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    1. Indications: The main objectives of cleft palate repair are complete closure of the palatal cleft and the creation of an adequately functioning velopharynx for production of intelligible speech.
    2. According to Bardach, the most important components of the classic two flap or three flap (V-Y) modification palatoplasty are as follows: 
      1.  Atraumatic undermining of the mucoperiosteal flaps on both oral and nasal surfaces of the cleft.
      2. Partial dissection of the neurovascular bundles from these flaps to allow for a tension free approximation of the oral surface of the flaps.
      3. Precise dissection of the soft palate musculature from their abnormal insertions on the posterior edge of the hard palate and from the nasal periosteum to allow for repositioning and creation of a physiologically appropriate velopharyngeal muscular sling.
      4. Closure of the hard palate in two layers and suturing the oral and nasal layers together in order to eliminate dead space and stabilize the flaps.
      5. 3 flap palatoplasty is appropriate when the cleft is bilateral and of the secondary palate posterior to the incisive foramen. 
    3. Complications
      1. Oronasal fistula occurs in 2-3% of patients. This most often occurs at the junction of the hard and soft palate.
      2. Velopharyngeal insufficiency can remain an issue if the soft palate is inadequately lengthened during the case. Speech therapy is often inadequate to address this problem and it may require a palate lengthening procedure such as sphincter palatoplasty or a pharyngeal flap
      3. Prolonged operative time with the Dingman in place can lead to tongue edema. This problem can be prevented by letting the mouth gag down periodically.
    1.  Laboratory studies
      1.  Hemoglobin and hematocrit should be obtained. Allowable blood loss may be estimated. 
    2. Consent
      1. Informed consent should be obtained
  2. Other Considerations:
    1. Embryology: Palatogenesis takes place from week 5 to 12 of embryologic development. Anteriorly the maxillary prominences grow, pushing the nasal prominences together in the midline. These fuse to form the primary palate, defined as the central maxillary alveolar arch that houses the four incisors as well as the hard palate anterior to the incisive foramen. After primary palate fusion, the secondary palate begins to develop. The palatine shelves arise from the maxillary prominence and fuse to form the secondary palate from anterior to posterior beginning at the incisive foramen at week 8 and ending with the uvula by week 12. The type and degree of palatal cleft directly result from the point at which this process is interrupted
    2. Anatomy:  The width of the palatal cleft is one of the main considerations in pre-operative planning. The wider the cleft, the wider the strip of mucoperiosteum that must be left on the medial edge of the cleft.  These strips will be turned over and used to create the nasal layer of the cleft repair. Narrow cleft is defined as gap width <1cm. Medium cleft is defined as gap width from 1 to 1.5cm. Wide cleft is defined as gap width>1.5cm.
    3. Middle ear disease - Incidence of middle ear effusion with cleft palate is higher than the general population especially in children under 2. Eustachian tube dysfunction is thought to be primarily due to the abnormal insertion and formation of the tensor and levator veli palatini in patients with cleft palate. Cartilage hypoplasia and cranial base abnormality have also been posited as potential etiologies. Any cleft palate patient undergoing general anesthesia warrants exam of ears under anesthesia for evaluation of effusion and necessity of tympanostomy tubes.
    1. Room Setup
    2. Instrumentation and Equipment
      1. Microscope 
      2. Phillipinne board
      3. Dingman retractor 
      4. Monopolar Colorado tip cautery set at 8 cut, 8 coag, blend 1
    3. Medications (specific to nursing)
      1. Injection: Vitrase (hyaluronidase) 5U with 1:200,000 Epinephrine is injected into the palate and vomer for hemostasis and hydrodissection. 
      2. 3/4"x3/4" (Elvis) neurosurgical patties soaked in Vitrase (hyaluronidase) 5U with 1:200,000 Epinephrine are used for hemostasis during the case.
      3. Avitene
      4. Bacitracin
    4. Prep and Drape
      1. Bed is turned 90 degrees to the door. The child is laid supine on the Phillippine board with the head off of the edge of the Phillippine board onto the table in maximal extension.
      2. Prep and drape in the usual sterile fashion for an intra-oral procedure.
      3. Place Dingman retractor carefully taking care not to damage the teeth, the alveolus, the lips, or the cheeks.  
    5. Drains and Dressings
      1.  none
    6. Special Considerations
      1. Each cleft palate must be examined carefully both pre-operatively and intraoperatively. Wide clefts will require more extensive lateral dissection to medialize the mucosal flaps and may require a vomer interposition flap.  
    1. Oral Rae endotracheal tube 
    2. Antibiotics: Unasyn 50 mg/kg or equivalent should be ordered for administration prior to incision. 
    3. Steroids: Decadron 0.25 mg/kg is given at the beginning of the case.
    1. Examination of the ears is performed bilaterally. Tympanostomy tubes may be placed if indicated. 
    2. Positioning: The bed is rotated 90 degrees towards the door. All pressure points are padded. The patient's head is positioned in extension off of the end of the Philippine board. The patient is prepped and draped. The Dingman retractor is placed taking care to seat it firmly without damaging the cheeks, lips, teeth or tongue. Vitrase is injected and allowed time to take effect. 
    3. Incisions: Planned incisions extend from the uvula down the medial cleft mucosa to separate the nasal and oral mucosa. once the blade reaches the incisive foramen the incision extends anteriorly to the contralateral primary palate ending at the alveolus at the approximate location of the canine. This incision is performed bilaterally using an 11 blade. These mucoperiosteal flaps are released from anterior to posterior when the lateral secondary palate mucosa is incised usually with Colorado tip monopolar electrocautery. 
    4. Hard palate dissection: Cold steel or Colorado tip monopolar electrocautery may used to dissect the mucoperiosteal flaps from the palatal bone from anterior to posterior. Cottle or Woodson elevators are often used to undermine. A gauze may be used to elevate in the region of the neurovascular pedicle emerging from the greater palatine foramen. As the flap is undermined, it is useful to maintain tension using a single hook retractor or a stay suture.  The Von Graefe is used to dissect around the neurovascular bundle and protect it. In order to lengthen and provide mobility to the flap, it is often necessary to further dissect the neurovascular bundle from the mucoperiosteal flap. 
    5. Soft palate dissection: Soft palate muscle remains attached to the oral mucosa while the plane of dissection is carried out between the muscle and the nasal mucosa. Extensive lateral dissection is often necessary to free the mucoperiosteal flap so it can be adequately medialized for a tension free repair. The soft palate musculature should be stripped from their hard palate and periosteal attachments in order to mobilize them for transposition medially to recreate a more physiologic palatal sling. The edges of the primary palate triangle flap are then dissected free from the palate using a cottle and McIndoe in order to provide a cuff of tissue to suture the anterior medial edges of the mucoperiosteal flaps.
    6. Note: If the mucoperiosteal flaps are too narrow transversely due to a wide cleft, the vomer mucosa may be incised, undermined and used as an interposition graft to close the palate. 
    7. Closure: Using 4.0 Vicryl sutures, first the nasal mucosa is closed from anterior to posterior (alveolus to uvula) with care to approximate the raw mucosal edges in an interrrupted tension free fashion. Care must be taken to evert the mucosa nasally with knots on the nasal surface.  Next the soft palate is addressed. The soft palate muscles are transposed medially and sutured together in order to create a functional muscular sling. The oral layer is then closed from posterior to anterior starting at the uvula and progressing towards the anterior flap. Often vertical mattress sutures are used in order to obliterate dead space between the oral and nasal mucosa. Vertical mattress sutures are also preferred to secure the tip of the lateral flaps to the medial edges of the anterior flap. Simple interrupted sutures are used to further tighten all remaining gaps and to finish closure of the anterior triangle. Avitene is then tightly packed over palatal bone into the lateral defects left by the medialized flaps using wet gauze for 2-4 minutes. 
    8. The stomach, oropharynx, nasopharynx, and nasal cavity are gently suctioned. The Dingman is removed. Bacitracin is applied to the lips and the patient is turned back to Anesthesia for extubation. Armboards should be placed prior to arousal in order to prevent trauma to the palate.
  6. Images
    1. Simplified schematic per Bardach and Salyer 1999
    1. Diet: Strict cup diet for 3 weeks. No straws, spoons, forks or sharp implements. 
    2. Armboards on at all times unless directly in the arms of a parent or guardian. Supervised play. 
    3. Antibiotics for 1 week (amoxicillin; clindamycin if penicillin allergic)
    4. Follow up in 3 weeks
    1. Salyer and Bardach's atlas of craniofacial & cleft surgery 1998





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