Intravelar veloplasty: Surgical modification according to anatomical defect

Intravelar veloplasty: surgical modification according to anatomica defect

Kurt-W. Bfitow, Fred J. J a c o b s Clinic for Facial Cleft Deformities, Department of Maxillo-Faeial and Oral Surgery, University of Pretoria, South Africa

1£.- W. Biitow, E J. Jacobs: Intravelar veloplasty: surgical modification according to anatomical deject. Int J Oral Maxillofac. Surg. 1991; 20: 296-300. Abstract. The patient is often left with an oro-nasal fistula after the intravelar veloplasty procedure for the primary closure of the hard and soft palate cleft. The junction between the hard and soft palate is submitted to maximal tension during this procedure and is where the fistula most often occurs. The primary intravelar veloplasty procedure is discussed and 7 surgical modifications are introduced. The aim of these modifications is the prevention of an oro-nasal fistula and each is specifically adapted according to the existing anatomical form and defect of the cleft palate. The surgical modifications are divided into 2 main groups: those based on localised swivel flaps and those based on distant flaps.

Key words: intravelar veloplasty; cleft soft palate; oro-nasa[ fistula; surgical modifications; staphyloplasty. Accepted for publication 1 June 1991

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The term intravelar veloplasty was introduced by BI~AITHWAITE& MAURICE2 and later by KRIENS24'25 as a description of the anatomical-functional approach for the primary closure of the soft palate cleft. This type of procedure involves the dissection of the abnormally rotated muscles of the soft palate from the palatal bone and their rotation and suturing in a more normal sphincter-action type of position. This anatomical approach has become very popular in m o d e r n cleft surgery and forms an essential part of the functional principle in cleft palate repair ~4,2~. The long-term result is fewer velopharyngeal reconstructive procedures at a later stage 29. The primary intravelar veloplasty allows not only less dissection of the mucosa/mucoperiosteum, but differs greatly from previous procedures in that rotation and suturing of muscles are performed. The conventional veloplasties 12,34,35,36 are very different. However, there is a relatively high incidence of oro-nasal fistula development at the junction area between the hard and soft palate cleft (JHSPC) 22. The conventional veloplasties, palato-veloplasty or uranostaphyloplasty procedures, entail closure of the cleft by large dissections of hard and soft palate, which eventually lead to severe midfacial growth disturbances~,4,~ ~,~6,22,33. Should these latter procedures be used at a later stage in order to avoid mid-

facial growth disturbances, severe speech problems would most probably develop3,10,~3,30,31,37. The aim of this research was to introduce 7 different surgical modifications to the primary intravelar veloplasty to prevent the formation of small oronasal fistula at the JHSPC.

Surgical methods The decision as to which of the 7 modifications should be used depends on the anatomical morphology of that particular cleft deformity, i.e. the form and width of the JHSPC, as well as the availability of structures or tissue to be used in the flap design2°. A further factor is the timing of the closure: should the hard or soft palate be closed first and should 2 procedures be necessary? This depends on the therapy protocol laid down by the clinic5'7. The vomer-extension flap procedure with or without an early releasing incision may only be used if the soft palate has already been closed at an earlier stage (at about 5 months of age). However, where no hard palate cleft is present or the hard palate has already been closed, the soft palate should be closed between 7 and 12 months of age. Most suggested modification procedures are done at this stage. Hence, depending on the therapy protocol 5'7 the soft palate cleft repair, or staphyloplasty, may be done before or after the hard palate repair, or uranoplasty. The modification of the intravelar veloplasty involves a careful dissection (Figs. 1 and 2) and alignment of all the relevant muscle components of the soft palate, name-

ly, the uvula, palato-pharyngeus, levator veli palati and tensor veli palati. There is therefore a functional closure (Fig. 3). The tissue adjacent to the hamulus process is not dissected, neither is the hamulus process fractured to relieve the tension of the palatal mucosa, nor the tendon of the tensor veli palati muscle cut 8. A special suture sling is inserted around the tendon of the tensor veli palatini muscle medially to the hamulus, bilaterally, and connected under maximal tension (Fig. 4). This tension sling leads to better Eustachian tube function after intravelar veloplasty, thus lowering the high incidence of middle ear effusion 8. The 7 surgical modifications of the intravelar veloplasty have been divided according to the localised swivel flap and distant flap techniques.

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Fig. l. Anatomical configuration of the muscles in the cleft soft palate.

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Fig. 2. Dissection o f the muscles from the

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Fig. 4. A tension suture for the tensor veli palati muscle.

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surgical modification

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releasing incision at the JHSPC is used where there is no cleft in the hard palate or where a previous cleft there has been closed: The oral lateral releasing incision. A short lateral parallel releasing incision is made unilaterally or bilaterally, in the area of maximal mucosa/mucoperiosteal tension, which is the area adjacent to the JHSPC. It is made halfway between the tuberositas-hamulus area and the cleft itself. The vascular bundle of the great palatine foramen lies lateral to this releasing incision and should not be involved (Fig. 8). The incision, if possible, should be planned in such a way that the sutured cleft margins of the oral and nasal mucosa should not overlap vertically, but should be next to each other (Fig. 9). This is made possible by incisions of unequal length and where unilateral incisions are made only. This type of surgical modification is applied where there is a broad v-shaped cleft at the JHSPC. The nasal lateral releasing incision. The technique used here is very similar to that used for the oral lateral releasing incision. The incision is made half-way between the inferior nasal meatus and the border of the cleft margin. The incision is usually unilateral as the nasal mucosal closure is usually more tension-free than closure of the oral mucosa/ mucoperiosteum (Fig. 10). A laterally dis-

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Fig. 5. The triangular mucoperiosteal inserFig. 3. Alignment and suturing of the muscles

tion flap.

in the soft palate.

Localised swivel flap techniques

TrkTngular mucoperiosteal insertion flap. The dissection entails an anteriorly oblique cut into the hard palate mucosa/mucoperiosteum at the JHSPC. The mucosa adjacent to the oblique cut is de-epithelialised, then pushed under the adjacent mucoperiosteum and sutured, with a horizontal mattress stitch, so that there is a double-layered closure (Fig. 5). This triangular mucoperiosteal insertion flap is indicated where the JHSPC is narrow and sharply pointed. Partial oblique backcut technique. A 4 to 6 mm posterior-aligned releasing incision is made in the hard palatal mucoperiosteum, 3 to 5 mm anterior to the cleft margin, either unilaterally or bilaterally. This wedge-shaped incision allows tissue in the mucoperiosteum/ mucosa to be released medio-laterally as well as antero-posteriorly at the JHSPC (Fig. 6). Should one side of the soft palate be shorter than the other, i.e. shorter in the antero-posterior dimension, then the technique may be used unilaterally only. A perpendicular in-

cision is then also made in the nasal mucosa (Fig. 7). The partial oblique backcut technique is indicated for the broad u-form type of defect at the JHSPC and where an anterior-pedicled vomer flap is not available as an alternative method. The lateral releasing incision. The lateral

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Fig. 7. Unilateral lengthening as a partial oblique backcut technique.

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Fig. 6. The partial oblique backcut technique.

Fig. 8. The oral lateral releasing incision.

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Fig. 9. A coronal view indicating the lateral shift of the suture line.

bilaterally, lateral to the vomer bone. The nasal mucosa of the cleft margin is then first sutured anteriorly to the vomer bone, thus above the anterior-pedicled vomer flap, which is displaced inferiorly. This flap is then repositioned as a middle layer onto the nasal mucosa (Fig. 11). The muscle layer and the oral mucosa are sutured afterwards. This technique is especially useful where a broad and long, therefore a posteriorly positioned vomer bone and a u-shaped or quadrangular-shaped JHSPC, are present. Vomer-extension flap technique. This technique should be used where the soft palate cleft closure, i.e. the staphyloplasty, has been done before the hard palate cleft closure, i.e. the uranoplasty. Once the soft palate cleft has been closed, an extension flap may be dissected at the age of 7 months. The flap design is U-shaped or quadrangular, similar to the anterior-pedicled vomer flap, the only difference being that this flap is an extension

Fig. 10. A coronal view of a nasal lateral releasing incision.

;.'I ~ placed cleft margin is preferable so that there is no overlapping with the sutured oral margin. This above mentioned type of releasing incision is applied where there is tension in the nasal mucosa / mucoperiosteum at the JHSPC. It is used far less frequently than the oral lateral releasing incision and then always in conjunction with the latter.

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of the inferiorly based vomer-septum flap. The inferiorly based vomer flap is used for the closure of the hard palate cleft, which is done in the same procedure. A 2 m m horizontal incision is made in the mucosa of the already closed soft palate cleft at the JHSPC. The extension flap is used as an intermediate layer in this incision and sutured by'means of vertical mattress sutures. This sufficiently broad (in the medio-lateral dimension) and long (in the antero-posterior dimension) vomer extension flap should be positioned, tension-free, at the JHSPC (Figs. 12 and 13). The extension part may even include part of the arachnoids if a long antero-posterior flap seems necessary (Fig. 14). This type of surgical modification is used where the cleft is narrow and where the uranoplasty is to be done after the staphyloplasty. "

Vomer extension flap after lateral releasing incision. This technique is similar to that used for the modification of the vomer extension flap. However, the staphyloplasty, performed 2 months earlier, by means of a uni- or bilateral lateral releasing incision as part of the intravelar veloplasty (Fig. 15), leaves a narrowed and U-shaped healed cleft at the JHSPC. The vomer-extension flap is then performed in the same surgical procedure as the uranoplasty (Figs. 12 and 13).

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Distant flap techniques

Anteriorly-pedicled vomer flap technique. The mucoperiosteal flap may be elevated from the posterior portion of the vomer bone. It is anteriorly pedicled, and usually adjacent to the anterior part of the cleft and therefore next to the border of the vomer-palatine or

Fig. 12. Vomer-extension flap technique - its outline.

.vom. t maxi,..ybo.eusonTh.i.eCvom.r tion is made posteriorly and perpendicular to the bone and it is then extended

Fig. 14. The vomer-extension flap is extended to include part of the arachnoids. ~ , ~ ~

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i Fig. 11. The anteriorly pedicled vomer-flap

Fig. 13. The vomer-extension flap and an in-

Fig. 15. The incisions for the vomer-extension

technique,

feriorly pedicled vomer-flap sutured in position.

flap with a previous lateral releasing incision.

Intravelar veloplasty - surgical modification

This type of modification is used where there is a wide hard/soft palate cleft and where the staphyloplasty has been done before the uranoplasty.

Results

A total of 103 patients aged 5 to 12 months, underwent modified intravelar veloptastics. No patients had had any previous surgical involvement of the hard/or soft palate clefts. This study of the 7 surgical modifications did not include separate recordings of the nasal and oral lateral releasing incisions. However, 11 patients with very broad JHSPC received the combination of a lateral releasing incision and an anterior-pedMed vomer flap. Ninety-eight patients (59 male and 39 female) showed complete healing (Table 1). All patients were examined 6 months post-operatively. A small oro-nasal fis• tula developed at the JHSPC between the 4th and 9th day (average: 7th postoperative day) in 5 of the patients (3 male and 2 female). Three of the patients presented with rudimentary clefttype fistulas and a further 2 had greater oval-shaped fistulas of 2 x 0.5 and 3 x 2 ram. Three of the oro-nasal fistulas occurred after the oblique backcut technique, one of them after the vomer extension flap and lateral releasing incision, and a further one followed the combination of 2 techniques, namely, the lateral releasing incision with an anteriorly-pedicled vomer flap. Discussion

The uranostaphyloplasty, i.e. a combined procedure for both the hard and soft palate cleft, was mainly developed

for the problem of a recurring oro-nasal fistula at the JHSPC 26'27'2s'32 and has been widely described as such. Apart from our previous report 2°, the surgical modification of the staphyfoplasty at the JHSPC, with or without the uranoplasty, has most probably only been reported once before as a triangular extension flap forming part of the CAMPBELL 9 uranoplasty23. The conventional uranostaphyloplasty techniques were mostly based on the total dissection of mucosa and mucoperiosteum from muscles and bone. Most often there was no repositioning and suturing of the velo-muscles. These techniques resulted in midfacial growth disturbances and speech pathology. The well-known intravelar veloplasty was introduced to minimise these side effects. The minimum dissection of the cleft margin most probably also led to a relatively high incidence of oro-nasal fistulae, which was as much as 23% in our previous patient group, but which has been reported to be as low a s 7 . 8 % 22. Should it therefore be deemed necessary to close an oro-nasal fistula, maybe even by means of repeated procedures, midfacial growth disturbances as well as impaired speech development ~9may again become a problem, especially in the 1 to 8 year age group. This is most probably caused by the increased amount of scar tissue in the palate. The oro-nasal fistula at the JHSPC is often surgically treated at a later stage, usually in the adolescent years, and then by means of extensive procedures such as tongue flaps 173s, buccal fat pads 15 and a combination of techniques with the vomer flaps 6. Whenever one suspects that an oronasal fistula at the JHSPC after the primary closure of the cleft palate defect

Table 1. Surgical modifications for cleft palate repair

Type of modification

Type of JHSPC*-shape

No. of patients

Successful Successful closure %

1. Triangular insertion flap 2. Partial oblique backcut 3. Lateral releasing incision (oral and nasal) 4. Anteriorly pedicled vomer flap 5. Vomer-extensionflap 6. Vomer-extensionflap after lateral releasing incision 7. Combination of lateral releasing incision and anteriorly pedicled flap

V-shaped narrow U-shaped broad V-shaped broad

37 6 25

37 3 25

100 50 100

U-shaped broad V-shaped narrow V-shaped broad

5 7 12

5 7 11

100 100 91.7

U-shaped very broad

11

10

90.9

103

98

95.1

Narrow cleft: 0-7 mm; broad cleft: 7 12 ram; very broad cleft: + 12 mm. *Junction area of the hard and soft palate cleft.

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may develop, one or more of these surgical modifications to the intravelar veloplasty may be implemented. However, any pre-operative or directly post-operative viral a n d / o r bacterial infection may have a negative effect on the healing process, particularly in the flaps which are sutured under tension. The hairline oro-nasal fistula which is not visible, will not have any negative effect on speech development. Such an opening should only be probed and then surgically closed once midfacial growth has been completed. The broader and the more U-shaped the JHSPC is, the more likely an oronasal fistula may occur there, and this was seen where the oblique backcut procedure, the anterior-pedicled vomer flap and the vomer extension flap with lateral releasing incisions were used. In retrospect, a longer and/or bilateral lateral releasing incision should have been used for more tension-free closure. A narrower cleft would then have remained at the JHSPC after the first surgical involvement and this would have simplified the second surgical involvement of the hard or soft palate cleft. The 7 surgical modifications introduced for the intravelar veloplasty alleviate one of the biggest single disadvantages of this particular staphyloplasty technique. Thus, the small oro-nasal fistula may be prevented in most cases, even when great tension has been exerted on the mucosa/mucoperiosteum. The intravelar veloplasty should therefore be maintained as an important procedure in the functional approach of the primary closure of the soft palate cleft.

References

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Address: Professor Kurt- W Biitow Department Maxillo-Facial and Oral Surgery P. O. Box 1266 Pretoria 0001 South Africa