|Year : 2019 | Volume
| Issue : 2 | Page : 68-71
Palatal Flap Mobilization in Cleft Palate Repair: A Simplified Technique
Akinwale A Efunkoya1, Olusola I Amole1, Uchenna K Omeje1, Benjamin I Akhiwu2, Otasowie D Odunde3
1 Department of Oral and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Dental and Maxillofacial Surgery, Jos University Teaching Hospital, Jos, Nigeria; formally, Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Oral and Maxillofacial Surgery, University of Calabar Teaching Hospital; formally, Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||04-Nov-2019|
Dr. Uchenna K Omeje
Department of Oral and Maxillofacial Surgery, Bayero University Kano/ Aminu Kano Teaching Hospital Kano
Background: Closure of the cleft palate defect without tension is frequently a challenge. Many surgical techniques exist for cleft palate repair. These techniques mostly inculcate some form of palatal flap mobilization. Adequate mobilization of the palatal flaps can achieve closure without tension, thereby reducing the incidence of palatal fistulae. Aim: This article aims to describe and illustrate a simplified technique of palatal flap mobilization in cleft palate repairs. Materials and method: A descriptive narrative of cleft palatal repair was done with emphasis on a simplified technique for palatal flap mobilization. Variations of this technique for von Langenbeck, Bardach, and isolated soft palatal repairs are also described with illustrations. Conclusion: A simplified technique of palatal mobilization can enhance palatal cleft closure without tension, thereby reducing incidence of palatal fistulas.
Keywords: Palatal flap mobilization, cleft palate repair, simplified technique
|How to cite this article:|
Efunkoya AA, Amole OI, Omeje UK, Akhiwu BI, Odunde OD. Palatal Flap Mobilization in Cleft Palate Repair: A Simplified Technique. Sub-Saharan Afr J Med 2019;6:68-71
|How to cite this URL:|
Efunkoya AA, Amole OI, Omeje UK, Akhiwu BI, Odunde OD. Palatal Flap Mobilization in Cleft Palate Repair: A Simplified Technique. Sub-Saharan Afr J Med [serial online] 2019 [cited 2021 Apr 15];6:68-71. Available from: https://www.ssajm.org/text.asp?2019/6/2/68/270248
| Introduction|| |
The aim of cleft palatal repair is to surgically close the palatal defect, thereby improving swallowing and speech., Problems that may be encountered in palatal cleft repairs include wound dehiscence, palatal fistula, and flap necrosis.,,, Wound dehiscence and palatal fistulas may arise as a result of tension in the surgical repair,,, while flap necrosis may arise due to damage to palatal vessels.
Various techniques exist for cleft palate repair; however, a common feature of these repairs is palatal flap mobilization to bridge the cleft defect. Adequate palatal flap mobilization will enhance cleft repair without tension, thereby reducing the risks of wound dehiscence and fistula formation. Each of the existing cleft palate surgeries includes techniques for palatal flap mobilization. The existing techniques still occasionally give rise to closure under tension. We present a simplified mobilization technique that may reduce or eliminate tension in cleft palate repairs.
Palatal wound dehiscence or fistula formation create psychological problems for the cleft parent, the need for a repeat surgery, and additional cost to patient management. Thus, a technique that allows for adequate mobilization and tension-free closure is desirable to minimize or eliminate these potential problems. This article aims to describe and illustrate a simplified technique of palatal flap mobilization that can be applied to a number of existing cleft palate surgeries. The article also seeks to illustrate the use of this technique with the von Langenbeck, Bardach, and isolated soft palatal cleft repairs [Figure 1].
|Figure 1 Schematic illustration of repairs of cleft palate at different stages. Upper left: Mobilized tongues of flap after reconstitution of nasal layer. Upper middle: Immediate postoperative picture of complete palatal cleft. Upper right: Isolated soft palatal cleft after reconstitution of nasal layer. Lower left: Isolated soft palatal cleft after repair. Lower middle: Photograph following reconstitution of nasal layer repair. Lower right: Preoperative photograph (complete palatal cleft).|
Click here to view
| Applied Anatomy of the Cleft Palate|| |
An understanding of the palatal anatomy is key to understanding surgical repair. The hard palate is supplied by the greater palatine artery that enters the palate from the greater palatine foramen. The lesser palatine artery and nerves pass through the lesser palatine foramen. The greater palatine artery is surrounded by an extension of the periosteum close to its exit from the greater palatine foramen. This cuffing of periosteum as a result of the tugging of palatal mucoperiosteum through the Sharpey’s fibers into the miniature grooves on the palate creates resistance to tongue-ward displacement when trying to mobilize the palatal flaps in cleft palate repair.
| ”Dimple”-Assisted Neurovascular Bundle Mobilization (DANBM)|| |
In both the normal individual and the cleft patient, there is a dimple in the lateral portion of the soft palate just posterior to the junction of hard and soft palate. This dimple possibly corresponds to the insertion of ligaments or muscles into the palatal mucosa. This dimple lies just posterior to the location of the greater palatine foramen with the greater palatine artery exiting through the foramen and running anteriorly.
This dimple can be used to assist mobilization of the neurovascular bundle through blunt dissection. The technique is simple and can be applied to various cleft repair techniques. A mosquito artery forceps is introduced in a closed position into the tissues posterior to the dimple via a lateral incision just posterior to the maxillary tuberosity. By use of blunt dissection (gently opening up the hemostat to raise the palatal mucosa away from its bed), the entire mucosa can be stretched to separate the greater palatine artery from its periosteal cuffing. This is evidenced by the palatal dimple disappearing from the mucosa. This results in marked mobility of the palatal flap with a sudden greater tongue-ward displacement of the entire palatal tissues. This mobility can be tested by gently gripping the edge of the cleft palatal mucosa on one side and moving it to its counterpart. Once the palatal mucosa crosses the midline, adequate mobility has been achieved to ensure palatal closure without undue tension.
Care should be taken to ensure that the entire bulk of the flap is being displaced away from the bone by the artery forceps to prevent palatal mucosal tears.
| Applying the Technique to Various Cleft Repairs|| |
von Langenbeck Repair
The normal procedural steps for this repair are followed, starting with peri-defect incisions and nasal closure. For mobilization of the neurovascular bundle, the lateral palatal incision is extended just posterior to the maxillary tuberosity. A mosquito artery forceps is inserted through this incision (taking care to be posterior to the palatal dimple) and used to elevate the soft palatal mucosa as previously described.
Bardach Two-Flap Repair
The normal procedural steps are followed from peri-defect incisions to nasal closure to raising the two palatal flaps. A mosquito artery forceps is inserted posterior to the dimple as previously described and used to elevate the greater palatine artery from its bed. The vessel is usually easily visible and almost skeletonized with resultant increased palatal flap mobility.
Isolated Cleft Palate Repairs
Isolated soft palatal cleft repairs seldom pose any problem with mobilization and tension-free closure. Some isolated cleft palate cases have variable extensions into the hard palate. In these cases, mobilization of the hard palatal tissue may be difficult. Palatal mobilization in such cases is greatly aided by a lateral palatal incision (similar to the von Langenbeck technique). From this incision, a mosquito artery forceps can be introduced distal to the palatal dimple as previously described to effect palatal mobilization.
| Discussion|| |
Adequate mobilization of the palatal flaps is one of the objectives while carrying out cleft palate repair. Challenges with palatal flap mobilization arise mostly due to the periosteal cuffing around the greater palatine artery. The technique described can provide increased mobility of the palatal flaps. This provides the advantages of closure without tension, allowing proper muscular readaptation to enhance velopharyngeal function, as well as decreasing the risks of palatal fistulas and wound dehiscence during the repair. The technique also reduces the risk of inadvertent damage to greater palatine artery by positioning all instrumentation behind and away from the vessel.
Dimple-assisted neurovascular bundle mobilization, however, results in a larger area of palatal mucosa separated from the palatal bones than other techniques. This larger area of separation could result in greater amounts of fibrous healing with resultant long-term mid-facial retrusion in the growing child. Mid-facial retrusion following cleft palate repair has however been documented with other cleft palate repair techniques., DANBM also has a risk of soft palatal mucosal tears where an insufficient amount of palatal tissue is displaced in a tongue-ward direction by the hemostat. The mucosal tears are avoidable and can be repaired using 3/0 or 4/0 vicryl sutures after completing the cleft palate repair.
A number of isolated soft palatal clefts can be adequately repaired without the need for additional palatal mobility using DANBM. The technique is versatile and can easily be adapted to the von Langenbeck repair and the Bardach repair. Furlow’s double-reversing "Z" palatoplasty, however, may also not require DANBM as the technique is limited to the soft palate and mobility in this region is rarely problematic.An alternative approach to ensuring palatal mobility without use of DANBM is to approach the neurovascular bundle through a lateral incision and lightly incise the periosteal cuffing on the posterior aspect of the vessel. This is however a blind procedure and requires some expertise to perform.
| Conclusion|| |
A simplified technique of palatal mobilization can enhance palatal cleft closure without tension, thereby reducing incidence of palatal fistulas. DANBM is a simple technique that is easily learnt and can be applied to wide palatal clefts to ensure closure without tension.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Landis P, Cuc T. Articulation patterns and speech intelligibility of 54 Vietnamese children with unoperated oral cleft: clinical observation and impressions. Cleft Palate J 1972;12:234-43.
Hoppenreijs T. Primary palatorraphy in the adult cleft palate patient: surgical, prosthetic and logopaedic aspects. J Craniomaxillofac Surg 1990;18:141-6.
Hupkens P, Lauret GJ, Dubelaar IJM, Hartman EHM, Spawn PHM. Prevention of wound dehiscence in palatal surgery by preoperative identification of group A Streptococcus
and Staphylococcus aureus
. Eur J Plast Surg 2007;29:321-5.
Abdurrazaq TO, Micheal AO, Lanre AW, Olugbenga OM, Akin LL. Surgical outcome and complications following cleft lip and palate repair in a hospital in Nigeria. Afr J Paediatr Surg 2013;10:345-7.
] [Full text]
Rossell-Perry P. Cleft palate surgery. Lima, Peru: San Marcos; 2014.
Diah E, Lo LJ, Yun C, Wang R, Wahyuni LK, Chen YR. Cleft oronasal fistula: a review of treatment results and a surgical management algorithm proposal. Chang Gung Med J 2007;30:529-7.
Ibrahim A, Mshelbwala P, Obiadazie A. A descriptive study of clefts of the primary and secondary palate seen in a tertiary health institution in Nigeria. Niger J Surg Res 2013;15:7-12. [Full text]
Sancho MA, Parri FJ, Raigosa JM, Lerena J, Cacéres F, Muñoz ME. Palatal necrosis in children: case report[in Spanish]. Cir Pediatr 2006;19:115-6.
Andersson EM, Sandvik L, Semb G, Abyholm F. Palatal fistulas after primary repair of clefts of the secondary palate. Scand J Plast Reconstr Surg Hand Surg 2008;42:296.
Musgrave RH, Bremner JC. Complications of cleft palate surgery. Plast Reconstr Surg 1960;26:180-9.
Helling ER, Dev VR, Garza J, Barone C, Nelluri P, Wang PT. Low fistula rate in palatal clefts closed with the Furlow technique using decellularized dermis. Plast Reconstr Surg 2006;117:2361-5.
Shi B, Losee JE. The impact of cleft lip and palate repair on maxillofacial growth. Int J Oral Sci 2015;7:14-7.
Farronato G, Kairyte L, Giannini L, Galbiati G, Maspero C. How various surgical protocols of the unilateral cleft lip and palate influence the facial growth and possible orthodontic problems? Which is the best timing of lip, palate and alveolus repair? Literature review. Stomatologija 2014;16:53-60.
Flores RL, Cutting CB. Cutting’s technique of cleft palate repair. In: Shi B, Sommerlad BC, Eds. Cleft lip and palate primary repair. Berlin: Springer.