Uvular Transposition: A New Method of Cleft Palate Repair

Dr. Redha AliConsultant 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).

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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.

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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.

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Fig. 4

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

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Fig. 5

Fig. 5. Anatomical realignment of the muscle

in the midline.

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Fig. 6

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

plasty.

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• 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.