A Method of Unilateral Operation for Early Repair of Unilateral Complete Cleft Palate.

Preliminary Report
RUYAO SONG, M.D., D.D.S., D.SC. YEGUANG SONG, M.D. CUNMING LIU, D.D.S., M.D. HAIHUAN MA, M.D. YU ZHAO, M.D. RU ZHAO, M.D. ZHEN FANG
Objective: This article describes a method of unilateral operation and the preliminary results of a group of patients with unilateral complete cleft palate undergoing the operation at early age. Design: The unilateral operation consists of four relaxation maneuvers. After all of the four maneuvers have been performed on the deformed side of an unilateral complete cleft palate, the deformed side can be moved posteriorly and medially to contact with the normal side. Then the cleft can be closed without tension. Results: From 1995 to 1998, 19 cases of unilateral complete cleft palate were repaired with this method at 512 months of age. Postoperatively, there were no deaths nor dehiscences. Under the care and guidance of an experienced speech pathologist, 15 of 17 of these children have normal vocal quality at 1 2 years of age. Conclusions: The unilateral operation is a rational, adequate, and safe method for early repair of unilateral complete cleft palate. Its design addresses four principles. First, operating only on the deformed side of a unilateral complete cleft palate leaves the normal side unperturbed. Second, complete relaxation of the deformed side is achieved before closing the cleft. Third, in comparison with conventional procedures, which operate on both sides of the palate, this method has the advantage of less surgical trauma, less blood loss, and shorter time of operation. Fourth, all of these advantages are benecial to early cleft palate repair, which is an important factor in achieving good speech.
KEY WORDS: cleft palate, palatal surgery, speech development

According to Veau and Borel (1931) and Oldeld (1949), unilateral complete cleft palate composes 38% and 39% of the four classes of cleft palate. The signicant characteristic of this common congenital deformity is that it has a deformed side and a normal side. (Fig. 1). In closing the cleft, surgeons have used the Celsus method, making relaxation incisions on both sides of the palate (Fig. 2) and doing extensive surgery on the deformed side as well as on the normal side since the time of Dieffenbach (1826) and Langenbeck (1861). Furthermore, during surgery most surgeons do not perform blunt dissection down the medial aspect of the medial pterygoid plate to the base of the skull for freeing the velopharyngeal structures prior to medial shifting and suturing as advocated by Ernst (1925).

From the Plastic Surgery Hospital and Institute of Chinese Academy of Medical Sciences, Ba-Da-Chu, Beijing 100041, P.R. China Submitted October 1999; Accepted June 1999. Reprint requests: Prof. Ruyao Song, M.D., D.D.S., D.Sc., Plastic Surgery Hospital, Ba-Da-Chu, Beijing 100041, P.R. China. 243

Consequently, the relaxation is incomplete and dehiscence occurs occasionally in spite of relaxation incisions that have been made on both sides. In contrast to the above and the presently used procedures, we repair the unilateral complete cleft palate with a method of unilateral operation prior to 12 months of age (Figs. 3 and 4). First proposed by Song (1954), the method consists of four relaxation maneuvers: (1) formation of one large arterial mucoperiosteal ap; (2) division of the tendon tensor veli palatini muscle on the medial side of the hamular process (Fig. 5); (3) removal of the posteriomedial wall of the greater palatine foramen (Fig. 6); and (4) division of the horizontal plate of the palatine bone. After all of these maneuvers have been performed on the deformed side of an unilateral complete cleft palate, the operated side can be moved both posteriorly and medially into contact with the margin of the opposite side without tension. Obviously there is no need to operate again on the opposite side. Then the cleft is closed in the usual manner. In comparison with the conventional procedures, which

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FIGURE 3 The unilateral operation of closure for unilateral complete cleft palate. Single-pedicled ap only from the deformed side is used.

also repaired cleft palates at a very early age, even in the neonatal age group. Comparing those infants whose cleft palate were repaired at 37 months of age with children whose cleft palates were repaired at todays prevalent age of 1824 months, they showed more normal muscular development, earlier onset of language, fewer speech errors, less middle ear diseases, less stress for the children, and less distress in the parents (Paradise and Bluestone, 1974). Due to improvements in pediatric anesthesia and postoperFIGURE 1 Veaus diagram of anatomy and pathology of unilateral complete cleft palate. There is a well-developed normal side and an underdeveloped short side. From Victor Veau: Division Palatine. Masson, Paris, 1931. (With minor modication at tensor tendon.)

operate on both sides of the palate, this method has the advantage of less surgical trauma, less blood loss, and shorter time of operation. The primary goal of cleft palate repair is to achieve normal speech. In 1983, Randall et al. made a preliminary report on cleft palate closure of 38 patients (17 were available for speech evaluation) at 37 months of age. There was about 70% (11/ 17) of normal speech and no deaths. In recent years, Kaplan et al. (1974, 1980, 1982), Kaplan (1981), Osada et al. (1981), Cohen et al. (1981), Desai (1983), Barimo et al. (1987), Haapanen and Rantala (1992), Denk and Magee (1996), and others

FIGURE 2 The Celsus method of closure of unilateral complete cleft palate. Bipedicled aps from both of the normal and deformed sides are used.

FIGURE 4 Anatomic diagram of the unilateral operation. The horizontal plate of the palatine bone is divided from the vertical plate of the same bone and the palatal process of the maxillary bone and moved together with the aponeurosis and musculature of the soft palate both medially and posteriorly to contact with the cleft margin of the normal side.

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FIGURE 5 The tendon of the tensor veli palatini muscle is divided at the medial of the hamular process to relief the tension in the midline.

FIGURE 6 The posterior-medial wall of the greater palatine foramen is removed with a chisel.

ative nursing care, early cleft palate repair is no longer considered an excessive surgical risk. Given this fact and the desire for improved speech performance, we have repaired the unilateral cleft palate using the method described here prior to 12 months of age. METHOD A unilateral complete cleft palate has four signicant features: (1) there is a cleft on the deformed side extending from the alveolar ridge to the uvula; (2) the size of the deformed side is smaller and its length shorter; (3) the position of the greater palatine foramen is more forward than that of the normal side; and (4) the horizontal plate of the palatine bone and the aponeurosis and musculature of the soft palate attaching to the bony plate of the deformed side are displaced anteriorly. If a surgical procedure is to repair the unilateral complete cleft palate by operating on the deformed side only, four relaxation maneuvers should be used. First, a large arterial mucoperiosteal ap of the entire deformed side of the hard palate must be made to close the hard palate cleft (McCormack, 1949). Second, the tendon of the tensor veli palatini muscle on the medial side of the hamular process has to be divided to decrease the tension in the midline of the palate (Ombredanne 1912; Brown, 1940; Bennett et al., 1968). Third, the posterio-medial wall of the greater palatine foramen has to be removed to free the greater palatine vessels and nerve that tether the mucoperiosteal ap to the palatal bone (Limberg, 1927; Ruding, 1964; Conway, 1980). Fourth, the horizontal plate of the palatine bone, which is the posterior edge of the hard palate, has to be divided so that the anteriorly displaced insertion of the levator veli palatini muscle on the posterior edge of the hard palate of the deformed side and the levator muscle can be reoriented in a transverse direction to reconstruct a levator sling with the levator muscle of the normal side. Obviously, this maneuver differs from the intravelar veloplasty of Braithwaits (1968) and Krien (1970), who detach the levator muscles of both sides from their insertion on the

posterior edge of the palatal bone. It has three merits: (1) the soft palate attachment to the palatal bone is undisturbed, which is benecial to muscular development and function; (2) there is no raw surface leading to possible anterio-posterior scar contracture producing velar rigidity and (3) during cleft closure, there is no tension at the junction of the hard and soft palate, and dehiscences are not likely to occur at the junction of the hard and soft palate postoperatively. Anesthesia The child is given an endotracheal general anesthesia. The deformed side of the palate is inltrated with a dilute solution of lidocaine with epinephrine to reduce bleeding during surgery. Operative Technique 1. A marginal incision is made on each side of the cleft. Each incision extends from the end of the alveolar process to the tip of the uvula. The mucoperiosteum of the vomer is elevated as a wide-based ap to provide a two-layer hardpalate closure. 2. A relaxation incision is made on the deformed side of the palate, commencing anteriorly from the anterior cleft angle, joining the incision made on the margin of the cleft, and running posteriorly along the alveolar process until the posterior end of the process is reached. The incision is then continued posteriorly into the soft palate about 1.5 2.5 cm along the pterygomandibular raphe. 3. The mucoperiosteal ap of the deformed side of the palate outlined by the previous incisions is raised by a sharp hook and separated from the hard palate by a small periosteal elevator until the posterior edge of the palatine bone is reached. The ap is then turned downward. 4. With the same small periosteal elevator, use blunt dissection to expose the greater palatine foramen, the posterior-

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5.

6.

7.

8.

9.

10.

medial wall of the foramen, and the greater palatine vessels and nerve emerging through the foramen. Continue the dissection near the base of the hamular process. Now a large single pedicled mucoperiosteal ap pedicled on the posterior edge of the hard palate is formed. Commencing from the posterior edge of the hard palate, a short cut is made with a knife on the medial side of the hamular process to divide the tendon of the tensor veli palatini muscle. The soft tissue on the medial and posterior sides of the greater palatine foramen is elevated to expose the bone of that area. The posteromedial wall of the foramen and a portion of the canal adjacent to the foramen are removed with a small chisel to free the greater palatine vessels and nerve, which tether the mucoperiosteal ap to a forward position. Another cut is made with the same chisel from the cleft margin to the greater palatine foramen to divide the horizontal plate of the palatine bone from the palatal process of the maxillary bone. Through the later bone cut, the mucoperiosteum of the oor of the nose is elevated with a small periosteal elevator. Again, through this bone cut, a nasal ap of Cronin (1957) is cut out with a knife. The nasal ap and the divided horizontal plate of the palatal bone are displaced together both posteriorly and medially with the handle of the knife. When the large single pedicled mucoperiosteal ap is turned back to the hard palate, the gap caused by the retrodisplacement of the palate bone is lined superiorly with the mucoperiosteal ap of the mouth and inferiorly with the mucoperiosteal ap of the nasal cavity. The periosteum of these two aps may produce some membraneous bone to help maintaining the lengthened hard palate. The single pedicled mucoperiosteal ap, the freed greater palatine vessels and nerve, the divided horizontal plate of the palatine bone, and the musculature of the soft palate are displaced in one piece with the handle of a knife both medially and posteriorly. This movement brings the two sides of the cleft in close contact without the least tension. Now it is obvious that there is no need to perform similar maneuvers on the normal side of the palate again. A two-layer closure of the nasal and oral mucoperiosteum is performed for the cleft of the hard palate, and a threelayer closure of the nasal mucosa, muscle, and oral mucosa is performed for the soft palate cleft. Care should be taken in that the suturing of the muscle layer must comply with the requirement of the intravelar veloplasty of Krien (1970). Finally, an iodoform gauze packing is inserted in the relaxation incision to support the mobilized soft palate and to cover up the exposed bone area. (Fig. 7). RESULTS

FIGURE 7 The operative technique of the unilateral operation. A: Two marginal incisions and one lateral relaxation incisions are made. B: The vomer ap and the mucoperiosteal ap are reected. The horizontal plate of the palatine bone is divided after the posterior-medial wall of the greater palatine foramen is removed. The mucoperiosteum of the oor of the nose is also sectioned to form a Cronin nasal ap. C. The large singlepedicled mucoperiosteal ap, greater palatine vessels and nerve, horizontal plate of the palatine bone, aponeurosis, and musculature of the soft palate are pushed medially and posteriorly with the handle of a knife to contact with the cleft margin of the normal side. D: The hard palate is closed in two layers and the soft palate closed in three layers.

months. The widest cleft at the junction of hard and soft palate was 22 mm, the narrowest was 10 mm, and the average was 14.3 mm. The largest amount of blood loss was 100 mL, the least was 20 mL, and the average was 36 mL. Postoperatively, there were no deaths nor dehiscence. All of the children who underwent the unilateral operation were put under the care and guidance of an experienced speech pathologist shortly after they had recovered from the operation. Seventeen of the 19 were available for speech evaluation at the age of 12 years. Fifteen of the 17 were felt by the speech pathologist to have articulation within the normal range on subjective analysis and normal vocal quality. Two of these patients had minor hypernasality. All of these children were too small to tolerate instrumental speech evaluation. Long-term studies of growth and speech development of all of these patients are still being conducted. DISCUSSION The unilateral operation for the repair of unilateral cleft palate was rst presented in 1954 (Song, 1954) when only

From August 1995 to May 1998, 19 cases of unilateral complete cleft palate had been repaired with the method of unilateral operation. The age of patients ranged from 5 to 12

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three maneuvers of relaxation were used. In this paper, a fourth maneuver, division of the tendon of the tensor veli palatini muscle on the medial side of the hamular process (Bennett et al., 1968), is added, because most of the clefts were wider. The unilateral operation has been confused with the bone ap operations of Dieffenbach (1826), Davis (1928), Peer (1959), and Wynn (1976). However, the bone ap formed by the osteotomies of Davis, Peer, and Wynn were bipedicled aps, which could not be pushed backward to increase the length of the palate. In addition to this disadvantage, their osteotomy divided the palatal process of the maxillary bone and severed the greater palatine vessels and nerve, which could potentially interfere with growth of the maxilla. As noted, the ap of the unilateral operation is a single-pedicled mucoperiosteal ap. It can be moved both posteriorly and medially to lengthen the palate. Also, the palatal process of the maxillary bone and the greater palatine neurovascular bundle are preserved potentially avoiding pathogenic interference to maxillary growth. Finally, the most important difference is that the unilateral operation operates only on the deformed side of an unilateral cleft palate whereas all of the bone-ap operations operate on both the deformed and normal sides. While three of the four relaxation maneuvers are procedures used by previous surgeons, the last one, division of the horizontal plate of the palatine bone, is new. It avoids dehiscence at the junction of the hard and soft palate and raw surface on the nasal side of the soft palate leading to scar contracture, producing velar rigidity and shortness. Cronin (1957) made his nasal mucoperiosteal ap through the nostril, which can be a demanding maneuver. The unilateral operation allows the nasal ap to be created through the bone gap of the hard palate. In the past, long-term growth studies with arch-width analysis, serial casts, radiographic documentation, eruption-occlusion patterns, and midface protrusion had been performed by plastic surgeons and scientic researchers to investigate the effects of the different types of surgical procedure and early repair. Because of minor retardation in the anterioposterior growth of the maxilla and the fact that crowding of anterior teeth and cross-bite were not only seen in patients who had undergone the specic operation and in early age but also in some who had not had their palates operated (even in a few who had never had cleft palate), their ndings could not support their conclusions strongly. Now, with the unilateral operation, the operated deformed side can be compared with the unoperated normal side in the same patient. It is probable that this controversial problem would have a better solution soon. As the developmental perturbations during all of growth and the speech development over the early childhood years of these 19 patients are still being conducted, this article and its conclusions must be considered preliminary. REFERENCES
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