Palatorrhaphy Is usually performed in ope operation, but occasionally it is performed in two. In two operations the oft palate closure (i.e., staphylorrhaphy) is usually performed first and the hard palate closure (i.e., uranorrhaphy) is performed second. ()/Jjntin’s. The primary purpose. of the cleft palate repair is to create a mechanism capable of speech and deglutition without significantly Interfering with subsequent maxillary growth. Thus creation of a competent velopharyngeal mechanism and partitioning of the nasal and oral cavities are prerequisites to achieving these goals. The aim is to obtain a long ana mobile soft palate capable
of producing normal speech. Extensive stripping of soft tissues from bone will create more scar formation, which will adversely affect maxillary growth. The precarious nature of the problem indicates the complexity of the surgical procedures designed and the.ages at which they are instituted.
Surgical techniques. Opeative procedures for palatorrhaphy are as varied as techniques for Cleft lip repair. Each cleft of the palate is unique. They vary in Width, completeness, amount of hard .and soft tissue available, and
palatal length. Thus the surgical techniques used to close cleft palate deformities are extremely varied, not just from’ one surgeon to another but from one patient to the next. Hard palate closure. The hard palate is closed with soft tissues only. Usually no effort is made to create an osseous partition between the nasal and oral cavities. The soft tissues extending ‘around the cleft margin vary in quality. Some are atrophic and not particularly useful. Others appear healthy and readily lend themselves to dissection ,and suture integrity. In the most basic sense the soft tissues
are incised along the cleft margin and dissected .from the. palatal shelves until approximation over the cleft defect is possible. This procedure frequently necessitates the use of lateral relaxing incisions close to. the dentition (Fig. 27-ld). The soft tissues are then sutured in a watertight manner over the cleft defect and allowed to heal. The areas of bone
exposed by lateral relaxing incisions are allowed to heal by secondary intention. The superior aspect of the palatal flaps will also reepithelialize with respiratory epithelium, because this surface is now the lining of the nasal floor. When possible, it is advisable to obtain a two-layer closure
of the hard palatal cleft (Fig. 27-11 on page 637), which necessitates that-the nasal mucosa from the floor, latetal wall, and septal areas of the nose be mobilized and sutured’ together before the oral closure. When the vomer is long and. attached to the palatal shelf opposite the cleft, a mucosal flap can be raised from it and sutured to the palatal tissues on the cleft side (Fig. 27-12 on page 638). This procedure (i.e., vomer flap technique) requires little stripping of palatal mucoperiosteum and produces minimal scar contraction. The denuded areas of vomer and the opposite sides of the flap where no epithelium is present will reepithelialize. The ‘vomer flap technique is useful in clefts that are notwide and where the vomer is readily available for use. It is a onelayer closure. The closure of the soft palate is technically the most difficult of the operations yet discussed in the cleft-afflicted individual. Access is the
largest problem, because the soft palate is toward the back of the oral cavity. The combination of difficulty with light, retraction, and the fact that the clinician can work only from the oral side yet must correct both the oral and nasal sides of the soft. palate lead to difficulties. In addition, the clinician may have to work with extremely thin, atrophic tissues yet produce a closure that will hold together under function while healing is progressing. To help accomplish this goal, the soft palate is always closed
in three layers and in the same order: (1) nasal mucosa, (2) muscle, and (3) oral mucosa (Fig. 27-13). The margins of the cleft are incised from the posterior end of the hard palate to at least the distal end of the uvula (some surgeons carry the incision and closure down the palatopharyngeal
fold to elongate -the soft palate). The nasal mucosa is then dissected free from the underlying musculature and sutured to the nasal mucosa of the opposite side, The muscular layer requires special care. The musculature
of the cleft soft palate is not inserted across to the opposite side but instead is inserted posteriorly and laterally along the margins of the hard palate. These muscular insertions must be released from their bony insertions
and reapproxlrnated to those of the other sides. Only then will the velopharyngeal mechanism have a , chance to perform properly. ‘If the quantity of muscular I tissue Is inadequate for approximation of the musculature in the midline, the pterygoid hamular processes can
be in fractured, thus releasing the tensor palatini muscles toward the midline. This maneuver is frequently necessary, especially in wide clefts.
Occasionally, the soft palate is found to be short, and articulation with the pharyngeal wall is impossrcle. this situation is especially prevalent in incomplete palatal clefts-those of the soft palate only. In these cases the
palate can be closed in a mariner that not only brings the two lateral halves together in the midline but also gains palatal length (Fig. 27-14 on page 6-tO).The so-called W-Y push-back procedure (Wardill) and V-shaped push-back procedure (Dorrance and Brown) are commonly used. The mucoperiosteum of the hard palate is incised and elevated in a Planner that allows the entire soft tissue elements of the hard and soft palate to extend posteriorly, thus gaining palatal length.