**3. Surgical procedures for cleft palate repair**

tal repair. Second, postoperative speech results were assessed objectively by speech language therapists (SLT). Third, these objective data were shared with all surgeons to provide feedback

In this chapter, we described our surgical strategy of cleft palate repair that approaches each anatomical and pathological abnormality of cleft palate and evaluated postoperative speech outcomes including presence/severity of hypernasality, nasal emission, and nasalance scores after standardize palatal repair. We then compared speech outcomes to ones using our previous palatal repair protocol without following surgical strategy. Furthermore, we also com-

The concept of our strategy for CP repair was to approach each anatomical and pathological abnormality that may cause postoperative velopharyngeal incompetence (VPI): short palate, asymmetric palate, insufficient velar elevation, and a midline defect of the velum, to establish CP repair that can ensure VP closure (**Table 1**) [2]. The above factors were identified based on our experiences during the treatment of persistent VPI after CP repair. Therefore, our CP repair consisted of (1) presurgical orthopedics using Hotz's plate as much as possible to minimize the cleft space, (2) modified V-Y palatoplasty, allowing conservation of the periosteum in the anterior part of the maxilla, minimizing maxillary growth disturbance, (3) lengthening of the nasal mucosa using a large Z-plasty and a free mucosal graft, (4) muscular reconstruction producing a symmetrical levator sling and pharyngeal arch, and (5) two-layered suture of the palatal muscles.

**Possible causes of VPI Anatomical pathological abnormalities Surgical procedures in palatal repair**

• Presurgical orthopedics for narrowing the cleft space using Hotz's plate, as much as possible. • Sufficient retropositioning of the palatal muscle.

• Presurgical orthopedics improving the positional gap using Hotz's plate, as

• Symmetrical reconstruction of the palatal muscle referencing the anatomi-

cal landmarks.

much as possible. • Extension of the nasal mucosa by large Z-plasty with a free mucosal graft.

• Growth deficiency of the soft palate. • Insufficient retropositioning of the

ween the maxillary segments. • Discrepancy of the velar length between the segments.

• Malpositioning of the palatal muscles.

palatal muscles.

velopharynx • Antero-posterior discrepancy bet-

pared them to the nasalance scores of Japanese noncleft children.

**2. Surgical strategy of palate repair approaching each anatomical** 

for the next operation.

62 Designing Strategies for Cleft Lip and Palate Care

**and pathological abnormality**

Short palate • Wide cleft palate.

Asymmetric

We adopt a modified V-Y palatoplasty for cleft palatal repair, although a large number of surgeons have developed surgical procedures for palatal repair [3–10]. The reason why we adopt a modified V-Y palatoplasty for cleft palatal repair is due to the following previous reports. Brothers et al. observed that the success rates for VP closure after Furlow palatoplasty and the modified Wardill-Kilner procedure were 64.0 and 70.0%, respectively, using pressure-flow testing, and they concluded that there was no difference between the two procedures [11]. Van Lierde et al. also compared Furlow palatoplasty and the Wardill-Kilner procedure using the nasometry and observed significantly better results in those treated with the Wardill-Kilner procedure [12].

The surgical procedures of a modified V-Y palatoplasty are shown in **Figure 1**. On designing the incision line, anatomical landmarks at the velopharynx were marked carefully (**Figure 1a**). The palatal flaps were elevated while preserving the periosteum in the anterior and lateral parts of the hard palate, and the palatal muscles were bluntly dissected along the surface of the tensor aponeurosis and nasal mucosa in a single layer. For extension of the nasal mucosa of the soft palate, large Z-plasty was performed in the nasal surface of the soft palate (**Figure 1b**). Mucosal incision for the large Z-plasty was extended until the surgeon could confirm contact between the soft palate and posterior pharyngeal wall without any tension. When the velar length became shorter on complete closure of the Z-plasty, the mucosal defect that remained on the nasal side was filled using a free mucosal graft donated from the buccal area (**Figure 1c**). Palatal muscles were then sutured in the midline of the soft palate by the two-layered suture (**Figure 1d**).

Palatal muscle was sutured carefully on producing a symmetrical levator sling and also the symmetrical palatopharyngeal and palatoglossal arches and uvula, while referencing five anatomical landmarks, as described above.

**Figure 1.** Surgical steps in palate repair for UCLP.

On designing the incision line, anatomical landmarks at the velopharynx were marked using 0.05% Toluidine blue solution (**Figure 2**). The marked points included the tip and base of the uvula (nos. 1 and 2), point in which the extension line of the palatoglossal arch crossed the cleft edge (no. 3), posterior edge of the hard palate (no. 4), and midpoint between nos. 3 and 4 (no. 5).

The palatal flaps were elevated while preserving the periosteum in the anterior and lateral parts of the hard palate, and the palatal muscles including the levator veli palatini muscle, palatopharyngeal muscle, and musculus uvulae, although these muscles were not clearly identified, were bluntly dissected along the surface of the tensor aponeurosis and nasal mucosa in a single layer. Muscles were sufficiently retropositioned as the direction was turned sideways. The hamular process was not fractured.

For extension of the nasal mucosa of the soft palate, a large Z-plasty was made in the nasal mucosa of the soft palate (**Figure 3a**). Mucosal incision for the large Z-plasty was extended until the soft palate contact to the posterior pharyngeal wall without any tension. The mucosal defect produced by a large Z-plasty was closed. However, when the velar length became shorter on complete closure of the Z-plasty, the mucosal defect that remained on the nasal side was filled using a free mucosal graft donated from the buccal area (**Figure 3b**). Because the shortened velar length due to complete closure of a Z-plasty might cause an asymmetric VP form and asymmetric closure motion.

Palatal muscles were then sutured in the midline of the soft palate by the two-layered suture (nasal and oral sides) using a nonabsorbable thread (5-0 Nylon; **Figure 3c**). Palatal muscle was sutured carefully on producing a symmetrical levator sling and also the symmetrical palatopharyngeal and palatoglossal arches and uvula, while referencing five anatomical landmarks, as described above. The raw area of the hard palate was dressed using a collagen-based artificial dermis and covered using an acrylic plate for 1 week.

On designing the incision line, anatomical landmarks at the velopharynx were marked using 0.05% Toluidine blue solution (**Figure 2**). The marked points included the tip and base of the uvula (nos. 1 and 2), point in which the extension line of the palatoglossal arch crossed the cleft edge (no. 3), posterior edge of the hard palate (no. 4), and midpoint between nos. 3 and

The palatal flaps were elevated while preserving the periosteum in the anterior and lateral parts of the hard palate, and the palatal muscles including the levator veli palatini muscle, palatopharyngeal muscle, and musculus uvulae, although these muscles were not clearly identified, were bluntly dissected along the surface of the tensor aponeurosis and nasal mucosa in a single layer. Muscles were sufficiently retropositioned as the direction was turned sideways.

For extension of the nasal mucosa of the soft palate, a large Z-plasty was made in the nasal mucosa of the soft palate (**Figure 3a**). Mucosal incision for the large Z-plasty was extended until the soft palate contact to the posterior pharyngeal wall without any tension. The mucosal defect produced by a large Z-plasty was closed. However, when the velar length became shorter on complete closure of the Z-plasty, the mucosal defect that remained on the nasal side was filled using a free mucosal graft donated from the buccal area (**Figure 3b**). Because the shortened velar length due to complete closure of a Z-plasty might cause an asymmetric

Palatal muscles were then sutured in the midline of the soft palate by the two-layered suture (nasal and oral sides) using a nonabsorbable thread (5-0 Nylon; **Figure 3c**). Palatal muscle was sutured carefully on producing a symmetrical levator sling and also the symmetrical palatopharyngeal and palatoglossal arches and uvula, while referencing five anatomical landmarks, as described above. The raw area of the hard palate was dressed using a collagen-based arti-

4 (no. 5).

The hamular process was not fractured.

**Figure 1.** Surgical steps in palate repair for UCLP.

64 Designing Strategies for Cleft Lip and Palate Care

VP form and asymmetric closure motion.

ficial dermis and covered using an acrylic plate for 1 week.

**Figure 2.** Surgical steps in palatal repair. The figure demonstrates anatomical landmarks and the incision line.

**Figure 3.** Surgical steps in palatal repair. The figure demonstrates elevation of the palatal flaps conserving the periosteum in the anterior and lateral parts of the hard palate and a large Z-plasty on the nasal side (dotted line) (a), a free mucosal graft on the nasal side (b), and symmetrical muscular reconstruction producing a levator sling while referring to the anatomical landmarks (c).
