Two-Flap Palatoplasty Over 2 Decades of Experience

Abstract

Archives of Facial Plastic SurgeryVol. 9, No. 2 Abstracts: CommentaryFree AccessTwo-Flap Palatoplasty Over 2 Decades of ExperienceJason J. MillerJason J. MillerCorrespondence: Dr Miller E-mail Address: jjmillermd@hotmail.comSearch for more papers by this authorPublished Online:1 Mar 2007https://doi.org/10.1001/archfaci.9.2.144AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Plastic and Reconstructive SurgeryTwo-Flap Palatoplasty: 20-Year Experience and Evolution of Surgical TechniqueKenneth E. Salyer, MD; Karen W. E. Sng, MRCS(Edin), MMed(Surg)(Singapore); Elizabeth E. Sperry, ScD, CCC-SLPBackground: The two-flap palatoplasty was described more than 30 years ago, but there are few reports of long-term results using this technique. There are also very few long-term series of a single method of palatoplasty from a single surgeon.Methods: The authors reviewed the technique of the two-flap palatoplasty, with emphasis on the senior author's (K.E.S.) modifications. The authors also retrospectively reviewed 382 two-flap palatoplasties performed by the senior author in nonsyndromic patients over a 20-year period. The incidence of secondary velopharyngeal surgery was established. Detailed speech analysis was performed in a subset of 150 patients.Results: The proportion of patients with velopharyngeal insufficiency over 20 years was 8.92%, falling from 10.95% in the first decade to 6.43% in the second decade. There was no significant difference in velopharyngeal insufficiency between the cleft subtypes. Age at palatoplasty did not affect the development of velopharyngeal insufficiency, but it should be noted that most of the patients underwent palate repair before 12 months of age. Speech results were consistently good across the two decades. In the second decade, 91.14% had normal to mildly impaired resonance, 79.75% had no or inaudible nasal air emission, and 97.47% demonstrated no compensatory articulation errors.Conclusions: The two-flap palatoplasty is a reliable technique that has yielded excellent surgical and speech outcomes. Early and regular speech assessments and appropriate treatment when indicated are an integral part of the multidisciplinary approach to achieve good speech outcome.Plast Reconstr Surg. 2006;118:193-204Salyer et al have presented a large retrospective review of 382 palatoplasties performed over a 20-year period. Salyer performed a modification of Bardach’s1 technique as a single-stage repair. Most of the surgical procedures were done before the patient reached the age of 12 months, with a mean age of 9.37 months. Of the 382 patients, 150 had a detailed speech analysis performed with a minimum of 4 years of follow-up. The need for secondary palatal surgery was the main outcome measure of success, and the rate of velopharyngeal incompetence was 8.92%. Of the secondary surgical procedures performed, 88% were for a pharyngeal flap. The palatal fistula rate was 10%.Two-flap palatoplasty has been in practice for more than 30 years and is likely one of the more commonly used techniques in the United States. Salyer et al emphasize 3 key points of his surgical technique: (1) the construction of an adequately functioning muscle sling by thorough dissection and suturing without tension; (2) minimizing areas of exposed bone to reduce adverse effects on midfacial growth; and (3) complete palatal closure as a single-stage operation. Although some controversy exists regarding these points,2,3 there is certainly literature to support these surgical tenets.4-6Another interesting point Salyer et al emphasize is that the need for secondary surgery for velopharyngeal incompetence may be most influenced by inherent paucity of tissue present and not necessarily cleft type. Secondary surgery was only required in 6.6% of left unilateral cleft palates, 6.9% of right unilateral cleft palates, 10.3% of bilateral cleft palates, and 11.3% of cleft palates. Cutting et al4 described similar findings, with the need for secondary surgery in 6% of unilateral cases and 14% of bilateral cases. Marrinan et al7 also alluded to the importance of the vomeric muscular complex as a more important prognostic indicator compared with cleft type. These experienced surgeons agree that the liberal use of vomer flaps is an important aspect of their surgical technique. Another point of agreement of these experienced surgeons is the timing of cleft palate repair. Marrinan et al7 published a review of 228 palatoplasties in 1998. They divided these patients into 4 age groups (8-10 months, 11-13 months, 14-16 months, and ≥16 months). Among the 4 age groups, pharyngeal flap surgery was required in 11%, 14%, 19%, and 32%, respectively. Dr Salyer also comments on his change of philosophy over the past 20 years in that he now performs palatoplasty typically before the patient reaches the age of 12 months compared with 18 to 24 months, which was done previously.In summary, Salyer et al should be commended for sharing their vast experience and reinforcing specific concepts of cleft palate repair. It is only through critical review of one's technique and sharing of these findings that advances can be made in the challenging care of these patients.REFERENCES1. Bardach J. Rozszczepywarg; Gornej Podniebienia. Warsaw, Poland: Panstwowy Zaklad Wydawn; 1967 Google Scholar2. Marsh JL, Grames LM, Holtman B. Intravelar veloplasty: a prospective study. Cleft Palate J. 1989;26:46-50 Google Scholar3. Rohrich RJ, Love EJ, Byrd S, Johns DF. Optimal timing of cleft palate closure. Plast Reconstr Surg. 2000;106:413-425.10946942 Medline, Google Scholar4. Cutting CB, Rosenbaum J, Rovati L. The technique of muscle repair in the cleft soft palate. Operative Tech Plast Reconstr Surg. 1995;2:215-222 Google Scholar5. Bardach J, Kelly KM. Does interference with mucoperiosteum and palatal bone affect craniofacial growth? an experimental study in beagles. Plast Reconstr Surg. 1990;86:1093-1102.2243851 Medline, Google Scholar6. Pigott RW, Albery EH, Hathorn IS, et al. A comparison of three methods of repairing the hard palate. Cleft Palate Craniofac J. 2002;39:383-391.12071786 Medline, Google Scholar7. Marrinan EM, LaBrie RA, Mulliken JB. Velopharyngeal function in nonsyndromic cleft palate: relevance of surgical technique, age at repair, and cleft type. Cleft Palate Craniofac J. 1998;35:95-100.9527305 Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 9Issue 2Mar 2007 InformationCopyright 2007 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Jason J. Miller.Two-Flap Palatoplasty Over 2 Decades of Experience.Archives of Facial Plastic Surgery.Mar 2007.144-145.http://doi.org/10.1001/archfaci.9.2.144Published in Volume: 9 Issue 2: March 1, 2007PDF download