Two-stage palatal repair in non-syndromic CLP patients using anterior to posterior closure is associated with minimal need for secondary palatal surgery

Abstract

Objective: The aim of the present study was to assess the need for secondary palatal corrective surgery in a concept of palate repair that uses a protocol of anterior to posterior closure of primary palate, hard palate and soft palate.

Methods: A data base of patients primarily operated between 2001 and 2021 at the Craniofacial and Cleft Care Center of the University Goettingen was evaluated. Cleft lips had been repaired using Tennison Randall and Veau-Cronin procedures in conjunction with alveolar cleft repair. Cleft palate repair in CLP patients was accomplished in two steps with repair of primary palate and hard palate first using vomer flaps at the age of 10-12 months and subsequent soft palate closure using Veau/two-flap procedures 3 months later. Isolated cleft palate repair was performed in a one-stage operation using Veau/two-flap procedures. Data on age, sex, type of cleft, date and type of surgery, occurrence and location of oronasal fistulae, date and type of secondary surgery performed for correction of oronasal fistula (ONF)and / or Velophyaryngeal Insufficiency (VPI) were extracted. The rate of skeletal corrective surgery was registered as a proxy for surgery induced facial growth disturbance.

Results: In the 195 patients with non-syndromic complete CLP evaluated, a total number of 446 operations had been performed for repair of alveolar cleft and cleft palate repair (Veau I through IV). In 1 patient (0,5%), an ONF occurred requiring secondary repair. Moreover, secondary surgery for correction of VPI was required in 1 patient (0,5%) resulting in an overall rate of 1% of secondary palatal surgery. Skeletal corrective surgery was indicated in 6 patients (19,3%) with complete CLP in the age group of 15 - 22 years (n = 31).

Conclusions: The presented data have shown that two-step sequential cleft palate closure of primary palate and hard palate first followed by soft palate closure has been associated with minimal rate of secondary corrective surgery for ONF and VPI at a relatively low need for surgical skeletal correction.

Fig. 1

Demographic data

Fig. 2

A Unilateral complete cleft lip and palate. Red circle identify the critical transition areas between cleft alveolus and primary palate, between primary and secondary palate and between hard and soft palate. Incision lines on the medial side of the cleft in yellow for the extended Vomer flap that includes the mucoperiosteum of the premaxilla and extends to the buccal side of the alveolar cleft. The buccal part of the alveolar cleft and anterior part of the nasal floor had been already closed during lip repair. B Mobilization of the mucoperiosteum of the premaxilla and the vomer towards the lateral edge of the cleft. Increased mobility is gained by subperiosteal dissection in cranial direction. C Incision line on the lateral side of the cleft extending to the buccal side of the closed alveolar cleft. D Mobilisation of the lateral mucoperiosteum of the palatal bone for at least 5 mm. E Preparation of back-and-forth sutures that unite the periosteal surfaces of the of the medial mucoperiosteum of the premaxilla / vomer with the lateral mucoperiosteum of the palatal bone. F Upon activation a safe overlap of at least 2–3 mm between the two periosteal surfaces should be achieved. G After 3 months, the residual cleft soft palate is addressed with a typical Veau incision (in yellow) extending at least 5 mm beyond the border between the soft and the hard palate, making sure, that enough mucoperiosteum overlying the hard palate is involved. H Elevation of the mucoperiosteum on the cleft side has to be done carefully with blunt preparation through the scar tissue of the former vomer flap bridging the ledge of the palatal bone and the vomer / contralateral palatal bone. I Release of the false insertion of the palatal muscles and reconstruction of the muscular sling is done in typical manner after mobilization and suturing of the nasal mucoperiosteal layer. Bilateral excision of small wedges (in yellow) of the palatal mucoperiosteum at the anterior medial flap egdes. K Medialization of the palatal flaps for reconstruction of the oral layer with simultaneous “push back” through the VY elongation