Functional cleft palate surgery

Abstract

Cleft lip and palate (CLP) as a dislocation malformation confronts parents with a malformation of their child that could not be more central and visible: the face. In addition to the stigmatizing appearance, however, in cases of a CLP, food intake, physiological breathing, speech and hearing are also affected. In this paper, the principles of morphofunctional surgical reconstruction of the cleft palate are presented. With the closure of the palate, and restoration of the anatomy, a situation is achieved enabling nasal respiration, normal or near normal speech without nasality, improved ventilation of the middle ear, normal oral functions with coordinated interaction of the tongue with the hard and soft palate important for the oral and pharyngeal phases of feeding. With the establishment of physiological function, in the early phases of the infant and toddler, these activities initiate essential growth stimulation, leading to normalisation of facial and cranial growth. If these functional considerations are disregarded during primary closure, lifelong impairment of one or more of the abovementioned processes often follows. In many cases, despite secondary surgery and revision, it might not be possible to correct and achieve the best possible outcomes, especially if critical stages of development and growth have been missed or there has been significant tissue loss due to resection of existing tissue while primary surgery. This paper describes functional surgical methods and reviews long term, over many decades, results of children with cleft palate.

Keywords: Cleft lip palate; Eustachian tube; Facial growth; Hearing; Physiological surgery; Velopharyngeal function.

Fig. 1

Shown on the right side is the dislocated situation of the velopharyngeal muscles of the soft palate with radiation in the hard palate. On the left side the normal situation is shown.

Fig. 2

From the base of the skull on both sides, the TVPM and LVPM muscle trains come and unite with the opposite side. From caudal, the PGM and PPM come from the tongue and pharynx and form two superimposed sphincters of the velopharyngeal muscles, an "8" as it were.

Fig. 3

Surgical incisions.

Fig. 4

a–c:Retrouvular incision for reconstruction of velopharyngeal mm.

Fig. 5

a, b:Bridge flap incision.

Fig. 6

Mobilization of the bridge flap medially under subperiosteal detachment from the lateral epipharyngeal wall to the skull base. Here, the insertion tendon of the medial pterygoid muscle is shown.

Fig. 7

Tension-free bipedicled (bridge) flaps.

Fig. 8

Building the floor of the nose.

Fig. 9

a, b:Reconstruction of uvula and velopharyngeal mm., especially the bilateral palatoglossus m.

Fig. 10

Oral closure of the mucosa. Here you can already see the penetrating threads on both sides, with which in the next step the collagen cushions lead to a further medial tension relief after knotting.

Fig. 11

End of surgery with loose adaptation of the lateral wound edges of the bridge flap.