Cleft palate repair

Cleft palate repair

1. Cleft palate

2. CLASSIFICATION

3. Davis and Ritchie Group I - Clefts anterior to the alveolus (unilateral, median, or bilateral cleft lip) Group II - Postalveolar clefts (cleft palate alone, soft palate alone, soft palate and hard palate, or submucous cleft ) Group III: Alveolar process cleft (any cleft involving the alveolar process)

4. Veau  

5. Kernahan and Stark symbolic classification

6. LAHSHAL classification

7. International Confederation of Plastic and Reconstructive Surgery classification Group I – Defects of the lip or alveolus Group II – Clefts of the secondary palate (hard palate, soft palate, or both) Group III – Any combination of clefts involving the primary and secondary palate

8. Repair

9. Timing 12-18 months Babbling as indicator

10. Principles Closure of the defect. Correction of the abnormal position of the muscles of the soft palate, especially Levator Palati . Reconstruction of the muscle sling. Retropositioning of the soft palate so much so that during speech the posterior part of the soft palate comes in contact with the posterior pharyngeal wall during speech .

11. Minimal or no raw area should be left on the nasal side or the oral surface. Tension-free suturing. Two-layer closure in the hard palate region and a three-layer closure of the soft palate .

12. Pre op Pre operative evaluation Position: supine with neck extended Mouth gags: Kilner-Dott and Dingman mouth gags Adrenaline saline solution in dilution of 1:200,000

13. Surgical techniques von Langenbeck's bipedicle flap technique Veau-Wardill-Kilner Pushback technique Bardach's two-flap technique Furlow Double opposing Z- Plasty

14. Two-stage palatal repair Hole in one repair Raw area free palatoplasty Alveolar extension palatoplasty (AEP) Primary pharyngeal flap Intravelar veloplasty Vomer flap Buccal myomucosal flap

15. von Langenbeck technique

16. still used in isolated cleft palate repair

17. Veau-Wardill-Kilner Palatoplasty leaves an extensive raw area anteriorly and laterally along alveolar margin with exposed bare membranous bone. causes shortening of the palate and results in velopharyngeal incompetence. alveolar arch deformity and dental malalignment

18. Bardach two-flap plasty Free mucoperiosteal flaps based on the greater palatine vessels reconstruction of the muscle sling is performed as in intravelar veloplasty

19. Furlow Double Opposing Z- Plasty double reverse Z- plasty for the oral and nasal surfaces effective lengthening of the soft palate suture line is horizontal good overlap of the levator muscle

20. Two-stage Palatoplasty soft palate was repaired along with the lip at around four to six months of age and the hard palate was repaired at age of 10-12 years later reduced to four to five years Early palatal surgical intervention causes maxillary hypoplasia speech result was compromised

21. Hole in one repair (One-stage cleft lip and palate repair) in children above 10 months of age popularised by Prof. K.S. Goleria ‘hole in one’ is borrowed from the Game of Golf

22. Raw area free palatoplasty two-flap palatoplasty . palatal lengthening is performed by the nasal mucosa back-cut raw area is covered with a local flap like the vomer flap or buccal mucosal flap . On the oral side too an attempt is made to suture all the lateral incisions Healing with primary intention

23. Variations Bumsted's two-layer closure of palate in very wide cleft palate Widmaier-Perko Palatoplasty Supraperiosteal dissection of flap in the region of hard palate instead of mucoperiosteal flap. (to minimize the maxillary hypoplasia )

24. Osada's two-stage palatoplasty Frolova primary palatoplasty technique Anterior mucoperiosteal hinge for nasal lining in partial cleft palate Marginal musculo -mucosal flap

25. Post op Early feeding Arm restraint Analgesics

26. Complications

27. Immediate complications Haemorrhage Respiratory obstruction Hanging Palate Dehiscence of the repair Oronasal fistula formation

28. Late complications Bifid uvula Velopharyngeal Incompetence Abnormal speech Maxillary hypoplasia Dental malpositioning and malalignment Otitis media