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243

A Method of Unilateral Operation for Early Repair of Unilateral Complete

Cleft Palate. Preliminary Report

RUYAO SONG, M.D., D.D.S., D.SC.

YEGUANG SONG, M.D.

CUNMING LIU, D.D.S., M.D.

HAIHUAN MA, M.D.

YU ZHAO, M.D.

RU ZHAO, M.D.

ZHEN FANG

Objective:This article describes a method of unilateral operation and the

preliminary results of a group of patients with unilateral complete cleft palate

undergoing the operation at early age.

Design: The unilateral operation consists of four relaxation maneuvers.

After all of the four maneuvers have been performed on the deformed side of

an unilateral complete cleft palate, the deformed side can be moved posteriorly

and medially to contact with the normal side. Then the cleft can be closed

without tension.

Results:From 1995 to 1998, 19 cases of unilateral complete cleft palate wererepaired with this method at 512 months of age. Postoperatively, there were

no deaths nor dehiscences. Under the care and guidance of an experienced

speech pathologist, 15 of 17 of these children have normal vocal quality at 1

2 years of age.

Conclusions: The unilateral operation is a rational, adequate, and safe

method for early repair of unilateral complete cleft palate. Its design addresses

four principles. First, operating only on the deformed side of a unilateral com-

plete cleft palate leaves the normal side unperturbed. Second, complete relax-

ation of the deformed side is achieved before closing the cleft. Third, in com-

parison with conventional procedures, which operate on both sides of the pal-

ate, this method has the advantage of less surgical trauma, less blood loss,

and shorter time of operation. Fourth, all of these advantages are beneficial to

early cleft palate repair, which is an important factor in achieving good speech.

KEY WORDS: cleft palate, palatal surgery, speech development

According to Veau and Borel (1931) and Oldfield (1949),

unilateral complete cleft palate composes 38% and 39% of the

four classes of cleft palate. The significant characteristic of this

common congenital deformity is that it has a deformed side

and a normal side. (Fig. 1). In closing the cleft, surgeons have

used the Celsus method, making relaxation incisions on both

sides of the palate (Fig. 2) and doing extensive surgery on the

deformed side as well as on the normal side since the time of

Dieffenbach (1826) and Langenbeck (1861). Furthermore, dur-ing surgery most surgeons do not perform blunt dissection

down the medial aspect of the medial pterygoid plate to the

base of the skull for freeing the velopharyngeal structures prior

to medial shifting and suturing as advocated by Ernst (1925).

From the Plastic Surgery Hospital and Institute of Chinese Academy of Med-

ical Sciences, Ba-Da-Chu, Beijing 100041, P.R. China

Submitted October 1999; Accepted June 1999.

Reprint requests: Prof. Ruyao Song, M.D., D.D.S., D.Sc., Plastic Surgery

Hospital, Ba-Da-Chu, Beijing 100041, P.R. China.

Consequently, the relaxation is incomplete and dehiscence oc-

curs occasionally in spite of relaxation incisions that have been

made on both sides.

In contrast to the above and the presently used procedures,

we repair the unilateral complete cleft palate with a method of

unilateral operation prior to 12 months of age (Figs. 3 and

4). First proposed by Song (1954), the method consists of four

relaxation maneuvers: (1) formation of one large arterial mu-

coperiosteal flap; (2) division of the tendon tensor veli palatini

muscle on the medial side of the hamular process (Fig. 5); (3)

removal of the posteriomedial wall of the greater palatine fo-

ramen (Fig. 6); and (4) division of the horizontal plate of the

palatine bone. After all of these maneuvers have been per-

formed on the deformed side of an unilateral complete cleft

palate, the operated side can be moved both posteriorly and

medially into contact with the margin of the opposite side

without tension. Obviously there is no need to operate again

on the opposite side. Then the cleft is closed in the usual man-

ner. In comparison with the conventional procedures, which

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244 Cleft PalateCraniofacial Journal, May 2000, Vol. 37 No. 3

FIGURE 1 Veaus diagram of anatomy and pathology of unilateral com-

plete cleft palate. There is a well-developed normal side and an underde-

veloped short side. From Victor Veau: Division Palatine. Masson, Paris,

1931. (With minor modification at tensor tendon.)

FIGURE 3 The unilateral operation of closure for unilateral complete

cleft palate. Single-pedicled flap only from the deformed side is used.

FIGURE 4 Anatomic diagram of the unilateral operation. The hori-

zontal plate of the palatine bone is divided from the vertical plate of the

same bone and the palatal process of the maxillary bone and moved to-

gether with the aponeurosis and musculature of the soft palate both me-

dially and posteriorly to contact with the cleft margin of the normal side.

FIGURE 2 The Celsus method of closure of unilateral complete cleft

palate. Bipedicled flaps from both of the normal and deformed sides are

used.

operate on both sides of the palate, this method has the ad-

vantage of less surgical trauma, less blood loss, and shorter

time of operation.

The primary goal of cleft palate repair is to achieve normal

speech. In 1983, Randall et al. made a preliminary report on

cleft palate closure of 38 patients (17 were available for speech

evaluation) at 37 months of age. There was about 70% (11/

17) of normal speech and no deaths. In recent years, Kaplan

et al. (1974, 1980, 1982), Kaplan (1981), Osada et al. (1981),

Cohen et al. (1981), Desai (1983), Barimo et al. (1987), Haa-

panen and Rantala (1992), Denk and Magee (1996), and others

also repaired cleft palates at a very early age, even in the

neonatal age group. Comparing those infants whose cleft pal-

ate were repaired at 37 months of age with children whose

cleft palates were repaired at todays prevalent age of 1824

months, they showed more normal muscular development, ear-

lier onset of language, fewer speech errors, less middle ear

diseases, less stress for the children, and less distress in the

parents (Paradise and Bluestone, 1974).

Due to improvements in pediatric anesthesia and postoper-

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Song et al., REPAIR OF UNILATERAL COMPLETE CLEFT PALATE 245

FIGURE 5 The tendon of the tensor veli palatini muscle is divided at the

medial of the hamular process to relief the tension in the midline.FIGURE 6 The posterior-medial wall of the greater palatine foramen is

removed with a chisel.

ative nursing care, early cleft palate repair is no longer con-

sidered an excessive surgical risk. Given this fact and the de-sire for improved speech performance, we have repaired the

unilateral cleft palate using the method described here prior to

12 months of age.

METHOD

A unilateral complete cleft palate has four significant fea-

tures: (1) there is a cleft on the deformed side extending from

the alveolar ridge to the uvula; (2) the size of the deformed

side is smaller and its length shorter; (3) the position of the

greater palatine foramen is more forward than that of the nor-

mal side; and (4) the horizontal plate of the palatine bone and

the aponeurosis and musculature of the soft palate attaching to

the bony plate of the deformed side are displaced anteriorly.

If a surgical procedure is to repair the unilateral complete

cleft palate by operating on the deformed side only, four re-

laxation maneuvers should be used. First, a large arterial mu-

coperiosteal flap of the entire deformed side of the hard palate

must be made to close the hard palate cleft (McCormack,

1949). Second, the tendon of the tensor veli palatini muscle

on the medial side of the hamular process has to be divided

to decrease the tension in the midline of the palate (Ombre-

danne 1912; Brown, 1940; Bennett et al., 1968). Third, the

posterio-medial wall of the greater palatine foramen has to be

removed to free the greater palatine vessels and nerve that

tether the mucoperiosteal flap to the palatal bone (Limberg,

1927; Ruding, 1964; Conway, 1980). Fourth, the horizontal

plate of the palatine bone, which is the posterior edge of the

hard palate, has to be divided so that the anteriorly displaced

insertion of the levator veli palatini muscle on the posterior

edge of the hard palate of the deformed side and the levator

muscle can be reoriented in a transverse direction to recon-

struct a levator sling with the levator muscle of the normal

side. Obviously, this maneuver differs from the intravelar ve-

loplasty of Braithwaits (1968) and Krien (1970), who detach

the levator muscles of both sides from their insertion on the

posterior edge of the palatal bone. It has three merits: (1) thesoft palate attachment to the palatal bone is undisturbed, which

is beneficial to muscular development and function; (2) there

is no raw surface leading to possible anterio-posterior scar con-

tracture producing velar rigidity and (3) during cleft closure,

there is no tension at the junction of the hard and soft palate,

and dehiscences are not likely to occur at the junction of the

hard and soft palate postoperatively.

Anesthesia

The child is given an endotracheal general anesthesia. The

deformed side of the palate is infiltrated with a dilute solution

of lidocaine with epinephrine to reduce bleeding during sur-gery.

Operative Technique

1. A marginal incision is made on each side of the cleft. Each

incision extends from the end of the alveolar process to

the tip of the uvula. The mucoperiosteum of the vomer is

elevated as a wide-based flap to provide a two-layer hard-

palate closure.

2. A relaxation incision is made on the deformed side of the

palate, commencing anteriorly from the anterior cleft an-

gle, joining the incision made on the margin of the cleft,

and running posteriorly along the alveolar process until

the posterior end of the process is reached. The incision

is then continued posteriorly into the soft palate about 1.5

2.5 cm along the pterygomandibular raphe.

3. The mucoperiosteal flap of the deformed side of the palate

outlined by the previous incisions is raised by a sharp

hook and separated from the hard palate by a small peri-

osteal elevator until the posterior edge of the palatine bone

is reached. The flap is then turned downward.

4. With the same small periosteal elevator, use blunt dissec-

tion to expose the greater palatine foramen, the posterior-

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246 Cleft PalateCraniofacial Journal, May 2000, Vol. 37 No. 3

FIGURE 7 The operative technique of the unilateral operation. A:

Two marginal incisions and one lateral relaxation incisions are made. B:

The vomer flap and the mucoperiosteal flap are reflected. The horizontal

plate of the palatine bone is divided after the posterior-medial wall of the

greater palatine foramen is removed. The mucoperiosteum of the floor of

the nose is also sectioned to form a Cronin nasal flap. C. The large single-

pedicled mucoperiosteal flap, greater palatine vessels and nerve, horizontal

plate of the palatine bone, aponeurosis, and musculature of the soft palate

are pushed medially and posteriorly with the handle of a knife to contact

with the cleft margin of the normal side. D: The hard palate is closed in

two layers and the soft palate closed in three layers.

medial wall of the foramen, and the greater palatine ves-

sels and nerve emerging through the foramen. Continue

the dissection near the base of the hamular process. Now

a large single pedicled mucoperiosteal flap pedicled on the

posterior edge of the hard palate is formed.

5. Commencing from the posterior edge of the hard palate,

a short cut is made with a knife on the medial side of thehamular process to divide the tendon of the tensor veli

palatini muscle.

6. The soft tissue on the medial and posterior sides of the

greater palatine foramen is elevated to expose the bone of

that area. The posteromedial wall of the foramen and a

portion of the canal adjacent to the foramen are removed

with a small chisel to free the greater palatine vessels and

nerve, which tether the mucoperiosteal flap to a forward

position.

7. Another cut is made with the same chisel from the cleft

margin to the greater palatine foramen to divide the hor-

izontal plate of the palatine bone from the palatal process

of the maxillary bone.8. Through the later bone cut, the mucoperiosteum of the

floor of the nose is elevated with a small periosteal ele-

vator. Again, through this bone cut, a nasal flap of Cronin

(1957) is cut out with a knife. The nasal flap and the

divided horizontal plate of the palatal bone are displaced

together both posteriorly and medially with the handle of

the knife. When the large single pedicled mucoperiosteal

flap is turned back to the hard palate, the gap caused by

the retrodisplacement of the palate bone is lined superiorly

with the mucoperiosteal flap of the mouth and inferiorly

with the mucoperiosteal flap of the nasal cavity. The peri-

osteum of these two flaps may produce some membra-

neous bone to help maintaining the lengthened hard palate.

9. The single pedicled mucoperiosteal flap, the freed greater

palatine vessels and nerve, the divided horizontal plate of

the palatine bone, and the musculature of the soft palate

are displaced in one piece with the handle of a knife both

medially and posteriorly. This movement brings the two

sides of the cleft in close contact without the least tension.

Now it is obvious that there is no need to perform similar

maneuvers on the normal side of the palate again.

10. A two-layer closure of the nasal and oral mucoperiosteum

is performed for the cleft of the hard palate, and a three-

layer closure of the nasal mucosa, muscle, and oral mu-

cosa is performed for the soft palate cleft. Care should be

taken in that the suturing of the muscle layer must comply

with the requirement of the intravelar veloplasty of Krien

(1970). Finally, an iodoform gauze packing is inserted in

the relaxation incision to support the mobilized soft palate

and to cover up the exposed bone area. (Fig. 7).

RESULTS

From August 1995 to May 1998, 19 cases of unilateral com-

plete cleft palate had been repaired with the method of uni-

lateral operation. The age of patients ranged from 5 to 12

months. The widest cleft at the junction of hard and soft palate

was 22 mm, the narrowest was 10 mm, and the average was

14.3 mm. The largest amount of blood loss was 100 mL, the

least was 20 mL, and the average was 36 mL. Postoperatively,

there were no deaths nor dehiscence. All of the children who

underwent the unilateral operation were put under the care

and guidance of an experienced speech pathologist shortly af-

ter they had recovered from the operation. Seventeen of the

19 were available for speech evaluation at the age of 12 years.

Fifteen of the 17 were felt by the speech pathologist to have

articulation within the normal range on subjective analysis and

normal vocal quality. Two of these patients had minor hyper-

nasality. All of these children were too small to tolerate in-

strumental speech evaluation. Long-term studies of growth and

speech development of all of these patients are still being con-

ducted.

DISCUSSION

The unilateral operation for the repair of unilateral cleft

palate was first presented in 1954 (Song, 1954) when only

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