eMedicine Specialties > Plastic Surgery > Craniofacial

Craniofacial, Cleft Palate Repair: Follow-up

Author: Pravin K Patel, MD, Associate Professor of Surgery, Division of Plastic Surgery, Northwestern University School of Medicine; Chief of Plastic and Craniofacial Surgery, Shriners Hospitals for Children; Head of Craniofacial Surgery, Children's Memorial Hospital
Coauthor(s): Raja Ramaswamy, MS, The Chicago Medical School; Mitchell F Grasseschi, MD, Assistant Professor, Department of Plastic Surgery, Feinberg School of Medicine, Northwestern University; Private Practice, Plastic and Reconstructive Surgery; Mary M O'Gara, MA, CCC-SLP, Associate Professor, Department of Plastic Surgery, Northwestern University Medical School; Speech/Language Pathologist: Consultant to the Cleft Lip and Palate Institute, Allied Health Professional Staff Appointment, Shriners Hospital for Children; Erin K McGraw, MA, CCC-SLP/L, Speech-Language Pathologist, Cleft Palate and Craniofacial Team, Shriners Hospital for Children-Chicago
Contributor Information and Disclosures

Updated: May 1, 2009

Outcome and Prognosis

Long-term Sequelae

Palatal fistula

Fistula as a result of dehiscence of the initial cleft palate repair can be difficult problem. A fistula of sufficient size can lead to significant problems, ranging from oral fluid and food regurgitation into the nasal chamber to speech difficulties secondary to nasal air emission. Factors that may contribute to fistula formation are the type of cleft, type of repair, wound tension, single-layer repair, dead space deep to the mucoperiosteal flap, and, occasionally, unmasking of a nonfunctional fistula with transverse maxillary arch expansion.

Repair requires re-elevation of the mucoperiosteal flaps with the goal of a two-layer closure (a nasal layer and an oral layer). However, the incidence of recurrence after initial fistula closure is high. Faced with recurrence, the surgeon's options extend to pharyngeal flaps, facial artery myomucosal flaps (FAMM), and tongue flaps. When speech disturbance occurs as a result of a fistula of significant size, prosthetic obturation of the fistula (even temporary) can be considered when weighed against repeated failed surgical procedures.

Velopharyngeal incompetence

Morris, in his review of the literature, reported an incidence of velopharyngeal competence of 75%, as defined by the absence of consistent evidence of VPI. No differentiation was made on the type of cleft or the technique of repair. Peterson-Falzone reported 83.4% competence based on the same criteria.10 However, when using the criterion of no nasal emission or hypernasality, the incidence of velopharyngeal competence decreases to 60%.

The analysis of velopharyngeal competence after various techniques is difficult to interpret in the different studies. The anatomy of the cleft has a great degree of variability that is usually not controlled. The reader is referred to the authors' article on Craniofacial, Pharyngoplasty and Pharyngeal Flaps for further reading.

Growth and morphology

The severity and laterality of the clefts as well as the choice of cephalometric measurements used in the assessment account for much of the variability in the reported effects of clefting in facial growth. Grayson et al studied the net effect of palatal clefts on the facial skeleton as viewed by lateral cephalogram and determined by mean tensor analysis. The authors note reduced facial bone growth in all directions but principally in the horizontal dimension. The effect was most pronounced at the level of the palate and slightly less so in height of the mid face. Vertical facial growth was most restricted in subjects who had clefts of the primary and secondary palate compared with those who had clefts of the secondary palate alone.

Graber was the first to document disturbance of facial growth as a result of palatal surgery. Multiple studies have demonstrated a casual relationship between increased lip pressure from a repaired cleft lip, periosteal denuding and reduced blood flow in the palatine artery during mucoperiosteal flap elevation and the collapse of the dental arch contraction of the arch, and hypoplasia of the maxilla. Even pharyngeal flap surgery was shown to decrease the width and length of the maxillary arch in cleft palate surgery.

Future and Controversies

The management of a patient with cleft palate is complex. No current universal agreement exists on the appropriate treatment strategy. Several main points should be emphasized. Normal speech should be the most important consideration in the therapeutic plan. Growth disturbance should be minimized but not at the expense of speech impairment because facial distortion can be satisfactorily managed with future surgery, whereas speech impairment can often be irreversible. The authors believe, as do many others, that repair of cleft palate to establish a competent velopharyngeal sphincter should be completed at age 6-12 months. Surgical interventions should be designed to cause minimal disruption of the palate to decrease the severity of subsequent growth problems.

Cleft patients should be managed in a center with a multidisciplinary team. Cleft palate remains a significant challenge for current and future plastic surgeons.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Alexander Margulis MD, Kara K Criswell MD, and Bryan K Criswell MD to the development and writing of this article.



More on Craniofacial, Cleft Palate Repair

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References
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References

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Further Reading

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Keywords

cleft palate, cleft palate repair, facial cleft, cleft lip and palate, CL/P, cleft lip repair, cleft lip, birth defect, congenital defect, cleft lip surgery, cleft lip treatment, cleft lip feeding, cleft treatment, cleft lip pictures, cleft lip surgical repair, cleft lip repair pictures

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Contributor Information and Disclosures

Author

Pravin K Patel, MD, Associate Professor of Surgery, Division of Plastic Surgery, Northwestern University School of Medicine; Chief of Plastic and Craniofacial Surgery, Shriners Hospitals for Children; Head of Craniofacial Surgery, Children's Memorial Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Raja Ramaswamy, MS, The Chicago Medical School
Raja Ramaswamy, MS is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Mitchell F Grasseschi, MD, Assistant Professor, Department of Plastic Surgery, Feinberg School of Medicine, Northwestern University; Private Practice, Plastic and Reconstructive Surgery
Disclosure: Nothing to disclose.

Mary M O'Gara, MA, CCC-SLP, Associate Professor, Department of Plastic Surgery, Northwestern University Medical School; Speech/Language Pathologist: Consultant to the Cleft Lip and Palate Institute, Allied Health Professional Staff Appointment, Shriners Hospital for Children
Mary M O'Gara, MA, CCC-SLP is a member of the following medical societies: American Cleft Palate/Craniofacial Association and American Speech-Language-Hearing Association
Disclosure: Nothing to disclose.

Erin K McGraw, MA, CCC-SLP/L, Speech-Language Pathologist, Cleft Palate and Craniofacial Team, Shriners Hospital for Children-Chicago
Erin K McGraw, MA, CCC-SLP/L is a member of the following medical societies: American Cleft Palate/Craniofacial Association and American Speech-Language-Hearing Association
Disclosure: Nothing to disclose.

Medical Editor

Larry Hollier, Jr, MD, Assistant Professor, Department of Plastic Surgery, Baylor University College of Medicine
Larry Hollier, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, AO Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

S Anthony Wolfe, MD, Chief, Division of Plastic Surgery, Miami Children's Hospital; Voluntary Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami School of Medicine
S Anthony Wolfe, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic and Reconstructive Surgery, Florida Medical Association, and Southeastern Society of Plastic and Reconstructive Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

 
 
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