Cleft Lip Repair: Presurgical management
 Narrows the cleft or realigns the segments
 Can result in less tension on repaired lip
 Options
 Taping
 Dental elastics
 Active dental appliance such as Latham appliance
 Lip adhesion
 
Primary repair of unilateral cleft
 Older technique was straight-line repair - bring structures together and suture
 Newer techniques involve inserting “patch” of tissue to lengthen philtral ridge & give good lip configuration
 
 Primary repair of bilateral cleft
 Premaxilla protrudes anteriorly allowing two lateral segments to collapse behind it
 Expansion of lateral segments sometimes required so that prolabium will be able to drop back into position
 Prolabium has no muscle fibers causing a shrunken appearance
 Straight-line repair with some trimming of the prolabium
 Initially looks tight and bunched up but will stretch out and achieve more normal size within a few weeks
 
 Additional Surgical Concerns
 In either bilateral or unilateral cleft, orbicularis muscle is divided & ends abnormally inserted at base of ala
 muscles must be detached and realigned into correct orientation
 failure to do so results in distortion of lip on activation
 Nasal area is also affected & will require repair
 Debate over when to perform nasal repair
 General consensus is to realign at time o f initial lip repair
 May still need secondary surgery at later date (9 mo - 5 yrs) but seems to assure better overall results
 
Repair of the Palate
 Timing of repair - 2 philosophies
 Early - between 6 & 15 months
 Lowers incidence of VPI
 Better for development of speech
 Late - between 15 & 24 months
 Less potential effect on growth of maxilla which effects appearance of midface
 Proposed solution was 2-stage process of closure
 Close velum early (6 months), obturate palate until closure at 4-5 years
 Problems include many fail to develop acceptable speech, hard palate harder to close at later time & orthodontic corrections are more difficult if delayed
 Timing of repair varies with centers & surgeons
 
Repair of the Palate
 More difficult than lip surgery
 Technically more demanding, greater chance for mishap
 Problems with dehiscence, fistula formation & excessive scarring (more difficult to correct)
 Must do more than simply close the palate; must be able to function dynamically for speech & swallow
 Regardless of technique 17-20 % of children with history of palate repair remain with velopharyngeal dysfunction requiring pharyngeal flap surgery
 
Surgery for VPI
 Problems remaining after primary surgery
 Short velum due to scarring
 Deep nasopharynx
 Poor velar movement
 Secondary surgery has one goal - improved function of the velum for speech
 Must wait until speech developments to determine if surgery will be needed
 Surgical decisions based on auditory perception of speech rather than instrumental measures
 Earliest at 3 ½ or 4 years of age
 Success greater than 90% in 4-5 yr old; drops for older children
 
 Pharyngeal wall augmentation
 Injection or implant to extend posterior wall
 Problems include too small, not at appropriate location, infections, resorption, migration of injectable material, over correction causing hyponasality & upper airway obstruction
 Rolled flap - success rate disappointing
 
 Pharyngeal flap
 Soft tissue obturator placed in the middle of the VP port creating 2 lateral ports for air passage
 Sphincter pharyngoplasty
 Dynamic sphincter that encircles single VP port
 
Pharyngeal Flap
 Flap raised from posterior pharyngeal wall & contains mucosal surface & underlying musculature
 Base of flap connected at top of velopharynx
 Free end sutured into velum
 Lateral ports left on both sides for normal nasal breathing
 During speech lateral pharyngeal walls move medially to close against the flap
 
Pharyngeal Flap: Key to success of surgery
 Patients with good lateral wall movement; particularly good for those with sagittal pattern
 Location set as high as possible
 Width is critical and is based on extent of lateral wall movement
 Challenge in patients with decreased lateral wall movement is to make flap wide enough so that walls can contact during closure but not so wide that it causes hyponasality or sleep apnea
 In some patients, especially those with hypotonia or compromised airway, speech results may have to take back seat to functional airway
 
Sphincter Pharyngoplasty
 Bilateral flaps raised from posterior faucial pillars & rotated posteriorly and attached to wall of nasopharynx at level of velopharyngeal closure
 Small pharyngeal flap is raised and attached to the lateral flaps leaving single round opening in center of pharynx
 Palatopharyngeus muscles & levator veli palatini contract to close the opening as a sphincter
 Best for individuals with poor lateral wall movement; not likely to be successful with short velum or gap that is primarily midline
 
Complications following Surgery
 Edema resulting in hyponasality & loud snoring post-operatively
 Temporary sleep apnea - resolves in 2-6 weeks
 Revisions or modifications may be needed following surgery due to growth spurts, stenosis of one or both lateral ports due to scarring, persistent hypernasality requiring closure of one port
 Success rate of pharyngeal flap as high as 90% with speech therapy; lower for sphincteroplasty -60%-80%
 
Prosthetic Devises
 Prosthesis - substitute for a body part that is missing or malformed
 Improvement in surgical techniques & earlier surgical repair have reduced the need for prosthetic treatment
 May be used as a temporary or a permanent solution to the problem
 Can be used to improve individual’s appearance, swallowing & speech

Indications & Contraindications
 Indications for prosthetic management
 Missing teeth, deviant dental anatomy, facial defects
 Surgery must be delayed for medical reasons
 Large palatal fistulas
 VPI secondary to unsuccessful surgical repair
 Following cancer treatment
 Velopharyngeal incompetence due to neuromotor disorders
 Contraindications
 Strong gag reflex or oral sensitivity
 Removable devices can be lost/broken therefore may not be useful for young children, mentally deficit, those with significant physical handicaps
 
Type of Prosthetic Devices
 Feeding obturators
 Keeps the tongue out of the cleft & provides solid surface for tongue compression of nipple
 Most often necessary for infants with multiple anomalies of the airway or severe brain abnormality
 Speech appliances
 Allow sound energy to be directed orally, reduce nasal air emission, improve intraoral air pressure
 Palatal lift
 Palatal obturator
 Speech bulb obturator
 
Palatal Lifts
 Elevates the velum & holds it in place against posterior pharyngeal wall
 Most useful in cases of VP incompetence especially in patients with dysarthria
 Not helpful if palate is short as no length is added
 Rationale for use
 Lift portion is gradually extended as patient tolerates until it reaches area of velar dimple
 Exerts upward force against velum; lateral walls must move against velum to complete closure
 Can interfere with production of nasal sounds causing hyponasal voice quality and nasal breathing
 
Palatal Obturator
 Used to close defects of hard palate or velum that are symptomatic for speech or cause nasal regurgitation during feeding and surgical management is not planned for near future
 Often used to cover palatal fistula
 Important for adults who have had tumors removed or have had traumatic injuries to palate
 In children, prosthesis should be in place prior to development of speech
 Must fit tightly in area of defect to prevent leaks of air pressure and/or liquids into nasal cavity
 
Speech Bulb Obturator
 Used in cases of short velum; bulb obturator fills in the remaining pharyngeal space; fits into nasopharynx behind the velum
 Removable at night to prevent sleep complications, some prefer to remove when eating, must be removed for cleaning
 SLP Role in Use of Prosthetic Devices
 Goal is to close VP port for improved speech without compromising upper airway
 During design and subsequent adjustments, provide feedback on speech changes resulting from modifications
 Pre/post assessments using perceptual techniques, nasometry & aerodynamic measures are helpful
 Best information re: fit & function of the appliance will come from nasopharyngoscopy
 Therapy to correct articulation & learn to use air pressure normally; speech bulb reduction therapy