54. The Surgical Treatment of Cleft Palate
Acknowledgments: The material as well as illustrations in this chapter has been borrowed from two books; Millard’s Cleft Craft (Vol. 2, Little Brown, 1980) and Management of Cleft Lip and Palate (Eds. Watson, Sell and Grunwell, Whurr Publishers, 2001). These books as well as the material reproduced here is hugely valuable to students of plastic surgery and may remain on the shelves of libraries unnoticed with passage of time. On the other hand this blog is seen on an average by 100 people every day. It is uploaded without a charge, can be downloaded free and does not earn any income either for the compiler or to its contributors who offer their experience free of charge. For the purpose of identification of the source, MCLCR and MCLPL are being used as abbreviations for the first and the second book mentioned above. Several of these illustrations have been photoshopped and have been given various colours for ease of understanding. The effort is altruistic and is a product of the age of the internet.
- The title of this chapter needs some explanation. In a majority of the literature dealing with the above subject the diagrams only show clefts of the secondary palate, that is clefts that begin at the incisor foramen extending up to the uvula (Fig. 1). These are complete clefts of the secondary palate; some of these diagrams also show incomplete clefts of the secondary palate (please see chapter 51). This group of clefts is distinct in that they occur more frequently in females (60/40) and their post-surgical outcomes particularly in terms of speech generally appear to be poorer as compared to the more grotesque looking clefts of the primary and secondary palate. These clefts are more frequently part of a syndrome and also may be associated with poor quality of tissue. Lest it may cause some confusion, it needs to be clarified that most complete clefts of the primary and secondary palate after the repair of the anterior cleft resemble a cleft of the secondary palate (Fig. 2).
- How clefts of the secondary palate occur together with clefts of the primary palate is somewhat mysterious because they occur at different times (the primary palate appears and fuses at an earlier time than the secondary palate). During that ‘time frame’ of up to 8 weeks of gestation, the proliferation of the embryonic cell mass is so rapid that it has been calculated that should that speed continue till parturition, the creature that will be created would have such a size that the universe will appear like a grain of sand in the palm of this creature (Fig. 3). This early exponential expansion of the cell mass boggles the scientific method which must then rely on indirect evidence to construct a possible narration of what happens. As to the indirect and inferential evidence about the formation of clefts in the palate, some illustrations are presented below about the inferential conclusions (Fig. 4-6).
- The closure of the palatal cleft: All modern methods to close palatal clefts rest on the shoulders of Von Langenbeck (Germany, latter half of the 19th century) and Victor Veau (France, early 20th century). Langenbeck showed that mucoperiosteal flaps can be raised safely and moved medially to close the palatal cleft if the neurovascular bundle emerging from the greater palatine foramen is preserved and Victor Veau showed the importance of pushing the palate back (to lengthen it) by dissecting away the abnormal attachments of the velar muscles to the posterior one third of the bony palate which have caused the velar tissue to shorten. The raw areas resulting from raising mucoperiosteal flaps and then moving them medially in the Langenbeck method were smaller as compared to the method of Veau in which a horseshoe shaped raw area was created all around the hard palate. The method of Veau however scored over the Langenbeck technique in restoration of the velar muscles as near to normal as possible resulting in better speech. This contradiction has resulted in the description of more than one hundred operations at least, to take care of both these requirements i.e. to minimize the raw areas yet get the Velar muscles in their normal location and alignment (Fig. 7).
- Evolution: There is a little bit of Darwin in each one of us but only in some of us he comes awake when dogma comes to be discarded. In a period where statistical or mathematical models were yet to be applied rigorously to the surgical speciality, surgeons who were watching their own as well as results of other specialists in the field of surgery of clefts were drawing their own conclusions. Their observations seemed to show that:
a. Large raw areas may be responsible for maxillary deformation
b. Muscles of the soft palate needed to be reoriented for better speech
c. That though the cleft runs through the bone as well as soft tissue the two areas needed to be viewed and treated differently
d. Speech was definitely better when anatomical restoration was achieved before the age of two years
Here in a nutshell (and therefore incomplete) is how the matter progressed. Campbell (South Africa) as early as 1926 devised a septal flap to close the bony cleft and left the raw area to heal by secondary intention. Burian (Czechoslovakia) in 1955 demonstrated the use of a buccal flap across the alveolar gap and Muir (Scotland) in 1966 showed the use of labial tissue (vermilion) during a cleft lip repair which would have normally been discarded to serve a similar purpose (Fig. 8-11).
In the region of the soft palate Widmaier (Germany) in 1961 erased the abnormal attachment of the velar muscles from the bones of the hard palate to rearrange them in their normal position and then closed the cleft in the soft palate leaving a diamond shaped defect behind the hard palate presumably by cutting the nasal layer at a higher level. Kriens (Germany) in 1971 did the same but by entering the soft palate (intra-velar) and the operation came to be known as intra-velarveloplasty. The closure of the hard palate followed in some months (Fig. 12-14).
In fact as early as 1944 Schwekendiek, an ENT surgeon (Germany) was doing something similar and was using a rubber band to relieve the tension in the two halves of the soft palate and repairing the cleft in layers and delaying the closure of the hard palate for several years. His son showed the results of this procedure twenty years later in 1964 in which the clefts of the hard palate had narrowed down enough to not require any release in the mucoperiosteum on the lateral side to close the residual clefts (Fig. 15-17).
This group of cases however were marred by poor speech results.
- It is on this background that Brian Sommerlad’s (England) work of the last twenty years needs to be viewed because the Vomer flap (together perhaps with naso-alveolar moulding; please see previous chapter) had done away with the need to do anything drastic on the hard palate. Sommerlad concentrated on the velar musculature, introduced the use of the microscope in the dissection of these muscles and showed that in his hands a velar closure was possible without making any cuts on the lateral side of the soft palate to release tension in order to effect a repair. At the junction of the hard and soft palate right in the centre where the nasal lining might be deficient he has recently used a U shaped turnover flap from the healed Vomerine flap to take care of any deficiency.] (Fig.18-23).
- Sommerlad’s technique of dissection of the velar muscles with the help of a microscope (or a powerful loupe) is now being followed by a majority of academic units in addition to the units that operate under the auspices of the Smile Train Project in India but sometimes with a rider. Based on several telephonic interviews with members of these units at least in some cases relaxing incisions in the lateral side of the soft palate are taken to aid the closure of the cleft. Some of these incisions are closed except perhaps behind the maxillary tuberosity to reduce the tension in the midline at the junction of the hard and soft palate where Sommerlad uses the turnover flap. The ideal that Sommerlad has set for us has not been completely achieved. In a further variation some units still raise long flaps on either side of the healed Vomerine flaps to enter the area of the soft palate to dissect velar muscles but later return these flaps from where they were raised without leaving any raw area. Some examples of these variations are presented below (Fig. 24-32).
- The anterior palate: Notwithstanding what is stated so far, the immediate post-alveolar fistula up to the incisor foramen is a troublesome entity to operate on if the Vomer flap done primarily fails. The cleft in the lip has already been closed and if the teeth have erupted, access to this area of failed closure, now a fistula, is difficult. The area is also somewhat scarred. Any mouth gag with prongs holding the teeth will allow the mouth to remain open but the prongs come in the way and are in fact resting on the very mucoperiosteum which needs to be mobilized as flaps. The mucoperiosteal flaps are narrow in the post-alveolar area and a dissection for a two layered closure around a narrow cleft not only tests the skill of the surgeon but has a high incidence of a breakdown. The problem can be solved by bringing in a muco-muscular buccal flap, its base placed near the alveolar cleft or near the gap in the erupted teeth. This flap can be swung through a right angle through the alveolar gap to close the post-alveolar fistula by using it either as a lining or cover (Fig. 33-38).
- Comment: There is no denying that the severely mutilated upper jaws that were seen in the past which also harboured large fistulae in countries such as India following surgery for clefts are now seen far less frequently than before. This certainly has to do with better surgical expertise and care in general. The restoration of the velar muscular anatomy to as normal as possible has also probably given better results as far as speech is concerned notwithstanding the fact that no two clefts are identical though we classify them by their anatomical location. The problem of speech after repair of clefts is particularly vexed because results depend upon many factors all of which cannot be attributed to the clefts. As to the skeletal deformities there is no way in which a surgeon can judge the inherent deficiency in the parts in which a cleft occurs, the deficiency manifesting later during growth spurts around the age of ten years as also the peri-pubertal years. The cleft surgeons are therefore frequently surprised by results over the long term, for instance, infants operated by them present themselves many years later as adults with almost normal speech without any help from speech therapists. On the other hand some children growing into adults never seem to acquire good speech in spite of sustained speech therapy as well as secondary procedures on the palato-pharyngeal area reminding us of what Hamlet said to Horatio, his friend, in the play Hamlet, by Shakespeare, “there are more things in heaven and earth, Horatio, than are dreamt up in your philosophy.” About the things concerning a cleft palate and speech, in the next chapter.
Mr. Brian Sommerlad has reviewed this article and has made the two following points:
- I believe that proper reorientation of the velar muscles cannot be done without separating them from the nasal and oral mucosa. Hence, I don’t think that this can be achieved by, for example, the Veau technique.
- I don’t advocate never performing lateral releasing incisions – just trying to avoid them if possible. In fact, in UCLPs I perform them in about 10% of cases. In CPs, it is more like 20% – mainly in the complete clefts of the secondary palate