MOC-CME

Evidence-Based Medicine: Cleft Palate

Kyle J. Chepla, M.D.
Learning Objectives: After reading this article, the participant should be able
Arun K. Gosain, M.D.
to: 1. Describe recent changes in treatment of cleft palate. 2. Compare the ef-
Cleveland, Ohio ficacy of different surgical treatments. 3. Assess their own knowledge of cleft
palate repair. 4. Determine where further individual in-depth study and devel-
opment are warranted.
Summary: The Maintenance of Certification in Plastic Surgery series is de-
signed to ensure professional development and measure continued competen-
cy within a specialty or subspecialty. The present article provides an evaluation
of the interval studies regarding the management of cleft palate with a specific
focus on craniofacial growth, speech outcomes, and obstructive sleep apnea
since the last Maintenance of Certification in Plastic Surgery article on the
subject published in 2010. This purpose of this article is to update plastic and
craniomaxillofacial surgeons on recent changes in treatment of cleft palate,
provide a means for accurate self-assessment, and guide further individual in-
depth study and development.  (Plast. Reconstr. Surg. 132: 1644, 2013.)

T
he incidence of isolated cleft palate is
approximately 0.1 to 1.1 per 1000 births and
varies by race, without a gender difference.
Multiple risk factors have been associated with
cleft palate and include genetic factors, terato-
gens (e.g., maternal alcohol intake, maternal
tobacco use, certain antiepileptic medications),
and several syndromes (i.e., Pierre Robin, velocar-
diofacial, Van der Woude, Apert, and Crouzon).
Cleft palate can involve only the soft palate
to varying degrees (incomplete cleft) or both the
soft and hard palate to the level of the incisive
foramen (complete cleft). Selection of the proper
corrective surgical technique is patient depen-
dent and should be based on the degree of palatal
involvement and the distance between the palatal
shelves. Repair of the hard palate typically uses var-
ious axial pattern flaps based on the greater pala-
tine arteries, and commonly used techniques for
repair of the hard palate include von Langenbeck
palatoplasty,1 Veau-Wardill-Kilner pushback,2–5
Bardach two-flap palatoplasty,6 and others.7
Repair of the soft palate requires dissection of the
anomalous palatal musculature to reposition the
levator palatini with variable manipulation of the
palatoglossus, palatopharyngeus, and tensor veli
palatini to restore the levator sling. Restoration of
From the Department of Plastic Surgery, University Hospi-
tals Case Medical Center.
Received for publication June 29, 2012; accepted July 13,
2012.
Copyright © 2013 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3182a80952
the normal muscular anatomy was first described
by Braithwaite8 in 1964 and subsequently radically
modified in 1970 by Kriens,9 who coined the term
“intravelar veloplasty.” Again, there are many com-
monly used techniques for recreating the levator
sling, including the double-opposing Z-plasty10,11
and those described by both Cutting et al.12 and
Sommerlad et al.13,14 Regardless of the technique
used, the goals of cleft palate repair remain as
follows: (1) lengthen the palate to minimize the
incidence of postoperative velopharyngeal insuffi-
ciency and promote proper speech development,
(2) minimize maxillary and alveolar growth dis-
turbances, and (3) prevent fistula formation.
The previous cleft palate Maintenance of Cer-
tification in Plastic Surgery article published in
201015 reviewed evidence-based literature with a
specific focus on preoperative assessment, anes-
thesia/analgesia, surgical technique, and patient
outcomes. In this article, we evaluate the interval
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
browser to access this content. Clickable links
to the material are provided in the HTML text
of this article on the Journal’s Web site (www.
PRSJournal.com).

1644 www.PRSJournal.com
Volume 132, Number 6 • Cleft Palate

literature and review articles with a high level of

evidence on cleft surgery with a specific focus on
maxillary growth, postoperative speech changes,
and obstructive sleep apnea. We also provide
a synopsis of our approach and treatment of a
patient with cleft palate, and videos demonstrat-
ing the Furlow double-opposing Z-plasty in a
patient with submucous cleft palate and a two-flap
palatoplasty in a patient with complete bilateral
cleft palate. (See Video, Supplemental Digital
Content 1, which demonstrates Furlow palato-
plasty, available in the “Related Videos” section
of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/A916; and Video 1. Supplemental Digital Content 1, which demonstrates
Video, Supplemental Digital Content 2, which Furlow palatoplasty, is available in the “Related Videos” section
demonstrates two-stage palatoplasty, available of the full-text article on PRSJournal.com or, for Ovid users, at
in the “Related Videos” section of the full-text http://links.lww.com/PRS/A916.
article on PRSJournal.com or, for Ovid users, at
http://links.lww.com/PRS/A917.)

ARTICLE SEARCH AND EVALUATION

A search of the PubMed database was per-
formed using the following terms: “cleft palate,”
“obstructive sleep apnea,” “maxillary growth,”
“maxillary development,” “craniofacial growth,”
“veloplasty,” “velopharyngeal insufficiency,” and
“speech.” The search was limited to studies pub-
lished since the last Maintenance of Certification
in Plastic Surgery article in 2009. All abstracts
were reviewed to determine level of evidence
as defined by the American Society of Plastic
Surgeons Evidence Rating Scale for Therapy Video 2. Supplemental Digital Content 2, which demonstrates
(Table 1) and were grouped by area of focus two-stage palatoplasty, is available in the “Related Videos” sec-
(maxillary growth, speech, obstructive sleep tion of the full-text article on PRSJournal.com or, for Ovid users,
apnea). Studies of patients with bilateral cleft lip at http://links.lww.com/PRS/A917.
and palate were excluded from review; however,
studies evaluating outcomes for patients with patients who are yet to undergo surgical repair,
either isolated cleft palate or unilateral cleft lip and nonclefted controls, to better elucidate skel-
and palate were included. etal changes. Chen et al.16 compared patients with
uncorrected cleft palate to noncleft controls and
MAXILLARY AND FACIAL GROWTH demonstrated a significant reduction in maxillary
Cleft palate is known to alter normal facial sagittal length (anterior nasal spine to posterior
skeletal development. Two recent studies com- nasal spine) and maxillary retrusion (decreased
pared facial growth in patients after surgery, sella, nasion, A point angle) in the uncorrected

Table 1.  American Society of Plastic Surgeons Evidence Rating Scale for Therapeutic Studies
Level of Evidence Qualifying Studies
I High-quality, multicenter or single-center, randomized controlled trial with adequate power; or systematic
review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or systematic review of these studies
III Retrospective comparative study, case-control study, or systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or “first
principles”

1645
 Plastic and Reconstructive Surgery • December 2013
cleft group. Another study of dental-arch mor-
phology in patients with surgically corrected cleft
palate demonstrated a significantly decreased
maxillary arch width and anterior arch length
compared with nonclefted control patients and
patients with uncorrected isolated cleft palate.17
More controversial is how surgical repair, par-
ticularly the timing, number of surgical stages, and
technique used, impacts maxillary growth. Several
authors argue that flap elevation damages the
periosteum and that subsequent postsurgical scar-
ring negatively impacts maxillary growth, which
could be minimized using a two-stage approach
with delayed repair of the hard palate.18–20 How-
ever, proponents of early, single-stage repair main-
tain that early closure improves speech outcomes
through promotion of proper phonologic devel-
opment and decreases articulation disorders asso-
ciated with velopharyngeal insufficiency, and that
the benefits of improved speech outcome out-
weigh potential maxillary growth restriction that
may ensue.21
Several recent studies comparing one-stage
versus two-stage cleft palate repair report conflict-
ing results with respect to subsequent maxillary
growth restriction. Yamanishi et al.19,22 compared
growth outcomes following a two-stage repair
consisting of Furlow palatoplasty at 12 months
followed by hard palate closure at 18 months,
to a single-stage Wardill-Kilner pushback at 12
months of age in 30 patients (Reference 19, Level
of Evidence: Therapeutic, III). Cephalometric
analysis at 4 years of age demonstrated a statisti-
cally significant increase in maxillary length and
anterior facial height in patients who underwent
a two-stage repair. In contrast, other studies have
failed to demonstrate significant maxillary growth
disturbance following single-stage elevation of
palatal mucoperiosteal flaps. Pradel et al.21 found
an increase in anterior and posterior transverse
dental arch width at 6 years of age when single-
stage intravelar veloplasty of the soft palate and
bipedicled mucosal flap closure of the hard pal-
ate was performed at 9 to 12 months compared
with patients undergoing two-stage repair. Liao et
al.18 randomized 72 patients to either one-stage or
two-stage cleft palate repair with delayed closure
of the hard palate. In this study, serial cephalo-
metric analysis until 20 years of age demonstrated
no difference in growth rate between the groups
but a decrease in maxillary length and protrusion
in patients who underwent single-stage repair. De
Mey et al.23 randomized 72 patients to single-stage
closure at 3 months of age or two-stage repair with
soft palate closure at 3 months and hard palate
1646
repair at 6 months of age (Level of Evidence:
Therapeutic, II). Cephalometric data at age 15
years was used to compare the patients to non-
clefted controls. At 10-year follow-up, the two-
stage repair demonstrated significantly reduced
anteroposterior maxillary growth compared with
controls; however, no significant difference was
seen between the two surgical groups. Finally, no
difference in sagittal growth on lateral cephalo-
grams was seen in a study evaluating single-stage
cleft palate repair versus two-stage repair at 12
months (soft palate) and 30 months (hard palate)
in a study by Zemann et al. (Level of Evidence:
Therapeutic, III).24
Another study examined the extent of muco-
periosteal flap elevation, which is believed to cause
maxillary growth disturbances, in patients under-
going single-stage repair. Kulewicz and Dudkie-
wicz25 evaluated long-term morphologic outcomes
using lateral cephalometric analysis after single-
stage surgical correction at age 7 months in 66
patients with unilateral cleft lip and palate (Level
of Evidence: Therapeutic, III). The patients were
divided into three groups based on the technique
of hard palate repair: group I, mucoperiosteal flap
elevated on both sides of the cleft; group II, mini-
mal (2 to 3 mm) mucoperiosteal dissection on
the cleft side and normal dissection on the non-
cleft side; and group III, single-layer closure using
vomer mucoperiosteal flaps and minimal palatal
mucoperiosteal elevation bilaterally. Cephalomet-
ric analysis demonstrated a significant reduction
in anteroposterior maxillary prominence (group
I versus groups II and III) and anterior vertical
maxillary height (group I versus group III). Group
III had the lowest number of significant growth
disturbances on cephalometric measurements
compared with noncleft age-matched controls;
however, there was no statistically significant dif-
ference between the three groups. Finally, evalu-
ation of the impact of cleft size, as a percentage
of total palatal surface area in 39 infants, using
lateral and posteroanterior cephalometric radio-
graphs, demonstrated a significant correlation
between increased cleft size and decreased maxil-
lary length and protrusion.26
SPEECH OUTCOMES
A properly functioning velopharyngeal mech-
anism is critical to proper speech development
and remains one of the primary goals of cleft
palate repair. Repositioning of the levator sling
and recreation of the normal anatomy results in
velopharyngeal competence for most patients
Volume 132, Number 6 • Cleft Palate
and reduces the need for secondary pharyngeal
flaps.27 In a study by Sullivan et al.,28 persistent
postoperative velopharyngeal insufficiency was
shown to be associated with patient age at palato-
plasty (timing), and degree of palatal involvement
(Veau score) (Level of Evidence: Therapeutic/
Prognostic, IV). They conclude that early, single-
stage repair reduces the development of learned,
compensatory misarticulations that can persist
despite surgical correction of the palatal anatomy,
but must be weighted against altered facial growth
secondary to early disruption of the maxillary
periosteum and soft-tissue envelope.
Willadsen29 recently reviewed the impact of
the timing of hard palate repair on speech out-
comes. Thirty-four children underwent two-stage
cleft surgery with velar repair at 4 months of age
and repair of the hard palate at either 12 months
(early) or 36 months (late) (Level of Evidence:
Therapeutic, II). Evaluation 18 months postop-
eratively demonstrated that the group that under-
went late repair of the hard palate produced fewer
labial stops and more velar stops, fewer vocaliza-
tions, and consonants permissible in word-initial
position. Thirty-six months postoperatively, this
group demonstrated a severely restricted phono-
logic system with more cleft speech characteristics.
Pradel et al.21 evaluated speech outcomes after
either a single- or two-stage cleft palate repair
(Level of Evidence: Therapeutic, III). Twelve chil-
dren underwent a two-stage repair with intravelar
veloplasty at age 9 to 12 months and repair of the
hard palate using bipedicled flaps at age 24 to 36
months, and 12 children underwent a single-stage
intravelar veloplasty and bipedicled flap repair
at age 9 to 12 months. At 4 years of age, patients
who underwent single-stage repair demonstrated
less altered resonance and less nasal emission.
When reevaluated at age 6 years, the children who
underwent two-stage repair had improved their
speech skills but still had not attained a level equal
to patients who had undergone single-stage palate
repair. This is in contrast to a study by Yaminishi
et al.19 that compared 30 patients who underwent
early two-stage double-opposing Z-plasty at 12
months and hard palate repair at 18 months, to
42 patients who underwent single-stage Wardill-
Kilner push-back palatoplasty at 12 months of age.
In this study, no statistically significant difference
was seen in the incidence of velopharyngeal insuf-
ficiency or articulation errors at 4 years of age.
Two techniques of palatal repair were com-
pared by Williams et al.,30 who randomized patients
to either a Furlow double-opposing Z-plasty or
a von Langenbeck palatoplasty with intravelar
veloplasty (Level of Evidence: Therapeutic, II).
Postoperative velopharyngeal function, measured
using a cul-de-sac test of hypernasality and mir-
ror test of nasal air emission, was significantly
improved in the group that had undergone Fur-
low double-opposing Z-palatoplasty.
OBSTRUCTIVE SLEEP APNEA
A recent retrospective study examined the inci-
dence of sleep-disordered breathing or obstruc-
tive sleep apnea in 459 cleft palate patients and
demonstrated a significantly increased incidence
of sleep-disordered breathing (37.5 percent) and
obstructive sleep apnea (8.5 percent) compared
with age-matched controls (Level of Evidence:
Prevalence, IV).31 No recent studies have evalu-
ated how surgical repair of the cleft palate may
help or worsen this condition.
CONCLUSIONS
The present literature review demonstrates
that many of the important issues surround-
ing repair of the cleft palate remain controver-
sial. Since the last Maintenance of Certification
in Plastic Surgery article on cleft palate repair
by Liau et al.,15 there is still no consensus in the
interval literature regarding the proper timing of
repair, number of stages, or surgical technique(s)
to maximize speech outcomes and minimize the
impact on long-term skeletal growth and facial
development. Although cleft severity will always
vary between patients, we believe that there should
not be an unstandardized approach to surgical
repair. We echo the assessment by Yang and Liao32
who, following a literature review of facial growth
after one- or two-stage palate repair, concluded
that there is still a need for well-designed, ran-
domized, prospective, long-term studies (Level
of Evidence: Therapeutic, III). Studies with a
high level of evidence will possibly one day guide
selection of surgical technique and the timing of
repair to optimize surgical and patient outcomes.
In the absence of such a consensus, we advocate
a single-stage repair of the hard and soft palate
at 9 to 12 months of age as demonstrated in the
accompanying videos. (See Video, Supplemen-
tal Digital Content 1, http://links.lww.com/PRS/
A916; and Video, Supplemental Digital Content
2, http://links.lww.com/PRS/A917.) We believe that
early surgical repair significantly improves speech
outcomes and that there is currently insufficient
evidence demonstrating a clinically relevant max-
illary growth disturbance relative to two-stage
1647
 Plastic and Reconstructive Surgery • December 2013
or late repairs. We institute regular orthodontic
follow-up through a multidisciplinary team begin-
ning at age 3 years, allowing us to monitor facial
and dental development carefully and initiate
palatal expansion with the onset of mixed denti-
tion when necessary. Regular visits through the
multidisciplinary team can identify and prepare
patients who may require subsequent orthogna-
thic surgery. We believe that late correction of
skeletal deficiency can yield a normal facial pro-
file, whereas late correction of refractory errors
secondary to prolonged velopharyngeal insuffi-
ciency is a much more difficult prospect, with far
less satisfying results.
Arun K. Gosain, M.D.
225 E. Chicago Avenue, Box 93
Chicago, Ill. 60611
argosain@luriechildrens.org
ACKNOWLEDGMENT
The authors offer special thanks to Matt Sugerik for
help in recording and editing the surgical videos.
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