Abstract
The reconstructions of the asymmetrical soft palate cleft is a surgical challenge when it comes to achieving symmetry and optimal soft palate muscular function. Three different versions of the intravelar veloplasty have been used: the intravelar veloplasty (1969) (type I), the modification according to anatomical defects (1991) (type II), and the modification using part of Sommerlad’s technique and part of Ivanov’s technique (2008) (type III). The perioperative outcomes of the type II and type III intravelar veloplasty were assessed and compared in asymmetrical cleft cases. Two hundred and seventy-seven soft palate clefts were reconstructed: 153 type II and 124 type III. Of these, 49 were asymmetrical (17.7%); 23 underwent the type II procedure and 26 the type III procedure. Of the type II procedure cases, 30.4% remained asymmetrical postoperatively compared to 3.8% of the type III cases. The uvula appeared subjectively atrophic in 47.8% of the type II cases and in 7.7% of type III cases. Oro-nasal fistula occurred in 13.0% of the type II cases and 3.8% of the type III cases. Speech results will only be assessed after 4 years of age. The type III modified intravelar veloplasty has had a major beneficial impact on patients who had an asymmetrical soft palate cleft.
The soft palate cleft repair is an integral part of the modern cranio-maxillofacial surgical spectrum. It is especially challenging in light of the importance of optimization of velopharyngeal competency (resulting from insufficient and malformed tissue at the cleft site). Speech development is an important consideration when choosing a specific surgical technique for closure of the cleft, as well as the age at which the surgery should be performed. With any type of procedure in repairing the soft palate cleft, the surgeon and speech pathologist are frequently confronted with a short soft palate and a wide velopharyngeal space, both of which are known to diminish the quality of speech. This is of particular significance in an asymmetrical soft palate, where there can be a marked difference in the amount of tissue available on either side of the cleft to utilize in reconstruction.
Soft palate repair techniques have undergone a metamorphosis over the centuries. The first successful closure by approximating the cleft margins was apparently performed by Le Monnier (France) in 1766. In 1931, Veau took palatal musculature into account and suggested closure of the muscular layer, without considering the orientation of the musculature. This inadequate muscular function led to the concept of levator muscle dissection and rotation, and finally to a more thoughtful anatomical approach to muscular influence on functionality and the development of the well-known intravelar veloplasty. This was described by Kriens (1969) and is referred to as the type I intravelar veloplasty. It entails the dissection of the cleft margins in the sagittal plane with medial deflection of the dissected margins to meet centrally and thus form the nasal mucosal layer. The levator muscle is dissected loose from the palatal bone, rotated, and sutured centrally. The uvulas are dissected and sutured centrally. The hamulus is fractured inwards and the tensor muscle and tendon is stripped off. The oral mucosal layer is approximated and releasing incisions are placed laterally. This technique was performed in the facial cleft deformity clinic until 1987. Thereafter it was modified according to anatomical defects (the type II intravelar veloplasty) and included uvula muscle repair. This change included seven different modifications to the original intravelar veloplasty. Similarly to the type I repair, the nasal layer is reconstructed following sagittal dissection of the cleft margins. Muscular reconstruction is done and a tensor sling is included to place the tensor muscle tendons under maximal tension, in order to facilitate improved Eustachian tube function. The hamulus is not fractured. Various triangular flaps, releasing incisions, and back-cuts are utilized to relieve tension, depending on the anatomical deformity present. In 2008, a further modification was made to the type II procedure using part of Sommerlad’s technique, part of Ivanov and Agueeva’s technique, and changes to the handling of the paired uvula muscle – the type III intravelar veloplasty. With the type III intravelar veloplasty, in addition to the type II modifications, the levator muscle is dissected and reconstructed, facilitating posterior repositioning. The palatoglossal–palatopharyngeal muscle bundle is dissected and approximated centrally. Both uvulas are not dissected, with one uvula (from the shorter cleft side) being preserved and centralized, whilst the longer uvula is dissected and inserted as a triangular flap into the nasal mucosal layer. Since 2008, this type III veloplasty has been used as the standard approach for the repair of the soft palate cleft.
The asymmetrical soft palate cleft ( Fig. 1 ) presents a major concern for the surgeon. The symmetrical and asymmetrical appearances were recorded by gross observation. The cleft must ideally be repaired so that the muscles are aligned and sutured (myopexy) as a perfect functional unit. This article describes new modifications to the standard intravelar veloplasty, which have previously not been described in conjunction with one another. This study entailed the evaluation of the incidence of asymmetrical soft palate cleft, the repair procedure for the soft palate cleft based on its preoperative anatomical appearance, and the preliminary results of the repair of the soft palate, including the position of the paired uvula. The aim of the study was to evaluate the perioperative outcomes in respect to symmetry, uvula appearance, and oro-nasal fistula development, comparing the type II and newly introduced type III intravelar veloplasty techniques.
Materials and methods
Database
Data collected over the past 7 years in the facial cleft deformity clinic were analyzed for two separate periods. During the first period, from 2005 to 2008 (group 1), patients with clefts involving the soft palate had their clefts repaired by means of a type II intravelar veloplasty. During the second period, from 2008 to 2012 (group 2), similar patients underwent the type III intravelar veloplasty procedure. All patients born with a cleft lip, alveolus and palate (CLAP), a COMBI cleft, a hard palate and soft palate cleft (hPsP), and those with an isolated soft palate cleft (sP) ( Table 1 ) were included in this research data.
| All types of clefts involving the soft palate | CLAP | COMBI | hPsP | sP | Total (with soft palate cleft) |
|---|---|---|---|---|---|
| Total clefts, N = 3644 | 1440 | 154 | 600 | 678 | 2872 |
| Soft palate cleft repaired, 2005–2012 | 124 | 13 | 73 | 67 | 277 |
| Asymmetrical soft palate cleft repaired, 2005–2012 (percentage of soft palate cleft) | 12 (9.7%) | 3 (23.1%) | 20 (27.4%) | 14 (20.9%) | 49 (17.7%) |
Surgical technique
The surgical technique for the type III intravelar veloplasty, an advancement of the type II technique, consists of the creation of a straight line dissection on the edge of the longer side of the cleft soft palate with inclusion of the uvula, whereas on the short side of the cleft soft palate, the straight line incision is stopped anteriorly ( Fig. 2 a ) to the uvula, which will be preserved and partially released by means of a perpendicular incision involving the oral and nasal mucosal layer ( Fig. 2 b). A triangular opening is affected on the nasal mucosal side, achieving a posterior rotation of this preserved uvula ( Fig. 2 c). Furthermore, the oral mucosal layer is released at the anterior region of the cleft or hard and soft palate junction, with a small oblique incision to release the oral layer posteriorly. After the surgical release of the levator muscle anteriorly at the palatal bone and medially adjacent to the medial pterygoid plate, the muscle is rotated posteriorly, on both sides. The palatoglossal–palatopharyngeal muscle bundles are released close and anteriorly to both uvulas and again rotated posteriorly ( Fig. 2 d). At this stage the tension-free nasal mucosa is sutured with the non-preserved dissected uvula rotated at 90°; this uvula’s posterior point is sutured into the perpendicular nasal releasing incision on the opposite side ( Fig. 2 c).
The non-preserved uvula mucosa with its muscle (from the longer side of the cleft soft palate) is now covering the nasal mucosal triangular area at the shorter side of the cleft soft palate with the result that the preserved uvula (short side) with its adjacent tonsillar pillars is positioned more posteriorly. The palatoglossal–palatopharyngeal muscle bundles are approximated and sutured by means of a double figure of eight suture. The preserved uvula is therefore centralized and rotated posteriorly. Since this preserved uvula is not dissected, it maintains its size in volume, length, and function. The levator muscles are rotated and aligned with vertical mattress sutures, with one posterior suture engaging the nasal mucosa, adjacent to the palatoglossal–palatopharyngeal sutured bundle, thereby avoiding a dead space between the muscle bundle and the nasal mucosa ( Fig. 2 e). These two levator muscle sutures (one anterior, one posterior) are knotted only after the lateral oral mucosa is released, as the levator muscle is further freed from the lateral part of the superior constrictor muscle so that it can be maximally rotated to facilitate zero tension at their interdigitation. A special long-term soluble material is used to stitch (tenopexy) and to activate the tensor muscle bundle, adjacent to the pterygoid hamulus, with the aim of maintaining patency of the Eustachian tube in the long term ( Fig. 2 e). The bilateral lateral mucosa is now released and the lateral part of the superior constrictor and levator muscles are separated posteriorly and anteriorly to the tenopexy, without engaging the tendon of the tensor veli palatini muscle. On the long side of the cleft soft palate, the oral mucosal releasing incision is rotated slightly medially in the anterior region in order to position posteriorly the oral mucosal tissue for the short side cleft soft palate, only for the isolated soft cleft palate (sP) ( Fig. 2 e). Otherwise one has to create an anterior perpendicular oral releasing incision for the CLAP and hPsP. Once the oral mucosa has been sutured at the cleft edge, the myopexy of the levator muscle is now completed, as the previously threaded through sutures are knotted. An absorbable haemostatic gelatin sponge is generally used to fill the gap at the releasing incisions and is kept in place by a loose uninterrupted reverse knotted suture ( Fig. 2 f).
Evaluation
The postoperative symmetry was evaluated by measuring the position of the reconstructed uvula in relation to the midline, as well as the relative distances of the uvula to the posterior margins of the maxillary tuberosities. The distance between the reconstructed posterior border of the soft palate and the posterior wall of the pharynx was measured and compared to the preoperative measurements. The uvula’s appearance was visually judged to be lying centrally or rotated laterally or posteriorly. The development of an oro-nasal fistula at the junction of the hard palate and soft palate was evaluated postoperatively at the time of patient follow-up (generally at the 3-month follow-up), by means of inspection. The postoperative results were compared between the two groups ( Tables 2 and 3 ).
