Palatoplasty Using Alveolar Ridge Incisions: A Novel Approach for Addressing Cleft Palate Deformities

Abstract

Background:
Traditionally, plastic surgeons have performed palatoplasties using mucoperiosteal flaps with lateral incisions that are medial to the alveolar ridge. However, narrow flaps can cause limitations in some cases. To construct larger and wider flaps and minimize exposed bone after closure, we propose a novel technique that entails creating the lateral incisions at the top of the alveolar ridge, instead of the base of the alveolar ridge, to capture more tissue when repairing the hard palate.

Methods:
A retrospective chart review was conducted for patients undergoing cleft palate repair with the aforementioned technique. Information collected included basic demographic and diagnostic factors related to cleft palate deformity and history of previous facial surgeries. Operative report details and postoperative complications were analyzed.

Results:
Nineteen patients with hard palate clefts were included in the analysis, with the majority being women (68%). There was a balanced representation of patients with Veau classifications of II (47%) and III (42%). The majority of patients had an isolated cleft palate (74%) and incomplete deformity (63%), with no other craniofacial deformities. One (5%) had postoperative self-limited oronasal fistula managed conservatively.

Conclusions:
We present a novel approach for repairing cleft palate deformities by extending the lateral incision to the top of the alveolar ridge to create larger mucosal flaps. Further longitudinal studies are needed to evaluate how this unique approach compares to traditional methods-with respect to impact on maxillary growth processes, requirement for subsequent surgeries beyond two years of follow-up, and ultimately normalized speech over time.

Full text

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Disclosure: The authors have no nancial interest to
declare in relation to the content of this article. No funding
was received for this work.
Craniofacial/Pediatric
From the Division of Plastic and Reconstructive Surgery, University
of California – Los Angeles, Los Angeles, Calif.
Received for publication January 11, 2022; accepted February 24,
2022.
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
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000004275
INTRODUCTION
Occurring in one out of 1700 births, cleft palate
defects arise due to the failure of fusion of the palatine
shelves during the process of embryogenesis.1 The subse-
quent deformity may involve the soft and/or hard palate,
and may extend through the alveolus in a unilateral or
bilateral fashion. The manifestations of cleft palate are
largely functional: patients with clefts of the hard palate
may experience feeding difculties due to the inability
to generate negative intraoral pressure, whereas those
with clefts of the soft palate may experience disrup-
tion of the velopharyngeal port and subsequent speech
dysfunction.1,2 Thus, the aims of palatoplasty repair are
primarily (1) to restore the separation of the oral and
nasal cavities; (2) to create a velopharyngeal port to pre-
vent hypernasality; and (3) to address Eustachian tube
dysfunction and recurrent otitis media.1–3 In addition
to these goals, plastic surgeons must attempt to avoid
the possibility of creating a palatal stula and maxillary
growth disturbance for these patients.
A variety of palatoplasty techniques have been
reported and implemented for the restoration of cleft
palate deformities; these include the Furlow palatoplasty,
two-ap palatoplasty, palatoplasty with vomer aps, and
palatoplasty with veloplasty.2 The elevation of bilateral
hard palate mucosal aps has historically entailed scor-
ing incisions made at the gingivopalatal sulcus. Although
these aps may be sufcient for repairing most defects,
some patients, especially those with wide U-shaped clefts
or those with very inclined palatal shelves, may benet
from the mobilization of larger aps. Extensive manipu-
lation may predispose patients to a higher risk of wound
complications, stula formation, or maxillary growth
Sumun Khetpal, MD
Harsh Patel, MD
Michael DeLong, MD
Mengyuan T. Liu, MD
Wayne H. Ozaki, MD, DDS, FACS
Abstract
Background: Traditionally, plastic surgeons have performed palatoplasties using
mucoperiosteal aps with lateral incisions that are medial to the alveolar ridge.
However, narrow aps can cause limitations in some cases. To construct larger and
wider aps and minimize exposed bone after closure, we propose a novel technique
that entails creating the lateral incisions at the top of the alveolar ridge, instead of
the base of the alveolar ridge, to capture more tissue when repairing the hard palate.
Methods: A retrospective chart review was conducted for patients undergoing cleft
palate repair with the aforementioned technique. Information collected included
basic demographic and diagnostic factors related to cleft palate deformity and his-
tory of previous facial surgeries. Operative report details and postoperative com-
plications were analyzed.
Results: Nineteen patients with hard palate clefts were included in the analysis, with
the majority being women (68%). There was a balanced representation of patients
with Veau classications of II (47%) and III (42%). The majority of patients had
an isolated cleft palate (74%) and incomplete deformity (63%), with no other
craniofacial deformities. One (5%) had postoperative self-limited oronasal stula
managed conservatively.
Conclusions: We present a novel approach for repairing cleft palate deformities
by extending the lateral incision to the top of the alveolar ridge to create larger
mucosal aps. Further longitudinal studies are needed to evaluate how this unique
approach compares to traditional methods—with respect to impact on maxillary
growth processes, requirement for subsequent surgeries beyond two years of fol-
low-up, and ultimately normalized speech over time. (Plast Reconstr Surg Glob Open
2022;10:e4275; doi: 10.1097/GOX.0000000000004275; Published online 18April 2022.)
Palatoplasty Using Alveolar Ridge Incisions: A Novel
Approach for Addressing Cleft Palate Deformities
ORIGINAL ARTICLE

PRS Global Open • 2022
2
disturbance. To construct larger aps to minimize tis-
sue mobilization, a number of alternative methods
have been proposed. The senior author (WO) prefers
creating lateral incisions the top of the alveolar ridge
to recruit aps of greater area. To the authors’ knowl-
edge, this unique approach toward restoring cleft palate
deformities has not yet been proposed or discussed in
the literature.
The purpose of this study was multi-fold: (1) to
introduce the senior author’s novel technique for inci-
sion along the dental margin, as opposed to the alveo-
lar ridge to hard palate junction, for creation of larger
mucosal aps during palatoplasty; (2) to assess clinical
outcomes (ie, requirement of subsequent surgeries)
associated with this technique relative to historical con-
trols within the literature; and nally, (3) to discuss the
specic anatomic considerations and criteria for utiliza-
tion of this approach. We hypothesize that the proposed
technique will confer lower rates of postoperative s-
tula by reducing closure tension without causing den-
tal complications. Furthermore, we anticipate that the
larger aps afforded by this technique may be favor-
able for patients with wide or challenging cleft palate
deformities.
METHODS
Overview of Technique
The patient is orally intubated and a Dingman retrac-
tor is used to provide exposure. Approach to the soft
palate typically involves standard Furlow palatoplasty or
linear closure with an intravelar veloplasty (5 mm or less
Furlow palatoplasty, >5 mm linear closure with intravelar
veloplasty). For the hard palate, incision is made at the
cleft margin to separate nasal and oral mucosa circumfer-
entially. Lateral incisions are made at the top of the alve-
olar ridge (or the dental sulcus when teeth are present)
rather than in the junction between the base of the alveo-
lar ridge and hard palate. The aps are bluntly elevated
in the subperiosteal plane from the underlying maxillary
and palatine bone with care to preserve greater palatine
neurovascular bundle bilaterally. For clefts extending
through the alveolus, two similar mucosal aps are ele-
vated on either side of the cleft. Vomer aps are elevated
when required. The nasal mucosa is then repaired with
4-0 Vicryl sutures, followed by a repair in midline of the
mobilized mucoperiosteal aps with 4-0 Vicryl sutures.
Posteriorly, the nasal mucosa, muscle, and oral mucosa
are repaired with 4-0 Vicryl suture. A 4-0 Nylon is used for
a tongue stitch, and the patient is admitted overnight for
airway observation. An illustration of the senior author’s
technique is shown in Figure1.
Clinical Chart Review
A retrospective chart review approved by the
University of California – Los Angeles (UCLA)
Institutional Review Board (IRB#20-001420) was con-
ducted for all of the senior author’s patients undergo-
ing hard palate palatoplasty (CPT 42200) between the
years 2015 and 2020, representing all years available in
electronic health records at UCLA. Patients with isolated
soft palate defects (Veau I) were excluded. Basic demo-
graphic variables (ie, gender, ethnicity, age at time of
repair) were extracted from charts along with relevant
diagnostic variables, including Veau classication, type
of palate, laterality, associated craniofacial syndrome(s),
and history of previous facial surgeries. Operative report
details were also recorded for each patient, including
type of repair performed, duration of surgery, duration
of anesthesia, length of stay, speech quality, postopera-
tive oronasal stula, dental anomalies, requirement of
subsequent surgeries, and duration of follow-up by plas-
tic surgery craniofacial team. All analyses conformed to
Strengthening the Reporting of Observational Studies in
Epidemiology guidelines.
RESULTS
Demographic Information
Nineteen patients were included in the analysis, of
which the majority were women (68%). There were a
larger portion of Hispanic (61%) patients, compared
with those of other ethnicities. A comprehensive sum-
mary of the demographic information can be found in
Table1.
Diagnostic Factors
There was a balanced representation of patients
with Veau classications of II (47%) and III (42%);
one patient (4%) had a cleft defect of Veau IV classi-
cation. The majority of patients had an isolated cleft
palate (74%) and incomplete deformity (63%), with
no other craniofacial deformities. Only two (10%) had
associated craniofacial syndromes. Six patients had prior
facial surgery (including cleft lip repair, rhinoplasty, and
mandibular distraction) before cleft palate repair. A
comprehensive summary of the diagnostic information
can be found in Table 1. On average, the procedures
lasted 124 minutes, and patients remained admitted for
Takeaways
Question: In palatoplasty, can larger and wider aps be
constructed through creating incisions along the alveolar
ridge? What are the clinical outcomes and complications
associated with this technique?
Findings: A retrospective chart review was conducted for
patients undergoing cleft palate repair. Demographic
information, operative report details and postoperative
complications were analyzed. Nineteen patients with
hard palate clefts were included, with the majority being
women (68%). The majority of patients had an isolated
cleft palate (74%) and incomplete deformity (63%), and
two (10%) had postoperative oronasal stula managed
conservatively.
Meaning: This technique represents a safe and effective
surgical option for cleft palate patients.

Khetpal et al. • Alveolar Ridge Incisions for Cleft Palate Repair
3
1.06 days. A comprehensive summary of the procedural
details can be found in Table2.
Requirement for Subsequent Surgeries and Follow-up
Of the 19 patients, no patients required subsequent
revision interventions for repair of cleft defects. In total,
81% of patients had no reported hypernasality or mispro-
nunciations at speech pathology evaluation. One (5%)
patient had postoperative oronasal stula (at the junc-
tion between hard and soft palate, measuring 2 mm) but
closed spontaneously without requiring secondary sur-
gical repair. Four (21%) patients had dental anomalies,
which included class I occlusion, presence of tooth within
cleft, microdontia of mandibular incisors with associated
mandibular deviation, and hypoplastic #A. Of note, none
of the patients encountered issues with primary tooth
eruption.
DISCUSSION
This study sought to introduce a novel technique in
addressing cleft palate deformities, particularly those that
would require extensive tissue mobilization. In all, we
found that this approach confers favorable clinical out-
comes for patients with cleft palate, and may be utilized to
mitigate extraneous tissue mobilization and manipulation
for ideal approximation of aps.
The primary outcome of cleft palate repair lies in the
achievement of velopharyngeal competence without s-
tula.4–14 Of our 19 patients, one patient (with Veau clas-
sications of III) had postoperative oronasal stulas. The
patient did not require further surgical intervention. This
stula rate is comparable to those stated in the literature,
as studies by Yuan et al found a 4.5% rate of palatal s-
tula in 117 patients undergoing primary cleft palatoplasty,
and Sullivan et al found a rate of 2.9% of 449 patients.4,5
While the rate of postoperative stula within our cohort
Fig. 1. Illustration of senior author’s technique. A, Illustration demonstrating the mainstay technique
for correction of cleft palate deformities, specically through the elevation of aps with lateral inci-
sions (dotted white lines) that are medial to the alveolar ridge, at the gingivobuccal sulcus. B, Display of
the senior author’s technique, which involves scoring incisions (dotted black lines) at the gum line for
recruitment of larger aps.
Table 1. Overview of Patient Demographic and Diagnostic
Information
Gender
Women 13 (68%)
Men 6 (32%)
Average body mass index 16.5
Ethnicity
Asian American 0 (0%)
White 6 (31%)
African American 0 (0%)
Hispanic 11 (61%)
Unknown 2 (11%)
Veau classication
2 9 (47%)
3 8 (42%)
4 1 (4%)
Not recorded 1 (5%)
Type of palate
Isolated cleft palate 14 (74%)
Unilateral cleft lip and palate 5 (26%)
Bilateral cleft lip and palate 1 (5%)
Incomplete 12 (63%)
Complete 7 (37%)
Syndromic 2 (10%)
8p22. translocation 1 (5%)
Pierre Robin sequence 1 (5%)
Nonsyndromic 17 (90%)
History of previous surgeries 6 (32%)
Table 2. Overview of Procedural and Postoperative Details
Type of repair
Furlow palatoplasty 12 (44%)
Palatoplasty 4 (15%)
Palatoplasty with intravelar veloplasty 4 (15%)
Palatoplasty with vomer ap 1 (4%)
Two-ap palatoplasty 5 (19%)
Palatoplasty and cleft lip revision 1 (4%)
Speech quality
Normal 22 (81%)
VPI 1(4%)
Nasal speech 2 (7%)
Speech delay 1 (4%)
Unknown 1 (4%)
Oronasal stula 2 (7%)
Dental anomalies 5 (19%)
Duration of surgery (min) 117
Duration of anesthesia (min) 193
Length of stay (d) 1.22
Subsequent surgeries 2 (7%)
Duration of follow-up (y) 1.83

PRS Global Open • 2022
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was 5%, it is important to recognize the likely high
degree of selection bias among our patients. Prior reports
included patients with all cleft palate types, whereas the
present report is limited to larger clefts that include the
hard palate. The observed stulae were also in the midline
representing a potential paucity of tissue, which should
theoretically be improved by the creation of larger aps.
There were no notable complications at the dental margin
or with the patient dentition, suggesting no adverse effects
of making the releasing incision at this location. Future
studies could directly compare how traditional incision
techniques compared with the discussed approach for
patients of greater Veau hierarchy. This ultimately may
provide helpful insight and guidance for plastic surgeons
considering various techniques for correcting palatal
deformities of higher severity.
In terms of speech outcomes and assessment of velo-
pharyngeal competence, the majority (79%) of patients
had normal speech quality with no apparent velopharyn-
geal insufciency (VPI) after palatoplasty. Only one patient
with a Veau classication of III was recorded to have VPI;
two were found to have hypernasal speech; one other was
determined to have speech delay. In all, the rates of VPI
within our cohort were lower than those reported in the
literature.4–14 In fact, Sullivan et al conducted a 29-year
analysis of patients undergoing palatoplasty, and found
that of 449 patients, 85.1% had postoperative VPI.5 The
study also found signicant correction between the inci-
dence of VPI and increased Veau hierarchy and age at the
time of palatoplasty.5 While our results suggest superior
outcomes in maintaining velopharyngeal competence,
further studies may stratify patients by Veau classication,
and in doing so, achieve more accurate comparison of
patient cohorts.
In terms of revision surgeries, no patients within our
analyzed sample required further intervention. Of note,
our investigation included 2 years of follow-up, and there-
fore is limited in assessing longitudinal outcomes associ-
ated with requirement for future surgeries for renement
of facial appearance—namely rhinoplasty, orthognathic
surgery, and alveolar bone grafting. Future studies could
explore these differences between patients who received
this approach of cleft palate repair, relative to traditional
incision techniques. In addition, it remains unclear to
what extent the scarring along the alveolar ridge impacts
primary tooth eruption. While our analysis did not reveal
any patients with this complication, future longitudinal
studies may explore how the senior author’s technique
may affect growth of primary teeth.
There are several limitations of this study that war-
rant consideration. First, while the average period of
follow-up was nearly 2 years in this investigation, our
ability to longitudinally assess the clinical outcomes of
this technique is limited; specically, information sur-
rounding the need for subsequent surgeries, such as
rhinoplasty, bone grafting, and orthognathic surgery,
was incomplete within our cohort. Future studies could
implement a longer follow-up period and a greater sam-
ple size for evaluation of patients to better understand
how the technique may mitigate complications, as well as
the potential need for re-operation. Second, given that
our study utilizes historical controls reported in the lit-
erature to assess the safety and efcacy of the discussed
technique, the external validity and generalizability
of results may be compromised. Third, although the
study favors the utilization of this technique, it remains
unclear which deformities are best addressed with this
approach. Future studies could perform stratied analy-
ses based on Veau classication, as well as other sever-
ity measurements, to better assess how the technique
compares to those of traditional incision types. In doing
so, objective algorithms can be developed to better help
plastic surgeons navigate reconstruction of cleft palate
deformities. Finally, it remains unclear how this tech-
nique impacts the ultimate tension placed along suture
lines, and how this may inform differences in compli-
cation rates; future studies may incorporate geometric
analysis to further quantify this aspect of the aforemen-
tioned technique.
CONCLUSIONS
This study presents a novel approach toward the cor-
rection of cleft palate deformities—particularly those that
have traditionally involved extensive tissue mobilization
and manipulation. Our analysis evaluates the practice of
scoring incisions at the gum line, as opposed to gingivo-
labial sulcus, to elevate large aps during palatoplasty.
We established that this technique offers a safe and effec-
tive surgical option for patients with clefts involving the
hard palate. Future studies can explore how this unique
approach compares to traditional incision techniques—
with respect to maxillary growth disturbances, require-
ment for subsequent surgeries beyond two years, and
ultimate aesthetic appearance.
Wayne H. Ozaki, MD, DDS, FACS
Department of Surgery
Division of Plastic and Reconstructive Surgery
University of California – Los Angeles
200 Medical Plaza, Suite 460
Los Angeles, CA 900995
E-mail: WOzaki@mednet.ucla.edu
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