68 
Technique for Cleft Palate Repair
Brian Sommerlad, Serryth Colbert
KEY POINTS
• The main debates over indications in cleft palate repair are
about timing and whether closure of the hard palate
should be delayed.
• The author’s technique of cleft palate repair involves a
single layer vomerine flap closure of the hard palate at lip
repair to repair the hard palate and nasal floor.
• Twenty percent of cleft palate cases require lateral releasing
incisions—the von Langenbeck technique.
INTRODUCTION
Embryology
The palate is formed by the palatal processes of the maxilla. The
central part of the lip (prolabium) and the premaxilla arise
from the medial nasal prominences of the frontonasal process
and the lateral alveolar segments from the lateral processes of
the maxilla. The primary palate, embryologically, is that part of
the anterior palate, alveolus, and lip in front of the incisive
foramen. This fuses from behind forward in the fifth to sixth
week of intrauterine life. The secondary palate fuses from the
incisive foramen in the seventh to eighth week of intrauterine
life. Each of these processes may be arrested at any point, and
this accounts for the varying types of clefts of the lip and palate
(see Chapter 67, Figures 67-2 and 67-3).
Types
Clefts of the palate may occur alone or be associated with uni-
lateral or bilateral cleft lip. They may be complete or incomplete
and if incomplete may involve soft palate alone or soft and part
of the hard palate.
Submucous cleft palate (SMCP) is a condition where the
mucosa is largely intact (apart, classically, from a bifid uvula)
but the musculature is similar to that seen in a complete cleft
palate.
One method of describing palatal type is the “striped-Y”
technique (see Chapter 67, Figure 67-4).1
Morphology
In a unilateral cleft lip and palate (UCLP), the vomer is attached
to the palate on the non-cleft side. The cranial portion of the
vomer is almost vertical, and the caudal part is angulated (often
at almost 90 degrees) toward the palatal shelf to which it is
attached (see Chapter 67, Figure 67-21).
972
• The Veau-Wardill-Kilner pushback procedure should be
consigned to history.
• The Sommerlad intravelar veloplasty has the least negative
impact on maxillary growth and is associated with good
speech outcomes.
In a complete bilateral cleft lip and palate (BCLP), the vomer
passes back from the premaxilla and is not attached to the
palatal shelves (see Chapter 67, Figure 67-15).
In an isolated cleft palate, the vomer is usually midline
and vertical and attached to the hard palate as far back as the
anterior extent of the cleft (see Chapter 67, Figure 67-21).
In clefts of the soft palate alone, the vomer is not involved.
Isolated clefts of the palate are sometimes divided into V-shaped
clefts and U-shaped clefts, although the distinction is often
not clear.
The classical SMCP shows the features of:
• Bifid uvula
• Notch of the hard palate
• Diastasis of the soft palate (velar) musculature
Kaplan described the occult SMCP, where these typical fea-
tures did not exist.2 Sommerlad and colleagues argued that
there was a spectrum of severity in submucous clefting and
described a scoring technique where the degree of abnormality
of the triad was scored according to severity.3 Although usually
regarded as a separate entity from isolated cleft palate, SMCP is
probably just part of the spectrum. Functionally, the effects of
a submucous cleft on feeding and speech may be just as severe
as those of a complete cleft.
Incidence
The incidence of cleft lip and palate in Caucasians is about 1
per 1000 and of isolated cleft palate about 1 per 1500. The
incidence of SMCP has been given as 1 in 2000, but this depends
on a diagnosis that is less accurate. Clefts of the lip and palate
are more common in Asians (approximately 1.8 per 1000) and
less common in Afro-Caribbeans (about 0.4 per 1000). They are
also more common in males than in females. In contrast, iso-
lated clefts of the palate demonstrate little difference in either
sex or racial incidence.
 CHAPTER 68  Technique for Cleft Palate Repair
Etiology
There are several hypotheses regarding the pathogenesis of cleft:
• Hypoplasia: The palatal shelves are simply too small to meet
at the critical time.
• Dysplasia: The palatal shelves may be prevented from joining
by the tongue or, rarely, hamartomas or other space-
occupying lesions.
• Breakdown: In some situations, there may be a tenuous
union that breaks down.
Different mechanisms may be responsible.
Etiological Factors
The current view is that the etiology of cleft palate is multifacto-
rial. However, some relevant factors are:
• Genetic: Cleft palate associated with cleft lip may have a
genetic basis in that the incidence in a first-degree relative
(offspring or sibling) is approximately 40 times as common
as the rest of the population. In isolated cleft palate, the
genetic influence appears to be less marked. A number of
genes associated with clefts have been identified, but their
significance is still uncertain in most cases.
• Teratogens: There is good evidence that maternal smoking
increases the incidence of clefting, as does high alcohol
intake and certain antiepileptic drugs (such as, phenytoin
and sodium valproate).
• Syndromes: See later.
Anatomy
The musculature of the cleft velum is disordered. The levator
palati muscle arises from its normal origin in the skull base and
passes downward and medially to be inserted into the cleft
margin in the anterior half of the velum (but not directly into
the back of the hard palate as commonly stated). This is in dis-
tinction to the anatomy in the normal cleft velum, where the
levator muscle reaches the midline in the middle 40% of the
velum.4 The palatopharyngeus and the palatoglossus muscles
(on the oral or caudal side of the velum) are also attached some-
what anteriorly with fibers fanning out—the more lateral fibers
being orientated in a lateroposterior direction and passing
toward the maxillary tuberosity and the more posterior fibers
being more oblique. These fibers occupy the anterior two-thirds
to three-quarters of the velum. In contrast, in the normal cleft
velum, these fibers rarely reach the back of the hard palate. The
presence of the musculus uvulae muscles in the cleft palate is
controversial and rarely seen (except, possibly, in some very
occult submucous clefts). The role of the musculus uvulae in the
non-cleft is debated. Its absence has been thought by some to
produce the V-shaped groove or lack of convexity of the nasal
surface of the palate and therefore to be a major cause of velo-
pharyngeal incompetence (VPI).4 It may have a role in elevation
of the posterior velum to increase contact with the posterior
pharyngeal wall after elevation of the velum by the levator.
Others argue that the musculus uvulae may not be very impor-
tant in normal velopharyngeal function.4 The tensor palati
muscle is not actually a palatal muscle but passes down from
skull base to the pterygoid hamulus where, in the cleft, it par-
tially attaches and appears to diverge into two components: (1)
a triangular tendinous insertion into the back of the hard palate,
lying closely applied to the nasal mucosa, and (2) a more flimsy
component, which passes orally toward the oral surface. In the
normal palate, in comparison, the tensor tendon surrounds the
973
hamulus (to which it is also partially attached) and then fans out
to form the palatal aponeurosis (the anterior third of the velum).
Hearing
There is an increased incidence of serous otitis media (glue ear)
in babies with clefts of the palate. This is probably due to the
abnormal anatomy of the palatal muscles. Both the levator
palati and the tensor palati muscles have a role in eustachian
function.
Associated Syndromes
In cleft palates associated with cleft lip (UCLP and BCLP),
associated syndromes occur in probably less than 10% of cases.
However, in isolated cleft palate associated syndromes are
described in up to 50%. The most common syndromes are:
• Pierre Robin syndrome: Better described as a sequence,
because it is a descriptive term to describe a cleft palate
(usually U-shaped) associated with a small jaw (microgna-
thia), a retrodisplaced tongue, and, classically, airway prob-
lems in the neonatal period. The Pierre Robin sequence
includes patients with:
• Sticklers syndrome: Where there is associated myopia and
joint problems
• Craniofacial microsomia
• Treacher Collins syndrome
• Velocardiofacial syndrome (22q11.2 deletion syndrome):
This microdeletion, identified by the fluorescent in situ
hybridization (FISH) test, may be associated with overt cleft
palate, classical SMCP and varying degrees of less classical
SMCP, and, in some cases, simply VPI with no apparent
palatal abnormality.
• Van der Woude syndrome: This autosomal dominant condi-
tion (with varying expressivity) is usually diagnosed because
of associated lower lip pits, and it is unusual in that it may
be expressed as either cleft lip, with or without cleft palate,
or isolated cleft palate.
• Apert and Crouzon syndromes: In these syndromes, the cleft
is unusual in that there is usually a very high arched palate.
There are, however, many other syndromes associated with
clefting.
SURGERY
Cleft Palate (CULP, Bilateral Cleft Lip and Palate,
and Isolated Cleft Palate)
The main debates over indications in cleft palate repair are
about:
• Timing
• Whether closure of the hard palate should be delayed
It is generally agreed that at least the soft palate should be
repaired ideally before 12 months old. The main contraindica-
tions to palate repair at the optimal age are:
• Associated conditions: An example is congenital cardiac con-
ditions, which result in an unacceptable anesthetic risk.
• Suboptimal weight: Although repair of the palate may
improve feeding and actually increase weight gain.
• Unrepaired clefts in an adult: Arguably, compensatory pat-
terns of articulation may be so well embedded in some adults
with unrepaired clefts that palate repair is unlikely to make
very much difference to speech. Certainly, such patients
usually require considerable speech therapy input.
Repair of the SMCP is not always mandatory.
974 CHAPTER 68  Technique for Cleft Palate Repair

PREOPERATIVE HISTORY AND CONSIDERATIONS
Management in the Neonatal Period
Feeding
Because of reduced ability to suck and particularly to draw the
nipple into the mouth, babies with clefts of the palate usually
have some difficulty feeding, and breastfeeding can only be
achieved with considerable efforts and modification of tech-
niques. In the Western world most babies with cleft palates are
mostly bottle fed, although many mothers use expressed milk.
The principle of bottle feeding is to allow a steady stream of
milk, usually by a modified teat and a soft bottle.
Airway
Babies with Pierre Robin sequence may have significant airway
problems, largely because of the retrodisplaced tongue, which
obstructs both the nasal and the oral airway.
Many would argue about the indications for each of these
techniques and the order of this algorithm. There are enthusi-
asts for tongue-lip adhesions and others who rarely perform
them. The role of mandibular distraction is debated. All would
agree that tracheostomy is best avoided if possible, but it can be
life-saving and can result in a previously underweight baby
thriving by reducing the work of respiration. However, trache-
ostomy has a morbidity and mortality rate. Nasopharyngeal
airways are a very safe and nonsurgical solution for many
patients. However, the introduction and positioning is critical.
They can be managed by parents at home.5
Pre-Surgical Orthopedics
There has been much controversy about the role of pre-surgical
orthopedics. These involve a plate, which may be active or
passive. In clefts of the lip, this may be associated with tech-
niques of strapping or nasoalveolar molding. A recent prospec-
tive randomized controlled trial failed to show benefits for
feeding or significant benefits for speech.6
premaxilla and vomer to become continuous with the lateral lip
incision (see Chapter 67, Figure 67-21). The flap is elevated and
inserted underneath the oral mucoperiosteum, which has been
elevated following incision at the margins of the cleft using a
Beaver 69 blade. Double-breasting of the flap beneath the oral
mucoperiosteum is important to achieve successful closure (see
Chapter 67, Figure 67-22). In a bilateral cleft, complete eleva-
tion of the vomerine flap on both sides may jeopardize the
blood supply of the premaxilla and prolabium. The author now
carries out only a very conservative vomerine flap on the second
side (usually the narrowest) with the flap not being elevated
only behind the pre-vomerine suture.
In unilateral clefts of the lip and palate, this results in a
degree of closure in most cases, which leaves virtually a cleft of
the soft palate for palate repair. Closure will be less adequate on
the less radically treated side in a bilateral cleft.
Palate Repair
At palate repair, the author aims to repair the cleft from the
margins without lateral releasing incisions. This is now possible
in approximately 80% of cases, and in only about 20% of cases
are lateral releasing incisions (the von Langenbeck technique8,9)
necessary (Figure 68-1).
The operative steps are as follows:
1. Insertion of a modified mouth gag (Figure 68-2).10 This is
designed to allow good exposure, particularly with an oper-
ating microscope, to avoid compression of the endotracheal
tube against the mandible.
2. Insertion of a gauze throat pack.
3. Infiltration of local anesthetic with adrenaline.

Hearing
Neonatal assessment of hearing, as in all babies, is important.
If there is evidence of persistent conductive hearing loss or glue
ear in a cleft baby, it may be necessary to insert ventilation tubes
(grommets) at the time of palate repair. There is some evidence Bilateral von
that repairing the palate musculature improves eustachian Langenbeck
function and therefore hearing, and the author prefers to defer relieving
grommet insertion and reassess the hearing 3 to 6 months after incisions
surgery. If there is persistent significant hearing loss at that
stage, either grommet insertion or short-term hearing aids are
recommended.

OPERATIVE APPROACH
The Author’s Technique
Single Layer Vomerine Flap Closure of the Hard Palate
at Lip Repair
The author aims to repair the entire palate at 6 months. The
operating microscope has been used in all palate repairs since
1991.7 Since 1993, the author has used a single layer vomerine
flap closure of the hard palate in clefts of the lip and palate to
repair the hard palate and nasal floor.7 An incision is made at
the junction of palatal and vomerine mucosa, extending poste-
riorly down the crest of the vomer and anteriorly around the FIG 68-1  Cleft margin incision with von Langenbeck relieving
side of the premaxilla on the oral side if the groove between the incisions bilaterally. (Courtesy Steve Atherton and David Drake.)
 CHAPTER 68  Technique for Cleft Palate Repair 975

Modified
mouth
gag

FIG 68-2  Modified mouth gag. (Courtesy Steve Atherton and FIG 68-3  Incision along cleft margin at junction of oral and nasal
David Drake.) mucosa. (Courtesy Steve Atherton and David Drake.)

4. Incision along the margin of the cleft at the junction of the

oral and nasal mucosa (Figure 68-3). This junction is
usually clearly seen, because the nasal mucosa is more pink
and telangiectatic or more pigmented in patients with
darker skin and is usually on the oral side of the edge of the
cleft. This incision extends from the midline in the front of
the cleft far enough to enable the oral flaps to be elevated
in a subperiosteal plane, to expose the bony palatal shelves
(Figure 68-4).
5. The oral mucoperiosteal flaps are elevated with the dissec-
tion extending back to the posterior edge of the hard palate.
There are frequently dimples seen on the oral side of the
palate at a point where oral mucous glands are attached to
the posterior border of the hard palate and anterior tensor
palati tendon. Care needs to be taken to elevate these
mucous glands intact from the posterior border of the hard
palate and the white tendinous nasal component of the
tensor palati tendon.
6. If necessary, the greater palatine neurovascular bundle is
exposed, and an instrument is passed around the greater
palatine neurovascular bundle to free it—sometimes after
gentle incision of the periosteal sheath surrounding it. This
step of the procedure is only undertaken in wider clefts,
where radical mobilization of the oral layer is necessary.
7. The oral component of the tensor tendon can be seen and
felt behind the greater palatine vessels, and this is incised if
necessary to achieve mobilization of the oral layer.
8. The dissection is continued back into the soft palate, sepa-
rating the oral mucosa and underlying mucous glands from FIG 68-4  Oral flap elevated, exposing palatal shelf. (Courtesy
the underlying musculature—the palatopharyngeus and Steve Atherton and David Drake.)
976 CHAPTER 68  Technique for Cleft Palate Repair
FIG 68-5  Mobilization of nasal mucosa from nasal surface of
palatal shelf. (Courtesy Steve Atherton and David Drake.)
palatoglossus muscles. This is done by a combination of
knife and blunt dissection and extends to the posterior
border of the vomer laterally to the pterygoid hamulus.
9. The nasal mucosa is then mobilized if necessary from the
nasal surface of the palatal shelves (Figure 68-5). This is best
done after an incision at the edge of the palatal shelves, and
then a blunt dissection is made in a subperiosteal plane.
10. The nasal mucosa, with its attached muscle, is then sutured
with non-absorbable sutures (the author uses 5/0 Monocryl)
inserted in the nasal mucosa close to the edge but then
picking up more of the mucous glands (and a little muscle
anteriorly). The aim is a suture that will evert the nasal layer
toward the nasal surface (Figure 68-6).
11. Where a vomerine flap has been used for closure of the hard
palate in UCLP at the time of lip repair, a posterior-based
flap of the neo-mucosa overlying the vomer may be raised
to facilitate closure of the anterior nasal layer.
12. An incision is then made on each side of the midline, begin-
ning 3 to 5 mm from the midline posteriorly, and passing
closer to the midline anteriorly, just lateral to the previously
inserted nasal layer sutures. This knife dissection extends
deeply to the nasal mucosa, leaving mucous glands laterally.
The nasal mucosa is recognized because of its almost blue
color and a fine plexus of vessels running on it. Using knife
dissection and a sucker for retraction, the plane is then
developed between the nasal mucosa and the palatal
muscles. This allows the nasal surface of the levator palati
muscle to be identified as it passes toward the cleft margin
in the anterior half of the velum.
13. With a skin hook in the musculature, the palatopharyngeus
medially and the nasal component of the tensor tendon
FIG 68-6  Closure of nasal layer with eversion of nasal mucosa
toward nasal surface. (Courtesy Steve Atherton and David
Drake.)
laterally are divided from the back of the hard palate by
knife dissection to the nasal mucosa and by a combination
of gentle knife incision and brushing back, the beginning
of the retrodisplacement of the musculature is performed.
14. The knife then turns almost at right angles and in an
anteroposterior direction, and most of the tensor palati
tendon is divided just medial to the hamulus.
15. With tension maintained on the muscle, the combined
levator palati and palatopharyngeus muscle is further retro-
displaced with a combination of sharp and blunt dissection.
When the most posterior fibers of the tensor palati tendon
are divided medial to the posterior end of the hamulus, a
noticeable freeing is usually achieved, and the palatopha-
ryngeus fibers can be split with a dental scaler to demon-
strate the levator palati muscle with its thin sheaths passing
cranially toward the skull base. Frequently there is a vessel
lying anterior to the levator palati muscle, and a small
branch passing anteriorly can be divided after coagulation,
leaving the major vessel intact as it is retrodisplaced.
16. Dissection continues until the muscle bundle is free from
the nasal layer and mobile (Figure 68-7). Care is taken to
avoid unnecessary damage to the neurovascular structures.
17. A stab incision is made into the nasal mucosa (unless an
accidental hole has been created). This helps to avoid a
hematoma.
18. The muscle is united, usually in the posterior half of the
velum, with non-absorbable 4/0 or 5/0 nylon sutures
(Figure 68-8). The posterior suture is inserted to maintain
correct orientation and rotation of the muscles. Two sutures
are then inserted in the levator palati muscle. The knots are
on the nasal side. The anterior of these muscle sutures
 CHAPTER 68  Technique for Cleft Palate Repair 977

FIG 68-7  Levator palati muscle bundle mobilized and free from FIG 68-9  Closure of oral layer with bilateral von Langenbeck
nasal layer. (Courtesy Steve Atherton and David Drake.) relieving incisions. (Courtesy Steve Atherton and David Drake.)

includes the divided and retrodisplaced tendons of the

tensor palati tendon.
19. Closure of the oral layer commences. The first suture in the
oral layer is inserted just in front of the retrodisplaced
muscle sling and picks up the nasal mucous glands. A
twisted loop mattress suture is used at this point and usually
one or two further sutures anteriorly.11 (A twist in the loop
with the needle inserted through the twisted loop from the
side to which it is twisted reduces the likelihood of stran-
gulating the small segments of oral mucosa.) The aim of
these sutures, uniting oral and nasal layers, is to keep the
muscle in a posterior position and to occlude dead space
and further reduce the chances of hematoma. The author
uses a 4/0 Monocryl suture on a modified 5/8 curved needle
(Ethicon B-17).
20. Closure of the remainder of the oral layer overlying the
muscle and including the uvula and also anteriorly is com-
pleted. In very wide clefts (usually more than 10 mm in
Levator
width at the back of the hard palate and 6 mm in the hard
palati
united palate), lateral releasing incisions are sometimes necessary
(in about 20% of cases), and these lateral releasing incisions
are sometimes made prospectively at the beginning of the
procedure if it is thought that they will be necessary, but
otherwise they are sometimes performed at the end of the
procedure if closure, particularly at the junction of hard
and soft palate, is thought to be too tight (Figure 68-9).
However, the tension in the oral layer is reduced as soon as
the gag is released, and it may be worth partly releasing the
gag and retesting the tension before embarking on late
FIG 68-8  Levator palati muscle bundles united in posterior half lateral releasing incisions.
of velum. (Courtesy Steve Atherton and David Drake.) 21. After aspiration of the pharynx, the throat pack is removed.
978 CHAPTER 68  Technique for Cleft Palate Repair
22. The author then performs a suction test, which involves
putting a sucker in one nostril, occluding the nose around
it, and testing the passive length and mobility of the velum.
If the velum closes against the posterior pharyngeal wall
spontaneously and stays up when the suction catheter is
removed, this is graded as follows:
0—No closure
1—Remains elevated after gentle elevation with finger
2—Elevates spontaneously
3—Remains elevated after removal of the sucker
This has been shown to be predictive of outcome in both
primary repairs and palate re-repairs.
Submucous Cleft Palate Repair
The SMCP is repaired using a similar technique with the fol-
lowing differences:
• The incision does not have to reach as far forward, but the
oral flaps do need to be elevated subperiosteally to expose
the back of the hard palate.
• Mobilization of the greater palatine vessel and division of the oral
component of the tensor palati tendon should not be necessary.
• The aim is to keep the nasal layer intact. This can be chal-
lenging in patients with a very thin translucent zone. In these
cases, careful instillation of local anesthetic between the oral
and nasal layers may facilitate this dissection, which should
be made with a knife.
• The dissection lateral to the midline needs to be carried out
with care. There are often very few nasal mucous glands
present and the nasal layer may be thin.
ALTERNATIVE TECHNIQUES
Pushback Procedures
A three or four flap Veau-Wardill-Kilner pushback procedure,
which aimed to lengthen the palate, has not been shown to be
effective in improving speech and almost certainly increases the
incidence of crossbite and maxillary retrusion.12-15 It may result
in fistulae at the junction of the flaps, which can be extremely
difficult to close. The author believes that this technique should
be consigned to history.
The Two-Flap Technique
The long two-flap technique, which was popularized by Bardach,
does not aim to achieve pushback but is believed by its propo-
nents to improve exposure.16 Many specialists simply replace
the flaps to avoid leaving raw areas.
The Double Opposing Z-plasty
The double opposing Z-plasty technique, as described by
Furlow, is popular in many centers.17 It may be performed
without lateral releasing incisions or with lateral releasing inci-
sions.18 The aim is to achieve lengthening of the velum by
Z-plasty and retrodisplacement of the muscle with the mucosal
Z flaps, with the muscle left attached to the oral flap on one side
and the nasal flap on the other.
Many surgeons feel unhappy with this technique in wide
clefts and, therefore, use it in easy and narrow clefts. It is diffi-
cult to compare outcomes with other techniques.
Delayed Hard Palate Closure
The technique of delayed hard palate closure was pioneered by
Schweckendiek, who repaired soft palate at about 18 months
old and delayed repair of the hard palate until 12 years old.19
Others have repaired the hard palate at 7 to 8 years old or
younger.20 The soft palate closure may be performed by a similar
technique to that described by the author. Closure of the ante-
rior nasal layer may be facilitated by a posteriorly based flap
from the vomer.
POSTOPERATIVE CARE
Airway
The airway may be compromised in the early postoperative
period. A tongue stitch, inserted at operation, may be a useful
emergency measure. If problems are anticipated, a nasopharyn-
geal airway can be very helpful but needs to be of appropriate
length (with the end situated below the palate but above the
epiglottis) and requires regular effective suction. A blocked
nasopharyngeal airway is worse than none.
Feeding
The author allows babies to feed immediately after repair by
whichever method they fed before. This needs to be linked with
effective analgesia, which does not sedate the baby too much.
Antibiotics
The need for antibiotics is debated. The author uses penicil-
lin V elixir for 5 days in infants as prophylaxis against infec-
tion with β-hemolytic streptococcus, which can be potentially
very disruptive to the repair. The evidence for this is not
strong.
Arm Restrainers (Splints)
Many surgeons recommend restrainers to prevent infants
potentially disrupting the repair with fingers or thumb. Follow-
ing a small randomized controlled trial on the author’s patients,
this has been abandoned.21
OUTCOMES
Closure of the palate is the most important component of cleft
surgery, and the aim is to optimize the following:
• Speech and language
• Maxillary growth and arch development
• Hearing
• Appearance, which is influenced to a major degree by maxil-
lary retrusion
• Psychological and social well-being, which is also influenced
by appearance as well as by speech and hearing
All of these factors are very dependent on appropriate, well-
performed palate surgery.
The final outcome of palate surgery cannot be assessed until
maturity, because maxillary arch relationship and maxillary
growth tend to become less satisfactory with age and as VPI also
may become unsatisfactory later in life.7
Consideration also needs to be given to the effect of speech
problems or maxillary retrusion in early childhood, even if they
can be corrected by secondary surgery. The aim of primary
surgery should be to achieve the best possible outcome with
minimal need for secondary surgery. The burden of care for
patients and for parents of children is important.
Because of the poor quality of much of the literature, few
well conducted inter-center or prospective studies with large
numbers of patients, and even fewer randomized trials, the
 CHAPTER 68  Technique for Cleft Palate Repair 979

evidence for individual techniques is poor. However, some
general conclusions can be made.
Speech and Language
It is generally agreed that at least the soft palate is best repaired
before 12 months old to provide the basis for the acquisition
of speech and language and to minimize the need for speech
and language therapy.22 Velopharyngeal competence is usually
recorded as pharyngoplasty rates, and these are dependent on:
• Inclusions and exclusions
• The length and completeness of follow-up
• The threshold of the cleft team to perform operations, such
as pharyngoplasty
• The patient’s and/or parent’s wishes
Follow-up in most series has been relatively short. A major
survey of patients with UCLP in the United Kingdom showed
the need for secondary velopharyngeal surgery in about 30% of
cases in 5- and 6-year-olds and 12- and 13-year-olds. Two of
the reported series have been those of Cutting, who reported a
higher pharyngoplasty rate at 6 years old, and Sommerlad, who
reported a secondary surgery rate of 4.9% at 6 years old and
5.9% at 10 years old.23 However, a few patients will require
surgery between 10 and 20 years old. All such figures need to
be taken with some skepticism because of the difficulties
described earlier. A randomized controlled trial of muscle repair
(intravelar veloplasty) versus none showed no significant differ-
ence.24 However, the author has confirmed that the intravelar
veloplasty did not involve very radical muscle correction and
that there were differences between the surgeons in the study.
A later study comparing outcomes in patients from the original
randomized controlled trial with later patients who had more
radical muscle dissection demonstrated better speech and
hearing in patients having the more radical dissection.25
A study of the author’s speech outcomes has recently been
carried out.26 This involved an independent analysis of speech
recordings taken at 5 years old by two specialist speech and
language pathologists blinded to the study. The patients were
born between 1993 and 2005, and all non-syndromic clefts were
included in the preliminary study. Unfortunately, of 877 patients
operated on in that period, 165 had significant syndromes
affecting learning, 251 did not attend for 5-year review, and 70
had unsatisfactory audio/visual samples; 391 patients were
blindly assessed. The inter- and intra-reliability of the observers
was confirmed.
Of the 391 patients, 156 (40%) had UCLPs, 51 (13%) had
BCLPs, and 184 (4.7%) had isolated clefts of the palate. Of these
184 patients with isolated cleft palates, 72 were classified as
Pierre Robin sequence.
At 5 years old, 10 patients (2.6%) had had secondary surgery
for speech, two had insufficient velopharyngeal function, and
eight had borderline velopharyngeal function. The remaining
381 children were regarded as having sufficient velopharyngeal
function. The overall VPI rate (including those who had had
VPI surgery) was 5.2%; 15% (58) had had speech therapy for
cleft-related errors. The outcomes in these 391 patients are
shown in Figure 68-10.

FIG 68-10  Independently assessed speech outcomes from recordings in 391 unselected 5-year-
old patients after cleft palate repair. Each row of four boxes represents one patient. Columns
represent speech score. Column 1 is nasality, column 2 is audible nasal emission, column 3 is
nasal turbulence, and column 4 is passive cleft speech characteristics (indicative of velopharyn-
geal dysfunction). Dark green, Normal; light green, inconsistent; yellow, mildly abnormal; orange,
moderately abnormal; red, severely abnormal; purple, patients where assessment of recordings
is not possible. (Adapted from Bardach J, Salyer KE: Cleft palate repair. In Bardach J, Salyer KE,
editors: Surgical techniques in cleft lip and palate, St Louis, 1991, Mosby Year Book.)
980 CHAPTER 68  Technique for Cleft Palate Repair
The 10 patients (2.6%) who had had secondary surgery
had been managed by palate re-repair (5), modified Hynes
pharyngoplasty (3), secondary Furlow (1), and buccinator flap
lengthening (1). There were correlations between the overall
velopharyngeal function (VPC sum score), the extent of the
cleft, and the diagnosis of van der Woude syndrome. Overall
fistula rate was 12.8% and was greater in those who had had
lateral releasing incisions, those performed earlier in the period
(and therefore earlier in the surgeon’s learning curve), and in
wider clefts.
Maxillary Growth and Arch Development
Maxillary growth is commonly measured by:
• Arch relationship, recorded by models of the upper and
lower arches in occlusion: A simple but reproducible scoring
system has been devised by Mars—the Goslon scoring
system; where 1 and 2 are good, 3 is fair (and probably
manageable orthodontically), and 4 and 5 are poor and
indications for orthognathic surgery.27 This system does
measure the relationship of the maxilla to the mandible
(which may also be retruded) but not the position in relation
to skull base.
• Cephalometry, which measures maxillary position in rela-
tion to the skull base: SNA measures the relationship of the
maxilla to the skull base, and SNB measures the relationship
of the mandible. ANB records the difference between maxilla
and mandible and should be positive.
Outcome in relation to maxillary growth has been the focus
of many important inter-center studies (Eurocleft, Americleft,
and CSAG).28-30 This has shown wide variation between centers
and stimulated the changes in cleft care that have occurred in
Europe and are now occurring in the United States.
It is still not clear which regime is best as far as maxillary
growth is concerned. For example, delayed hard palate repair
has been shown in some series to give a good result in maxillary
growth.31 There are others where this has not been confirmed.
In summary, the consensus view can be summarized as
follows:
• Impairment of maxillary growth in clefts is largely but not
entirely due to surgery, with both lip repair and palate repair
being implicated. There is some debate as to which is the
more important. Most adult patients with an unrepaired
cleft do not show evidence of impaired maxillary growth.
Nevertheless, there are some patients who are intrinsically
hypoplastic.
• The most important surgical factor is the amount of surgery
carried out on the hard palate as part of palate closure. Tech-
niques that minimize surgery on the hard palate appear to
produce better growth.
• Delayed repair of the hard palate may be beneficial for
growth but is almost certainly detrimental to speech.
• Recording maxillary growth at 10 years old (as in many
studies) is inadequate, because the relationship of maxilla
and mandible usually deteriorates during adolescence.
Hearing
It is uncertain whether hearing outcome is related to the age
and technique of palate repair, because good inter-center studies
are not available.
However, for an infant in the important months of acquisi-
tion of speech and language, optimal hearing is indicated and,
if necessary, despite the potential disadvantages, ventilation
tubes (grommets) may be indicated. If necessary, hearing aids
should be used.
Appearance
Although it is generally assumed that in patients with cleft lip
and palate it is the lip repair that is most important for appear-
ance, in fact the palate repair is the most important factor in
determining maxillary growth (and as maxillary retrusion is
often the most obvious cleft feature visually); palate repair is
important in determining appearance, particularly during ado-
lescent years. Although patients can be submitted to orthogna-
thic surgery and even early distraction, the fact that a child is
obviously different from his or her peers in the school years can
be a major problem.
Psychological and Social Well-Being
By being crucial for speech and communication, perhaps rele-
vant for hearing and also because of the effect on maxillary
growth and therefore appearance, an effective and minimally-
destructive palate repair is crucial for the development of a
rounded individual. However, many studies have shown poor
correlation between the objective outcomes in these factors and
satisfaction with appearance.
COMPLICATIONS AND SIDE-EFFECTS
The major complications and side-effects of cleft palate repair
can be divided into early, intermediate, and late.
Early Complications
The two most worrying immediate complications are bleeding
and airway obstruction:
• Bleeding: Bleeding probably occurs most commonly from the
lateral releasing incisions or from the margins of elevated
flaps. Hemostasis needs to be meticulous. Some surgeons
pack any spaces left after elevation of palatal flaps. The team
managing the infant postoperatively needs to be aware of
silent bleeding, which is where the infant swallows blood.
• Airway: Closure of the palate may compromise the airway,
partly because of postoperative swelling and also because of
changes produced in the anatomy of the pharynx by closure.
This is particularly relevant in babies with Pierre Robin
sequence. Some surgeons use a temporary tunnel stitch,
which does allow immediate control of the tongue position
and potential improvement in the airway in the first postop-
erative hours. The use of an optimally positioned nasopha-
ryngeal airway can be very helpful in the postoperative
period.
Intermediate Complications
• Fistulae: Fistula rates are variably reported from 0% to 50%
probably based to some extent on the care taken to look
for them.
• Dehiscence: Dehiscence of the repair is probably usually the
result of either infection or hematoma, or closure under
excess tension. Partial dehiscence results in fistula formation.
In the Wardill-Kilner pushback technique, these often occur
at the junction of the flaps in the hard palate and are very
difficult to close. In other repairs, they most commonly
occur at the junction of the hard and soft palate. They can
be minimized by the avoidance of hematoma and by avoid-
ing undue tension.
 CHAPTER 68  Technique for Cleft Palate Repair
Late Complications
• Maxillary retrusion: Cleft palate surgery in the developing
child is known to be associated with maxillary hypoplasia.
The decreased prominence of maxillary complex could be
caused mainly by the shortened maxillary length; mean-
while, posterior position of the maxillary body may have
some influence on the maxillary protrusion.32
POSTOPERATIVE CARE
Early
Antibiotics
Primary closure of cleft lip and palate is classified as a clean-
contaminated operation, and wound infection is a recognized
risk. The risks are associated with the duration of operation
with primary cleft operations often requiring 1 to 2 hours of
operating time.33 The consequences of surgical wound infection
after repair of cleft lip or palate can be devastating in both the
short term and the long term. A major wound infection after
primary repair of a cleft is likely to require a further admission
for a secondary intervention; however, final outcomes such as
speech and growth may also be compromised. Antibiotics are
likely to reduce the incidence of wound infection and complica-
tions, but this has never been clearly shown in randomized
clinical trials in repair of clefts.34
Airway
Anesthesia for cleft surgery in infants and children carries a
higher risk with general anesthesia and airway complications
due to associated respiratory problems. The literature shows a
higher incidence of perioperative respiratory complications
when associated with the common cold symptoms in children
for cleft repairs.35 Morbidity during general anesthesia is associ-
ated with the difficult airway, endotracheal tube compression/
disconnection, disconnection or accidental extubation, and
postoperative airway obstruction.36,37 Assessment of the degree
of difficulty during intubation is not always possible preopera-
tively. Any child with hypoplastic mandible or wide cleft palate
increases the risk of tongue prolapse into the nasopharynx and
poses a problem during induction of anesthesia.38
Feeding
Provision of efficacious feeding instructions to the parents after
cleft palate repair can be a challenge for health care providers.
Feeding should commence as soon as the baby is awake after
receiving anesthetic. A nasogastric tube may be used if difficul-
ties are encountered with feeding. Children should only be dis-
charged when they are back to a normal feeding pattern of milk
and pureed food.
Arm Splints
Arm restraints are used in children after cleft surgery to prevent
traumatic disruption of the repair. However, a prospective ran-
domized trial of 46 children having primary cleft palate repair
showed that arm splints did not decrease the incidence of oro-
nasal fistulae.39 The use of arm splints after cleft palate repair
has been abandoned by the authors.
Late
Speech
The Sommerlad intravelar veloplasty has the least negative
impact on maxillary growth and is associated with good speech
981
outcomes.40 Significant elongation in palate length is obtained
using with improved velopharyngeal competence.41
Growth
The isolated cleft palate repair using the Sommerlad intravelar
veloplasty has been shown to have the advantages of less injury
and less scar tissue, indicating less inhibitory effect on the
growth of the maxilla.42 The Sommerlad intravelar veloplasty
with levator veli palatini retropositioning reduces the extent of
denuded palatal bone, making the Sommerlad technique advan-
tageous for maxillary growth.43
PITFALLS
• Delayed repair of the hard palate may be beneficial for growth but is
almost certainly detrimental to speech. The aim of primary surgery
should be to achieve the best possible outcome with minimal need
for secondary surgery.
• A recent prospective randomized controlled trial failed to show ben-
efits for pre-surgical orthopedics in terms of feeding or speech.
• The Veau-Wardill-Kilner pushback procedure may result in fistulae,
which can be extremely difficult to close. This technique should be
consigned to history.
• There are some patients who have an intrinsically hypoplastic maxilla.
Recording maxillary growth at 10 years old (as in many studies) is
inadequate, because the relationship of maxilla and mandible usually
deteriorates during adolescence.
ACKNOWLEDGMENTS
Thank you to Steve Atherton of Medical Illustration and
David Drake, Consultant and Cleft and Oral and Maxillofacial
Surgeon, both of Morriston Hospital, Swansea, Abertawe Bro
Morgannwg, for providing the photos for this chapter.
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