Tw

wo-Flap Palatoplasty
G
Gregory C. Allen, MD
Deepartment of Pediatric Otolaryngology
Asssociate Medical Director, Cleft Palate Team
Chhildren's Hospital Colorado

Associate
s i t Professor
P f
De
epartments of Otolaryngology and Pediatrics
Un
niversity of Colorado, Denver
 Basic Principles
• All palate clefts are not created equal
• All patients with cleft palate are not create equal
• Safety is paramount, “to abstain from doing harm”
 It is, at times, approprriate to not repair a cleft palate,
 But do not let a diagno osis or genetic test result be the decision
maker.
 We do not treat diagnoses, we treat individual patients/children.
• Goals
G l off repair
i
 Separate the oral and nasal cavities and create a competent
velar mechanism that is able to aid in,
• Speech production with
w appropriate resonance, and
• Prevention of nasal regurgitation of food and liquids.
 History
• Janusz Bardach (196 67) is generally credited with
modern description anda the rise in popularity of the two
fl palatoplasty.
flap l t l t
• Extension of techniqu ues described by Veau using oral
and nasal mucosal fla aps
• In his description, the
e entire palate, hard and soft, were
closed in a single proocedure.
• No attempt is made inn retroposition
(pushback) of the pallatal flaps.
• Minimal or no expose ed bone remains after
f
the procedure, thus reducing scarring and
deleterious effects on
n growth
growth.
 Indications an
nd Timing
• Complete unilateral and
a bilateral clefts of the primary
and secondary palate e
• Modifications allow th
he closure of almost all clefts,
regardless of width
• Keys include
 Dissection, retropositioning and reconstruction of the palatal
muscular sling
 Use
U off vomer mucosa a for
f nasall closure
l
 Lengthening but prese ervation of neurovascular pedicle
 Surgical Technique
• Patient preparation
 Supine, oral RAE ETT T, shoulder roll, neck extended
 Slight Trendelenburg position, good lighting
 Antibiotics, local anes
sthesia and vasoconstriction
 Dingman mouthgag
• Flap marking, design, and incisions
 Dissect one side at a time.
 Incision
I i i along
l cleft
l ft ed
dge
 Incision along lingual surface
of alveolus
 Maximize use of vome er mucosa
 Don’t be afraid of NVB B
 Surgical Technique
• Elevate mucosa off of
o hard palate
• Identify NVB. Don’t be afraid of it
• 360o around NVB. Ho ockey stick elevator helpful here.
• Dissect nasal mucosa a off hard palate “around the corner”
as far as possible/neccessary
cessary.
• Dissect palatal musclle off back of hard palate and free
edge
g of cleft. Push it posteriorly.
p y
• Free muscle and submucosal
tissue from oral side of
o soft palate.
• Move to the other side and repeat.
• Incise and elevate voomer mucosal
flap.
 Surgical Technique
• Work especially ca areful on anterior palate.
Smaller fistulas at alveolus are desirable – less
speech impact, lesss food, easier to close at
ABG. Right angle Beaver blade helpful in
making
ki iincisions
i i h
here. D
Dental
t l mirror
i can even
be used in elevatin ng mucosa.
• Check all flaps forr adequate
adeq ate length.
length
• Lengthen NVB as necessary
 B
Backcut
k t and d di
disse
ectt off
ff undersurface
d f off anterior
t i flap
fl
 Stretch it hockey stick
s elevator
 Osteotomy through the posterior foramen
 Surgical Technique
• Closure from front to back, then back to front
• Nasal mucosa closed d against vomer mucosa as far back
as possible. I use a 5-0
5 Monocryl with a TF needle. I run
this stitch in the middle with interrupted sutures anteriorly
near alveolus (remem mber…smallest fistula possible at
alveolus).
• Once I run out of vom mer, I switch
to interrupted suturess closing
nasal side of palatal mucosa
m to
same on the other sid de. Use
same suture material with knots
on the nasal side.
 Surgical Technique
• Close retropositioned
d muscle with BIG bites. I
use 4-0 PDS, usuallyy 3-5 sutures.
• This often removes much
m of the tension for
the subsequent oral closure.
c
 Surgical Technique
• Oral mucosal closure e proceeds from back to front.
• Uvula and the crappyy tissue here closed with mattress
sutures.
• Proceed anteriorly. Iff it gets tight switch to vertical
mattress suture techn nique Many use mattresses all
nique.
along here.
• Once you reach anterior palate use three bites with the
second bite grabbing the nasal layer to anchor the hard
palate mucosa.
 Surgical Technique
• Anchor anterior muco osa to alveolar mucosa. These
sutures may be air kn nots.
• Fill lateral defects, if desired,
d with material of your
choice. I use Surgicel rolled in little cigar shapes (one
scub tech says they a are little “nickel
nickel joints”
joints held with a
mosquito hemostat). Air knots over the top to hold
them in place.
 Postoperative
e Care
• Humidified O2/RA, Mo
onitor SaO2
• Pain control
• 23 hr stay in most
• Discharge criteria
 Ad
Adequate
t PO iintake
t k
 Room air SaO2 > 92%% when sleeping
 Good pain control
• Follow-up
 2 weeks, 6 weeks, 6 months
m
• Controversial
C t i l
 Arm splints (No-No’s)
 Diet – liquids only
 Antibiotics
 Results
• Salyer, et al (2006
6)
 N = 382
 8.92% needed seccondary palatal surgery
 Decreased with su
urgeon’s experience
Complications
s
• Early
 Bleeding
 Airway
• Late
 Fistula
 VPI
 Maxillary Growtth disturbance
 Surgical
g Techniques
q in Cleft Lip
p
and Palate

• Janusz Bardach and

a Kenneth E. Sayler y
• Published in text fo
orm most recently in 1991
• Available online att http://medpro.smiletrain.org/