, or hemi-
facial microsomia, and when the tonsils are large.2 In a prospective study of 45 pa-
tients, including 12 with Pierre Robin sequence,3 perioperative steroids signifi-
cantly reduced the incidence of airway distress and fever, and did not increase the
incidence of stulas. None of the 22 infants given dexamethasone, including the
nine with Pierre Robin sequence, showed signs of airway distress, whereas 4 of 23
control patients, including one of the three with Pierre Robin sequence, developed
stridor; two of these patients improved only after receiving steroids.
A tongue stitch will provide traction, which relieves airway obstruction in the re-
covery room. Randall and LaRossa4 advocate taping or suturing a nasopharyngeal
airway in place through the alar base for 12 to 24 hours.
Bleeding
If the infant is upset and crying strenuously, sedation and elevation of the head may
stop the bleeding, thus avoiding reoperation.
Fistula
Even when recognized early postoperatively, stulas are best allowed time to heal.
Only after several months should they be evaluated for repair. Many will close, and
a few of those that persist will be asymptomatic.
LONG-TERM PROBLEMS AND THEIR PREVENTION
The three major long-term problems that may require reoperation after
cleft palate repair are oronasal stulas, inhibition of maxillary growth,
and a still-incompetent velopharyngeal valve.The incidence of each re-
mains signi cant.

Fistulas
Overt upper respiratory infections and throat cultures that are positive for patho-
gens are reportedly associated with an increase in the incidence of wound compli-
cations5 and stulas6;if either is detected, surgery should be delayed. McClellan and
Patterson7 advised that antibiotic therapy should be begun preoperatively.
During primary palate repair, avoidance of excess tension and protection of the
blood supply to the aps help to prevent tissue loss and the development of large
stulas. Making certain that the oral and nasal mucosal surfaces are separated and
everting the edges of the mucoperiosteal aps with horizontal mattress sutures to
ensure raw-to-raw apposition will help avoid the common slitlike stula. My stula
rate with the double opposing Z-plasty repair has been 2 (5.4%) of 37.8 Cohen et
al9 reported a 10% stula rate with this method of palatoplasty;compared with the
43% rate with Wardill-Kilner pushback, 22% with von Langenbeck repair, and 0%
with Dorrance pushback.
Inhibition of Maxillary Growth
Although the causes of inhibition of maxillary growth and the best methods for
avoiding it are probably as controversial today as ever, leaving a minimum of hard
palate mucosal scar, preferably only along the cleft,10 and leaving hard palate mu-
coperiosteum in the hard palate where it belongs seem to encourage good maxil-
lary growth. Orthodontic expansion of the arch can be more easily achieved in pre-
paration for alveolar bone grafting just before eruption of the canine teeth if the nos-
tril oor is repaired along with the lip,but the alveolar cleft is not repaired at either lip
or palate repair.Treatment of maxillary growth de cits will not be discussed.
Velopharyngeal Insuf ciency
There is good evidence to show that an overlapping velar muscle sling should be
constructed and the entire palate closed by the time a child is 8 or 9 months of age
to provide the best opportunity for velopharyngeal competence and speech that is
unmarred by compensatory articulations.
Palate repair by double opposing Z-plasty meets these criteria.8,10,11 Among my 33
consecutive patients who underwent this repair in infancy, all of whom were exam-
ined 3 to 15 years after surgery, 30 have velopharyngeal competence, one has inter-
mittent VPI, and only two developed VPI (both corrected by sphincter pharyn-
goplasty). Maxillary growth to date is good; maxillary advancement has not been
necessary in any of the seven patients with unilateral cleft lip and palate, and in
only two of the six with bilateral cleft lip and palate who have been followed be-
yond 10 years of age.8
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PART III
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EVALUATION OF SPEECH:
A PLASTIC SURGEON’S VIEWPOINT
There are two sources of abnormal speech in the patient who has a repaired cleft
palate.The palate repair should result in a velopharyngeal mechanism that can close
completely and rapidly and open suf ciently for adequate nasal air ow. When this
goal is not achieved,the ow of air and sound through the velopharyngeal port can-
not be controlled. As a consequence, the patient may use alternate compensatory
valving mechanisms that also mark the patient’s speech as abnormal. Both of these
sources are evaluated by testing the patient’s speech. Although a speech-language
pathologist must be in charge of this evaluation, plastic surgeons who repair palatal
clefts, stulas,or velopharyngeal mechanisms should be able to competently examine
each patient’s speech;they should also be able to understand and discuss the ndings
with the speech pathologist and perform,be present during,or at the very least review
the videotapes of each patient’s video uoroscopy and nasendoscopy with the clinician
who performed the study.The surgeon is best equipped to understand and use the in-
teresting and valuable dynamic anatomic information revealed by these studies.
Selection of the most appropriate secondary surgical procedure for each
patient must be a joint decision between the speech-language patholo-
gist and the surgeon.The surgeon who is satis ed with anything less is
accepting the role of surgical technician.
For this reason a review of the evaluation of velopharyngeal valve function and
speech is in order.
Although the ultimate goal of the speech-language pathologist and the plastic sur-
geon is the same—to ensure that each infant with a cleft palate will speak normally—
the speech pathologist is more broadly concerned with all of the nuances of the pa-
tient’s speech, whereas the plastic surgeon’s interest and responsibility are focused on
the velopharyngeal mechanism.
After cleft palate repair, patients with hearing, intelligence, and neurologic function
adequate for normal speech may have abnormal speech resulting from a velopha-
ryngeal valve that is incapable of closing completely and rapidly and opening suf-
ciently for adequate nasal air ow, from articulation errors learned as compensation
for the lack of velopharyngeal competence, or from both. Hogan’s wonderfully
succinct discussion12 emphasizes the critical distinction between nasal escape and
hypernasality, the primary effects of VPI, and its secondary effect, compensatory ar-
ticulation, which may persist after surgery has made the velopharyngeal valve po-
tentially competent. The two factors are certainly linked; the patient whose
velopharyngeal mechanism does not have the inherent capacity for quick, com-
plete closure is hampered in eliminating compensatory articulations.13
The basic treatment decision—surgery, speech therapy, or both—depends
on accurately determining into which category each patient falls.

I think of the speech mechanism as being composed of three parts analogous to a
computer system.The computer is the hardware, which is directed by various soft-
ware programs in speci c tasks that may drive an external mechanical device such
as a printer. In the case of speech, our brain, which is analogous to the computer,
is directed by our speech software, which is learned over months and years begin-
ning in infancy and becomes more dif cult to change after adolescence.
When there is a cleft or there has been an unsuccessful cleft repair, or there is a per-
sistent fistula coupling the oral and nasal cavities, the software that is loaded is
awed;the normal instructions for velopharyngeal function do not cause the valve
to close, so the abnormal instructions that produce compensatory articulations are
loaded in their place.
This analogy makes clear the most important decision regarding treatment of VPI.
Is the problem in the valve, in the software, or in both? The valve is treated by the
surgeon and the software by the speech pathologist, and their treatments will be
carried out at different times.
Before the software for normal speech can be installed by the speech-
language pathologist, the velopharyngeal valve must function prop-
erly, which is the responsibility of the surgeon or the prosthetist.
PRIMARY COMPONENTS OF VPI:
NASAL ESCAPE AND HYPERNASALITY
The primary consequences of an incompletely closed velopharyngeal valve (velo-
pharyngeal incompetence) are nasal escape and hypernasality. In normal English-
language speakers, nasal air ow occurs only with the consonants /m/, /n/, and /ng/.
The velopharyngeal port is normally open for vowel sounds that are adjacent to or
surrounded by /m/, /n/, or /ng/, but more noticeably in some regions and in some
activities such as country music singing.Therefore clinical evaluation of speech must
be able to distinguish normal from abnormal nasal air ow (nasal escape), nasal res-
onance (hypernasality), and articulation (compensatory).
Clinical testing should (1) be easily performed, immediately available, and inex-
pensive;(2) detect the presence of nasal escape and hypernasality in speech, even in
the face of substitute valving such as glottals; (3) identify whether the velopharyn-
geal mechanism is incapable of closure (indicating a need for physical management)
or is capable of closure for vocal but nonverbal sounds (indicating a potentially
functional velopharyngeal mechanism rendered nonfunctional by learned articula-
tory errors);(4) generate results that can be counted or quanti ed, and recorded for
use in evaluation and comparison of treatment results; and (5) be organized to be
speci cally useful in planning treatment, particularly for making the basic treat-
ment decision as to whether the appropriate next step is speech therapy or instru-
mental evaluation in preparation for surgical planning.
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Nasal Escape
Nasal escape is abnormal nasal air ow that occurs during the pronunciation of any
consonant except /m/, /n/, or /ng/. Although nasal escape may be audible (nasal tur-
bulence), it is frequently inaudible in conversational speech and in testing;therefore
its reliable detection depends on more than a trained ear. The fogged mirror under
the nares is a time-honored method. Two methods are used in the University of
Florida Craniofacial Clinic. First, Bzoch’s paper paddle, held under each naris or in
front of the lips, is visibly de ected by air ow through the ori ce in front of which
it is held.14-16 Second, if a stethoscope is used by removing the chest piece and hold-
ing the end of the tubing under the naris or in front of the lips, even inaudible air-
ow will create a loud turbulence audible in the examiner’s ears. Third, a lm of
soap formed over the naris by the examiner’s ngertip wet with soap solution will
be blown out of the naris if there is any air ow. This method is a little harder to ad-
minister, but more sensitive.17 With any test for nasal air ow, both nostrils should be
examined.
Bzoch’s paper paddle
Soap lm method
Stethoscope tubing method

Hypernasality
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Chapter 30
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The vocal resonating chamber extends from the vocal cords to the lips and consists
of the pharynx, the oral cavity, and intermittently the nasal cavity. Hypernasality is
the vowel sound abnormality that results from the inappropriate inclusion of the
nasal cavity as part of the vocal resonating chamber. The cul-de-sac test is used to
determine whether the nasal cavity is a part of the vocal resonating chamber dur-
ing vowel sounds. As the patient says test syllables by pronouncing such words as
“beet,”“boat,”“boot,”“Bert,” the nose is alternately left open and pinched closed.15
Normally the velopharyngeal port, closed throughout each of these syllables, ex-
cludes the nasal cavity from the vocal resonating chamber, so that pinching the
nose has no effect on the sound (left). However, if the velar port is open, the nasal
cavity is a part of the resonating chamber and a difference in the sound can be
heard as the sound characteristics of the chamber are changed when the nasal por-
tion is converted from an open resonator to a closed one (a cul-de-sac) as the nose
is pinched (right).
When a vowel sound occurs between the nasal consonants /m/, /n/, or /ng/, the
velar port remains open for the vowel, and the cul-de-sac test should indicate hy-
pernasality. An abnormally constricted velar port or nasal airway eliminates the
sound shift, indicating hyponasality.

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The speech-language pathologist’s evaluation of each patient at each clinic visit in-
cludes examination by these techniques for nasal escape, hypernasality, and hy-
ponasality using 10 standardized test syllables.The results are recorded on the Bzoch
Clinical Test form15 as / 10. By separating the results of tests for nasal escape, hy-
pernasality, and hyponasality (on the left of the form) from those for tests of artic-
ulation (on the right side), the Bzoch Clinical Test form helps in determining the
basic decision between surgery and/or speech therapy for further treatment. This
record can then be used for tracking each patient over time, for comparisons be-
tween patients, and for studies of and between patient groups.This record is as im-
portant as the range-of-motion measurements we make and record after we repair
exor tendons.The plastic surgeon should test each of his or her patients using the
same methods and record the “unof cial” ndings.The speech-language pathologist
brings an unbiased position and invaluable experience and expertise to the exami-
nation. As an example, Kummer et al18 found that when VPI was present, the size of
the residual opening correlated with two speech characteristics:smaller residual gaps
were related to nasal rustle (nasal escape made audible by turbulent ow) and larger
residual gaps with greater degrees of hypernasality and inaudible nasal escape.
Multiple instruments have been devised in hopes of indirectly assessing speech for
nasal escape and hypernasality. Spectroscopy, vibrometry of the external nasal sur-
face, comparison of microphone pickup at the nose and mouth (nasometer), and
light transmission across the velopharyngeal port involve a variety of equipment in
the nose and mouth, and correlate from well to not so well with speech assess-
ment.19-23 Although some of these tests, in particular the pressure- ow measure-
ments of Warren et al,24 are valuable research tools, in the clinical setting they seem
to be an expensive, dif cult, often imprecise, and sometimes frightening substitute
for a careful clinical perceptual examination.
Although the several forms of nasometer that rate nasality are being used more and
more to “quantify” hypernasality, their correlation with clinical speech testing,21,22
including perceptual ratings of hypernasality25 and with each other,26,27 is far from
precise. The recent emphasis on hypernasality as the measure of velopharyngeal
function seems unfortunate because nasal air ow is a far more exact quantitative
measurement.
It is abnormal to leak any air when blowing a pea-shooter, playing a
wind instrument, or blowing out a candle, and every normal velopha-
ryngeal mechanism is able to close completely to stop all nasal air ow
during speech,28,29 even though some subjects may not close completely,
particularly during running speech.24
An upper limit for velopharyngeal port conductance, described as area of the port
opening,24,30 of 0.05 cm2, and for nasal air ow31,32 (10 cc/second) have been accu-
rately correlated with normal speech, as have nasal air ow characteristics,33 but nei-
ther a precise measurement of hypernasality nor a hypernasality measurement that
correlates adequately with listener perceptual judgment is available.34

1061
Chapter 30
Secondary Cleft Palate Surgery
Bzoch Clinical Test form
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.

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PART III
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SECONDARY EFFECTS OF VPI:
COMPENSATORY ARTICULATIONS
Compensatory articulations are the alternate methods learned in an attempt to ap-
proximate the speech sounds that cannot be made correctly with an incompetent
velopharyngeal valve.14,35 Not a part of normal speech, they occur in two circum-
stances when speech is learned with an incompetent velopharyngeal mechanism:
(1) When palate repair is not completed until after speech has been learned36 and
(2) when primary repair does not result in a functional velopharyngeal mechanism.
They indicate that VPI has been present but do not tell us whether it still is.37
Substitute valving for plosives (/p/, / b/, / t/, /d/, / k/, /g/ ) attempts to stop air ow be-
fore it reaches the velopharyngeal port in an effort to eliminate nasal escape by re-
ducing or stopping all air ow through the vocal tract.The misarticulation is called
a glottal stop if the cords or larynx stop air ow and a pharyngeal stop if air ow is
stopped by the base of the tongue and pharyngeal walls.The attempt to reduce nasal
air ow by constricting the nostrils is a visible compensatory articulation called a fa-
cial grimace, or “rabbiting.”
Alternatively, the patient may harness the nasal air ow by making it audibly turbu-
lent (“nasal snort”) to substitute for /s/, /sh/, /z/, and /v/, a pattern of sound substi-
tution that is particularly dif cult to “unlearn.”
The accurate dissection of these sounds and the distinguishing of them from other
misarticulations, such as those related to the teeth and the endearing ones common
for the young child (“baby talk”), are performed by the speech-language patholo-
gist and recorded for each patient at each clinic visit.
It is critical to understand that compensatory articulations may coexist with an in-
competent velopharyngeal mechanism, may persist to mar speech after the velopha-
ryngeal mechanism has been made competent by primary37 or secondary surgery,
or may even, in a “catch-22” fashion, inactivate a velopharyngeal mechanism that
could function if articulation were normal, as Henningsson and Isberg38 have
shown. In some patients with a large residual velopharyngeal gap, when attempted
velopharyngeal closure does not come close, the effort is abandoned, the patient
may use the glottis as a substitute valve, and video uoroscopic and nasendoscopic
examinations will show little or no velopharyngeal motion.39 As Henningsson and
Isberg38 point out, “once air ow has been stopped at the level of the glottis, the
movements of the velopharyngeal valve serve no communicative purpose,” and
may be abandoned. This phenomenon may be incorrectly interpreted as showing
a “paralyzed palate” or a “black hole.”40 This situation, in which VPI itself is an in-
grained articulation, is probably what so often defeats the surgical correction of
VPI in adults. Much like the native accent that most adults, unlike children, cannot
shed when they learn a foreign language, the habits of VPI, especially hypernasal-
ity and nasalized sibilants, may be very dif cult to unlearn for the adult who is pro-
vided with a new competent velopharyngeal mechanism.

Because compensatory articulations are so often an ingrained part of the patient’s
speech, a nonspeech test of the velopharyngeal mechanism would be very helpful. If
the velopharyngeal mechanism could be shown to close under some circumstances,
even though it does not in speech, speech therapy might be helpful and, perhaps
more important,a secondary operation might be useless.Nonvocal tests such as blow-
ing are said to be of little help in therapy, but blowing is used to test for nasal air ow
in children too young to reliably respond with speech syllables.Voiced but nonspeech
tests,such as Bzoch’s repetitive /pi-pi-pi-pi-pi/,may be better in identifying velopha-
ryngeal competence outside speech.15 I have found a good test to be a prolonged
/sssssss/,which most children will try when told to “hiss like a snake.” It gives time to
test for nasal emission, which will be present unless there is a tight seal. It is surpris-
ing how often a patient can hiss without nasal escape but reverts to the nasalized sibi-
lant to initiate a word beginning with /s/, an example of phoneme-speci c VPI, a
compensatory articulation that persists after the patient has been provided with a
competent velopharyngeal mechanism used normally for other articulations.41
TESTING TRAPS
Of course there are traps in performing tests for nasal escape and hypernasality, just
one of the many reasons the speech-language pathologist should be in charge.
First, because glottal and pharyngeal compensatory articulations produce closure
proximal to the velopharyngeal port that halts air ow through both the nose and
mouth, the tests for nasal escape will show none. However, testing for air ow from
the mouth will also show none, and the cul-de-sac test should reveal hypernasality
during the vowel portion of the test syllables. The other compensatory articula-
tions, such as nasalized sibilants and fricatives, should indicate both nasal escape and
hypernasality because they do not stop air ow through the nasal tract.
A second testing trap is the presence of nasal obstruction, either temporary as with
an upper respiratory infection or chronic as with a deviated septum. These ob-
structions will prevent nasal air ow, and if the nasal resonating cavity is lled with
septum, turbinates, or swollen mucosa, there will be no hypernasality regardless of
the competency of the velopharyngeal mechanism.The patient should be tested to
make sure he or she is able to hum, sniff, and breathe through the nose to ensure
there is adequate nasal air ow. The cul-de-sac test using nasalizing vowels such as
those in the words “meet,” “moot,” “moat,” “mert” (or “mean,” “moon,” “moan,”
“mourn”) should show a shift in resonance when the nostrils are pinched because
the velopharyngeal port is normally open for these syllables;the lack of a shift with
these syllables indicates hyponasality.15
A third testing trap, a palatal stula, is discussed in more detail in the section on re-
operation for palatal stula closure. Even a small stula can produce nasal escape,
which can cause the velopharyngeal mechanism to become insuf cient.Therefore
any patient with a stula should always have his or her speech tested with the s-
tula closed with gum or a small piece of tissue as well as with the stula open.42
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PLANNING TREATMENT FOR VPI
The most basic treatment decision is whether the patient’s velopharyngeal mech-
anism is incapable of closure, which will require surgery, or whether compensa-
tory articulations, the responsibility of the speech-language pathologist and the pa-
tient, are marring speech, or both. It is important in speech evaluation that nasal
escape and hypernasality, the direct evidence of VPI, be tested for and recorded
separately from compensatory articulations, which alert us to look carefully for VPI
but do not tell us whether VPI is still present.37 At least one widely used speech rat-
ing system does not make this distinction43,44 and so may diagnose patients as hav-
ing severe VPI on the basis of articulatory errors alone, in the absence of nasal es-
cape and hypernasality. This does not help to make the basic treatment decision
between speech therapy and physical management.When a secondary operation is
done to correct VPI after cleft palate repair and VPI persists, it is particularly impor-
tant to make the distinction between VPI persisting because the patient’s speech
software program does not include velopharyngeal closure instructions or whether
the VPI operation has failed to provide a valve anatomically capable of closing. In
the rst instance the treatment is speech therapy and in the second, another oper-
ation on the velopharyngeal valve.
At the completion of clinical testing, a patient may fall into one of four categories
based on the status of velopharyngeal valving and compensatory articulation. If
there is no VPI and there are no VPI-related articulatory errors, routine follow-up
to document continuing velopharyngeal competency is all that is necessary. If nasal
escape and hypernasality are present but there are no VPI-related articulatory errors,
surgical (or occasionally prosthetic) modi cation of the velopharyngeal mechanism
is indicated, and instrumental testing, which at the University of Florida Craniofa-
cial Clinic is video uoroscopy and usually nasendoscopy, is performed to provide

information for a decision regarding the type of surgery. If there are articulatory er-
rors but no VPI, speech therapy is begun. If both VPI and VPI-related articulatory
errors are present, speech therapy is undertaken for a specific period of time,
usually 3 to 6 months, before instrumental testing. The speech therapy serves two
functions. First, if VPI persists, articulation is improved before surgery and the in-
formation gained from instrumental testing gives a more accurate picture of the
velopharyngeal mechanism. Second, if the velopharyngeal mechanism becomes
competent when activated by speech therapy, surgery has been avoided and ther-
apy is continued as long as necessary for the development of normal articulation.
PALATAL FISTULAS
DIRECT EFFECTS
A stula connecting the oral and nasal cavities may produce hypernasality and nasal
escape. Because there is free egress of air from the nostrils, intraoral pressure does
not rise, which results in weak pressure consonants.38 A small stula that is asymp-
tomatic when oral and nasal pressures remain essentially equal because of an incom-
petent velopharyngeal mechanism may produce unwanted noises when the velopha-
ryngeal mechanism is repaired, permitting oral pressure to exceed nasal pressure.42
EFFECTS OF SIZE AND LOCATION
Henningsson and Isberg42 have shown that stulas larger than 4.5 mm2 (a circular
stula 2.4 mm, less than 1⁄8-inch in diameter) may produce nasal escape and hyper-
nasality. A very small palatal stula may be asymptomatic or it may be symptomatic
because of leakage of food or fluid from a nostril, or by malodor. Air audibly
squeezed through a stula with the tongue or during snif ng or speech produces
various unattractive whistles, squeaks, or other sounds.This type of stula is usually
dif cult to see, but if a patient says the stula is there, it probably is. A Freer eleva-
tor or probe may be used to help locate it.
The location of a stula is important;air ow will occur only through a stula pos-
terior to the oral articulation closure point. All stulas are posterior to the lips, the
articulation point for the bilabials /p/ and / b/, so any stula may leak air on these
sounds. For /d/, / t/, / j/, and /ch/, which are articulated with the tongue against the
alveolus just behind the teeth, air ow will occur only through stulas of the hard
or soft palate. The sounds / k/ and /g/ (as in “go”), which are articulated by the
tongue against the palate at the hard palate–soft palate junction, produce air ow
only through the few stulas posterior to that point.42
INDIRECT EFFECTS
It is easy to understand that in the presence of a stula, nasal escape and hyper-
nasality may be caused by the passage of air and sound through the stula, through
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an incompetent velopharyngeal port, or through both. However, Isberg and Hen-
ningsson,45 in 1987, clari ed an important secondary effect of stulas. They ob-
tained anteroposterior and lateral cineradiograms of 10 patients with repaired clefts
who had hard palate fistulas and VPI.The cineradiography was performed first with
the stulas open and then closed with chewing gum.The velar and lateral pharyn-
geal wall movements for each patient were then compared by superimposing
matching cine frames taken with the stulas open and then occluded. In every pa-
tient, for sounds articulated anterior to the stula (causing air to leak through the
fistula), both velar and lateral wall movement was greater when the fistula was
sealed. In 4 of the 10 patients (including two of three who had had pharyngeal
flaps), the velopharyngeal mechanism became competent and VPI disappeared
when the stula was sealed with gum, and in ve of the other six VPI became min-
imal. As expected, velopharyngeal activity was no different with the stula open or
closed for sounds articulated behind the stula.
The fact that the velopharyngeal mechanism that is insuf cient in the presence of
a stula becomes more active when the stula is occluded should lead us to several
conclusions:
1. The central nervous system can recognize and discontinue useless efforts,
such as attempted velopharyngeal closure, in the face of an air leak through
the stula. (If you were hungry and in an apple orchard, how many times
would you jump unsuccessfully for the lowest apple before giving up and
looking for a stick, a ladder, or a limb?)
2. Testing, both clinical and instrumental, should be performed with stulas
both open and occluded with tissue or gum to help determine whether the
stula should be closed, the velopharyngeal mechanism should be operated
on, or both.
3. When the palate is repaired in two stages, the large stula that is present un-
til the hard palate is closed is detrimental to velopharyngeal function and
articulation, even though it is planned and not accidental.
Although one would predict that the wound contraction and scarring associated
with a palatal stula might interfere with midface growth, there are no studies on
this subject.
FISTULA R EPAIR
It is counterintuitive but true that even though the great majority of stulas are
only millimeters in dimension, postoperative stulas have been more common af-
ter stula repair than after cleft palate repair.9,46-48 The learning curve for successful
stula repair may be slower than for cleft repair because the stiffness, diminished
vascularity, and distortion of the tissues by scarring are not easily appreciated.We do
not recognize the dif culty because the stula is so much smaller than the cleft was.

One nds from papers on stulas9,46,47,49-53 that:
1. The great majority are small, slit stulas less than 1 cm in length. (Using
horizontal mattress sutures to ensure raw-to-raw mucoperiosteal ap appo-
sition in the primary repair would likely have eliminated most of these s-
tulas. 8,54)
2. In the past, the failure rate of stula repair has been surprisingly high, often
higher than the stula rate after the initial palate repair.9,46-48
3. In general, as one would expect, fistulas are most common after bilateral
cleft lip and palate repair, least after soft palate cleft repairs, and more com-
mon after repair of large clefts.
4. In general, the incidence is highest after pushback repairs, intermediate for
von Langenbeck repairs, low after double opposing Z-plasty, and lower af-
ter two- ap repairs.55 In two-stage repair, 100% have a hard palate stula
until the second stage is completed, and stulas occur after the second-stage
repairs in a higher incidence than would be expected for the remaining
now-narrower, unscarred hard palate cleft.48,56
5. Several studies have reported considerable differences in post–cleft repair s-
tula rates among surgeons after cleft repair.9,57 It is not clear whether this
was due to differing distances along the learning curve or inherent to the in-
volved surgeons.
SURGICAL R EPAIR
Factors to be considered in an operative plan include size and position.
Size
Although the great majority of stulas are small and are most likely present because
of tension or mucosa left in the closure line, they may be remarkably dif cult to
close successfully.9,46,49-53 Unless they are producing VPI, repair can often be delayed
and performed concomitantly with other surgery. Large stulas, which are often the
result of ap loss, are more likely to be symptomatic and to need early repair.
Of the 30 stulas reported by Cohen et al,9 only ve were larger than 5 mm. In the
series of Abyholm et al,46 in which 70% of the 152 stulas were in the region of the
alveolus, only 2 of the 152 were larger than 1 cm. A total of 138 were narrow slits.
In view of the small size of most stulas, the failure rate for stula repair has been
surprisingly and distressingly high. In a group of 84 patients, Rintala47 repaired the
stulas of 63 patients once, of 12 patients twice, of eight patients three times, and
of one patient six times, nally achieving anatomic closure in 55 patients (65%)
and physiologic closure in another 14 (17%). Abyholm et al46 were able to close s-
tulas in 81 (72%) of 113 patients with one operation. Cohen et al9 successfully
closed with one operation the stulas posterior to the alveolus in 21 (63%) of 33
patients. Eight of the recurrent stulas have been repaired, six successfully.
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Because most fistulas are small, most are repaired with palatal tissues; turnover
aps and vomer aps for lining, adjacent mucoperosteal aps, and re-elevated muco-
periosteal aps.
Intraoral aps that do not originate from within the alveolar arch or velum may be
considered local,but they add new tissue to the palate from beyond the alveolar mar-
gins.These aps include tongue aps,buccal aps,and buccinator myomucosal aps.
A pharyngeal ap can be brought over the velum into the hard palate to provide
nasal lining and bulk for the closure of large hard palate stulas.Tongue aps58-63 can
provide a large volume of tissue, but the need for a second operation to divide and
inset the ap is a disadvantage, and the time between the two operations may be
troublesome. Because of airway dif culties, beware of using a tongue ap and a
pharyngeal ap at the same time.
Buccinator myomucosal aps bring a generous amount of thin pliable tissue into
the palate. As dictated by the position of the stula, the aps may be based poste-
riorly on muscle branches from the internal maxillary artery64,65 or anteriorly as an
island based on muscle branches from the facial artery66,67 and placed in the hard
palate by routing the pedicle through the alveolar cleft.These aps are available bi-
laterally,65 are raised and inset in one operation, and make it easy to bring new tis-
sue to a stula from outside the palate.
All of the 309 stulas in the series of Rintala,47 Cohen et al,9 and Abyholm et al46
were repaired with local intraoral tissue: palatal, vomer, and buccal mucosal tissue
including four tongue aps and one pharyngeal ap. Although these data con rm
the fact that the vast majority of palatal stula closures are achieved with local tis-
sues, many articles have described methods for stula closure using distant tissue, in-
cluding conchal cartilage grafts,68 superiorly based69 and inferiorly based70 nasolabial
flaps, more distant flaps including Furnas’ temporal osteocutaneous island flap,71
tube pedicles from the arm,72 free tissue transfers such as the radial forearm ap73,74
or dorsalis pedis ap75 and free aps prelaminated to provide a mucosal surface at
the time of ap transfer to the palatal stula.76,77 In Cleft Craft III Millard78 provides
a wonderfully presented, fascinating array of stula closures by most of these tech-
niques and some other methods by many surgeons.
Position
In 1991, Cohen et al9 classi ed stula sites as prealveolar, alveolar, postalveolar (be-
tween the alveolus and the incisive foramen), hard palate, hard palate–soft palate
junction, and soft palate. Since then, most reports have excluded from their calcu-
lations perialveolar stulas because most have been left unrepaired intentionally.

Cancellous bone
Fistulas in the Alveolar Region (Prealveolar, Alveolar, Postalveolar)
It is usually best to delay repair of stulas in the alveolar region until the time of alve-
olar bone grafting after orthodontic arch expansion because then two objectives can
be accomplished with one operation and because unrecognized slit stulas may be
made patent, more symptomatic, and thus more easily identi ed by arch expansion.
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The lateral gingival ap procedure described by Abyholm et al79 is eminently suited
for closing prealveolar stulas, as well as the cleft of the alveolus and any associated
residual stulas at the back of the alveolus, in conjunction with alveolar bone graft-
ing at approximately age 8 to 12 years after orthodontic positioning of the alveo-
lar segments.80 The gingival ap–alveolar cleft incision goes around the stula open-
ing.The mucoperiosteum lining the cleft is dissected through any extension of the
stula posterior to the alveolus (the most dif cult part of the dissection) and in-
verted through the back of the alveolar cleft and through the stula up into the
oor of the nose, where it may be sutured or held up and back out of the cleft
with a Freer elevator while cancellous bone is packed beneath it to completely ll
the alveolus and any stula behind it. The gingival ap, which is dissected so that
its base hangs on the labial sulcus and is therefore mobile, is then swung medially
across the stula, cleft, and bone graft.
This procedure beautifully reconstructs the full height of the alveolus with gin-
giva, not a buccal mucosal patch. The suture line is medial to rather than over the
bone graft, and the single vertical scar is usually very inconspicuous. It is effective
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Postalveolar stulas, which are between the alveolus and the incisive foramen, are
dif cult to see, hard to reach, and hard to mobilize. The surgeon repairing stulas
in this dif cult position needs to think of the anatomy in three dimensions and
be prepared to approach from the intraoral and anterior nasal directions.81 The mu-
coperiosteum is rigid yet friable. It is easier to obtain closure of this area in conjunc-
tion with alveolar bone grafting than with local closure alone. Lehman et al,82 after
orthodontically aligning the alveolar segments, successfully closed 19 alveolar-
postalveolar stulas by careful closure of nasal and oral mucosal layers, placing can-
cellous bone in the space between and covering the bone anteriorly with a buccal
ap passed through the alveolar cleft. Henderson83 had excellent results with his
“tadpole” island advancement flap in this area, although this method has not worked
quite so well for others.51 Guzel and Altinas84 described closing 9 of 10 recurrent
anterior palatal fistulas with the use of tongue flaps. I have used the buccinator
myomucosal ap based anteriorly to close large (2 to 3 cm diameter) postalveolar-
anterior hard palate stulas in three patients. In one, with a repaired bilateral cleft
lip and palate, bilateral aps were stacked, one for oral lining and one for nasal lin-
ing, with one pedicle passed through each of the two alveolar clefts.
Hard and Soft Palate Fistulas
The methods that Cohen et al9 described for closing 31 hard palate stulas and
two soft palate stulas mirror the experiences of others46,47:20 local mucoperiosteal
aps with and without turnover aps, seven vomer aps alone or in combination
with local aps, two local plus buccal mucosal aps, two total revisions of palate re-
pair, and two undescribed repairs. Bone grafts were used in four of the more ante-
rior repairs. Nearly half of the stulas were 2 mm or smaller, and less than 20% were
more than 5 mm. In 12 (37%) of the 33 patients, the repair failed to completely
close the stula.Two of the four repairs incorporating bone grafts failed, and 50% of
two-layer closures failed versus 25% of one-layer closures, which is contrary to con-
ventional wisdom.52,78 No pharyngeal aps,tongue aps,or extraoral aps were used.
More unusual palatal aps reported elsewhere for hard palate closure include Mil-
lard’s island ap,81,85,86 which ingeniously shifts the tissues of the hard palate but
does not bring additional tissue into the hard palate.
Suggestions for Fistula Repair
Lehman’s article on stula repair87 provides organized planning and valuable details
for successful stula closure.
One should operate on the palate, not the stula.88
Incisions should follow original incision scars to avoid elevating mucoperiosteum
based only on scar, which may necrose. To move the stiff, scarred tissue, local ap
incisions should extend beyond the margins of the stula to provide access for ad-
equate dissection and mobilization; large mucoperiosteal aps move more easily
than small ones.With good exposure, in large stulas a surprisingly large amount of

mucoperiosteal tissue may be unfolded from the stula margins where it has con-
tracted. When used, turnover flaps should be large enough to “latch” and stay
turned over when pushed through the stula.
The mucosal continuity of the stula must be interrupted completely
around the stula, a particularly dif cult maneuver close behind the
alveolus.
The oral and nasal mucosal margins must be kept separated during healing. Inci-
sions and aps should be planned as much as possible so that oral and nasal suture
lines do not overlie each other, especially at the ends of a stula where small resid-
ual stulas tend to persist. Raw surface interfaces such as with turnover aps should
extend beyond the stula.
For narrow hard palate stulas I usually re-elevate the original mucoperiosteal aps
by incising the old cleft scar, skirting the fistula, which permits the flaps to be
brought out of the palatal vault into the horizontal plane as in a primary double op-
posing Z-plasty repair, converting vault into width so that the margins will reach
each other.8,10 One must be careful not to cut through the nasal mucosa when sep-
arating the two layers along the cleft;an angled Beaver blade can be helpful in mak-
ing this plane of dissection. A needle is useful in nding the bony margin of the
palatal shelf where elevation becomes subperiosteal.
The mucoperiosteal ap closure is always with horizontal mattress sutures.
The incision must go completely around the stula so that no oronasal mucosal
continuity remains;mucosa on either abutting margin of a suture line will prevent
healing, with persistence of the stula. Granulations along the stula margin need
excision, as they may contain epithelium.88 The stiff, scarred mucoperiosteum
around the stula tries to return to its original shape and position, bringing the
mucosal margins of the nasal and oral surfaces back together to reestablish the s-
tula.The edge of a ap can be underscored to uncurl and evert its margin, or when
ap width can be spared, the mucosa along the ap margin can be excised. It is
important to evert the ap margins with mattress sutures to produce raw tissue to
raw tissue apposition. Using round rather than cutting needles to minimize dam-
age to friable tissue margins55 is a logical suggestion.
In some instances, particularly when the patient is already in an orthodontic appli-
ance, a prosthetic appliance may be a better solution than surgical repair,89 partic-
ularly as a temporizing measure.
When repair of a palatal stula fails, one must consider Vásconez’s Third Law of
Flaps: If Plan A Fails, Do Not Make Plan B Exactly Like Plan A.90 One must ex-
amine the operative plan and execution to try to determine the cause for failure to
avoid repeating mistakes.
Today, the approach to palatal stulas has changed and results are improving.
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Operate on the palate, not the stula. On volunteer surgery trips such as Interplast,I have
repaired smaller hard palate stulas by elevating the mucoperiosteal aps through the
cleft scar (see p. 1071), often in conjunction with a double opposing Z-plasty for a
poorly repaired velum when on preoperative examination VPI has persisted with the
stula closed with tissue paper. Denny and Amm88 raise mucoperosteal aps using
lateral incisions along the gingiva-tooth margin,giving the aps added reach medially
to close hard palate stulas, with success in 31 (97%) of the 32 undergoing their rst
stula repair,and 23 (82%) of 28 operated on after at least one unsuccessful earlier at-
tempt. All six failures were in their 22 patients with bilateral cleft lip and palate.
Use of autogenous interposition materials has led to significantly better results.
Bone grafts, in use for many years, are routinely used to reconstitute the alveolus
and have been used for hard palate stulas, where they help to separate the nasal and
oral layers. In 68 patients whose fistulas were closed with techniques including
bone grafting, Jackson53 had three graft extrusions and four or ve residual stulas,
but Cohen et al9 had stula persistence in two of the four cases in which they used
bone grafts.
A conchal cartilage graft larger than the 8 mm hard palate stula it was to close was
placed under sutured mucoperiosteal aps and left exposed nasally by Matsuo et al91
in 1991.The stula healed, and 13 months later nasendoscopy revealed epithelium
on the cartilage surface. Jeffery et al92 successfully closed 11 of 14 small hard palate
stulas by incising the stula margin and slipping in a cartilage graft, leaving both
surfaces of the cartilage exposed.
Vandeput et al93 closed 17 stulas, most in the alveolus–anterior palate area, with
dermis-fat grafts, pushing the fat side through the bony cleft under the nasal aps,
with the dermis sutured to the underside of the oral aps covering the bony cleft.
Alveolar bone grafts were placed with three of the dermis-fat grafts. The central
portions of both the fat and the dermis were frequently left exposed. All 17 stu-
las healed.
Interposition of AlloDerm for closing a palatal stula was rst reported by Clark et
al94 in 2003.The AlloDerm became exposed but healed, so in six cases with clefts
wider than 15 mm, a two- ap repair was used placing AlloDerm under the mu-
coperiosteal aps. All seven repairs healed without stulas, although in two cases the
nasal ap was torn and in two the AlloDerm became exposed orally.
In 2003, Kirschner et al95 reported on an experimental model in which AlloDerm
was placed in 1 cm mature stulas created in three piglet hard palates. Neither nasal
nor oral mucosa was closed over the exposed AlloDerm. All three stulas healed
and when examined 3 weeks postoperatively, the AlloDerm was completely epithe-
lialized and vascularized, with cellular in ltration. In seven patients, they then in-
terposed AlloDerm between the oral and nasal layers. In ve only the oral layer
was closed and in two both layers were sutured. In one patient, the AlloDerm be-
came exposed through the oral closure. All seven stulas closed completely.

In 2005,Davison et al96 reported interposing AlloDerm between the oral and nasal lay-
ers of ve consecutive patients, each of whom had had a minimum of three previous
unsuccessful attempts at postpalatoplasty stula repairs. All ve healed completely.
In 2006, Steele and Seagle97 published a study that reviewed all palatal stula repairs
over a 101⁄2-year span comparing various “conventional” repairs in 12 patients and
AlloDerm interposition in nine patients.The conventional repairs failed in 2 of 12
patients, one an interposition of conchal cartilage. There were no failures in the
nine patients with AlloDerm interposition, in which the hard palate mucoperios-
teum was elevated as an anteriorly based ap back posterior to the stula, nasal
mucosa mobilized, in six of the nine cases sutured, and a patch of AlloDerm sutured
to the undersurface of the mucoperiosteal ap whose stula was closed with evert-
ing mattress sutures.
These five series93-97 describe a total of 31 AlloDerm interpositions, often with
AlloDerm exposed on the oral or nasal side and 17 dermis–fat graft interpositions.93
All 48 healed without a failure. Interposition with dermis, either autologous or de-
cellularized, seems to be a major improvement both in the initial closure of wide
clefts and the closure of stulas.The cost of the stula repair that was not needed be-
cause of AlloDerm might well outweigh the considerable expense of the material.
RESIDUAL VELOPHARYNGEAL INCOMPETENCE
AFTER PALATE REPAIR
A competent velopharyngeal mechanism can close completely and rapidly and
open suf ciently for adequate nasal air ow, and so can eliminate both nasal escape
and hypernasality.13,98 Timely construction of a functional velopharyngeal mecha-
nism has not been achieved when there is any degree of VPI or when VPI-induced
articulation errors mar the patient’s speech. The still-incompetent velopharyngeal
mechanism is the major problem after cleft palate repair.
CRITERIA FOR SUCCESS?
The frequently made statement that approximately three out of four children have
good speech after cleft palate repair15,37,78,99,100 may mean that their speech ranges
from normal to intelligible, or only that they have not had a secondary procedure
for VPI.101,187,191 However, in some series VPI is graded by speech-language pathol-
ogists into three major categories: (1) none (speech perceptually within normal
limits); (2) not none, but not too severe (this category is often subdivided); and (3)
severe (patients who require or who have had a secondary procedure for VPI are in
this category). In most studies some or all of the patients in the “not none, but not
too severe” category are counted as successes.
The “not none, but not too severe” category constitutes a very signi cant propor-
tion of patients.Five recent series have been selected both because they are from em-
inent centers and because they provide data that permit patients with velopharyn-
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geal competence to be distinguished from patients with marginal or uncertain VPI.
Velopharyngeal competence was present in 14% (6 of 43) of Schweckendiek’s pa-
tients as studied by Bardach et al,99 29% (6 of 21) with von Langenbeck repair, 27%
(10 of 37) with pushback repair, and 50% (11 of 22) with von Langenbeck repair
with intravelar veloplasty (IVV) in Dreyer and Trier’s series102;24% (8 of 34) of non-
IVV and 37% (14 of 38) of IVV patients in the study by Marsh et al103; 46% (53 of
114) with two-stage repair (Meijer and Cohen104);and 22% (8 of 37) in the Zurich
two-stage repair.105 For the purpose of example only, combining these series gives a
velopharyngeal competency rate of 34% (116 of 346), less than half of the 75% that
we think of as the expected success rate.Twenty percent of the patients (68 of 346)
underwent a secondary procedure for VPI and were classi ed as failures, leaving al-
most half (47%) of the patients (184 of 346) in the “not none, but not too severe”
category,where they are nearly always included in the successful category.In this ex-
ample they would swell the success rate to 80%.These patients are included among
those whom Morris106 describes as “almost but not quite” and “sometimes but not
always.” As the surgeons responsible for the function of the velopharyngeal valve,we
should not consider any palatoplasty that leaves any degree of VPI as successful.
If all patients with any degree of VPI are included in the “failure” group, the group
can then be subdivided by speech-language pathologists in a way that provides spe-
ci c information for determining further therapy, which would include the op-
tion of no further therapy for the part of the group with truly “insigni cant”VPI.
Other than kidding ourselves that our primary repairs function better than they ac-
tually do, the real problem with considering the patients in this category as successes
is twofold:(1) Such patients may then receive little or no further consideration for
treatment and are left with speech that is not quite right; and (2) we fail to seek
treatment solutions for lesser degrees of VPI that do not warrant the risk and ex-
pense of surgery, even though many of those patients may exhibit socially abnor-
mal speech under some circumstances. A study distinguishing between those pa-
tients with unqualified velopharyngeal competence and those with “probable
competence,” “marginal competence,” and “probable incompetence” would shift
the focus to searching for the causes of less severe VPI and searching for solutions
for these patients.107
As an example,108 for 2 years we agonized over, administered speech therapy to,
and performed video uoroscopy on one of our patients who had received Te on
injections because she had “sometimes but not always” velopharyngeal function.
Immediately after her second Te on injection, her velopharyngeal function and
speech became quite normal. I suspect that most patients with intermittent VPI
and those with abnormal voice quality because they are straining to make closure
would be helped by treatment that could eliminate “insigni cant” gaps and make
velopharyngeal closure less of an effort.109
In a study of 27 patients undergoing double opposing Z-plasty for VPI after late
unsuccessful von Langenbeck palatoplasty,13 valve function was determined by rat-
ing nasal escape, hypernasality, and closure visualized on nasendoscopy.The degree