Video Atlas Phẫu Thuật Khe Hở Môi Và Vòm Miệng

Repair of the Bilateral Cleft Lip Deformity
85
requiring regular visits to the orthodontist to adjust the
direction of forces applied to the alveolus, premaxilla,
and nasal cartilages.
Active appliances expedite the realignment pro-
cess through active mechanical forces applied through
fixed intraoral plates. The Latham appliance is the
most well-recognized active instrument — it is a sur-
gically placed, pin-based appliance secured to the
maxillary segments across the cleft.16 With regular
screw tightening, the maxillary/alveolar segments are
approximated. Outward force is placed across the lip
to retract the premaxilla. The choice between active
versus passive appliances is controversial and often
dictated by orthodontic expertise as well as availabil-
ity in resource-poor settings, where presurgical care is
limited. Whenever possible, we prefer that our patients
undergo presurgical orthopedic structural alignment
with NAM if available. When operating internation-
ally, we endeavor to collaborate with our partner insti-
tutions to establish these necessary multidisciplinary
services to achieve the best outcomes. Attempts to
repair bilateral clefts with protruded premaxillas and
without presurgical orthopedics can result in quite
unsatisfactory outcomes or lip dehiscence. We have
found these tools to be essential for tension-free, single-
stage repair with optimal aesthetic outcomes. Of note,
these techniques are performed in infants in whom the
Figure 7–2.  Nasoalveolar molding (NAM) in a patient with
bilateral cleft lip. NAM involves an intraoral mold, lip taping
across the cheeks and prolabium, and bilateral nasal stents for
nasal cartilage alignment.
A
B
Figure 7–3.  Outcome following nasoalveolar molding (NAM) in patient with bilateral cleft lip. A. Pre-NAM image demonstrating
wide complete cleft lip on the right and incomplete cleft lip on the left. Note the protruding premaxillary segment, wide alae, and
lower lateral cartilages splayed out across the clefts. B. Following 2 months of NAM, the right alveolar and premaxillary segments
have been approximated, and the premaxilla set back. In addition, there is reduction in alar base width, release of tension across
the lower lateral cartilages, and elongation of the columella.

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Video Atlas of Cleft Lip and Palate Surgery
alveolus, premaxilla, and nasal cartilage are still mobile
and pliable. After 1 year of age, these tissues lose their
flexibility. Thus, in repair of older patients or in cases
where presurgical orthopedic care is not available,
the principle of tension-free closure must be upheld.
In particular, if repair is being attempted over a wide
cleft and protruding premaxilla, two-stage repair may
be warranted. Although presurgical orthopedic align-
ment and closure of the cleft carry the risk of inhibit-
ing midfacial growth, achievement of a competent oral
sphincter important for functions, such as speech and
eating, must take precedence.
Timing of Repair
Although optimal timing of repair is controversial,
most surgeons perform bilateral cleft lip repair at
approximately age 3 to 6 months, following presurgi-
cal orthopedics. The rule of 10’s (hemoglobin 10 g/dL,
weight 10 lbs, and 10 weeks of age), coined by Hans
Wilhelmsen and Ross Musgrave, is used as a reference
that considers the anesthetic complications of general
anesthesia in infants.17 In many parts of the develop-
ing world, there are large numbers of adolescents and
adults with cleft deformities awaiting surgical repair.
In these cases, the same surgical principles outlined
herein apply; however, multistage repair in the setting
of wide, complete bilateral clefts may be necessary in
the absence of presurgical orthodontic care.
Surgical Equipment and Tools
• Measuring caliper
• Castroviejo fine tissue forceps
• Ribbon-handled suture scissors
• Strabismus scissors
• Skin hooks
• Bipolar cautery forceps (Jeweler’s fine-tip)
and bipolar electrosurgical unit
Anesthesia
• Infants and young children require general
anesthesia through oral intubation.
• Patients over the age of 12 years, especially in
poor resource settings, can undergo cleft lip
repair under local anesthesia with or without
IV sedation after thorough patient and family
counseling (see Chapter 6).
• Regardless of age, local anesthesia is
important for both analgesic effects and
vasoconstrictive properties.
Surgical Procedure
Repair of Bilateral Cleft Lip
(Video of Repair of Bilateral Cleft Lip Deformity)
1. A surgical timeout is performed following a stan-
dard patient safety checklist prior to administering
anesthesia. We use a surgical safety protocol modi-
fied from the World Health Organization (WHO)
surgical safety checklist (Figure 7–4).18
2. Anesthesia: If the patient is under 12 years of age,
cleft lip repair is performed under general anes-
thesia via a preformed oral endotracheal (ET) tube.
The preformed ET tube curvature minimizes pos-
sible interference with access to the surgical site.
The ET tube is secured to the skin with fluid-resis-
tant tape. The tube should be taped at midline just
under the lower lip so that it does not affect the
shape or position of the upper and lower lips. Tape
is used to close the eyelids for protection.
3. Prophylactic intravenous antibiotics are administered.
4. A throat pack, tied to a silk suture and moistened
with saline, is placed. As a safety measure, the
nursing team and anesthesia team separately docu-
ment when the throat pack is inserted. At the end
of the case prior to extubation, the throat pack must
be removed, with verbal confirmation between the
surgeon, anesthesiologist, and nurse.
5. The patient is placed in supine position. The oper-
ating table is set in reverse Trendelenburg position.
A shoulder roll is placed to extend the neck and to
ensure that the ET tube does not interfere with sur-
gical dissection of the upper lip. The head is sup-
ported in a soft silicone gel head rest.
6. The connections of the ET tube are kept within
visualization of the surgical field to allow for moni-
toring and avoidance of accidental disconnection.
7. A second patient safety checklist pause is performed.
8. Initial inspection involves assessment of the cleft
deformity. In this case illustration, the patient has
an asymmetric bilateral cleft, with a left complete
and a right incomplete cleft (Figure 7–5).

Repair of the Bilateral Cleft Lip Deformity
87
9. Surgical markings: Analysis of the cleft defect
begins with marking landmarks and flaps with a
fine marking pen as illustrated (Figure 7–6):
A. The prolabial flap is designed such that the
distance between high point and low point
(midpoint) on each side of the philtrum is 2 to
2.5 mm, depending on the age of the patient
(2 mm in younger patients and 2.5 mm in
older/unrepaired patients).

i. The low point of Cupid’s bow is marked
(1). Two high points (2) are then marked
2 mm from the low point. If the low point
is not clearly visible from head on view, it
can be visualized from the sky line view.
ii. The midpoint junction of the columellar–
labial angle is marked at the crease (3). If
the premaxilla is rotated to one side and
the low point cannot be easily identified,
a line can be dropped from this midpoint
at the base of the columella (3) to meet
the low point.
iii. The low point (1) and two high points (2)
on the prolabium are connected via a line
drawn 0.5 mm below the vermilion bor-
der in the red lip to preserve integrity of
the vermilion border across the median
Figure 7–4.  Surgical safety checklist (modified from the WHO surgical safety checklist).
Figure 7–5.  Preoperative photograph of patient with asym-
metric bilateral cleft lip (left complete, right incomplete).

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Video Atlas of Cleft Lip and Palate Surgery
tubercle and maintain this tubercle in the
preserved prolabial flap.
B. The philtral ridges (ph) are then marked, start-
ing at the out-flaring of the footplate superi-
orly and finishing at the high point of Cupid’s
bow inferiorly. The trapezoid that results from
the outline of the philtral ridges and Cupid’s
bow establishes the prolabial flap.
C. The cutaneous elements lateral to the philtral
ridges represent columellar (C) flaps that will
be subsequently trimmed to small V-shaped
flaps and rotated laterally to recreate the
out-flaring of the medial crural footplates. In
the past, and prior to nasoalveolar (NAM)
therapy, these flaps were preserved as forked
flaps that were used to achieve columellar
lengthening or banked for subsequent nasal
reconstruction.
D. On the lateral lip elements, the high point or
peak of Cupid’s bow (2b) corresponds to the
point at which the vermilion tubercle reaches
its maximal width before tapering off superi-
orly into a two-dimensional line.
E. The alar bases are marked (4).

i. On the complete cleft side, the medial
most point of the lateral cleft segment is
marked (5).
F. Advancement flaps (A flaps) are outlined
on both sides of the defect. The white roll is
maintained within the vermilion flaps. Note
that the lateral extension of the flap along the
nostril sill crease does not go beyond the level
of the inner surface of the ala once it has been
mobilized to its repaired position, thereby
avoiding a scarring incision in the alar crease.
G. The mucosal flaps (M flaps) are outlined. The
M flap is used to re-create the nasal floor in
the case of a complete cleft. In the case of an
incomplete cleft lip, the flap is discarded as
the nasal floor is intact.
H. Most of the dry vermilion in the prolabial
area is discarded, and only a small inverted
V-shaped segment at the base of the frenulum
is preserved. If left unresected, this dry ver-
milion will grow significantly as the patient
matures and will produce a bulge of dry
mucosal lining in the gingivobuccal sulcus.
10. Local anesthesia (see Chapter 6)
A. Local anesthesia is then infiltrated to achieve
facial nerve blocks bilaterally at the infraorbital
nerves and external nasal nerves, as well as
locally in the nose and upper lip surgical sites.
B. The concentration and volume of anesthetic
mixture used is dependent on patient weight
and age. We recommend the following combi-
nation of short- and long-acting anesthetic:

i. Patient under the age of 12 years:
a mixture of 1:1 (xylocaine 0.5% in
A
B
C
Figure 7–6.  Surgical markings. A. Intraoperative photo. B. Diagram of neutral position. C. Diagram of retracted position.

Repair of the Bilateral Cleft Lip Deformity
89
1:200,000 epinephrine and bupivacaine
0.25% in 1:200,000 epinephrine) and a
dose of 0.5 cc of the combined mixture
per kilogram.
ii. Patient over the age of 12 years: a mixture
of 1:1 (xylocaine 1% in 1:100,000 epineph-
rine and bupivacaine 0.5% in 1:200,000
epinephrine) and a dose of 1 cc of the
combined mixture per kilogram.
C. Infraorbital nerve block is performed at the
beginning of the case to allow adequate
short- and long-term anesthetic effect.19 This
will provide anesthesia to the upper lip and
nostril areas. When administering, the non-
dominant hand is placed at the inferior aspect
of the globe. The needle is then inserted at the
approximate location of the infraorbital fora-
men. In the pediatric age group, the foramen
opens along the midline of an imaginary line
between the pupil and the oral commissure.
The needle is aimed superolaterally toward
the infraorbital foramen. One should avoid
going through the foramen, and the needle tip
should be pulled off the premaxilla in order to
avoid injury to the infraorbital nerve fibers.
D. External nasal nerve block is achieved by
infiltrating no more than 0.5 cc of anesthetic
mixture. Care should be taken to ensure the
needle does not penetrate into the nasal cav-
ity. Injection can be aided by use of traction
through the needle to raise the skin off the
underlying upper lateral cartilage. A bleb
should form.
E. Local anesthetic is injected using no larger
than a 25-gauge needle. A pause of 12 minutes
following injection is strictly followed to allow
maximum vasoconstriction. Based on our
experience, this significantly minimizes intra-
operative bleeding and the need for bipolar
cautery. Monopolar cautery is not used, thus
avoiding significant injury to the surrounding
structures.
Labial Dissection
11. Incisions are performed through the skin and sub-
cutaneous layers using a #15 blade knife to ensure
appropriate skin flap thickness (Figure 7–7).
12. A thick prolabium flap, including the subdermal
layers, is elevated. The C flaps lateral to the philtral
columns are outlined by continuing the incision
superior to the vermilion border. These flaps are
raised in the subdermal plane and will be subse-
quently trimmed considerably for use in re-creating
the medial aspect of the nasal floor when needed.
The remaining tissue in the prolabium is de-epithe-
lialized. Most of dry vermilion is discarded except
for a 2-mm inverted V-mucosal triangle at level of
frenulum (Figure 7–8). If left in place, the dry ver-
milion results in excess and cosmetically unaccept-
able dry mucosal bulge with growth of the patient.
13. The prolabial flap is elevated to the base of the col-
umella and thinned. In order to re-create the illu-
sion of a philtral dimple, the central portion should
Figure 7–8.  The majority of the dry vermilion in the prolabium
is discarded except for a 2-mm inverted V mucosal triangle at
the level of the frenulum. The advancement (A) flap and muco-
sal (M) flap on the right is incised.
Figure 7–7.  Prolabial incision. The incision connecting the high
points to the low point is made 0.5 mm below the vermilion
border, thereby preserving the vermilion within the prolabial flap.

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Video Atlas of Cleft Lip and Palate Surgery
be thinned slightly more than the lateral aspects of
the flap, thereby mimicking the natural depression.
14. Incisions are carried out on the lateral lip elements
through the skin and subcutaneous tissue with #15
blade, staying above the white roll. Incision is then
continued to the mucosal flaps.
15. On the lateral lip elements, the mucosal (M) flap is
elevated and discarded in the case of incomplete
cleft.
16. With a double prong retractor placed in the nostrils
and a double hook and converse retractor placed
at the noncleft side to provide tension, a #15 blade
knife is used to make an incision at the gingivobuc-
cal sulcus. The incision is extended approximately
3 cm in length and can be extended further if addi-
tional medial mobilization of the flap is needed. The
periosteum is preserved. The surgeon should always
keep a spatial orientation of the location of the infra-
orbital nerve and avoid any dissection in that area.
17. Using curved strabismus-type scissors, the orbicu-
laris oris muscle is elevated off the overlying skin
and underlying mucosa to facilitate the inferior
and medial mobility of the flap and muscle (Fig-
ure 7–9). The surgeon’s finger is maintained at
the outside of the lip, palpating the skin to avoid
accidental buttonholing. Muscle elevation should
not extend beyond 7 to 10 mm from the cleft and
should stop at the level of vermilion border to pre-
serve structural integrity of the muscle and its con-
nections to the overlying vermilion and mucosa
(Figure 7–10).
18. Using sharp scissors, on the incomplete cleft side,
the fibers of the orbicularis oris muscle are sepa-
rated from the alar base to allow inferior rotation
and medial advancement of the flap.
19. The alar base attachments to the piriform aperture
are released to allow medial mobilization of the
ala. These attachments, if not dissected, limit the
medial mobilization of the alar base with the alar
base flap suspending suture that will be placed later.
Attention is turned to the contralateral cleft, which in
this case is a complete cleft lip deformity.
20. An incision along the lateral lip element is made to
raise the advancement flap. The flap incisions are
made through the epidermal and dermal layers as
one unit to ensure a flap thickness that is adequate
for placement of subcutaneous sutures during lip
closure. Flap thickness is essential when the trans-
verse suture is placed to medialize the advance-
ment flaps (Figure 7–11).
21. The lateral mucosal flap is elevated. In the case of
a complete cleft defect, this flap is preserved and
used to create the nasal floor.
22. A gingivobuccal incision is made, and the orbicu-
laris oris muscle is dissected in the same manner as
previously described, ensuring that the attachments
to the alar base are separated. Muscle dissection from
overlying skin is done in a downward and graduat-
ed manner and stops at level of vermilion border. Dis-
section is carried out with cutting techniques. Avoid
Figure 7–9.  Following incision along the gingivobuccal sulcus,
the orbicularis oris muscle is elevated off the overlying skin
using sharp scissors.
Figure 7–10.  The orbicularis oris has been elevated off the
overlying skin and mucosa. Muscle elevation stops at level of
vermilion border to preserve the structural integrity of the muscle
and its connections to the overlying vermilion and mucosa. The
alar base attachments to the piriform aperture are then released.

Repair of the Bilateral Cleft Lip Deformity
91
extensive undermining of the lip (limit to 7 to 10
mm from the edge), that can disrupt anatomic
landmarks and result in postoperative lip edema.
23. The alar rim is then retracted with a wide double
hook. An incision is made at the upper edge of the
vibrissae (nasal hairs) approximately 2 mm pos-
terior to the posterior border of the lower lateral
cartilage, paralleling the alar rim. This technique
preserves the lower lateral cartilages. The lower
lateral cartilage should not be accessed through
lateral dissection from the alar base; if performed,
there is a risk of disrupting the natural contour of
the ala and buckling of the alar rim (Figure 7–12).
24. Blunt scissors are used to release the attachments
of the orbicularis oris muscle to the alar base. The
integrity of the alar valve is maintained by avoiding
extension of the incision into the mucosa. The extent
of dissection is assessed by evaluating the degree of
mobility of the alar base toward the midline.
Nasal Dissection
25. Using ribbon handle scissors and strabismus scis-
sors to access the nasal cartilage medially through
a closed technique, the nasal skin is elevated off the
underlying lower lateral cartilages. Small snips/
cuts should be performed, avoiding wide spreading
maneuvers with the scissors that might tear through
the fragile lower lateral cartilage (Figure  7–13).
This dissection frees up the lower lateral cartilages
and allows their medial rotation. The ensuing dou-
ble dome sutures and transverse crural transfixion
sutures provide anterior nasal tip projection and
enhance tip support.
Lip Closure
26. On the left complete cleft defect, the lateral muco-
sal (M) flap is transposed to build the anterior nasal
floor and minimize incidence of residual bucco-
nasal fistulae (Figure 7–14).
27. Starting at the inner aspect of the lip, the lateral
buccal mucosal flaps are sutured in midline using
a triangular suture (5-0 Vicryl™ on RB-1 needle).
The residual inverted midline prolabial mucosal
Figure 7–13.  Rhinoplasty. The nasal skin is elevated off the
underlying lower lateral cartilages through a closed technique.
Figure 7–12.  The alar base flap is elevated by making an inci-
sion along the upper border of vibrissae, stopping 2 mm poste-
rior to the posterior edge of lateral crus.
Figure 7–11.  The advancement flap and mucosal flap incisions
are made at the lateral lip element on the left. The mucosal flap
is elevated and will be used to create the nasal floor across the
complete cleft defect.

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Video Atlas of Cleft Lip and Palate Surgery
Figure 7–15.  The lateral buccal mucosal flaps are sutured in
the midline. The orbicularis oris muscle is then brought in from
laterally and sutured utilizing Hamdan sliding V-cheiloplasty
technique, thereby restoring muscle continuity.
Figure 7–16.  Hamdan sliding V-cheiloplasty. Muscle sutures
are placed starting inferiorly and ascending superiorly with
each suture placed more lateral to the previous suture in order
to achieve lip lengthening.
Figure 7–14.  The mucosal (M) flap is transposed across the
complete cleft on the left side to build the anterior nasal floor.
triangular flap is sutured to the top of these flaps
to ensure bucconasal sulcus closure (Figure 7–15).
28. Orbicularis oris muscle is then sutured across the
premaxilla utilizing Hamdan sliding V-cheilo-
plasty technique (Figures 7–16 and 7–17). In this
technique, muscle sutures are placed in a V-shaped
manner to allow lip lengthening and medial mobi-
lization of the alae. Anchor the orbicularis oris
muscle to the premaxillary periosteum through a
4-0 or 3-0 Vicryl™ suture to provide extra support
for the medialization of the muscle and to prevent
any accidental slippage of the muscle.
A. Multiple sutures are applied to the remaining
portions of the vermilion component of the
orbicularis oris muscle to ensure proper align-
ment of the tubular shaped muscle fibers. 5-0
VicrylTM or 5-0 or 6-0 MonocrylTM is used
for these final muscle sutures. Proper muscle
alignment is a crux of cleft repair and ensures
that the framework of the lip is well placed.
When attention is not directed toward proper
muscle alignment, the result is muscle defi-
ciency that is commonly labeled as a whistle
deformity. These muscle deficiencies cannot be
corrected by dermal grafts or Z-plasties. These
techniques do not restore muscle continuity
and usually contract postoperatively.
29. Alar base flap suspending sutures (ABFSS) using
4-0 Vicryl™ suture are then applied to both alar
bases and tied in a loop fashion to approximate the
alar bases and support their medialization (Fig-
ure 7–18). This suture techniques is placed in an
inferior to cephalad direction and tightened gently
to ensure nostril symmetry and prevent future lat-
eralization of the alae (Figure 7–19).
30. On the lateral lip elements, 0.5 to 0.75 mm vermil-
ion border flaps are raised to prevent notching of
the high points. These flaps are matched to the

93
Figure 7–17.  Each suture symmetrically aligns and unites the muscle fibers to achieve continuity.
Figure 7–18.  Alar base flap suspension suture (ABFSS) medi-
alizes the displaced ala on the cleft side.
Figure 7–19.  Alar base flap suspending suture is applied to
both alar bases.

94
Video Atlas of Cleft Lip and Palate Surgery
prolabial vermilion high points of Cupid’s bow
and are rotated inferiorly to achieve better align-
ment of the prolabial flap and its vermilion border
component (Figure 7–20).
31. The C flaps are trimmed to small V-shaped flaps
and rotated laterally. The C flaps are then sutured
to the medial tip of the alar base flaps, thus re-
creating the natural out-flaring of the medial cru-
ral footplates. This is especially useful in complete
clefts of the lip to prevent excessive medialization
of the medial tips of the alar base flaps.
Rhinoplasty
32. Two interdomal sutures are placed at the lower and
upper edge of the domes using 4-0 or 5-0 Monocryl™
on PS-2 needle (in the pediatric and adult age
group) to provide tip elevation and support (Figure
7–21). The mobility and medial rotation of the lower
lateral cartilages have been facilitated by their care-
ful dissection from the overlying nasal skin and by
the medialization of the alar bases through the alar
base flap suspending suture (ABFSS).
A. A 4-0 or 5-0 Monocryl™ on PS-2 transfixion
suture is then applied at the level of the
transverse crura to prevent their posterior
displacement postoperatively.
B. A 5-0 or 4-0 Vicryl™ transverse suture is
placed 2 to 3 mm behind the tip of the
advancement flap. This is followed by apply-
ing an inverted suture at the recipient site,
usually just medial to where the ABFSS was
placed.
C. A triangular suture is then placed at the base
of the nostril sill to approximate the medial
edge of the alar base flap, the base of the
medial crural foot plate, and the opposing
upper edge of the advancement flap.
33. To address anterior soft tissue angle redundancy,
one to two suspending sutures are applied between
the anterior soft tissue angle and the upper lateral
cartilage (same side or opposing side) depending
on the angle and degree of suspension needed,
following a similar to technique utilized in unilat-
eral cleft lip repair (4-0 Monocryl™ on PS-2 needle
or straight Keith needle) (Figures 7–22 and 7–23).
The sutures are placed 2 to 3 mm behind the rim
of the anterior soft angle passing through the skin
and reentering through the same hole, thereby sus-
pending the soft tissue to the upper lateral carti-
lage. The trajectory of the needle is in an ipsilateral
or contralateral direction depending on needed
elevation.
Final Closure
34. The subcutaneous layer is then closed with inverted
6-0 or 5-0 Monocryl™ or Vicryl™ sutures (Figure
7–24). The epidermis is closed with running 5-0 or
6-0 fast absorbing plain gut suture on a PC-1 needle.
Figure 7–20.  Vermilion border flaps are raised to align the
prolabium vermilion with the lateral lip vermilion.
Figure 7–21.  Location of interdomal and transfixion sutures.

Repair of the Bilateral Cleft Lip Deformity
95
35. Dermabond™ is finally applied over the skin por-
tion of the cleft lip repair.
36. Prior to extubation, the throat pack is removed
with confirmation made between the surgeon,
anesthesiologist, and nursing team. The patient is
then turned over to anesthesia team for extubation.
Analysis of postoperative outcomes is essential
for assessing the success of repair and adjustment as
necessary. Illustrative outcomes of bilateral cleft lip
repair are highlighted in Figure 7–25. With the use of
local anesthetic and facial blocks described previously,
we are able to achieve successful repair of cleft lip
deformities in awake adult patients without the need
for general anesthesia, which is often unavailable in
resource-limited settings. In our international experi-
ence, we have encountered many adults with unre-
paired cleft lip deformities who we have repaired using
local anesthesia alone (Figure 7–26). The principles for
repair of the infant patient with cleft lip are the same as
in the adult patient, while keeping in mind the lack of
additional growth of adult tissue when designing the
flaps. The success of cleft lip repair in the adult patient
has given promise to many individuals who lacked the
opportunity for such repair during infancy.
Postoperative Considerations
• Lip care:  All lip sutures are absorbable. When
anchoring sutures using 6-0 Monocryl™
are used (at the vermilion border, at tip of
Figure 7–22.  The C flaps have been trimmed and inset at the
nasal floor to re-create the out-flaring of the medial crural
footplate. Double interdomal and anterior soft tissue suspend-
ing sutures applied.
Figure 7–23.  Suspending sutures placed between anterior
soft tissue and ipsilateral upper lateral cartilage.
Figure 7–24.  Bilateral cleft lip deformity repaired. Note sym-
metry of nostril sills and nostril axes, tip support, columellar
length, and continuity of orbicularis oris muscle.

96
Figure 7–25.  Pre- and post-
operative images demonstrat-
ing successful repair of the
bilateral cleft lip.

Repair of the Bilateral Cleft Lip Deformity
97
the C flap, and the quadrangular nasal sill
sutures), they can be removed at 7 to 10 days
postoperatively. Topical antibiotic ointment
is applied at the nasal sill with a Q-tip for
the first 10 days only in cases of significant
crusting along the incision. Avoid using
topical antibiotic over Dermabond™, which
might cause its early resorption.
A
B
C
Figure 7–26.  Bilateral cleft lip repair in the adult patient under local anesthesia alone. A, B. Preoperative images demonstrat-
ing asymmetric bilateral incomplete cleft lip in the adult patient. C. Intraoperative image demonstrating flap dissection being
performed in the awake adult patient under local anesthesia. D, E. Postoperative images demonstrating repair. Note the symmetry
in the peaks of Cupid’s bow and in the alae.
D
E

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Video Atlas of Cleft Lip and Palate Surgery
• Feeding:  We use a soft catheter-tip syringe or
a teaspoon for feeding during the initial 7 to
10 days. Thereafter, breast or bottle feeding
can be resumed for infant patients.
• Activities:  For the first 10 days, we routinely
use elbow immobilizers in infant patients.
They must be removed several times per
day when the infant is under supervision
to minimize the risk of trauma to the lip.
Pacifiers are not encouraged for the first
10 days.
Complications
• Unsatisfactory outcomes may result from
improper technique, most commonly:

(1)  Inadequate muscle dissection resulting
in closure across the premaxilla under
tension and possible muscle diastasis.

(2)  Insufficient dissection and freeing of the
alar base, resulting in a laterally displaced
ala and nostril asymmetry.

(3)  Inadequate rhinoplasty with a short
columella, poor tip projection, and
redundant anterior soft tissue angle.
• Dehiscence may result from inadvertent
injury to the lip postoperatively or from
overzealous attempts to close the lip across
a wide cleft and protruding premaxilla in
a single-stage procedure (Figures 7–27 and
7–28). Dehiscence is more commonly seen
with surgeons inexperienced in cleft lip
surgery and unfamiliar with the necessity for
layered closure. Revision is challenging and
should not be performed for at least 6 months,
and preferably 1 year, to allow for adequate
tissue healing.
• Excess scar formation and secondary
notching can result from closure under
tension or superimposed infection.
Hypertrophic scars can be managed with
massaging for several months. At times,
the massages can be complemented with
topical steroid cream for 7 to 10 days. If the
hypertrophic scar is still prominent, steroid
injection can be attempted. Scar revision can
be considered, but not before a 12-month
postoperative period.
• Wound infections can have devastating
outcomes, including complete breakdown
of the surgical repair, often leaving residual
tissue that is markedly reduced and scarred ​
— a challenge for later repair (Figure 7–29).
• Hematoma formation is rare given the limited
dissection of the skin from the underlying
orbicularis oris muscle.
Figure 7–28.  Lip dehiscence resulting from attempted closure
under tension with inadequate flap mobilization.
Figure 7–27.  Lip dehiscence resulting from attempted closure
across a protruding premaxilla.

Repair of the Bilateral Cleft Lip Deformity
99
Pearls and Pitfalls
Cleft care requires a multidisciplinary approach with
the need for pre- and postoperative orthopedic care,
speech pathology intervention, psychosocial support,
nutritional education, genetic counseling, and palatal
surgery repair when indicated. The following pearls
and pitfalls should be heeded:
• Obtain preoperative pediatric and anesthesia
evaluation to ensure optimal patient health,
age, and nutritional status for surgery.
• Preoperative orthopedic care takes advantage
of the malleability of the infant alveolus,
premaxilla, and nasal cartilage to optimize
the scaffold for subsequent simultaneous
reconstruction of the bilateral cleft lip and
nasal deformities.
• Infraorbital and external nasal nerve blocks
significantly reduce postoperative pain.
In adult patients, these are useful tools to
perform cleft lip repair or revision.
• Correct surgical markings and the proper
design of the prolabial and advancement flaps
set the plan for the surgery; attention should
be paid to the design of the philtral columns
and prolabium width. Extensive incisions in
the alar creases should be avoided.
• Supraperiosteal dissection is important for
the release of abnormal muscle attachments
to the alar bases and skin to allow adequate
mobilization of the advancement flaps.
• Alignment of the orbicularis oris muscle over
the premaxilla is necessary to create an intact
oral sphincter, essential for a functionally and
aesthetically acceptable upper lip. Various
edges of the vermilion component of the
orbicularis oris muscle should be carefully
approximated and sutured to provide smooth
and uninterrupted flow of muscle and to
avoid any notching or muscle deficiency.
• Dissection of the muscle from the overlying lip
should be limited to the areas described previ-
ously, usually no greater than 10 mm from the
cleft edge. Extensive dissection is unnecessary.
• Anchor the orbicularis oris muscle to the
premaxillary periosteum through a 4-0 or
3-0 Vicryl™ suture for extra support and to
prevent any accidental slippage of the muscle.
• The sliding V-cheiloplasty technique for
muscle approximation also medializes the alar
bases and minimizes the lateral vectors of pull
on the alae.
A
B
Figure 7–29.  A. Wound infection and tissue necrosis in the setting of wound closed under tension. B. Resultant complete break-
down and loss of tissue.

100
Video Atlas of Cleft Lip and Palate Surgery
• Cupid’s bow symmetry is achieved through
careful alignment of the prolabial flap with
the vermilion border of the advancement
flaps, making sure that the two high points
are at the same latitude.
• Alar base suspending suture anchors the alar
bases in their medialized position.
• Nasal dissection and reconstruction should
aim to restore nasal anatomy while avoiding
cartilage resection, delivery techniques, or
concentric intranasal incisions that would
risk stenosis and require long-term use of
postoperative nasal plugs.
• Nasal dome symmetry and tip support is
best achieved through release of the soft
tissue overlying the lower lateral cartilages
and subsequent realignment of the cartilage
through the interdomal and suspending
sutures. This approach emphasizes the
cartilaginous scaffold necessary to achieve a
lengthened columella and defined tip.
• Anterior soft tissue angle sutures enhance
nostril symmetry and address the redundancy
seen in this area while avoiding unnecessary
resection.
• The chief pitfall in bilateral cleft lip repair is
attempted closure of the lip under tension.
Failure to optimize the bony and cartilaginous
structure preoperatively with orthopedic
manipulation increases the risk of closure
under tension. The consequences of attempted
repair of a wide cleft and protruding
premaxilla include:
• Inability to repair the lip.
• Repair under tension with secondary
wound breakdown.
• Intraoperative realization that the lip
cannot be repaired with decision to perform
lip adhesion, often with breakdown of the
adhesion due to wound tension.
• Tissue necrosis, wound breakdown, and
infection.
• Poor alignment of the orbicularis oris muscle
with inadequate suturing of fibers with
secondary diastasis can result in muscle
deficiency manifested by central notching.
• Inappropriate surgical markings, particularly
with design of the prolabium flap, can
result in a wide philtrum, especially when
measurements outside the normal 2 to 2.5 mm
are used for the low-to-high point distances.
• Central fullness along the philtral dimple due
to inadequate trimming of the undersurface
of the prolabial flap. Careful trimming of
prolabium flap is performed to mimic the
natural depression along the philtral dimple.
• Asymmetry in the final outcome of the lip
that is noticeable at Cupid’s bow due to
minor differences in the low-to-high point
measurements.
• Notched vermilion border along the high
points will result if there is inadequate
rotation of the vermilion border flaps.
• Collapsed, depressed, and flattened nose that
is not addressed by restructuring the nasal
cartilage support framework will persist and
magnify with the growth of the patient.
References
1. Bhattacharya S, Khanna V, Kohli R. Cleft lip: the histori-
cal perspective. Indian J Plast Surg. 2009;42:4–8.
2. Mulliken JB. Correction of the bilateral cleft lip nasal
deformity: evolution of a surgical concept. Cleft Palate
Craniofac J. 1992;29:540–545.
3. Trier W. Repair of bilateral cleft lip: Millard’s technique.
Clin Plast Surg. 1985;12:605–625.
4. Millard DJ. Cleft Craft. Boston, MA: Little Brown & Com-
pany; 1976.
5. Mulliken JB. Bilateral complete cleft lip and nasal defor-
mity: an anthropometric analysis of staged to synchro-
nous repair. Plast Reconstr Surg. 1995;96:9–23.
6. McComb H. Primary repair of the bilateral cleft lip nose:
a 15-year review and a new treatment plan. Plast Reconstr
Surg. 1990;86:882–889.
7. McComb H. Primary repair of the bilateral cleft lip nose:
a 4-year review. Plast Reconstr Surg. 1994;94:37–47.
8. Mulliken JB. Repair of bilateral cleft lip and its variants.
Indian J Plast Surg. 2009;42:79–90.
9. Cutting C, Grayson B, Brecht L, Santiago P, Wood R,
Kwon S. Presurgical columellar elongation and primary
retrograde nasal reconstruction in one-stage bilateral cleft
lip and nose repair. Plast Reconstr Surg. 1998;101:630–639.
10. Nakajima T, Yoshimura Y, Sakakibara A. Augmentation
of the nostril splint for retaining the corrected contour of
the cleft lip nose. Plast Reconstr Surg. 1990;85:182–186.
11. Kernahan DA. The striped Y- a symbolic classification for
cleft lip and palate. Plast Reconstr Surg. 1971;47:469–470.
12. Yuzuriha S, Oh AK, Mulliken JB. Asymmetrical bilateral
cleft lip: complete or incomplete and contralateral lesser
defect (minor-form, microform, or mini-microform). Plast
Reconstr Surg. 2008;122:1494–1504.

Repair of the Bilateral Cleft Lip Deformity
101
13. Bezuhly M, Fisher DM. Single-stage repair of asym-
metrical bilateral cleft lip with contralateral lesser form
defects. Plast Reconstr Surg. 2012;129:710,751–757.
14. Grayson BH, Cutting C, Wood R. Preoperative columella
lengthening in bilateral cleft lip and palate. Plast Reconstr
Surg. 1993;92:1422–1423.
15. Lee CTH, Garfinkle JS, Warren SM, Brecht LE, Cut-
ting CB, Grayson BH. Nasoalveolar molding improves
appearance of children with bilateral cleft lip–cleft palate.
Plast Reconstr Surg. 2008;122:1131–1137.
16. Georgiade NG, Latham RA. Maxillary arch alignment in
the bilateral cleft lip and palate infant using the pinned
coaxial screw appliance. Plast Reconstr Surg. 1975;56:​52–60.
17. Wilhelmsen H, Musgrave R. Complications of cleft lip
surgery. Cleft Palate J. 1966;3:223–231.
18. WHO. WHO surgical safety checklist; Safe Surgery Saves
Lives. Retrieved from
safesurgery/en/index.html.
19. Salloum ML, Eberlin KR, Sethna N, Hamdan US. Com-
bined use of infraorbital and external nasal nerve blocks
for effective perioperative pain control during and after
cleft lip repair. Cleft Palate Craniofac J. 2009;46:629–635.

(Trang không có chữ)

Section IV
Primary Repair of Clefts of the
Hard and Soft Palate and Alveolus

104
Video Atlas of Cleft Lip and Palate Surgery
Introduction
Lawrence T. Herman and Sara H. Runnels
This section will address the evaluation and manage-
ment of the clefting deformity as it enters the oral and
nasal cavities. The clefting process can be viewed as
a “Highway” of clefting potentially commencing at
the nose and terminating in the nasopharynx. The
Highway is either paved (normal anatomy) or unpaved
(clefted) at various sections along the way. The High-
way can be unilateral or bilateral. The paved areas
being normal do not require correction. The unpaved
areas being clefted will require surgical correction.
Many variations of the clefting process may be encoun-
tered but in the end, one must secure the full paving
of the “cleft Highway.” This section will address that
Highway of clefting as it presents in the oral and nasal
cavities. The cleft will be addressed as it passes through
the nasoalveolus with the challenges of repair in this
area. Other sections will discuss options for repair of
the clefting Highway as it involves the hard and soft
palate. The section will therefore be inclusive of the fol-
lowing chapters:
Chapter 8    Repair of Incomplete Cleft Palate
Chapter 9    Repair of Unilateral Complete Cleft
Palate
Chapter 10  Repair of Bilateral Complete Cleft
Palate
Chapter 11  Repair of Soft Palate Cleft and
Submucous Cleft Palate
Chapter 12  Repair of Nasoalveolar Clefts
This section will cover the important points related
to the successful repair of the cleft deformity in the
palate (hard and soft) and the nasoalveolus. Avoiding
tension, necrosis, and breakdown of mobilized tissue
are key points in prevention of untoward sequelae. The
creation of fistulae secondary to cleft palate repair is to
be avoided, as fistulae are more challenging to repair
than the virgin deformity. Understanding the anatomy
and the specific maneuvers required to adequately
mobilize all flaps are primary requirements for the suc-
cessful cleft palate surgeon. The choice of technique is
of secondary importance to the experience of the sur-
geon. This point has been clearly documented in study
after study. The aspiring surgeon is therefore encour-
aged to gain skill and experience with a specific tech-
nique. Alternative techniques can be explored when
proficiency is well developed. The section will address
the straight-line closure technique for the hard palate
popularized by Veau, Kilner, Von Langenbeck, and oth-
ers. A straight-line closure technique and the Furlow
Z-plasty technique will both be presented for repair of
the isolated soft palate cleft and submucous cleft pal-
ate. The nasoalveolar cleft, including various options
in timing and surgical technique, will be discussed in
the final chapter.
Preoperative evaluation of the defect with consid-
eration of age, medical status, anesthesia personnel,
postanesthesia capabilities, and family support are all
covered. The importance of organizing the operative
space with proper instrumentation is emphasized, as
are the specifics of multilayer closure with tension-free
flaps. Mobility of the oral mucosal flaps in cleft palate
repair will be achieved via isolation of the pterygoid
hamulus and releasing all muscle from it, and by iden-
tifying the neurovascular bundle, releasing all muscle
circumferentially, and fully skeletonizing the neuro-
vascular bundle. These are the key points to full mobi-
lization. No dissection is ever necessary lateral to the
hamulus for this purpose. Dissection in this area will
only result in increased bleeding.
Intravelar veloplasty is accomplished with redi-
rection of the musculature of the soft palate. This can
be accomplished via both straight-line closure and Fur-
low techniques. Nasal layer closure is accomplished by
liberally freeing nasal mucosa off the lateral aspects of
the hard palate. The goal therefore is to achieve a ten-
sion-free closure with two layers in the hard palate and
three layers in the soft palate.
The chapter on the nasoalveolar cleft will address
the absolute need for two layers of soft tissue closure
and possibly a third layer of bone. Full nasal layer clo-
sure is mandatory prior to placement of a bone graft.
A fully mobilized and well-vascularized oral layer is
also of vital importance for the closure of the nasoalve-
olar cleft and prevention of future breakdown. Various
flap designs and techniques will be presented.

105
Chapter 8
Repair of Incomplete Cleft Palate
Lawrence T. Herman, Sara H. Runnels, Kyle J. Chambers,
and Thomas Q. Gallagher
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Navy, the
Department of Defense, nor the U.S. Government.
LCDR Gallagher is a military service member. This
work was prepared as part of his official duties.
Title 17 U.S.C. 105 provides that “Copyright protec-
tion under this title is not available for any work of
the United States Government.” Title 17 U.S.C. 101
defines a United States Government work as a work
prepared by a military service member or employee
of the United States Government as part of that per-
son’s official duties.
Abstract
This chapter will cover the important points related to the
successful repair of the incomplete cleft palate. Avoiding ten-
sion, necrosis, and breakdown of mobilized tissues are the key
points to prevention of untoward sequelae. The creation of
fistulae secondary to cleft palate repair should be avoided as
fistulae are more challenging to repair than the virgin defor-
mities. This section will address the straight-line closure
technique popularized by Von Langenbeck. Mention will
also be made of the V-Y option. Preoperative evaluation of
the defect with consideration of age, medical status, anesthe-
sia personnel, postanesthesia capabilities, and family support
are all covered. The importance of organizing the operative
space with proper instrumentation is emphasized, as are the
specifics of multilayer closure with tension-free flaps. Mobil-
ity of the oral mucosal flaps will be achieved via isolation of
the pterygoid hamulus and releasing all muscle from it, and
by identifying the neurovascular bundle, releasing all muscle
circumferentially, and fully skeletonizing the bundle. These
are the key points to full mobilization. No dissection is ever
necessary lateral to the hamulus. This point should not be
overlooked, as little or no bleeding will be encountered when
all dissection is from the hamulus medially. Clear identifica-
tion of the hamulus therefore is of paramount importance as
an initial surgical maneuver. Intravelar veloplasty is accom-
plished via redirection of the musculature within the soft
palate. Nasal layer closure is performed by liberally freeing
nasal mucosa off the lateral aspects of the hard palate. The
goal is to achieve a tension-free closure with two layers in the
hard palate and three layers in the soft palate.
Multilayer repair of the incomplete cleft palate with
two-layer closure of the hard palate and three-layer
closure of the soft palate is discussed. A straight-line
closure technique as described by Von Langenbeck
is outlined. Emphasis is placed upon the specifics
required for successful closure and avoidance of post-
operative sequelae/fistulae.1–7
Goals
1. Prevent passage of liquids and food into the nose
by separation of the oral and nasal cavities.
2. Reposition the muscular velum (especially the
levator veli palatini muscle) to allow for velo-
pharyngeal function, important for speech and
swallowing.
3. Prevent middle ear disease with consequent hear-
ing abnormalities.
4. Allow for normal facial growth.
5. Prevent palatal fistulae and need for secondary
surgery.

106
Video Atlas of Cleft Lip and Palate Surgery
Surgical Indications
Palatal defects may extend from the uvula and soft
palate (secondary palate) anteriorly into the hard pal-
ate and nasoalveolus. It is important to fully assess the
extent of the defect prior to commencing the surgical
procedure. The amount of tissue transfer required and
the degree of flap mobility will be dependent on the
anatomy of the cleft.
Incomplete Cleft Palate
The defect is in the midline inclusive of the entire soft
palate with extension into the hard palate (Figure 8–1).
It will not include the primary palate (the section of the
palate anterior to the nasopalatine foramen) and thus
will not include the alveolus.
Timing
There is a balancing act between the need to close the
palate for normal speech and swallowing versus the
deleterious effects seen on maxillary growth secondary
to early closure. For patients with only an incomplete
cleft palate, minimal dissection of tissue off the lateral
aspects of the hard palate is required, and therefore
little effect on maxillary growth will be encountered.
Most centers now close an incomplete cleft palate at 6
to 12 months.
Surgical Equipment and Tools
• Dingman retractor and three blades
• Leibinger side retractor and two blades
• Towel clips
• Jeter needle holder (Lorenz)
• Jeter dissectors (Lorenz)
• Long straight needle holder with fine tip
• Short snaps (one straight and one curved)
• Long snaps (one straight and one curved)
• McKesson type suction tip (4 mm tip × 7")
• Frazier tip suction (#10)
• Small double skin hook
• Small single skin hook
• Senn retractor (blunt, three prongs)
• Small retractor (Ace)
• Minnesota retractor
• Dental aspirating syringe
• Periosteal elevators
• Curved freer elevator
• Small awl (Ace)
• Small curved Allis
• Dental mirror
• Long pickups (one with teeth, one without)
• Short Adson pickups (one with teeth, one
without)
• College pliers (curved)
• Semken tissue forcep
• #7 knife handle
• #5 round style handle with angle
• #12 Locklin scissor (16 cm)
• Iris scissor (delicate tip, curved)
• Reynold’s curved scissor
• Curved Metzenbaum scissor 14.5 cm
• 16 cm curved Kelly scissor
• Bandage scissor
• Small bite blocks (small adult and child)
• Bone file
• Pediatric extraction forcep
• Small rongeur
• Large rongeur
• Small mallet
• Set of seven small osteotomes
• Dental extraction elevator
• Olsen–Heger needle holder
• 12.5-cm Ryder vascular needle holder
• 15.5-cm Ryder vascular needle holder
• Curved probe with eye
• Joseph nasal scissors, curved
• Fine caliper (0 to 40 mm)
• Bishop–Harmon tissue forcep
Figure 8–1.  Defect is in the midline inclusive of the entire soft
palate with extension into the hard palate.

Repair of Incomplete Cleft Palate
107
Anesthesia
• An oral Rae® tube facilitates good access to
the nose and alveolar cleft itself. At times, a
nasal intubation may be considered in the
noncleft naris.
• The patient is placed in Trendelenburg
position with a shoulder or neck roll utilized
to hyperextend the head for enhanced
visualization of the defect.
Surgical Procedure (Straight-Line
Closure/Von Langenbeck Technique)
(Video of Repair of Incomplete Cleft Palate)
1. Successful palatal surgery starts with adequate
staffing, equipment, instruments, supplies, and
positioning of the patient on the OR table.
2. The patient is placed in Trendelenburg position
with a shoulder roll to hyperextend the head for
improved visibility of the operative field. The top
of the patient’s head should be at the edge of the
operating table.
3. The endotracheal tube must be positioned exactly
in the midline and stabilized with strong anesthe-
sia tape. If an oral Rae® tube is used, the bend of
the tube must be exactly at the edge of the lower
lip. Failure to position it as such could result in
pushing the tube deep into the right main stem
bronchus while activating the Dingman mouth
gag.
4. The surgeon sits or stands at the head of the table
and wears a headlight.
5. The Dingman retractor is placed with the largest
blade possible (sizes 1 to 3 available) to retract the
tongue but not impinge upon the posterior pharyn-
geal wall. Visibility of and access to the operative
field are the objectives.
6. A moist throat pack is placed under the Dingman
tongue blade. An additional towel can be placed
under the Dingman blade handle to further tilt
the head and thereby improve operative field
visibility.
7. Infiltrate the soft tissues with local anesthetic solu-
tion containing epinephrine. Wait at least 7 min-
utes for maximal hemostatic effect. Good visibility
of the operative field is paramount in successfully
completing the technical aspects of palatal surgery.
Diligent attention to items 1 to 7 will enhance the
chances of accomplishing this feat.
8. Incisions are marked with a marking pen. This
will prove most important as the cutting of inci-
sion lines becomes technically challenging, and
the markings assist in continued orientation of the
blade. An angled blade handle improves access to
the difficult anterior aspects of the cuts.
9. The incision begins with a small releasing incision
behind the maxillary tuberosity. This continues
anteriorly as needed, staying close to the palatal–
gingival margin of the teeth. This can be contin-
ued in a circumferential manner along the anterior
teeth connecting with the contralateral side. This
provides for the releasing of the oral mucosa in
one continuous flap. This flap can be completely
released to allow for a pushback movement or
remain attached to bone at the nasopalatine fora-
men for improved blood supply to the flap. Use a
#15 blade with the incision down to bone.
10. Medially, incise full thickness along the margin of
the palatal shelf up to the junction of the hard and
soft palate, leaving enough tissue medially to bring
together for a nasal side closure. Once at the junc-
tion, continue the incision in a split-thickness fash-
ion within the mucosa of the soft palate. Continue
this up to the uvula either with a #11 blade or sharp
scissors.
11. A periosteal elevator is used to help identify the
position of the hamulus. This is an important step;
isolating and uncovering the hamulus is critical to
mobilization of the oral mucosal flaps. More impor-
tantly, the location of the hamulus will serve as a
stop point for lateral dissection of the soft tissues
(Figure 8–2). No dissection lateral to the hamulus
will ever be necessary in the repair of the cleft pal-
ate deformity. Freeing of muscle off the hamulus
and around the neurovascular bundle will achieve
all necessary mobility of the flap. Dissection into
the tissues lateral to the hamulus will only result
in excessive bleeding and will not provide any
measure of increased mobility of the flaps. This is
a most important point and should not be taken
lightly. Lay the periosteal elevator against the pala-
tal aspect of the teeth with the point directed at the
uvula. Mark this spot with an X. You may also be
able to palpate the hamulus.
12. Raise a full thickness flap off the tuberosity using
two periosteal elevators for control and visibility;
sweep medially and posteriorly towards the pre-
viously marked hamulus point. Carefully cut any
firmly attached tissue with a #15 blade. Sweep the

108
Video Atlas of Cleft Lip and Palate Surgery
tissue off the posterior maxilla before you dissect
out the hamulus. Carefully use the two periosteal
elevators to identify and isolate the hamulus. You
will see the white fascia layer covering the hamu-
lus. With the hamulus isolated, use a #11 blade to
incise up the neck of the hamulus and across the
tip in a t-shaped fashion. Sweep up the hamulus
to release all muscle and fascia attachments; avoid
fracturing the hamulus if possible. Fracturing of
the hamulus is said to negatively affect maxillary
growth. Sweep tissues from the posterior maxilla
toward the midline. You should begin to see sig-
nificant movement of the soft tissue toward the
midline. Do not dissect lateral to the hamulus, as
this will only cause unnecessary bleeding.
13. At the anterior most aspect of the oral mucosal flap
just behind the anterior teeth, grasp the edge of the
flap with a forceps and carefully elevate the flap
from the palatal shelves with a periosteal elevator.
Any fibrous attachments should be sharply incised
to prevent tearing of the flap. The other option, as
mentioned, is to maintain attachment of the oral
side flap at the position of the nasopalatine fora-
men (Figure 8–3).
14. Identify the neurovascular bundle and its exit point
at the greater palatine foramen. This is critical to
the survival of the flap. The greater palatine artery
must not be damaged, as the vitality of the flap is
largely dependent upon the viability of this artery.
Once the flap has been raised, it can be gently
retracted using a silk suture attached to the inferior
spring of the Dingman mouth gag. This step will
not be possible if the flap remains attached at the
nasopalatine foramen.
15. Dissect out the levator veli palatini muscle from
the oral side of flap. It must also be fully released
circumferentially from around the neurovascu-
lar bundle (most important for mobility) and the
posterior edge of the hard palate. This should
be accomplished with care using sharp, curved
scissors. Do not spread with the scissors but use
a cutting action only. A skin hook can be used to
gently retract the edge of the flap to better visu-
alize the bundle as it is skeletonized. If not fully
skeletonized and freed of muscle and soft tissue,
the palatine vessels will act as a tether and restrict
movement of the flap medially.
16. Carefully dissect the muscle from the nasal side
of the flap (within the soft palate) in a horizontal
manner. At this time, the muscle bundle should
move passively toward the midline (referred to as
an intravelar veloplasty).
17. Raise the nasal side flap off the palatal bone care-
fully; this is done fiber-by-fiber using a Jeter or
Woodson elevator. Be very careful not to perforate
the flap at the posterior aspect of the hard palate.
This is where a firm, fibrous attachment always
exists. Carefully elevate the nasal layer along the
posterior border of the hard palate and along the
medial aspect of the hard palate.
At this point, all layers/flaps should move pas-
sively toward the midline. Any tension will likely lead
to wound breakdown and fistula formation. If neces-
Figure 8–2.  Location of the hamulus serves as a stop point for
lateral dissection of the soft tissues.
Figure 8–3.  Attachment of the oral side flap maintained at
the position of the nasopalatine foramen.

Repair of Incomplete Cleft Palate
109
sary, continue dissection in the critical areas as noted
in the foregoing to achieve greater mobility. Resist the
attempt to gain greater mobility by carrying the dis-
section lateral to the hamulus. This will not result in
increased mobility but only increased bleeding.
In summary, the muscle (levator and tensor) must
be free from the following:
(1)  Hamulus
(2)  Posterior hard palate
(3)  Neurovascular bundle
18. Check for passive approximation and coaptation of
the nasal layers. Place a suture through the nasal
layer near the tip of the uvula and attach it to the
Dingman for temporary stability. Close the nasal
side flaps using multiple interrupted 5-0 Vicryl™
sutures. Continue closing as anteriorly up to the
intact primary palate. Tight, secure closure of all
layers is mandatory (Figure 8–4).
19. With the nasal side closed passively, close the mus-
cle layer next (intravelar veloplasty). This will be
done in the midline thereby reorienting the levator
muscle from an anterior to a medial direction. Use
multiple 4-0 or 5-0 PDS™ sutures for closure. This
anastomosis presumably will allow for a dynamic
soft palate (Figure 8–5).
20. Close the oral layer using interrupted 4-0 or 5-0
Vicryl™ sutures. Continue oral layer closure up to
the intact primary palate and alveolar ridge. The
oral mucosal flap can then be tacked down to the
nasal side flap to eliminate the dead space. The lat-
eral edges of the oral layer can also be tacked down
to the adjacent palatal gingival cuff (Figure 8–6).
21. Hemostasis is best achieved with gauze pressure
following completion of the surgical procedure.
Persistent oozing will need to be managed with
the use of small amounts of Avitene™ placed into
any exposed areas. Surgicel® is to be avoided as it
markedly slows the healing process and usually
sloughs within a week of placement. The key is
to minimize bleeding by following the aforemen-
tioned guidelines for dissection (ie, never dissect
Figure 8–4.  Nasal side flaps closed using multiple interrupted
5-0 Vicryl™ sutures.
Figure 8–5.  Intravelar veloplasty is performed by reorienting the levator veli palatini muscle from an anterior to a medial direction.

110
Video Atlas of Cleft Lip and Palate Surgery
lateral to the hamulus). During the entire surgical
procedure, frequently apply gauze pressure to the
surgical sites for improved hemostasis.
22. Suction the oropharynx and remove the throat pack.
Carefully remove the Dingman mouth gag and be
diligent not to inadvertently extubate the patient.
Place the patient in a reverse Trendelenburg posi-
tion with the head up, remove the shoulder roll,
and keep pressure against the palate (for contin-
ued assist to hemostasis) until anesthesia is ready
to extubate the patient.
Postoperative Considerations
• Airway observation in the immediate
postoperative period is important. Swelling
within the first 24 to 48 hours could be
significant, and close monitoring is required.
• Bleeding can persist in the recovery room,
and the patient should not be discharged to a
hospital bed until all sites are dry.
• Encourage clear to full liquids for the first
2 weeks.
• Patients with teeth should be instructed in
good oral hygiene techniques.
• Steroids, antibiotics, and analgesics are
prescribed for the first 5 to 10 days.
• Close follow-up is required to assess for
vitality of all flaps and possible breakdown
at surgical sites.
Complications
• A major complication can be the severance
of the greater palatine artery. This is the
major blood supply to the oral mucosal flap.
Disruption of the blood supply to this flap
will result in necrosis of the flap. The flap
would then be lost with scarring and fistula
formation. Secondary repair is then rendered
more difficult.
• Postoperative bleeding may occur, which
would require return to the OR for control
of the field and investigation of the surgical
sites. Taking down flaps with appropriate
local measures to control bleeding would be
indicated. Deep sutures, cautery, or various
hemostatic agents may need to be employed.
• Inability to achieve complete tension-
free closure of all flaps. This is most
frequently seen at the junction of the hard
and soft palate. This is the greatest area
of tension resulting from the restricting
anatomy encountered at the hamulus and
neurovascular bundle. Full understanding of
the anatomy and the need for mobilization
at these sites will allow for physiologic
closure (note important details outlined in the
foregoing sections)
Pearls and Pitfalls
• Good preoperative planning and assessment
of the defect.
• Proper professional staffing and equipment in
place.
• Correct positioning of patient on the OR table
and adequate securing of the endotracheal
tube.
• Proper instrumentation and adequate
experience of the operating surgeon.
Specialized instruments can greatly assist the
surgeon with the surgical challenges. Surgery
of the cleft palate is conceptually easy but
technically difficult. An experienced surgeon
understands this problem and creates an
operating kit that is designed to minimize the
surgical/technical challenges.
• Sequence surgical procedures to avoid
attempting too much at any one time.
Figure 8–6.  Oral layer closed up to the intact primary palate
and alveolar ridge.

Repair of Incomplete Cleft Palate
111
Consider just closing the soft palate first in
the case of a very large cleft palate. This will
often allow for shrinkage of the hard palatal
component and facilitate future closure of this
portion of the cleft.
• Never dissect lateral to the hamulus. There
is no reason to manipulate in this area, as
mobility of the flaps will not be improved by
dissection in this area. Concentrate on freeing
muscle off the hamulus and skeletonizing the
neurovascular bundle. Avoid manipulation
in the area lateral to the hamulus. These
diligences will significantly and substantially
reduce bleeding.
References
Most of the didactic information contained in this
chapter is taken from notes based on 30 years of expe-
rience performing cleft palate surgery in developing
countries. Additional resources include:
1. Assael LA. Primary repair of cleft palate: A review of sur-
gical technique. Atlas Oral Maxillofac Surg Clin North Am.
1995;3(1):13–27.
2. Bardach J, Salyer KE. Surgical Techniques in Cleft Lip and
Palate. 2nd ed. St. Louis, MO: Mosby Year Book; 1991.
3. Bardach J. Cleft palate repair: Two-flap palatoplasty.
Research, philosophy, technique, and results. In: Bardach
J, Morris HL, eds. Multidisciplinary Management of Cleft
Lip and Palate. Philadelphia, PA: Saunders; 1990:352–365.
4. Fried H. Two-stage palate repair. In: Losee JE, Kirschner
RE, eds. Comprehensive Cleft Care. New York, NY:
McGraw-Hill Medical; 2008:413–429.
5. Millard RD, Jr. Refining the V-Y palate retropositioning.
In: Millard RD, ed. Cleft Craft. Boston, MA: Little Brown
& Co; 1980:419–448.
6. Millard RD, Jr. Mending the misplaced muscles. In: Mil-
lard RD, ed. Cleft Craft, Boston, MA: Little Brown & Co;
1980:497–523.
7. Precious D. Unilateral cleft lip and palate. Oral Maxillofac
Surg Clin North Am. 2000;12(3):399–420.

(Trang không có chữ)

113
Chapter 9
Repair of Unilateral Complete Cleft Palate
Lawrence T. Herman, Sara H. Runnels, and Kyle J. Chambers
Abstract
This chapter will cover the important points related to the suc-
cessful repair of the complete cleft palate. Avoiding tension,
necrosis, and breakdown of mobilized tissue are key points
in prevention of untoward sequelae. The creation of fistulae
secondary to cleft palate repair should be avoided as these are
more challenging to repair than the virgin deformity. Under-
standing the anatomy and the specific maneuvers required to
adequately mobilize all flaps is a primary requirement for the
successful cleft palate surgeon. The choice of technique is of
secondary importance to the experience of the surgeon. This
point has been clearly documented in study after study. The
aspiring surgeon is therefore encouraged to gain skill and
experience with a specific technique. Alternate techniques
can be explored when proficiency is well developed. This sec-
tion will address the straight-line closure technique popu-
larized by Veau-Kilner. Preoperative evaluation of the defect
with consideration of age, medical status, anesthesia person-
nel, postanesthesia capabilities, and family support are all
to be covered. The importance of organizing the operative
space with proper instrumentation is emphasized, as are the
specifics of multilayer closure with tension-free flaps. Mobil-
ity of the oral mucosal flaps will be achieved via isolation of
the pterygoid hamulus and releasing all muscle from it and
also by identifying the neurovascular bundle, releasing all
muscle circumferentially, and fully skeletonizing the bundle.
These are the key points to full mobilization. No dissection
is necessary lateral to the hamulus. Intravelar veloplasty is
accomplished with redirection of the musculature of the soft
palate. Nasal layer closure is performed by liberally freeing
nasal mucosa off the lateral aspects of the hard palate. The
goal is to achieve a tension-free closure with two layers in the
hard palate and three layers in the soft palate.
Multilayer repair of the complete cleft palate with
two-layer closure of the hard palate and three-layer
closure of the soft palate is essential. A straight-line
closure technique as described by Veau-Kilner is out-
lined. Emphasis is placed upon the specifics required
for successful closure and avoidance of postoperative
complications.1–7
Goals
1. Prevent passage of liquids and food into the nose
by separation of the oral and nasal cavities.
2. Reposition the muscular velum (especially the leva-
tor veli palatini muscle) to allow for velopharyngeal
function, important for speech and swallowing.
3. Prevent middle ear disease with consequent hear-
ing abnormalities.
4. Allow for normal facial growth.
5. Prevent palatal fistulae and need for secondary
surgery.
Surgical Indications
Palatal defects may extend from the uvula and soft
palate (secondary palate) anteriorly into the hard pal-
ate and nasoalveolus. It is important to fully assess the
extent of the defect prior to commencing the surgical
procedure. The amount of tissue transfer required and
the degree of flap mobility depends on the anatomy of
the cleft.
1. Unilateral cleft palate:  The vomer is visible but
attached to the hard palate on the noncleft side
(Figures 9–1 and 9–2).
2. Bilateral cleft palate:  The entire vomer is visible in
the midline of the defect.

114
Video Atlas of Cleft Lip and Palate Surgery
3. Submucous cleft palate:  Characterized by a bifid
uvula, a notched hard palate, and a zona pellucida
of overlying mucosa in the area where the soft pal-
ate musculature is abnormally oriented.
Timing
There is a balancing act between the need to close the
palate for normal speech and swallowing versus the
deleterious effects seen on maxillary growth secondary
to early closure. Most centers now close both the hard
and soft palate at 12 to 18 months.
Surgical Equipment and Tools
• Dingman retractor and three blades
• Leibinger side retractor and two blades
• Towel clips
• Jeter needle holder (Lorenz)
• Jeter dissectors (Lorenz)
• Long straight needle holder with fine tip
• Short snaps (one straight and one curved)
• Long snaps (one straight and one curved)
• McKesson type suction tip (4 mm tip × 7")
• Frazier tip suction (#10)
• Small double skin hook
• Small single skin hook
• Senn retractor (blunt, three prongs)
• Small retractor (Ace)
• Minnesota retractor
• Dental aspirating syringe
• Periosteal elevators
• Curved freer elevator
• Small awl (Ace)
• Small curved Allis
• Dental mirror
• Long pickups (one with teeth, one without)
• Short Adson pickups (one with teeth, one
without)
• College pliers (curved)
• Semken tissue forcep
• #7 knife handle
• #5 round style handle with angle
• #12 Locklin scissor (16 cm)
• Iris scissor (delicate tip, curved)
• Reynold’s curved scissor
• Curved Metzenbaum scissor 14.5 cm
• 16-cm curved Kelly scissor
• Bandage scissor
• Small bite blocks (small adult and child)
• Bone file
• Pediatric extraction forcep
• Small rongeur
• Large rongeur
• Small mallet
• Set of seven small osteotomes
• Dental extraction elevator
• Olsen–Heger needle holder
• 12.5-cm Ryder vascular needle holder
Figure 9–1.  Unilateral complete cleft palate with associated
nasoalveolar cleft.
Figure 9–2.  Schematic showing anatomy of a right unilateral
cleft palate.

Repair of Unilateral Complete Cleft Palate
115
• 15.5-cm Ryder vascular needle holder
• Curved probe with eye
• Joseph nasal scissors, curved
• Fine caliper (0 to 40 mm)
• Bishop–Harmon tissue forcep
Anesthesia
• An oral Rae® tube facilitates good access to
the nose and alveolar cleft itself. At times, a
nasal intubation may be considered in the
noncleft naris.
• The patient is placed in Trendelenburg
position with a shoulder or neck roll utilized
to hyperextend the head for enhanced
visualization of the defect.
Surgical Procedure (Video of
Repair of Unilateral Complete Cleft Palate)
1. Successful palatal surgery starts with adequate
staffing, equipment, instruments, supplies, and
positioning of the patient on the OR table.
2. The patient is placed in Trendelenburg position
with a shoulder roll to hyperextend the head for
improved visibility of the operative field. The top
of the patient’s head should be at the edge of the
operating table.
3. The endotracheal tube must be positioned exactly
in the midline and stabilized with strong anesthe-
sia tape. If an oral Rae® tube is used, the bend of
the tube must be exactly at the edge of the lower
lip. Failure to position it appropriately could result
in pushing the tube deep into the right main stem
bronchus while activating the Dingman mouth
gag.
4. The surgeon sits or stands at the head of the table
and wears a headlight.
5. The Dingman retractor is placed with the largest
blade possible (sizes 1 to 3 available) to retract the
tongue but not impinge upon the posterior pha-
ryngeal wall. Visibility and access to the operative
field are the primary objectives.
6. A moist throat pack is placed under the Dingman
tongue blade. An additional towel can be placed
under the Dingman blade handle to further tilt the
head and improve operative field visibility.
7. Infiltrate the soft tissues with local anesthetic solu-
tion containing epinephrine. Wait at least 7 min-
utes for maximal hemostatic effect. Good visibility
of the operative field is paramount in successfully
completing the technical aspects of palatal surgery.
Diligent attention to items 1 to 7 will enhance the
chances of accomplishing this feat.
8. Incisions are marked with a marking pen (Figure
9–3). This will prove most important as the cutting
of incision lines becomes technically challenging,
and the markings assist in continued orientation of
the blade. An angled blade handle improves access
to the difficult anterior aspects of the cuts.
9. Begin with a small releasing incision behind the
maxillary tuberosity. This continues anteriorly as
needed, staying close to the palatal gingival margin
of the teeth. This is done to allow for the maximum
width possible of the oral mucosal flaps. Use a #15
blade with the incision down to bone. In certain
cases (especially in developing countries where
future orthodontic treatment will not be an option),
the incision can be carried into the alveolar cleft
if present. This is done with the consideration of
simultaneously closing the alveolar portion of the
cleft. In unilateral clefts and with older patients,
this can be very effective. It allows for complete
closure of the clefting defect from the soft palate
up and through the nasoalveolus. This can be done
with or without a bone graft, as full closure of the
entire deformity will improve the patient’s quality
of life. A healthy soft tissue bed will also allow for
Figure 9–3.  Markings outlining the nasal and oral side flaps.
The incision can be carried up into the nasoalveolar cleft.

116
Video Atlas of Cleft Lip and Palate Surgery
future bone grafting if that option ever becomes a
possibility. Therefore, no harm and only benefit is
achieved by full closure of both palatal and alveo-
lar clefts in one surgical setting.
10. Medially, incise full thickness along the margin of
the palatal shelf up to the junction of the hard and
soft palate, leaving enough tissue medially to bring
together for a nasal side closure. Once at the junc-
tion, continue the incision in a split-thickness fash-
ion within the mucosa of the soft palate. Continue
this up to the uvula either with a #11 blade or sharp
scissors.
11. A periosteal elevator is used to help identify the
position of the hamulus (Figures 9–4, 9–5, and 9–6).
This is an important step; isolating and uncover-
ing the hamulus is critical to mobilization of the
oral mucosal flaps. More importantly, the location
of the hamulus will serve as a stop point for lateral
dissection of the soft tissues. No dissection lateral
to the hamulus will ever be necessary in the repair
of the cleft palate deformity. Freeing of muscle off
the hamulus and around the neurovascular bundle
will achieve all necessary mobility of the flap. Dis-
section into the tissues lateral to the hamulus will
only result in excessive bleeding and will not pro-
vide any measure of increased mobility of the flaps.
This is an extremely important point and should
not be taken lightly. Place the periosteal elevator
against the palatal aspect of the teeth with the point
directed at the uvula. Mark this spot with an X. You
may also be able to palpate the hamulus.
12. Raise a full-thickness flap off the tuberosity using
two periosteal elevators for control and visibility.
Sweep medially and posteriorly toward the previ-
ously marked hamulus point. Carefully cut any
Figure 9–6.  Bilateral markings identifying the location of the
hamulus.
Figure 9–4.  Periosteal elevator placed against the palatal
aspect of the maxillary teeth with point facing inward. This
placement accurately points to the location of the hamulus.
A marking will be made at this location.
Figure 9–5.  Marking pen used to mark the location of the
hamulus.

Repair of Unilateral Complete Cleft Palate
117
firmly attached tissue with a #15 blade. Sweep the
tissue off the posterior maxilla before you dissect
out the hamulus. Carefully use the two periosteal
elevators to identify and isolate the hamulus. You
will see the white fascia layer covering the hamu-
lus (Figure 9–7). With the hamulus isolated, use a
#11 blade to incise up the neck of the hamulus and
across the tip in a T-shaped fashion. Sweep up the
hamulus to release all muscle and fascia attach-
ments; avoid fracturing the hamulus if possible.
Sweep tissues from the posterior maxilla toward
the midline. You should begin to see significant
movement of the soft tissue toward the midline.
Do not dissect lateral to the hamulus, as this will
only cause unnecessary bleeding.
13. At the anterior most aspect of the oral mucosal flap,
grasp the edge with a forceps and carefully elevate
the flap from the palatal shelves with a perios-
teal elevator. Any fibrous attachments should be
sharply incised to prevent tearing of the flap.
14. Identify the neurovascular bundle and its exit point
at the greater palatine foramen (Figure 9–8). This
is critical to the survival of the flap. The greater
palatine artery must not be damaged, as the flap is
solely dependent upon this artery. If this artery is
cut, you cannot proceed with the case and should
reposition the flaps and close. Once the flap has
been raised, it can be gently retracted using a silk
suture attached to the inferior spring of the Ding-
man mouth gag.
15. Dissect out the levator veli palatini muscle from
the oral side of flap. It must also be fully released
circumferentially from around the neurovascu-
lar bundle (most important for mobility) and the
posterior edge of the hard palate. This should
be accomplished with care using sharp, curved
scissors. Do not spread with the scissors but use
a cutting action only. A skin hook can be used to
gently retract the edge of the flap to better visu-
alize the bundle as it is skeletonized. If not fully
skeletonized and freed of muscle and soft tissue,
the palatine vessels will act as a tether and restrict
movement of the flap medially.
16. Carefully dissect the muscle from the nasal side
of the flap (within the soft palate) in a horizon-
tal manner (Figure 9–9). At this time, the muscle
bundle should move passively toward the midline
(referred to as an intravelar veloplasty).
17. Raise the nasal side flap off the palatal bones care-
fully, fiber-by-fiber using a Jeter or Woodson eleva-
tor. Be very careful not to perforate the flap at the
posterior aspect of the hard palate. This is where
a firm, fibrous attachment always exists. Carefully
elevate the nasal layer along the posterior border of
the hard palate and along the medial aspect of the
hard palate into the alveolar cleft.
At this point, all layers/flaps should move pas-
sively toward the midline. Any tension will likely lead
to wound breakdown and fistula formation. If neces-
Figure 9–7.  The white fascia covering the hamulus is well
demonstrated. Note the dry field and lack of bleeding.
Figure 9–8.  The neurovascular bundle elevated and skeletonized.

118
Video Atlas of Cleft Lip and Palate Surgery
sary, continue dissection in the critical areas as noted
in the foregoing to achieve greater mobility. Resist the
attempt to gain greater mobility by carrying the dis-
section lateral to the hamulus. This will not result in
increased mobility but only increased bleeding.
In summary, the levator and tensor veli palatini
muscles must be free from the following:
(1)  Hamulus
(2)  Posterior hard palate
(3)  Neurovascular bundle
Repeat these steps on the contralateral side.
18. Check for passive approximation and coaptation of
the nasal layers. Place a suture through the nasal
layer near the tip of the uvula and attach it to the
Dingman for temporary stability. Close the nasal
side flaps using multiple interrupted 5-0 Vicryl™
sutures (Figures 9–10 and 9–11). Continue closing
as anteriorly as possible into the alveolar cleft (if
present). Tight closure of all layers is mandatory. In
cases of wide, bilateral clefts, it may be necessary to
use a flap from the vomer to facilitate nasal closure.
An incision is made over the crest of the vomer
with small lateral releases anterior and posterior
to facilitate turning the vomer flaps laterally. The
flaps are then turned right and left to approximate
the adjacent nasal mucosal flaps for suturing.
19. With the nasal side closed passively, close the mus-
cle layer next (intravelar veloplasty, Figure 9–12).
This will be done in the midline, reorienting the
levator muscle from an anterior to a medial direc-
tion. Use multiple 4-0 or 5-0 PDS™ sutures for clo-
sure. This anastomosis will presumably allow for a
dynamic soft palate (Figure 9–13).
20. Close the oral layer using interrupted 4-0 or 5-0
Vicryl™ sutures. As you suture anteriorly, it may be
necessary to place some horizontal mattress sutures
to allow the oral flaps to remain flat. This will help
avoid a folding-over effect of the flaps. Continue
oral layer closure as far up into the nasoalveolar
cleft as possible. The oral mucosal flap can then be
tacked down to the nasal side flap to eliminate the
dead space. The lateral edges of the oral layer can
also be anchored to the adjacent palatal gingival
cuff to further stabilize the flaps and prevent move-
ment in the postoperative period (Figures 9–14
and 9–15).
21. Hemostasis is best achieved with gauze pressure
following completion of the surgical procedure.
Persistent oozing will need to be managed with the
use of small amounts of Avitene™ placed into the
exposed areas of denuded palatal bone. Surgicel® is
to be avoided as it markedly slows the healing pro-
cess and usually sloughs within a week of placement.
The key is to minimize bleeding by following the
aforementioned guidelines for dissection (i.e., never
dissect lateral to the hamulus). During the entire sur-
gical procedure, frequently apply gauze pressure to
the surgical sites for improved hemostasis.
Figure 9–10.  Retraction of the oral side flaps and closure of
the nasal layer.
Figure 9–9.  Levator muscle is mobilized from posterior edge
of hard palate and underlying nasal mucosa.

Repair of Unilateral Complete Cleft Palate
119
22. Suction the oropharynx and remove the throat
pack. Carefully remove the Dingman mouth gag
and be diligent not to inadvertently extubate the
patient. Place the patient in a reverse Trendelen-
burg position with the head up, remove the shoul-
der roll, and keep pressure against the palate (to
help ensure hemostasis) until ready to extubate the
patient.
Postoperative Considerations
• Airway observation in the immediate
postoperative period is important. Swelling
within the first 24 to 48 hours could be
significant, and close monitoring is
required.
Figure 9–11.  Nasal layer closed primarily.
Figure 9–12.  Muscle layer closure.
Figure 9–13.  Intravelar veloplasty with
reorientation of the musculature of the
soft palate.
Figure 9–14.  Oral layer closure in the midline without tension.

Figure 9–15.  Final closure of the cleft palate. Oral side closed
primarily.

120
Video Atlas of Cleft Lip and Palate Surgery
• Bleeding can persist in the recovery room,
and the patient should not be discharged to a
hospital bed until all sites are dry.
• Encourage clear to full liquids for the first
2 weeks.
• Patients with teeth should be instructed in
good oral hygiene techniques.
• Steroids, antibiotics, and analgesics are
prescribed for the first 5 to 10 days.
• Close follow-up is required to assess for
vitality of all flaps and possible breakdown at
surgical sites.
Complications
• A major complication can be the severance
of the greater palatine artery. This is the
primary blood supply to the oral mucosal
flap. Disruption of the blood supply to this
flap will result in necrosis of the flap. The flap
would then be lost with scarring and fistula
formation. Secondary repair is then rendered
more difficult.
• Postoperative bleeding may occur, which
would require return to the OR for control
of the field and investigation of the surgical
sites. Taking down flaps with appropriate
local measures to control bleeding would
be indicated. Deep sutures, cautery, or
various hemostatic agents may need to
be employed.
• Inability to achieve complete tension-free
closure of all flaps. This is most frequently
seen at the junction of the hard and soft
palate. This is the area of greatest tension
resulting from the restricting anatomy
encountered at the hamulus and neuro-
vascular bundle. Full understanding of the
anatomy and the need for mobilization at
these sites will allow for physiologic closure
(note important details outlined in the
foregoing sections).
Pearls and Pitfalls
• Good preoperative planning and assessment
of the defect.
• Proper professional staffing and equipment
in place.
• Correct positioning of patient on the OR table
and adequate securing of the endotracheal
tube.
• Proper instrumentation and adequate
experience of the operating surgeon.
Specialized instruments can greatly assist the
surgeon with the surgical challenges. Surgery
of the cleft palate is conceptually easy but
technically difficult. An experienced surgeon
understands this problem and creates an
operating kit that is designed to minimize the
surgical/technical challenges.
• Sequence surgical procedures to avoid
attempting too much at any one time.
Consider just closing the soft palate first in
the case of a very large cleft palate. This will
often allow for shrinkage of the hard palatal
component and facilitate future closure of this
portion of the cleft.
• Never dissect lateral to the hamulus. There is
no reason to manipulate this area, as mobility
of the flaps will not be improved by dissection
here. Concentrate on freeing muscle off the
hamulus and skeletonizing the neurovascular
bundle. These diligences will significantly
reduce bleeding.
References
Most of the didactic information contained in this
chapter is taken from notes based on 30 years of expe-
rience performing cleft palate surgery in developing
countries. Additional resources include:
1. Assael LA. Primary repair of cleft palate: a review of sur-
gical technique. Atlas Oral Maxillofac Surg Clin North Am.
1995;3(1):13–27.
2. Bardach J, Salyer KE. Surgical Techniques in Cleft Lip and
Palate. 2nd ed. St. Louis, MO: Mosby Year Book; 1991.
3. Bardach J. Cleft palate repair: two-flap palatoplasty.
Research, philosophy, technique and results. In: Bardach
J, Morris HL, eds. Multidisciplinary Management of Cleft
Lip and Palate. Philadelphia, PA: Saunders; 1990:352–365.
4. Fried H. Two-stage palate repair. In: Losee JE, Kirschner
RE, eds. Comprehensive Cleft Care. New York, NY: McGraw-
Hill Medical; 2008:413–429.
5. Millard RD, Jr. Refining the V-Y palate retropositioning.
In: Millard RD, ed. Cleft Craft. Boston, MA: Little Brown
& Co; 1980:419–448.

Repair of Unilateral Complete Cleft Palate
121
6. Millard RD, Jr. Mending the misplaced muscles. In: Mil-
lard RD, ed. Cleft Craft. Boston, MA: Little Brown & Co;
1980:497–523.
7. Precious D. Unilateral cleft lip and palate. Oral Maxillofac
Surg Clin North Am. 2000;12(3):399–420.

(Trang không có chữ)

123
Chapter 10
Repair of Bilateral Complete Cleft Palate
Lawrence T. Herman, Sara H. Runnels, and Kyle J. Chambers
Abstract
This chapter will cover the important points related to the
successful repair of the bilateral complete cleft palate. Avoid-
ing tension, necrosis, and breakdown of mobilized tissue are
key points in prevention of untoward sequelae. The creation
of fistulae secondary to cleft palate repair should be avoided,
as fistulae are more challenging to repair than the virgin
deformities. This section will address the straight-line closure
technique and the use of the vomer flap. Preoperative evalu-
ation of the defect with consideration of age, medical status,
anesthesia personnel, postanesthesia capabilities, and family
support are all covered. The importance of organizing the
operative space with proper instrumentation is emphasized,
as are the specifics of multilayer closure with tension-free
flaps. Mobility of the oral mucosal flaps will be achieved via
isolation of the pterygoid hamulus and releasing all muscle
from it and also by identifying the neurovascular bundle,
releasing all muscle circumferentially, and fully skeleton-
izing the bundle. These are the key points to full mobiliza-
tion. No dissection is ever necessary lateral to the hamulus.
This point should not be overlooked, as little or no bleeding
will be encountered when all dissection is from the hamulus
medially. Clear identification of the hamulus is of paramount
importance as an initial surgical maneuver.
Utilization of tissue off the vomer for nasal side clo-
sure may be needed in repair of the bilateral cleft pal-
ate. This flap can provide additional tissue for nasal
layer closure but can compromise future growth of the
vomer. Often, with careful mobilization of nasal layer
mucosa from the lateral aspects of the hard palate, the
need for a vomer flap can be avoided. This chapter will
describe the technique for repair of the bilateral cleft
palate when a vomer flap is indicated. Intravelar velo-
plasty is accomplished with redirection of the muscu-
lature within the soft palate. The goal is to achieve a
tension-free closure with two layers in the hard pal-
ate and three layers in the soft palate. A straight-line
closure technique as described by Wardill, Veau, and
Kilner is outlined. Emphasis is placed upon the spe-
cifics required for successful closure and avoidance of
postoperative sequelae/fistulae.1–7
Goals
1. Prevent passage of liquids and food into the nose
by separation of the oral and nasal cavities.
2. Reposition the muscular velum (especially the
levator veli palatini muscle) to allow for velo-
pharyngeal function, important for speech and
swallowing.
3. Prevent middle ear disease with consequent hear-
ing loss.
4. Allow for normal facial growth.
5. Prevent palatal fistulae and the need for secondary
surgery.
Surgical Indications
Palatal defects may extend from the uvula and soft pal-
ate (secondary palate) anteriorly into the hard palate
and nasoalveolus (Figure 10–1). It is important to fully
assess the extent of the defect prior to commencing
the surgical procedure. The amount of tissue transfer
required and the degree of flap mobility will be depen-
dent on the anatomy of the cleft.

124
Video Atlas of Cleft Lip and Palate Surgery
Bilateral Complete Cleft Palate
The vomer is visible in the midline of the cleft palate
(Figures 10–2 and 10–3). The amount of tissue required
to repair these defects can be extensive, and a vomer
flap is often necessary.
Timing
There is a balancing act between the need to close the
palate for normal speech and swallowing versus the
deleterious effects seen on maxillary growth secondary
to early closure. Most centers now close both the hard
and soft palate at 12 to 18 months.
Surgical Equipment and Tools
• Dingman retractor and three blades
• Leibinger side retractor and two blades
• Towel clips
• Jeter needle holder (Lorenz)
• Jeter dissectors (Lorenz)
• Long straight needle holder with fine tip
• Short snaps (one straight and one curved)
• Long snaps (one straight and one curved)
• McKesson type suction tip (4-mm tip × 7")
• Frazier tip suction (#10)
Figure 10–1.  Diagram depicting a bilateral complete cleft palate.
Figure 10–2.  Wide bilateral complete cleft palate with vomer
visible in midline.
Figure 10–3.  Bilateral complete cleft palate with vomer vis-
ible in the midline.

Repair of Bilateral Complete Cleft Palate
125
• Small double skin hook
• Small single skin hook
• Senn retractor (blunt, three prongs)
• Small retractor (Ace)
• Minnesota retractor
• Dental aspirating syringe
• Periosteal elevators
• Curved freer elevator
• Small awl (Ace)
• Small curved Allis
• Dental mirror
• Long pickups (one with teeth, one without)
• Short Adson pickups (one with teeth, one
without)
• College pliers (curved)
• Semken tissue forcep
• #7 knife handle
• #5 round style handle with angle
• #12 Locklin scissor (16 cm)
• Iris scissor (delicate tip, curved)
• Reynold’s curved scissor
• Curved Metzenbaum scissor 14.5 cm
• 16-cm curved Kelly scissor
• Bandage scissor
• Small bite blocks (small adult and child)
• Bone file
• Pediatric extraction forcep
• Small rongeur
• Large rongeur
• Small mallet
• Set of seven small osteotomes
• Dental extraction elevator
• Olsen–Heger needle holder
• 12.5-cm Ryder vascular needle holder
• 15.5-cm Ryder vascular needle holder
• Curved probe with eye
• Joseph nasal scissors, curved
• Fine caliper (0 to 40 mm)
• Bishop–Harmon tissue forcep
Anesthesia
• An oral Rae® tube facilitates good access to
the nose and alveolar cleft itself. At times, a
nasal intubation may be considered in the
noncleft naris.
• The patient is placed in Trendelenburg
position with a shoulder or neck roll utilized
to hyperextend the head for enhanced
visualization of the defect.
Surgical Procedure (Video of
Repair of Bilateral Complete Cleft Palate)
1. Successful palatal surgery starts with adequate
staffing, equipment, instruments, supplies, and
positioning of the patient on the OR table.
2. The patient is placed in Trendelenburg position
with a shoulder roll to hyperextend the head for
improved visibility of the operative field. The top
of the patient’s head should be at the edge of the
operating table.
3. The endotracheal tube must be positioned exactly
in the midline and stabilized with strong anesthe-
sia tape. If an oral Rae® tube is used, the bend of the
tube must be exactly at the edge of the lower lip.
Failure to position it as such could result in push-
ing the tube deep into the right main stem bron-
chus while activating the Dingman mouth gag.
4. The surgeon sits or stands at the head of the table
and wears a headlight.
5. The Dingman retractor is placed with the largest
blade possible (sizes 1 to 3 available) to retract the
tongue but not impinge upon the posterior pharyn-
geal wall. Visibility of and access to the operative
field are the objectives.
6. A moist throat pack is placed under the Dingman
tongue blade. An additional towel can be placed
under the Dingman blade handle to further tilt the
head and improve operative field visibility.
7. Infiltrate the soft tissues with local anesthetic solu-
tion containing epinephrine. Wait at least 7 to 10
minutes for maximal hemostatic effect. Good
visibility of the operative field is paramount in
successfully completing the technical aspects of
palatal surgery. Diligent attention to items 1 to 7
will enhance the chances of accomplishing this feat.
8. Incisions are marked with a marking pen (Fig-
ure 10–4). This will prove most important as the
cutting of incision lines becomes technically chal-
lenging, and the markings assist in continued
orientation of the blade. An angled blade handle
improves access to the difficult anterior aspects of
the cuts.
9. The incision begins with a small releasing incision
behind the maxillary tuberosity. This continues
anteriorly as needed staying close to the palatal
gingival margin of the teeth. This is done to allow
for the maximum width possible of the oral muco-
sal flaps. Use a #15 blade with the incision down
to bone. In certain cases (especially in developing
countries where future orthodontic treatment will

126
Video Atlas of Cleft Lip and Palate Surgery
not be an option) the incision can be carried into
the alveolar cleft if present. This can be done on
one side in the bilateral cleft palate. This is done
with the consideration of simultaneously clos-
ing the alveolar portion of the cleft on one side. It
allows for complete closure of the clefting defect
from the soft palate up and through one side of the
nasoalveolus. One can do this with or without a
bone graft, as full closure of the deformity with at
least one side of the nasoalveolar cleft will improve
the quality of the patient’s life. More importantly, it
will make closure of the second side of the nasoal-
veolar cleft much easier at a future date. A healthy
soft tissue bed will also allow for future bone graft-
ing if that option ever becomes a possibility. There-
fore, no harm and only benefit will be achieved via
full closure of both palatal and alveolar clefts in
one surgical setting.
10. Medially, incise full thickness along the margin of
the palatal shelves up to the junction of the hard
and soft palate, leaving enough tissue medially to
bring together for a nasal side closure. Once at the
junction, continue the incision in a split-thickness
fashion within the mucosa of the soft palate. Con-
tinue this up to the uvula either with a #11 blade or
sharp scissors.
11. A periosteal elevator is used to help identify the
position of the hamulus. This is an important step;
isolating and uncovering the hamulus is critical
to mobilization of the oral mucosal flaps. More
importantly, the location of the hamulus will serve
as a stop point for lateral dissection of the soft tis-
sues. No dissection lateral to the hamulus will
ever be necessary in the repair of the cleft palate
deformity. Freeing of muscle off the hamulus and
around the neurovascular bundle will achieve all
the necessary mobility of the flap. Dissection into
the tissues lateral to the hamulus will only result
in excessive bleeding and will not provide any
measure of increased mobility of the flaps. This is
a most important point and should not be taken
lightly. Lay the periosteal elevator against the pala-
tal aspect of the teeth with the point directed at the
uvula. Mark this spot with an X. You may also be
able to palpate the hamulus.
12. Raise a full thickness flap off the tuberosity using
two periosteal elevators for control and visibility.
Sweep medially and posteriorly towards the pre-
viously marked hamulus point. Carefully cut any
firmly attached tissue with a #15 blade. Sweep the
tissue off the posterior maxilla before you dissect
out the hamulus. Carefully use the two periosteal
elevators to identify and isolate the hamulus. You
will see the white fascia layer covering the hamu-
lus (Figure 10–5). With the hamulus isolated, use
a #11 blade to incise up the neck of the hamulus
and across the tip in a T-shaped fashion. Sweep up
the hamulus to release all muscle and fascia attach-
ments. Avoid fracturing the hamulus if possible. It
has been reported that fracturing of the hamulus
will result in altered maxillary growth. Sweep tis-
sues from the posterior maxilla toward the midline.
You should begin to see significant movement of
the soft tissue toward the midline. Do not dis-
sect lateral to the hamulus, as this will only cause
unnecessary bleeding.
13. At the anterior most aspect of the oral mucosal flap,
grasp the edge with a forceps and carefully elevate
the flap from the palatal shelves with a perios-
teal elevator. Any fibrous attachments should be
sharply incised to prevent tearing of the flap.
14. Identify the neurovascular bundle and its exit point
at the greater palatine foramen. This is critical to
the survival of the flap. The greater palatine artery
must not be damaged, as the vitality of the flap is
solely dependent upon the viability of this artery. If
this artery is cut, you cannot proceed with the case
and should reposition the flaps and close. Once
the flap has been raised, it can be gently retracted
using a silk suture attached to the inferior spring of
the Dingman mouth gag.
15. Dissect out the levator veli palatini muscle from
the oral side of flap. It must also be fully released
Figure 10–4.  Incisions are marked with a marking pen.

Repair of Bilateral Complete Cleft Palate
127
circumferentially from around the neurovascu-
lar bundle (most important for mobility) and the
posterior edge of the hard palate. This should be
accomplished with care using sharp, curved scis-
sors. Do not spread with the scissors but use a cut-
ting action only. A skin hook can be used to gently
retract the edge of the flap to better visualize the
bundle as it is skeletonized. If not fully skeleton-
ized and freed of muscle and soft tissue, the greater
palatine vessels will act as a tether and restrict
movement of the flap medially.
16. Carefully dissect the muscle from the nasal side
of the flap (within the soft palate) in a horizontal
manner (Figure 10–6). At this time, the muscle
bundle should move passively toward the midline
(referred to as an intravelar veloplasty).
17. Raise the nasal side flap off the palatal bone very
carefully. This is done fiber-by-fiber using a Jeter or
Woodson elevator. Be very careful not to perforate
the flap at the posterior aspect of the hard palate.
This is where a firm, fibrous attachment always
exists. Carefully elevate the nasal layer along the
posterior border of the hard palate and along the
medial aspect of the hard palate into the alveolar
cleft. This is done bilaterally for the bilateral com-
plete cleft palate.
At this point, all layers/flaps should move pas-
sively toward the midline. Any tension will likely lead
to wound breakdown and fistula formation. If neces-
sary, continue dissection in the critical areas as noted
to achieve greater mobility. Resist the attempt to gain
greater mobility by carrying the dissection lateral to the
hamulus. This will not result in increased mobility but
only increased bleeding.
In summary, the muscle (levator and tensor veli
palatini) must be free from the following:
(1)  Hamulus
(2)  Posterior hard palate
(3)  Neurovascular bundle
Repeat these steps on the contralateral side.
18. Check for passive approximation and coaptation of
the nasal layers. If full and tension-free approxima-
tion of the nasal layer is not achievable, then raise a
vomer flap.
Vomer Flap
Use a #15 blade to create an incision in the midline
of the vomer bone mucosa (Figure 10–7). This is eas-
ily visualized within the bilateral cleft palate. The
vomer flap can then be raised and reflected (turned)
laterally (Figure 10–8). This flap will comprise a por-
tion of the nasal side closure and will be sutured pri-
marily to the previously raised nasal mucosal flaps.
The vomer mucosal flaps are sutured to the right and
left side nasal mucosal flaps with 5-0 Vicryl™ sutures
(Figure 10–9). As always, this must be done easily and
without tension. The closure of the nasal layer should
always commence at the most distal aspect of the cleft.
Figure 10–5.  Two periosteal elevators used to identify and
isolate the hamulus.
Figure 10–6.  Levator muscle is mobilized from posterior edge
of hard palate and underlying nasal mucosa.

128
Video Atlas of Cleft Lip and Palate Surgery
Start by placing sutures at the uvula and more forward
toward the vomer flaps. The initial closure at the uvula
and within the soft palate can be accomplished without
the vomer flap. As the hard palate is approached, the
need for additional tissue will be served by utilizing
the mucosa raised off the vomer. Within the hard pal-
ate, the nasal layer closure will require bilateral suture
lines. Tight, secure closure of all layers is mandatory.
19. With the nasal side closed passively, close the mus-
cle layer next (intravelar veloplasty). This is done
in the midline reorienting the levator veli palatini
from an anterior to medial direction. Use multiple
4-0 or 5-0 PDS™ sutures for closure. This anastomo-
sis will presumably allow for a dynamic soft palate
(Figure 10–10).
20. Close the oral layer using interrupted 4-0 or 5-0
Vicryl™ sutures. As you suture anteriorly, it may
be necessary to place some horizontal mattress
sutures to allow the oral flaps to remain flat. This
will help avoid a folding over effect of the flaps.
Continue oral layer closure as far up into the naso-
alveolar cleft as possible. The oral mucosal flap
can then be tacked down to the nasal side flap to
eliminate the dead space. The lateral edges of the
oral layer can also be tacked down to the adjacent
palatal gingival cuff to further stabilize the flaps
and prevent movement in the postoperative period
(Figure 10–11). These tacking sutures should be
placed loosely to allow for the pushback action of
the palatoplasty.
21. Hemostasis is best achieved with gauze pressure
following completion of the surgical procedure.
Persistent oozing will need to be managed with the
use of small amounts of Avitene™ placed into the
exposed areas of denuded palatal bone. Surgicel® is
to be avoided as it markedly slows the healing pro-
Figure 10–7.  Incision is made in the midline of the vomer
mucosa.
Figure 10–8.  Vomer flap is raised and reflected (turned) laterally.
Figure 10–9.  Vomer mucosal flaps are sutured to the right and
left side nasal mucosal flaps. Nasal layer closure will require
bilateral suture lines within the hard palate.

Repair of Bilateral Complete Cleft Palate
129
cess and usually sloughs within a week of place-
ment. The key is to minimize bleeding by following
the aforementioned guidelines for dissection (i.e.,
never dissect lateral to the hamulus). During
the entire surgical procedure, frequently apply
gauze pressure to the surgical sites for improved
hemostasis.
22. Suction the oropharynx and remove the throat
pack. Carefully remove the Dingman mouth gag
and be diligent not to inadvertently extubate the
patient. Place the patient in a reverse Trendelen-
burg position with the head up, remove the shoul-
der roll, and keep pressure against the palate (to
help ensure hemostasis) until anesthesia is ready
to extubate the patient.
Postoperative Considerations
• Airway observation in the immediate
postoperative period is important. Swelling
within the first 24 to 48 hours could be
significant, and close monitoring is required.
• Bleeding can persist in the recovery room,
and the patient should not be discharged to a
hospital bed until all sites are dry.
• Encourage clear to full liquids for the first
2 weeks.
• Patients with teeth should be instructed in
good oral hygiene techniques.
• Steroids, antibiotics, and analgesics are
prescribed for the first 5 to 10 days.
• Close follow-up is required to assess for
vitality of all flaps and possible breakdown at
surgical sites.
Complications
• A major complication can be the severance
of the greater palatine artery. This is the
major blood supply to the oral mucosal flap.
Disruption of the blood supply to this flap
will result in necrosis of the flap. The flap
would then be lost with scarring and fistula
formation. Secondary repair is then rendered
more difficult.
• Postoperative bleeding may occur, which
would require return to the OR for control
of the field and investigation of the surgical
sites. Taking down flaps with appropriate
local measures to control bleeding would
be indicated. Deep sutures, cautery, or
various hemostatic agents may need to be
employed.
Figure 10–11.  Lateral edges of the closed oral layer tacked
down to adjacent palatal gingival cuff to further stabilize the
flaps.
Figure 10–10.  Intravelar veloplasty is performed by reorient-
ing the levator veli palatini muscle from an anterior to a medial
direction.

130
Video Atlas of Cleft Lip and Palate Surgery
• Inability to achieve complete tension-
free closure of all flaps. This is most
frequently seen at the junction of the hard
and soft palate. This is the area of greatest
tension resulting from the restricted
anatomy encountered at the hamulus and
neurovascular bundle. Full understanding of
the anatomy and the need for mobilization
at these sites will allow for physiologic
closure (note important details outlined in the
foregoing sections).
Pearls and Pitfalls
• Good preoperative planning and assessment
of the defect.
• Proper professional staffing and equipment in
place.
• Correct positioning of patient on the OR table
and adequate securing of the endotracheal
tube.
• Proper instrumentation and adequate
experience of the operating surgeon.
Specialized instruments can greatly assist the
surgeon with the surgical challenges. Surgery
of the cleft palate is conceptually easy but
technically difficult. An experienced surgeon
understands this problem and creates an
operating kit that is designed to minimize the
surgical/technical challenges.
• Sequence surgical procedures to avoid
attempting too much at any one time.
Consider just closing the soft palate first in
the case of a very large cleft palate. This will
often allow for shrinkage of the hard palatal
component and facilitate future closure of this
portion of the cleft.
• Never dissect lateral to the hamulus.
There is no reason to manipulate in this area,
as mobility of the flaps will not be improved
by dissection in this area. Concentrate
on freeing muscle off the hamulus and
skeletonizing the neurovascular bundle.
Avoid manipulation in the area lateral to the
hamulus. These diligences will significantly
reduce bleeding.
References
Most of the didactic information contained in this
chapter is taken from notes based on 30 years of expe-
rience performing cleft palate surgery in developing
countries. Additional resources include:
1. Assael LA. Primary repair of cleft palate: a review of sur-
gical technique. Atlas Oral Maxillofac Surg Clin North Am.
1995;3(1):13–27.
2. Bardach J, Salyer KE. Surgical Techniques in Cleft Lip and
Palate. 2nd ed. St. Louis, MO: Mosby Year Book; 1991.
3. Bardach J. Cleft palate repair: two-flap palatoplasty.
Research, philosophy, technique and results. In: Bar-
dach J, Morris HL, eds. Multidisciplinary Management of
Cleft Lip and Palate. Philadelphia, PA: Saunders; 1990:
352–365.
4. Fried H. Two-stage palate repair. In: Losee JE, Kirschner
RE, eds. Comprehensive Clef Care. New York, NY: McGraw-
Hill Medical; 2008:413–429.
5. Millard RD, Jr. Refining the V-Y palate retropositioning.
In: Millard RD, ed. Cleft Craft. Boston, MA: Little Brown
& Co; 1980:419–448.
6. Millard RD, Jr. Mending the misplaced muscles. In: Mil-
lard RD, ed. Cleft Craft. Boston, MA: Little Brown & Co;
1980:497–523.
7. Precious D. Unilateral cleft lip and palate. Oral Maxillofac
Surg Clin North Am. 2000;12(3):399–420.

131
Chapter 11
Repair of Soft Palate Cleft and
Submucous Cleft Palate
Lawrence T. Herman, Sara H. Runnels, Derek J. Rogers,
Kyle J. Chambers, and Christopher J. Hartnick
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Army, the
Department of Defense, nor the U.S. government.
MAJ Rogers is a military service member. This work
was prepared as part of his official duties. Title 17
U.S.C. 105 provides that “Copyright protection under
this title is not available for any work of the United
States Government.” Title 17 U.S.C. 101 defines a
United States Government work as a work prepared
by a military service member or employee of the
United States Government as part of that person’s
official duties.
Abstract
This chapter will cover the important points related to the
successful repair of the soft palate cleft and the submucous
cleft palate. Avoiding tension, necrosis, and breakdown of
mobilized tissue are key points in prevention of untoward
sequelae. The creation of fistulae secondary to cleft palate
repair should be avoided, as fistulae are more challenging to
repair than the virgin deformities. This chapter will address
the straight-line closure technique popularized by Von Lan-
genbeck and the double Z-plasty technique described by Fur-
low. Preoperative evaluation of the defect with consideration
of age, medical status, anesthesia personnel, postanesthesia
capabilities, and family support are covered. The importance
of organizing the operative space with proper instrumenta-
tion is emphasized, as are the specifics of multilayer closure
with tension-free flaps. Mobility of the oral mucosal flaps
will be achieved via isolation of the pterygoid hamulus and
releasing all muscle from it and also by identifying the neu-
rovascular bundle, releasing all muscle circumferentially,
and fully skeletonizing the bundle. These are the key points
to full mobilization when utilizing this straight-line tech-
nique. No dissection is ever necessary lateral to the hamulus.
This point should not be overlooked, as little or no bleeding
will be encountered when all dissection is from the hamu-
lus medially. The Furlow technique does not necessitate
the need for exposure and freeing around the hamulus and
neurovascular bundle. Intravelar veloplasty is completed via
redirection of the musculature within the soft palate, which
is accomplished with both techniques but in a different man-
ner for each. Nasal layer closure is performed by liberally
freeing nasal mucosa in both the straight-line and Furlow
technique. The goal is to achieve a tension-free closure with
three layers in the soft palate inclusive of nasal mucosa, oral
mucosa, and muscle.
Soft Palate Cleft
A straight-line closure technique as described by Von
Langenbeck is outlined. Emphasis is placed upon the
specifics required for successful closure and avoidance
of postoperative sequelae/fistulae. Overt palatal clefts
may extend from the uvula through the soft palate and
hard palate anteriorly into the alveolus (Figure 11–1).
This chapter will deal only with clefts of the soft palate
including the submucous variation (Figure 11–2). The
Von Langenbeck technique is useful for closure of clefts
of this nature. The technique allows for medial move-
ment of palatal mucosa without detachment of tissue
anteriorly. The oral mucosal flap remains attached ante-
riorly inclusive of the nasopalatine artery. This supplies
additional blood supply to support healing and pre-
vent avascular breakdown. Scarring is minimized, and
less stress is placed upon the greater palatine vessels.
Venous return is also improved for less stasis and con-
gestion in the postoperative period.

132
Video Atlas of Cleft Lip and Palate Surgery
Submucous Cleft Palate
A submucous cleft palate consists of a notch in the pos-
terior hard palate, diastasis of soft palate musculature
in the midline (zona pellucida), and usually a bifid
uvula (Figure 11–3). The incidence of submucous cleft
palate is estimated at 1:1,250 to 1:6,000, occurring as an
isolated anatomic deformity or as part of a syndrome.1,2
The majority of patients with a submucous cleft pal-
ate are asymptomatic, but Moss et al found that up
to 10% may experience velopharyngeal insufficiency
(VPI).2 The primary reason for VPI in this patient
population is the anomalous attachment of the levator
veli palatini muscles to the posterior edge of the hard
palate sagitally, instead of forming a transverse sling.
Several studies have noted that the severity of VPI is
related to the degree of anterior displacement of these
muscles.3–5
Approximately 5% to 8% of patients with an iso-
lated cleft palate have velocardiofacial syndrome,
making it one of the most common syndromes asso-
ciated with cleft palate.6,7 Patients with velocardiofa-
cial syndrome and a submucous cleft palate present
unique challenges because these patients may have a
hypokinetic or akinetic velopharynx due to general-
ized hypotonia.7 Furthermore, these patients may have
medialized carotid arteries, often limiting them to only
a Furlow palatoplasty for repair (Figure 11–4). Rottgers
et al devised an algorithm for the use of Furlow palato-
plasty in patients with velocardiofacial syndrome and
suggested this technique to treat overt cleft palates
and kinetic submucous cleft palates.8 Patients with a
hypokinetic or akinetic velopharynx were treated with
a superiorly based pharyngeal flap or sphincter pha-
ryngoplasty. Multiple studies have shown that Furlow
palatoplasty is most effective in patients with a small
velopharyngeal gap.9,10
Figure 11–1.  Overt palatal cleft extending from the uvula
through the soft palate.
Figure 11–2.  Overt cleft of the soft palate.
Figure 11–3.  Submucous cleft palate with zona pellucida and
bifid uvula evident.

Repair of Soft Palate Cleft and Submucous Cleft Palate
133
Goals
As with any palatal procedure, three-layer, tension-free
closure is mandatory to:
1. Prevent passage of liquids and food into the nose
by separation of the oral and nasal cavities.
2. Reposition the muscular velum (especially the
levator veli palatini muscle) to allow for velo-
pharyngeal function, important for speech and
swallowing.
3. Prevent middle ear disease with consequent hear-
ing abnormalities.
4. Allow for normal facial growth.
5. Prevent palatal fistulae and need for secondary
surgery.
Surgical Indications
Soft palate defects may extend from the uvula up to
and slightly into the hard palate. The mucosa may
remain intact with submucous clefting of the muscula-
ture only. It is important to fully assess the extent of the
defect prior to commencing the surgical procedure. The
proper choice of technique will be greatly dependent
on the diligence of the differential diagnosis.
Depending upon the degree of the deformity, the
Von Langenbeck or Furlow palatoplasty may be used
alone or in combination with a superior pharyngeal
flap or sphincter pharyngoplasty to correct for VPI in
cases of submucous cleft palate. The Von Langenbeck
technique described in this chapter is useful in manage-
ment of the submucous cleft with one major addition.
At the commencement of the surgical procedure, if the
mucosa is intact (as seen with the submucous cleft pal-
ate) it will be necessary to convert this deformity into
an overt soft palate cleft.
The Furlow technique utilizes double Z-plasties in
the soft palate (see Chapter 22). These flaps will con-
tain either mucosa alone or muscle and mucosa. The
idea is to reposition the muscles of the soft palate into
a functional and dynamic position for the purposes of
speech and deglutition. This also allows for maximum
lengthening of the soft palate with elimination of VPI.
Furlow palatoplasty is most effective in patients with
a small velopharyngeal gap and relies on a dynamic
velopharynx. It may be the only feasible procedure in
a patient with medialized carotid arteries.
Timing
For patients with clefts of the soft palate, minimal dis-
section of tissue off the lateral aspects of the hard pal-
ate is required, and little effect on maxillary growth
will be encountered. Most centers now choose to close
these clefts at 6 to 12 months of age. This provides for
early velopharyngeal competency and the develop-
ment of normal speech. Submucous clefts are generally
repaired at 2-and-a-half years of age. This will be the
case only if the patient is manifesting signs of VPI and
speech is refractory to speech therapy. At a younger age
it is not possible to obtain reliable speech evaluations.
Interestingly, in some craniofacial centers, for patients
with complete clefts of the palate, the soft palate is
closed first followed several months later with hard
palate closure. The theory is that early reorientation of
Figure 11–4.  Computed tomography with contrast showing
medialization of the right internal carotid artery.