Cleft Lip and Palate: Technical Strategies for the Primary ... · PDF fileCleft Lip and Palate: Technical Strategies for the Primary Palatoplasty Piero Cascone, MD, Paolo Arangio,

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Cleft Lip and Palate: Technical Strategies forthe Primary PalatoplastyPiero Cascone, MD, Paolo Arangio, MD, Valerio Ramieri, MS, Enrico Foresta, MD

Rome, Italy

Surgical procedures in cleft lip and palate repair arecontinuously evolving. In the international litera-ture, many guidelines exist dealing with differenttimings and surgical approaches. The authors pres-ent a technical strategy on primary palatoplasty andthe guidelines for the surgical management ofcleft lip and palate adopted by the Department ofMaxillo-Facial Surgery of the Universita ‘‘La Sapi-enza’’ of Rome. This approach has been developedto allow a physiological facial growth and to pre-serve the essential main features of the stomatog-nathic system enclosing phonation and swallowing.Moreover, the authors present their own surgicaltechnique for primary palate repair at 24 to 48months with the galea-pericranium free flap.

Key Words: Cleft, lip, palate, surgical technique, galea,pericranium, flap, palate growth, facial growth,facial development, cleft surgery, cleft palate, cleftguidelines

C left lip and palate treatment is a continuouslyevolving subject in the international scien-tific world as far as surgical techniques arecontinuously evolving and different pro-

tocols are adopted in various centers.Nevertheless, it occurs a long time to verify the

correctness of a treatment; indeed, the related out-comes for a nonaccurate primary treatment are high-lighted at the end of the facial growth with differentpossible deformity levels involving the soft palate,the palatal vault, the maxillary growth, and the cor-rect dental eruption. This may take 20 years or more.

The authors present a technical strategy on sur-gical timing and technique for the reconstruction ofthe palatal vault based on surgical approach de-scribed by Skoog on tibial periosteal graft.1

CLINICAL REPORT

The patient was born with a left unilateralcleft lip and palate (Figs 1 and 2). At the age of

6 months, she underwent cleft lip repair accordingto the Tennison2 mod. Randall3 technique, soft palaterepair according to Bardach4Y6 technique, and pri-mary nose plastic according to the McComb7 tech-nique (Fig 3). At the age of 48 months, she underwentprimary palate repair using galea-pericranium freeflap (Figs 4Y14).

At the age of 9 years, she underwent earlysecondary alveoloplasty with iliac crest bone graft(Figs 15 and 16).

TECHNICAL NOTE

Focusing the attention on the second intervention,we propose a surgical technique to close the

primary palate and the oronasal fistula, thus leadingto appropriate palatal vault dimensions and to a

Fig 1 The patient at 3 months affected by complete leftcleft lip and palate.

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From the Department of Maxillo-Facial Surgery, Universita degliStudi di ROMA ‘‘La Sapienza,’’ Rome, Italy.

Address correspondence and reprint requests to Paolo Arangio,MD, Via Mogadiscio 15, 00199 Roma; E-mail: [email protected]

Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.8

correct tongue position permitting a harmonic max-illary growth together with the other elements ofthe splanchnocranium.

Under general anesthesia, with an orotrachealintubation, after positioning a Dingman gag (Fig 4),the borders of the cleft and the inferior area of thevomer are infiltrated with saline solution. Afterward,an incision with a beaver knife is performed startingfrom the borders of the residual cleft (Fig 5). Theincision, on the oral mucosa, along cleft margins, has

to be of the appropriate dimensions to be folded tocreate a satisfying nasal layer.

Then, a few millimeters of subperiosteal dissec-tion is realized to allow the galea-pericranium freeflap healing directly in the subperiosteal layer.

Afterward, in the vomer area, a dissection of 3 to4 mm of the mucosa is performed, and the nasal layerof the mucosa is mobilized to prepare it to the rotation

Fig 2 Detail of the palate cleft.

Fig 3 The patient at 3 years after cleft lip repair accordingto the Tennison mod. Randall technique, soft palate repairaccording to Bardach technique, and primary nose plasticaccording to the McComb technique.

Fig 4 IntraoperativeviewVpositioningoftheDingmangag.

Fig 5 Intraoperative viewVincision along the margins ofthe cleft.

Fig 6 Intraoperative viewVsizing of the cleft.

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Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.8

with the aim of reconstructing the nasal mucosallayer. On a proportional rate with the cleft (Fig 6), anincision in the temporal-parietal region is executed,and the galea-pericranium layer is reached. After-ward, a graft of suitable dimension to close the cleftis fit out and excised (Figs 7Y9). The flap is then

isolated and placed correspondently to the previouslyset-up site. The borders of the graft are pocketedunder the margins of the palatal flaps previously de-tached; the pericranium side is then positionedtoward the bone layer of the cleft and sutured withseparate 4/0 reabsorbable stitches (Fig 10).

DISCUSSION

S ince 1837 with Dieffenbach’s8 first description ofbony palate repair to our age, many authors

described different techniques to solve the problem

Fig 7 Intraoperative viewVsizing of the galea-pericraniumfree flap.

Fig 8 Intraoperative viewVexcision of the galea-pericra-nium free flap.

Fig 9 Intraoperative viewVthe galea-pericranium free flap.

Fig 10 Intraoperative viewVthe palate restored with thegalea-pericranium free flap.

Fig 11 Intraoperative viewVearly secondary alveolo-plasty (age of 9 years).

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Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.8

of hard palate cleft. Those interventions were mainlybased on sliding or rotating mucoperiosteal flaps.From 1977, Stricker and Chancholle,9 and lately otherauthors, described the possibility of closing the cleftpalate with various tissue grafts. Our school aims toperform a restorative therapy of the deformity beforethe age of 2 years with the final goal of not com-promising phonation, swallowing, and, in a widerperspective, the psychic and somatic developmentof the patient.

Basing on the work of Skoog on tibial periostealgraft, our school proposes a cleft palate and lip repairintervention using the galea-pericranium free flap.

Our timing is based on a surgical treatment di-vided in 3 times. At the age of 6 to 9 months or 8-kgweight, we perform a lip and soft palate repair (basedon the observation of Malek and Psaume10) and rhi-noplasty. As a consequence of this intervention, thecleft palate reduces his gap to 5 or 6 mm. At 24 to48 months, we suggest restoring the cleft palate with

Fig 12 Occlusal view after early secondary alveoloplasty.

Fig 13 Patient postoperative frontal view.

Fig 14 Patient postoperative lateral view.

Fig 15 Patient postoperative occlusal view.

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the galea-pericranium free flap according to the pre-viously described procedure. Finally, at the age of9 years, we repair the alveolar bone with iliac crestbone chip graft.

It is our opinion that this protocol respects thecharacteristics of superior maxilla development andthe other essential functions such as phonation andswallowing. In our experience, indeed, we observedthat interventions based on sliding or rotatingperiosteal or mucoperiosteal flap, for the most part,lead to a noncorrect upper maxilla growth. There are2 main features that are compromised. The first isrepresented by the scar retraction strength that mightaffect the sagittal and transversal upper maxillagrowth. The possible tension strength could be re-sponsible for a noncorrect transversal and verticaldevelopment of the maxillary bone, more specificallyof the palatal vault.

As a consequence of this possible outcome, theposition of the tongue is lowered as well, thus pro-ducing a continuous sagittal growth stimulus on themandible decreasing the physiological upper maxillasagittal pressure.

This mechanism could be responsible for theincreased incidence of class III dentoskeletal maloc-clusion in those kinds of patients.

Following this observations, we assess that, withthe galea-pericranium free flap, these 2 features arecompletely respected as observed in this patient whoat the age of 9 years presents a regular bone and facialdevelopment without any phonation or swallowingdeficit (Figs 11Y14).

CONCLUSION

The surgical approach the authors described is partof a long-lasting treatment. The exact timing the

authors suggest is composed of the first interventionat 6 to 9 months or at least 8-kg weight consistingof lip and soft palate repair and primary rhinoplasty.The second intervention is performed at 24 to48 months to close the cleft palate with the surgicalprocedure already described, and last, at the age of8 to 10 years, the early secondary alveoloplasty isperformed.

This timing perfectly respects the physiologicalfacial growth avoiding any possible tension causedby palatal scar retraction. Moreover, it perfectly re-spects tongue positioning in the palatal vault. Wemust underline the fundamental role of the tonguein the upper maxilla sagittal and vertical growthand the correct development of the mandible. Forthis reason, many patients affected by cleft lip andpalate will not have a nonharmonic facial devel-opment that might lead to a class III dentoskeletalmalocclusion.

REFERENCES

1. Skoog T. The use of periosteal flaps in the repair of clefts of theprimary palate. Cleft Palate J 1965;2:332Y339

2. Tennison CW. The repair of unilateral cleft lip by the stencilmethod. Plast Reconstr Surg 1952;9:115

3. Randall P. Triangular flap in the repair of unilateral cleft lip. In:Grabb WC, Rosenstein SW, Bzoch KR, eds. Cleft Lip and Palate.Boston, MA: Little, Brown, 1971

4. Bardach J, Morris HL, Olin WH. Late results of primaryveloplasty: the Marburg Project. Plast Reconstr Surg 1984;73:207Y218

5. Bardach J, Mooney M, Giedrojc-Juraha ZL. A comparativestudy of facial growth following cleft lip repair with or with-out soft-tissue undermining: an experimental study in rabbits.Plast Reconstr Surg 1982;69:745Y754

6. Salyer KE, Bardach J. Salyer & Bardach’s Atlas of Craniofacial &Cleft Surgery. 1st ed. Philadelphia: Lippincott Williams &Wilkins, 1999

7. McComb H. Primary repair of the bilateral cleft lip nose: a15-year review and a new treatment plan. Plast Reconstr Surg1990;86:882Y889

8. Dieffenbach JF. Practical Surgery. London, UK: Liston, JohnChurchill, 1837:471Y473

9. Stricker M, Chancholle AR, et al. La greffe periostee dans lareparation de la fente totale du palais primaire. Ann Chir Plast1977;22:117Y125

10. Malek R, Psaume J. Nouvelle conception de la cronologie etde la technique du treitment des fentes labio-palatines. AnnChir Plast 1983;28:237

Fig 16 Patient postoperative palatal view.

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