Uvular Transposition: A New Method of Cleft Palate Repair Dr. Redha Ali Consultant plastic and reconstructive surgery

This prospective study was done to determine whether a new cleft palate repair utilizing uvular transposition improved speech outcome as measured objectively by a speech pathologist. It facilitates velopharyngeal closure by significantly lengthening the palate, anatomically reconstructing the muscles of the palate, and decreasing the palatal excursion necessary to achieve closure. The effectiveness of cleft palate repair is determined by its success in the later development of normal speech and hearing, as well as normal growth of the face. Incorporating the mucosa and the soft-tissue mass of the uvula into the palate repairs facilitated a tension-free reconstruction even in the widest cleft.

Fig. 1 Fig. 1. Transposition of uvula (U) mass to the nasal surface of the soft palate results in a permanent ridge on the palate to assist with velopharyngeal closure. This functionally shortens the distance required to close the nasal pharyngeal aperture (LP = levator palatini).

Procedure The procedure was performed under general anesthesia with orotracheal intubation using a Ray tube. The patient received an intravenous cephalosporin or penicillin before initiating the procedure. The entire face, nose, and mouth were prepared and draped in a sterile fashion. A Dingman mouth-gag was used to visualize the entire oral cavity without compromise of the oral tracheal tube. A local anesthetic (with epinephrine 1:200,000) was injected along the margins of the hard and soft palate as well as the posterior tonsillar pillar. Enough anesthetic was injected into the uvula to make it tense. A 5-minute waiting period was allowed to achieve adequate hemostasis and to facilitate dissection.

Fig. 2 Fig. 2. Initial incision outline on oral mucosa of the soft palate cleft. A and B are the oral mucosal flaps and will include one-third of the uvula mass.

Fig. 3 Fig. 3. Note the abnormal insertion of the levator muscle on the back of the hard palate. The back-cuts for the Z-plasty are indicated. A and B are flaps of the oral mucosa including one-third of the uvula mass. A′ and B′ are flaps of nasal mucosa including two-thirds of the uvula mass.

Fig. 4 Fig. 4. Z-plasty closure of the nasal mucosal layer.

Fig. 5 Fig. 5. Anatomical realignment of the muscle in the midline.

Fig. 6 Fig. 6. Oral mucosal layer closure using a second Z-plasty.

Postoperative antibiotics, usually penicillin or cephalosporin, were given orally. Infants were allowed to resume oral feeding immediately postoperatively. The patients were discharged postoperatively once they could tolerate adequate oral feedings. The vast majority of patients were discharged on the next day. The patients were followed in the outpatient surgical clinic and enrolled in the Cleft Lip and Palate Clinic at 2 to 3 years of age. They were assessed yearly, or more often, depending on the patient's need. Cleft Lip and Palate team members included a plastic surgeon, a speech pathologist, an otorhinolaryngologist, a hearing specialist, an orthodontist, a genetic counselor, and a social worker, who all evaluated and followed these children.

Speech Evaluation Each patient's articulation, speech resonance, voice, and fluency were assessed perceptually during scheduled visits to the Cleft Lip and Palate Clinic. Perceptual ratings were performed by a single speech pathologist with 22 years' experience in the area of cleft palate speech disorders.

Discussion Anatomically, the uvula is ideally positioned to lengthen the palate and because it serves no function can be employed to lengthen the palate without injury to the hard palatal structures. Retaining two-thirds of the mass of the uvula on the nasal surface incorporates the uvular muscle and the vast majority of soft tissue onto the nasal surface of the palate. Transposing it as a Z-plasty results in a significant bulge on the nasal surface of the palate, which in many of our patients appears to be retained. The use of the extensive mucosa available both on the nasal and oral layers of the uvula allows very pliable, well vascularized tissue to be available for lengthening the palate. This allows soft pliable tissue that is not under tension to be incorporated over the direct intravelar veloplasty so that adequate motion of the palate is facilitated.

Summary We have been extremely pleased with the simplicity and results of this procedure. This repair can be performed in less than an hour with minimal risk of complication and no significant increase in operative time. None of the patients have had postoperative respiratory difficulty or an untoward perioperative event despite having surgery at a relatively early age. Our overall long-term speech evaluations with only two patients with significant velopharyngeal insufficiency confirm the efficacy of this adjunctive surgical technique. Review of the literature supports the success of this procedure, as velopharyngeal insufficiency with other currently used techniques ranges from 4 to 17 percent in some large series. The results of long-term studies on facial growth are presently underway and will require longer follow-up. We feel the technique described is a significant addition to the continually ongoing modification of the palatal repair aimed at improving long-term speech and developmental results.