Cleft Palate Repair: A History of Techniques and Variations

Abstract

Orofacial clefting is a common reconstructive surgical condition that often involves the palate. Cleft palate repair has evolved over three centuries from merely achieving anatomical closure to prioritizing speech development and avoiding midface hypoplasia. Despite centuries of advancements, there is still substantial controversy and variable consensus on technique, timing, and sequence of cleft palate repair procedures. Furthermore, evaluating the success of various techniques is hindered by a lack of universal outcome metrics and difficulty maintaining long-term follow-up. This article presents the current controversies of cleft palate repair and details how the history of cleft palate repair has influenced current techniques commonly used worldwide. Our review highlights the need for a global consortium on cleft care to gather expert opinions on current practices and outcomes and to standardize technique classifications. An understanding of global protocols is crucial in an attempt to standardize technique and timing to achieve anatomical closure with optimal velopharyngeal competence, while also minimizing the occurrence of maxillary hypoplasia and palatal fistulae.

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Reconstructive
From the *Operation Smile Incorporated, Virginia Beach, Va.;
†Department of Plastic and Reconstructive Surgery, Children’s
Hospital Los Angeles, Los Angeles, Calif.; and ‡Royal Children’s
Hospital, Melbourne, Australia.
Received for publication February 2, 2021; accepted September 10,
2021.
Copyright © 2022 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
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DOI: 10.1097/GOX.0000000000004019
INTRODUCTION
Orofacial clefting is one of the most common congeni-
tal anomalies worldwide and accounts for a considerable
portion of the global burden of reconstructive surgical dis-
ease.1,2 Involvement of the palate is common and can have
a deleterious effect on health and childhood development,
including malnutrition, speech abnormalities, psychologi-
cal consequences, and social isolation.1,3,4 Surgical correc-
tion is the standard treatment when attempting to restore
normal palatal form and function. However, cleft palate
repair is technically challenging. Complications following
repair are signicant when they occur and include speech
disturbance and maxillary growth deciency.4 Strengths
and weaknesses of various palatoplasty techniques as they
relate to outcomes are continually debated. This article
presents the current controversies of cleft palate repair
and provides an understanding of how commonly used
techniques have been inuenced by the history behind
cleft palate repair.
GOALS OF CLEFT PALATE REPAIR
Over the years, goals of cleft palate repair have
remained constant and focus on three areas: anatomical
closure of the palatal defect, producing normal speech,
and minimizing growth disturbance.5–7
Separation of the oral and nasal cavities and recon-
struction of the velopharyngeal valve assist with mastica-
tion, feeding, and preventing malnutrition.8 Adequate
speech development and early restoration of articulation
are crucial in childhood development and social integra-
tion. However, prioritizing speech through early cleft pal-
ate repair can lead to maxillary growth restriction, often
warranting surgical correction.6,9 Conversely, prioritiz-
ing midface growth by delaying hard palate repair could
potentially result in speech errors that may or may not
be corrected by further surgery or speech therapy. The
relative importance of growth and speech are constantly
debated among proponents of the various approaches.
Experts debate the advantages of different techniques
but generally agree that the following principles are dic-
tated by the goals of repair5,8,10,11:
1. Anatomical closure of the defect
2. Tension-free suturing
Priyanka Naidu, MBChB, MSc*
Caroline A. Yao, MD, MSc, FACS†
David K. Chong, MBBS, FRACS‡
William P. Magee III, MD, DDS,
FACS†
Summary: Orofacial clefting is a common reconstructive surgical condition that
often involves the palate. Cleft palate repair has evolved over three centuries from
merely achieving anatomical closure to prioritizing speech development and
avoiding midface hypoplasia. Despite centuries of advancements, there is still sub-
stantial controversy and variable consensus on technique, timing, and sequence
of cleft palate repair procedures. Furthermore, evaluating the success of various
techniques is hindered by a lack of universal outcome metrics and difculty main-
taining long-term follow-up. This article presents the current controversies of cleft
palate repair and details how the history of cleft palate repair has inuenced cur-
rent techniques commonly used worldwide. Our review highlights the need for a
global consortium on cleft care to gather expert opinions on current practices and
outcomes and to standardize technique classications. An understanding of global
protocols is crucial in an attempt to standardize technique and timing to achieve
anatomical closure with optimal velopharyngeal competence, while also minimiz-
ing the occurrence of maxillary hypoplasia and palatal stulae. (Plast Reconstr Surg
Glob Open 2022;10:e4019; doi: 10.1097/GOX.0000000000004019; Published online 28
March 2022.)
Cleft Palate Repair: A History of Techniques
and Variations
SPECIAL TOPIC

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3. Reorientation of the abnormally positioned soft pal-
ate musculature to reconstruct of the levator veli
palatini
4. Lengthening and retro-positioning of the soft palate
5. Minimizing denuded areas of bone and nasal or oral
mucosa
6. Layered closure of the hard and soft palate
Surgeons differ in their approach regarding the age
of closure, the sequence and timing of hard versus soft
palate repair, the number of anatomical layers required to
close the defect, and the amount of acceptable retro-posi-
tioning of tissues. There is debate on the consequences
of denuded areas post repair and the most appropriate
dissection technique to reorient the palatal muscles. Cleft
surgeons postulate the relative contributions of these sur-
gical decisions to stulae, speech, and maxillary growth.
Understanding modern-day techniques begins with exam-
ining the history of cleft palate repairs.
HISTORY OF PALATE REPAIRS
Cleft palate surgery has been dened over the last
three centuries by numerous surgeons (Fig. 1). Before
the 18th century, the mainstay of treatment was an obtura-
tor.12 Soft and hard palate repairs were considered sepa-
rate entities initially.10 Soft palate repair techniques were
described as early as the 1700s and centered on normal
speech production and velopharyngeal competence.5
Hard palate repair came over 70 years later and prioritized
tension-free anatomical closure and normal facial growth
and dentition.10,13,14
Soft Palate Repair Techniques
Velopharyngeal function and speech production
have been the focus of soft palate cleft repair, and aim to
lengthen the palate while closing the defect and recon-
structing the levator sling.8 The rst description of soft
palate closure in 1764 was provided by a French dentist,
Le Monnier, who cauterized the cleft edges and sutured
the defect closed.15 In the 1820s in Berlin, Von Graefe
described the soft palate as the most important “voice-
forming and voice-inuencing structure” and urged
the scientic community to consider the importance of
soft palate repair to correct speech anomalies in cleft
patients.16 Von Graefe de-epithelialized the cleft margins
before bringing the edges together. Following his success
in 1816, many other surgeons reported successful palatal
repairs using a similar technique.16,17
These early repairs employed very basic techniques of
approximating cleft edges with heavy sutures and focused
solely on anatomical closure, neglecting principles of
palatal function. This resulted in a short, immobile palate
that impaired speech production. Subsequent techniques
prioritized principles that would lengthen the soft palate.
In the 1900s, palatal lengthening became even more
important, especially following hard palate repair. Wardill
and Kilner modied Veau’s hard palate repair technique
Takeaways
Question: Cleft palate repair techniques have developed
over three centuries to ensure anatomical closure, while
attempting to normalize speech and limit midface hypo-
plasia. These variations are often regional.
Findings: Despite advancements, there is variable consen-
sus on technique, timing, and sequence of cleft palate
repair procedures.
Meaning: We lack high-quality long-term data to evaluate
outcomes of technique variations.
Fig. 1. Timeline of cleft palate repair technique variations.

Naidu et al. • History of Cleft Palate Repair
3
by retro-positioning the soft palate through an incision
in the nasal mucosa and relaxing incisions anteriorly
and laterally. The resultant two triangular aps could be
advanced posteriorly in a V-Y pushback to increase palatal
length.18,19 However, the defect in the nasal mucosa report-
edly caused shortening of the palate through scarring and
contracture, ultimately causing speech defects.20 To cor-
rect this, Veau proposed a two-layer closure of the nasal
lining.21
Since then, many methods have been suggested to
close the often-decient nasal mucosa, including pha-
ryngeal and vomer aps.8 Vomer aps are advantageous
because they are simple, well-vascularized, and provide
an effective nasal lining.22 Despite conicting evidence
as to whether these aps result in maxillary growth dis-
turbance,8,23,24 the Oslo Cleft Palate Team has used vomer
aps in a single-layer closure of cleft palates with great suc-
cess and minimal facial growth disturbance.25
In 1931, Veau described the abnormal arrangement of
soft palate musculature in the cleft palate patient, which
runs longitudinally and parallel to the cleft as opposed to
transversely in the normal patient.10,26 In one of the most
important contributions to improving speech, Veau advo-
cated separating soft palate musculature from its insertion
on the posterior hard palate to lengthen the soft palate
and reduce tension on the mucosal closure.5 However, the
orientation of muscles was still oblique and abnormal.
In 1969, Kriens described a technique to reconstruct
the velopharyngeal muscular sling by re-orienting the soft
palate musculature from oblique to transverse without
causing signicant disruption to the muscles related to the
Eustachian tube.27 His technique, known as intravelar velo-
plasty, was a milestone for soft palate repair as it restored
function of the muscular sling to reduce middle ear dys-
function and improve motion of the palate. The intrave-
lar veloplasty allowed three-layer closure of the soft palate:
nasal mucosa, soft palate musculature, and oral mucosa.
Since then, Leonard Furlow and Brian Sommerlad have
made important contributions to muscle repair.
Furlow’s double-opposing Z-plasty, described in 1978,
involves the creation and transposition of two mirrored
z-aps—an anterior mucosal ap and posterior myomuco-
sal ap—to create an overlapping muscular sling without
the need for relaxing incisions (Fig.2).10,28 The Z-plasty
allows for closure of the hard palate in one procedure
while (1) lengthening the soft palate without the need
for pushback, (2) re-aligning the musculature and recon-
structing the velopharyngeal sling, (3) reducing palatal
scarring and increasing palatal mobility, and (4) decreas-
ing negative effects on maxillary growth.28
Fig. 2. Furlow’s double -opposing Z-plasty technique (drawn by the rst author, modied from Hill MA et al).

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Furlow’s double-opposing Z-plasty is commonly used
today and achieves good speech outcomes.6,28 However,
this technique may struggle to close wider clefts and
require greater dissection and multiple hard palate aps
to achieve anatomical closure.29,30 Sommerlad31 positioned
velar muscles as anatomically as possible through radical
retro-positioning of the muscle and tensor tenotomy. He
limited dissection of the hard palate to prevent scarring
and midface hypoplasia. In a 10-year follow-up study,
80% of Sommerlad repairs did not need lateral relaxing
incisions or mucoperiosteal ap elevations. Using this
technique, rates of secondary velopharyngeal surgery
for speech decreased from 10.2% to 4.6% over a 15-year
period.31 These speech outcomes are superior in com-
parison with Langenbeck’s palatoplasty, where velopha-
ryngeal insufciency has been reported in up to 30% of
cases,32 and comparable to Furlow’s z-plasty that boasts up
to 98% velopharyngeal competence.33,34 Although a 2014
systematic review reported no difference in stula rates
between techniques, stula rates using Sommerlad’s tech-
nique occur in up to 15% of cases, which may be a result
of limited hard palate dissection.35 Furlow’s z-plasty has
been shown to have relatively low stula rates, up to 9.7%,
whereas stula rates using von Langenbeck’s palatoplasty
range vastly between 7% and 42%.36–38 In comparison with
these other techniques, stula rates using Sommerlad’s
repair have been considered acceptable in light of the
benet of decreased maxillary growth disturbance.35,38,39
Furthermore, both Sommerlad’s and Furlow’s techniques
were found to be associated with the lowest rates of middle
ear dysfunction and need for tympanostomy tubes.40
Hard Palate Repair Techniques
Dieffenbach in Berlin pioneered hard palate mucosal
elevation as a technique for closure of the hard palate in
1826.41 This technique was further advanced by the intro-
duction of relaxing incisions and lateral osteotomies to
ease hard palate closure. Closure of the cleft with the least
amount of tension has always been an important princi-
ple. In 1889, Billroth suggested fracturing of the hamulus
to aid in achieving this goal and increasing palate mobil-
ity.42,43 Although still in use, this technique, along with
postoperative scarring and contracture, resulted in poor
facial growth and increased complications of hearing and
middle ear function.23
von Langenbeck revolutionized hard palate repair
by introducing the bipedicle mucoperiosteal ap. The
technique involved incision along the oral side of the
cleft edges and a lateral relaxing incision along the pos-
terior alveolar ridge to create two mucoperiosteal aps
elevated from hard palate bones.44 These aps could
then be mobilized medially to close the hard palate while
ensuring improved vascular supply and tension-free clo-
sure (Fig. 3).9,45 Principles of closure were combined
from Dieffenbach and von Langenbeck in a technique
commonly known today as Langenbeck’s palatoplasty.5
However, this technique has been prone to contracture,
impeding speech production.45 To counter these compli-
cations, Langenbeck’s palatoplasty is often combined with
intravelar veloplasty.44
In addition to describing techniques of soft palate
repair, Veau also modied von Langenbeck’s bipedicle
ap technique to a unipedicle mucoperiosteal ap based
on the posterior greater palatine artery which connected
the lateral relaxing incisions to the anterior cleft mar-
gins.5 This technique prioritized tension-free closure
of the anterior cleft defect extending through the pri-
mary palate, but impaired maxillary growth through
scarring of the denuded bone areas.11,46 In contrast, von
Langebeck’s bipedicle mucoperiosteal ap technique
requires decreased dissection of the anterior palate and
therefore less disturbance of dentition and facial bone
growth.9,11
In 1967, Bardach, a Polish surgeon, modied
Langenbeck’s two-ap technique in an attempt to
decrease scarring and maxillary growth deciency by min-
imizing hard palate bony exposure.11 Mucoperiosteal aps
are based on the greater palatine artery posteriorly. Once
the cleft is closed, the two aps are sutured back to the
alveolar margins to reduce the amount of bone exposure
(Fig. 4).7,47 This technique successfully reduced palatal
scarring and minimized maxillary hypoplasia but did not
correct abnormalities of speech.
Technique Modications
Principles of soft and hard palate repair interact intri-
cately. Furthermore, as techniques have been passed down
from mentor to trainee, they have been modied and
combined over the years to achieve optimal results.
Soft palatoplasty variations can be considered in two
broad categories: (1) Furlow and its many modica-
tions, including the Children’s Hospital of Philadelphia
modication,48 the Mann technique, and others; and (2)
intravelar veloplasty techniques that range from simple to
more aggressive attempts at gaining length. This includes
radical intravelar veloplasty, and Cutting’s modication
thereof, which has evolved from a one-stage repair to a
two-repair utilizing vomer aps.49Radical intravelar vel-
oplasty has been associated with improved speech out-
comes, particularly when combined with the two-ap
palatoplasty.50 Sommerlad, in particular, deserves credit
for trying to gain length while keeping the nasal layer
intact.51 Modications of hard palate techniques are also
evident in recent years, including the hybrid palatoplasty
and minimal incision technique, which have reported
improved preservation of maxillary growth, with lower s-
tula rates compared with the use of relaxing incisions.52–55
The Veau-Wardill-Kilner technique was one of the rst
combined variations in the early 1900s, which combined
Veau’s unipedicle mucoperiosteal ap for hard palate
closure with Wardill-Kilner’s V-Y pushback approach to
lengthen the soft palate (Fig.5). Similarly, Bardach’s two-
ap hard palate repair was also combined with intravelar
veloplasty.5,13
In more recent years, Robert Mann has combined a
modied Furlow technique with interposing buccal aps
for hard palate closure. This technique aimed to achieve
tension-free closure and palatal lengthening whilst limit-
ing stula complication rates.56,57 Buccal aps have been
used with success in closure of wider clefts.58

Naidu et al. • History of Cleft Palate Repair
5
Timing and Sequence of Operations
Timing of cleft palate repair is complex and debated,
as it affects speech and midface growth.14,59 While early
palatoplasty prioritizes speech production, delayed pala-
toplasty minimizes midface growth disturbance.60
The one-stage palatoplasty (also known as the “hole-
in-one” repair) has become an increasingly popular tech-
nique in recent years, particularly in resource-limited
settings where repeated procedures are often not fea-
sible.61 This technique advocates for both hard and soft
palate closure around 10 months of age with minimal
disturbances in facial bone growth.14,62 In comparison,
other centers such as the Great Ormond Street Hospital
(GOSH) in London and Oslo Cleft Palate Team advo-
cate for a two-stage repair: early lip repair and single-
layer hard palate closure using a vomer ap at the age
of 3 months and posterior palate closure at 18 months,
using Langenbeck’s technique.24,63,64 A systematic review
of the literature showed that the need for orthognathic
surgery following a two-stage palatoplasty is comparable to
a one-stage palatoplasty, with orthognathic surgery rates
of 21% and 20.8%, respectively. However, velopharyngeal
insufciency rates and the need for corrective speech sur-
gery using the two-stage palatoplasty were signicantly
higher than the one-stage palatoplasty (23.9% compared
with 15.1%).65 Results within two-stage palatoplasty proto-
cols also differ. The Milan Cleft Protocol also advocates
for a two-stage repair; however, lip and soft palate repair
are scheduled between the age of 4 and 6 months and
hard palate repair between the age of 18 and 36 months.
This protocol has resulted in increased maxillary hypo-
plasia when compared with the Oslo Protocol (difference
in SNA greater than 2.6 degrees and ANB greater than
2.9 degrees).66
Schweckendiek introduced two-stage palatoplasty
between 1944 and 1951.9,67,68 His approach demonstrated
good results by repairing the soft palate at 3–6 months and
the hard palate at 11–12 years.13 Early palatoplasty is often
performed between 6 and 9 months; however, in some
centers, it is performed as early as 3–6 months of age to
facilitate good speech outcomes.10,28,47 Late palatoplasty,
between the age of 18 months to 15 years, prioritizes max-
illary growth, and is center- and surgeon-dependent,69 but
may be associated with increased speech delays.70 Other
centers choose to repair the hard palate earlier, within
the rst year or 18 months of life; they report minimal
maxillary growth disturbance and cite that facial growth
benets of repair after 5 years of age do not outweigh the
Fig. 3. Von Langenbeck’s palatoplasty technique (drawn by the rst author, modied from Sato FRL et al19).

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Fig. 4. Bardach’s two-ap palatoplasty technique (drawn by the rst author, modied from Leow AM et al9).
Fig. 5. Veau-Wardill-Kilner palatoplasty technique (drawn by the rst author,
modied from. Sato FRL et al19).

Naidu et al. • History of Cleft Palate Repair
7
detrimental effects on speech development.62,71,72 While
some studies have reported poor speech outcomes follow-
ing Scheckendiek’s technique, many European centers
(such as Goteburg) and surgeons (such as Talmant) have
championed delayed closure,73,74 achieving acceptable
speech outcomes while minimizing maxillary hypoplasia.75
DISCUSSION
As techniques evolved, principles became more
rened with greater attention to restoring precise anat-
omy to achieve the goals of repair. Technique and timing
of cleft palate repair are important concepts to ensure
good outcomes, but there is no consensus on either.76
Cleft palate repair variations differ between surgeons and
cleft centers worldwide. Original techniques are often
modied and combined to create variations, such as the
combination of Von Langenbeck’s procedure with other
techniques to reconstruct the velopharyngeal muscle sling
or lengthen the palate.9,77 As a result, comparison of tech-
niques between centers is particularly difcult and often
incomparable.9
Techniques also differ between regions. Bardach’s two-
ap palatoplasty and Furlow’s double-opposing z-plasty
are most commonly used in the United States.10 In Brazil
and the United Kingdom, the most commonly performed
techniques are Veau-Wardill-Kilner and Langenbeck’s pal-
atoplasty.78 Renowned European centers such as GOSH
and Oslo utilize the single-layer closure vomer ap tech-
nique.24 Furlow’s double-opposing z-plasty is a common
procedure worldwide due to good speech outcomes7; how-
ever, studies have reported obstructive sleep apnea and
difculty utilizing the technique in wider clefts.79,80
Most institutions agree that early palatoplasty should
occur before the age of 18 months,24,59,81–83 but best timing
is still debated and lacks high-quality evidence.10 Variations
in timing and sequence are also regional, with North
America tending toward early palatoplasty and Europe
tending toward delayed palatoplasty or the Oslo Protocol.
Different institutions have different protocols for tim-
ing and sequence of operations, often centered around
improving speech outcomes while limiting maxillary hypo-
plasia. However, the lack of standardized speech measure-
ments and variable techniques have hampered the ability
to objectively determine optimal timing.61,69 Some suggest
that timing should be based on the patient’s condition and
associated syndromes, the type of cleft, and the capabili-
ties of the cleft team.4 Surgery is often delayed or simpler
techniques are used when associated syndromes will not
allow prolonged anesthesia.5 The one-stage palatoplasty
is favored in both low- and high-resource settings.61,63,69
However, recent studies have shown that the two-stage
palatoplasty confers improved maxillary growth.73,74
There is no single technique or recommendation for
timing that prioritizes speech development, while limiting
midface hypoplasia and preventing palatal stulae. This
has resulted in controversy compounded by a lack of stan-
dardized techniques and outcome metrics, and difculties
in long-term follow-up and data collection. Many studies
are underpowered and lack generalizability. Outcomes
of cleft palate repair are not easily measured and require
sufcient numbers, long-term follow-up, and vigilant
collection of data to evaluate outcomes of a technique.
Evaluation of speech is often subjective and lacks stan-
dardized reporting mechanisms, while effects on facial
growth require 15–20 years of follow-up, which is often
not achieved.5
We lack universal metrics to assess appropriate speech
development, dene thresholds of the acceptable limits of
midface hypoplasia, and evaluate the impact of technique
on different cleft phenotypes. Furthermore, cleft severity,
extent of hypoplasia, and cleft width are highly variable.
Techniques are often not analyzed in the context of cleft
palate severity or width. Limiting hard palate dissection
mitigates midface hypoplasia; however, this is often not
possible in wider clefts.84,85 Many traditional techniques
are inadequate to address wider clefts, resulting in higher
rates of oronasal stulae,30 and necessitating more aggres-
sive dissection that impairs maxillary growth.85
CONCLUSIONS
Since the 18th century, there have been phenomenal
improvements in cleft palate repair with a more rened
understanding of the anatomy. Cleft palate repair has
evolved from merely striving for anatomical closure to
balancing speech improvement while minimizing midface
hypoplasia and preventing oronasal stulae. Despite this,
we still lack a universally accepted technique and proto-
col for timing to optimally achieve the goals of cleft pal-
ate repair while limiting complications. The variation and
abundance of techniques is a result of different goals of
cleft palate repair being prioritized at different times and
might suggest that no single technique is best for every
case. Furthermore, these techniques have traditionally
been passed on in a master-apprentice fashion, with very
few surgeons being exposed to the long-term sequelae of
more than one technique. As a result, there have been
numerous modications of techniques. A few regional
groups (such as Eurocleft, Scandcleft, and Americleft)
have acknowledged the need for greater collaboration in
standardizing best practice; however, these groups are still
limited to high-income regions, with surgeons in these
regions sharing similar opinions. In addition to standard-
izing protocols, a reclassication and standardization of
technique types and names would be benecial in com-
paring technique outcomes and training in various tech-
niques. Orofacial clefting is a global problem requiring
worldwide collaboration to address these knowledge de-
ciencies. This highlights the need for a global consortium
on cleft care to gather expert opinions on current tech-
niques and outcomes measurements in an attempt to con-
cede on a gold standard.
William P. Magee III, MD, DDS, FACS
Division of Plastic and Reconstructive Surgery
Keck School of Medicine of the University of Southern
California
1510 San Pablo Street, Suite 415
Los Angeles, CA 90033
E-mail: wmagee@chla.usc.edu

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