| Abstract|| |
Objectives: During cleft palate repair, velopharyngeal sphincter reconstruction is still a challenge to plastic surgeons. To improve results of surgical treatment of cleft palate and secondary velopharyngeal incompetence, a carefully designed modified procedure for palatoplasty is presented. Materials and Methods: Thirty patients with incomplete cleft palate corrected by this procedure from April 2003 to October 2007 were included. A u-shaped incision was made in the anterior palate to separate bipedicle flap based on the greater palatine arteries of both sides. After complete dissection of the nasal and palatal mucosa, palatal muscles were carefully dissected from the posterior edge of the bones of the hard palate, wherein the well-mobilised flap receded backward spontaneously and elongated the soft palate. After suturing the nasal mucosa in the midline, the dissected palatal muscles of both sides were sutured together in the anterior third of the soft palate. On suturing the nasal mucosa and the palatal muscles, the soft palate became elongated and the oral mucosa was seen receding backward spontaneously to cover the anterior part of the soft palate. Results: All corrected patients showed good results, with no recurrence, no post-operative fistulae, with accepted speech pattern and no need for further pharyngoplasty. The line of the sutured nasal mucosa and the palatal muscles became covered by the healthy non-sutured oral mucosa and the soft palate became elongated, with narrowing of the vellopharyngeal isthmus after this technique. Conclusion: The designed flap allows covering of sutured nasal mucosa and palatal muscles with a healthy unsutured oral mucosa and elongates the soft palate. Thus, there was no incidence of post-operative fistula and no need for further pharyngoplasties.
Keywords: Incomplete cleft palate, u-shaped flap palatoplasty, single bipedicel flap palatoplasty
|How to cite this article:|
Saleh A. Correction of incomplete cleft palate by u-shaped flap palatoplasty. Afr J Paediatr Surg 2010;7:185-7
| Introduction|| |
Palatal repair is the basis for a more physiological condition in the oral cavity as it is mandatory for middle ear ventilation and development of normal phonation.
The surgical purpose of primary cleft palate repair or velopharyngeal incompetence treatment is to provide an apparatus that permits adequate velopharyngeal function and development of normal speech quality.
This study aims to evaluate the results of correction of incomplete cleft palate by u-shaped flap palatoplasty. Velopharyngeal closure is achieved by tension in the velum and its elevation toward the pharyngeal wall that moves toward the rising velum and diminishes the lumen of the velopharynx. In cleft palate and secondary velopharyngeal incompetence, the velopharynx is partial or totally abnormal in morphology and in muscular structure and function. 
Many reports state that dynamic repair of velopharyngeal function results from muscle reconstruction procedures. which include palatoplasty and pharyngoplasty. 
Von Langenbeck, in 1861, described a technique for closure of cleft palate. Every repair performed today incorporates this principles of moving mucoperiosteal flaps medially to close the palatal defect. In 1868, Billroth thought that fracturing the ptyrigoid hamulus would improve the outcomes of cleft palate repair.
In 1937, Kilner and Wardill described the V-Y repositioning technique for repair of incomplete clefts or cleft of secondary palate. 
Furlow, in 1986, described a double-reverse Z-plasty technique to close palatal defect and elongate the soft palate. 
| Materials and Methods|| |
In the period from April 2003 to October 2007, patients with cleft soft palate and incomplete cleft palate and also patients with recurrent cleft palate were operated by the u-shaped single-flap technique.
The operation was carried out under general anaesthesia with an oral and central endotracheal tube, the head of the child being positioned on the knee of the surgeon and the mouth being held open by a Dingman mouth gag.
Adrenaline saline at a 1:200 concentration is infiltrated in the lines of incisions and the edges of the cleft uvula and palate were incised by scalpel 15, separating the nasal and the oral mucosa by a sharp dissection until it reached the fibres of the palatal muscles on both sides.
A u-shaped incision was made 2-3 mm from the gingival margin and was started 1-2 cm behind the site of the last molar teeth of one side passing forward and then crossing to the midline to be continued backward on the other side and stopping 1-2cm behind the site of the last molar teeth [Figure 1]. The u-shaped mucoperiosteal flap is then elevated from the bones of the hard palate by careful blunt dissection until it reaches the greater palatine arteries of both sides. The sharp dissection is then completed to reach the posterior incision and the abnormally inserted palatal muscles are then sharply separated from the posterior edge of the hard palate of both sides. After good mobilisation of the flap, the nasal mucosa is sutured with interrupted 5/0 vicryl sutures and the mobilised palatal muscles of both sides are then sutured together in the midline by two to three stitches of 4/0 vicryl in the anterior third of the soft palate [Figure 2].
|Figure 1 :The u-shaped flap is carefully elevated with the two great palatine arteries attached to it|
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|Figure 2 :The cleft was closed with long palate, narrow oropharyngeal isthmus and withought overlapping of suture lines.ltrasound showing a PPC in the hilum of the live measuring 2 x 5 cm|
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The well-mobilised flap recedes backward spontaneously. This backward movement of the flap becomes more prominent after suturing of the palatal muscles, when the soft palate becomes elongated, the velopharyngeal opening becomes narrowed and the oral mucosa covers the anterior part of the sutured nasal mucosa and palatal muscles.
The oral mucosa is then sutured in the midline with 5/0 vicryl interrupted sutures, the mobilised flap is prevented from falling down by fixation with stitches passing through the closed nasal mucosa or through the remaining mucosa at the edges of the gingival margin.
| Results|| |
Thirty patients (24 primary and six recurrent) with incomplete cleft palate were corrected by u-shaped single-flap palatoplasty over a period of 54 months.
The operative time for primary cleft palate repair was 75-90 min, this time being increased by 15-30 min during repair of the recurrent cleft palate.
Mean follow-up was 8.6 months, the range being 2-22 months. Few complications were encountered and four patients had partial obstructions to the airway that required treatment with steroids during the first two or three days. Minimal post-operative bleeding developed in five patients and stopped spontaneously without further interference. The exposed bones of the anterior palate seen after moving the mucoperiosteal flap backward become covered by granulation tissues within 1-3 weeks. The wounds of the oral layers had healed completely with no dehiscence, and none of the patients developed oronasal fistula. Children stayed in the hospital for a median of 4 days (range, 3-8 days).
The speech evaluation has shown that no hypernasality and no audible nasal escape was demonstrated in the single-word test in any of the corrected patients. For the continuous speech test, satisfactory articulation and intelligibility was noticed in all cases and secondary pharyngoplasty was never indicated in any of the corrected patients.
| Discussion|| |
In 1865, Gustav Passavant  postulated reconstruction of the velar muscles and lengthening of the soft palate as basic pre-conditions for normal speech development in cleft patients. Physiological muscular closure of the cleft was realized by Kriens in 1969,  who developed the method of intravelar veloplasty on the basis of Widmaier's technique of palatal cleft closure. 
Although it is theoretically very important to reconstruct the velopharyngeal sphincter and levator sling in primary cleft repair and secondary velopharyngeal incompetence management, the difficult problems with surgical planning and operative techniques should be understood in regard to factors related to velopharyngeal function. These factors are the length of the soft palate, the velar muscle repair, the improvement of the pharyngeal walls and the reduction of the enlarged pharyngeal cavity. It remains unclear whether these procedures are adequate in restoring complete velopharyngeal sphincter activity. 
The designed modification of cleft palate repair allowed closure of the anterior third of the soft palate without overlapping of suture lines at the site of the junction of the soft and hard palate. Thus, the sutured nasal mucosa and palatal muscles become covered with healthy unsutured oral mucosa in the midline(the most common site for occurrence of oronasal fistula). This abolishes the possibility of occurrence of oronasal fistula and none of the operated patients developed wound dehiscence or oronasal fistula. Mommaerts et al. reported six patients with wound dehiscence and oronasal fistula after correction of 45 patients with cleft palate by Z-plasty. Jeffery and Boorman  stated that the incidence of palatal fistulae following primary repair of the cleft palate varies widely, with the figure quoted ranging from 18% to 34%. The well-mobilised flap in the designed technique recedes backward spontaneously after suturing the palatal muscles and the soft palate becomes elongated. This elongation of the soft palate and narrowing of the oropharyngeal isthmus improves speech outcome and avoids the need for further pharyngoplasty. All operated patients showed good speech outcomes and none of them needed any forms of speech-correcting operations. Ningxin et al. stated that the complete and marginal velopharyngeal closure and good speech result in primary cleft palate repair were developed in 92% in a small group of follow-up patients during speech evaluation in the single-word test. Haapanen and Rantala  stated that speech outcome differs with age of correction of cleft palate, with hypernasality of 27% in young age, which increases to be 78% in patients treated at an older age. Haapanen  stated that the method of palate repair had a major effect on speech outcome.
| Conclusion|| |
The designed modification in the closure of incomplete cleft palate by u-shaped flap palatoplasty allows repair of incomplete cleft palate without overlapping of suture lines in the region of junction of the hard and soft palate. Thus, there is no possibility of occurrence of oronasal fistula. The designed modification also elongates the soft palate and narrows the oropharyngeal isthmus, with good speech outcomes and no need for further speech-supporting operations.
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