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wo-Flap Palatoplasty

Gregory C. Allen, MDepartment of Pediatric Otolaryngologyssociate Medical Director, Cleft Palate Teamhildren's Hospital Colorado

i t P fssociate Professorepartments of Otolaryngology and Pediatricsniversity of Colorado, Denver

Basic Principl• All palate clefts are n• All patients with cleft • Safety is paramount,

It is, at times, appropr But do not let a diagno But do not let a diagno

maker. We do not treat diagn

G l f i• Goals of repair Separate the oral and

velar mechanism that • Speech production w• Prevention of nasal

esot created equalpalate are not create equal“to abstain from doing harm”

riate to not repair a cleft palate,osis or genetic test result be the decisionosis or genetic test result be the decision

oses, we treat individual patients/children.

nasal cavities and create a competent is able to aid in,

with appropriate resonance, andregurgitation of food and liquids.

History• Janusz Bardach (196

modern description afl l t l tflap palatoplasty.

• Extension of techniquand nasal mucosal flaand nasal mucosal fla

• In his description, theclosed in a single pro

• No attempt is made in(pushback) of the pal

• Minimal or no exposethe procedure, thus rdeleterious effects ondeleterious effects on

67) is generally credited with and the rise in popularity of the two

ues described by Veau using oral apsapse entire palate, hard and soft, were ocedure.n retropositionlatal flaps.

fed bone remains after educing scarring and

n growthn growth.

Indications an• Complete unilateral a

and secondary palate• Modifications allow th

regardless of width• Keys include• Keys include

Dissection, retropositimuscular slingU f Use of vomer mucosa

Lengthening but prese

nd Timingand bilateral clefts of the primary ehe closure of almost all clefts,

oning and reconstruction of the palatal

f l la for nasal closure ervation of neurovascular pedicle

Surgical Tech• Patient preparation

Supine, oral RAE ETT Slight Trendelenburg Antibiotics, local anes Dingman mouthgag

• Flap marking, design Dissect one side at a

I i i l l ft d Incision along cleft ed Incision along lingual

of alveolus Maximize use of vome Don’t be afraid of NVB

nique

T, shoulder roll, neck extendedposition, good lighting

sthesia and vasoconstriction

, and incisionstime.gesurface

er mucosaB

Surgical Tech• Elevate mucosa off o• Identify NVB. Don’t b• 360o around NVB. Ho• Dissect nasal mucosa

as far as possible/necas far as possible/nec• Dissect palatal muscl

edge of cleft. Push it g• Free muscle and sub

tissue from oral side o• Move to the other sid• Incise and elevate vo

flap.flap.

niqueof hard palatee afraid of it

ockey stick elevator helpful here.a off hard palate “around the corner” cessarycessary.le off back of hard palate and free posteriorly.p ymucosalof soft palate.e and repeat.

omer mucosal

Surgical Tech• Work especially ca

Smaller fistulas at speech impact, lesABG. Right angle

ki i i i hmaking incisions hbe used in elevatinCheck all flaps for• Check all flaps for

• Lengthen NVB as B k t d di Backcut and disse

Stretch it hockey s Osteotomy throug Osteotomy throug

niqueareful on anterior palate.alveolus are desirable – less

ss food, easier to close at Beaver blade helpful in

h D t l ihere. Dental mirror can even ng mucosa.r adeq ate lengthr adequate length.necessaryt ff d f f t i flect off undersurface of anterior flap

stick elevatorh the posterior foramenh the posterior foramen

Surgical Tech• Closure from front to • Nasal mucosa closed

as possible. I use a 5this stitch in the middnear alveolus (rememnear alveolus (rememalveolus).

• Once I run out of vomto interrupted suturesto interrupted suturesnasal side of palatal msame on the other sidsame suture materialon the nasal side.

niqueback, then back to front

d against vomer mucosa as far back 5-0 Monocryl with a TF needle. I run le with interrupted sutures anteriorly

mber…smallest fistula possible atmber…smallest fistula possible at

mer, I switch s closings closing mucosa to de. Use with knots

Surgical Tech• Close retropositioned

use 4-0 PDS, usually• This often removes m

the subsequent oral c

niqued muscle with BIG bites. I y 3-5 sutures.much of the tension for closure.

Surgical Tech• Oral mucosal closure• Uvula and the crappy

sutures.• Proceed anteriorly. If

mattress suture technmattress suture technalong here.

• Once you reach antesecond bite grabbingpalate mucosa.

niquee proceeds from back to front.y tissue here closed with mattress

f it gets tight switch to vertical nique Many use mattresses allnique. Many use mattresses all

rior palate use three bites with the the nasal layer to anchor the hard

Surgical Tech• Anchor anterior muco

sutures may be air kn• Fill lateral defects, if d

choice. I use Surgicescub tech says they ascub tech says they amosquito hemostat). them in place.

niqueosa to alveolar mucosa. These nots.desired, with material of your l rolled in little cigar shapes (one are little “nickel joints” held with aare little nickel joints held with a Air knots over the top to hold

Postoperative• Humidified O2/RA, Mo• Pain control• 23 hr stay in most• Discharge criteria

Ad t PO i t k Adequate PO intake Room air SaO2 > 92% Good pain control

• Follow-up 2 weeks, 6 weeks, 6 m

C t i l• Controversial Arm splints (No-No’s) Diet – liquids only Antibiotics

e Careonitor SaO2

% when sleeping

months

Results• Salyer, et al (2006 N = 382 8.92% needed sec Decreased with su

6)

condary palatal surgeryurgeon’s experience

Complications• Early BleedingBleeding Airway

• Late• Late Fistula

VPI VPI Maxillary Growt

s

th disturbance

Surgical Techgand Palate

• Janusz Bardach a• Published in text fo• Available online atAvailable online at

niques in Cleft Lip q p

and Kenneth E. Sayleryorm most recently in 1991t http://medpro.smiletrain.org/t http://medpro.smiletrain.org/