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Two-Flap Palatoplasty
Abstract
This chapter provides an operative dictation template for a two-flap palatoplasty. It outlines the indications for the procedure potential complications and provides a detailed guide to the individual steps of the procedure.
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The two-flap palatoplasty was described more than 30 years ago, but there are few reports of long-term results using this technique. There are also very few long-term series of a single method of palatoplasty from a single surgeon.
The authors reviewed the technique of the two-flap palatoplasty, with emphasis on the senior author's (K.E.S.) modifications. The authors also retrospectively reviewed 382 two-flap palatoplasties performed by the senior author in nonsyndromic patients over a 20-year period. The incidence of secondary velopharyngeal surgery was established. Detailed speech analysis was performed in a subset of 150 patients.
The proportion of patients with velopharyngeal insufficiency over 20 years was 8.92 percent, falling from 10.95 percent in the first decade to 6.43 percent in the second decade. There was no significant difference in velopharyngeal insufficiency between the cleft subtypes. Age at palatoplasty did not affect the development of velopharyngeal insufficiency, but it should be noted that most of the patients underwent palate repair before 12 months of age. Speech results were consistently good across the two decades. In the second decade, 91.14 percent had normal to mildly impaired resonance, 79.75 percent had no or inaudible nasal air emission, and 97.47 percent demonstrated no compensatory articulation errors.
The two-flap palatoplasty is a reliable technique that has yielded excellent surgical and speech outcomes. Early and regular speech assessments and appropriate treatment when indicated are an integral part of the multidisciplinary approach to achieve good speech outcome.
Forty-five randomly selected patients with unilateral cleft lip, alveolus, and palate, all operated upon by Dr. Wolfram Schweckendiek were evaluated by three American specialists to assess the validity of primary veloplasty. Examination revealed an unusually high incidence of short palate and poor mobility of the soft palate. Facial growth was found to be highly acceptable in the majority of the patients. Unusually high incidence of velopharyngeal incompetence was found in these patients.
The two-flap palatoplasty technique, which I described for the first time in 1967, allows for complete closure of the palatal cleft, with two-layer closure in the area of the hard palate and three-layer closure of the soft palate. Using this technique, many palatal clefts can be close without leaving bare bone exposed lateral to the mucoperiosteal flaps in the area of the hard palate. Precise dissection of the muscles of the soft palate from the posterior edge of the bony palate and from the nasal periosteum allows for increased mobility as well as lengthening of the soft palate. Several key steps of this technique are presented in this paper. The results of our clinical studies revealed that normal speech production is achieved in approximately 75% to 80% of patients. Oronasal fistulas were found on the average of 5.2% in patients with all types of palatal clefts.
Cleft palate affects almost every function of the face except vision. Today a child born with cleft palate with or without cleft lip should not be considered as unfortunate, because surgical repair of cleft palate has reached a highly satisfactory level. However for an average cleft surgeon palatoplasty remains an enigma. The surgery differs from centre to centre and surgeon to surgeon. However there is general agreement that palatoplasty (soft palate at least) should be performed between 6-12 months of age. Basically there are three groups of palatoplasty techniques. One is for hard palate repair, second for soft palate repair and the third based on the surgical schedule. Hard palate repair techniques are Veau-Wardill-Kilner V-Y, von Langenbeck, two-flap, Aleveolar extension palatoplasty, vomer flap, raw area free palatoplasty etc. The soft palate techniques are intravelar veloplasty, double opposing Z-plasty, radical muscle dissection, primary pharyngeal flap etc. And the protocol based techniques are Schweckendiek's, Malek's, whole in one, modified schedule with palatoplasty before lip repair etc. One should also know the effect of each technique on maxillofacial growth and speech. The ideal technique of palatoplasty is the one which gives perfect speech without affecting the maxillofacial growth and hearing. The techniques are still evolving because we are yet to design an ideal one. It is always good to know all the techniques and variations so that one can choose whichever gives the best result in one's hands. A large number of techniques are available in literature, and also every surgeon incorporates his own modification to make it a variation. However there are some basic techniques, which are described in details which are used in various centres. Some of the important variations are also described.
Reconstructive surgery for cleft palate treatment and management
- Gj Wiet
Cleft palate repair treatment and management
- Pk Patel