Buccal myomucosal flap palate repair

The four key concepts of the ACRP

The ACRP has achieved statistically and clinically superior results at maturity for patients born with clefts. It uses many, but not all, of the surgical techniques of the traditional cleft repair approach, and adds a few. Buccal myomucosal flaps are one key technique. And they are a magnificent component in replacing tissue. Guiding when and how to use these techniques is the objective of the four key concepts, setting the course during preoperative planning and helping to guide choices during surgery. These four key concepts are fundamental to success:

• 1.

  Planning for the unique anatomy of the patient.

• 2.

  Assessing the tissue deficiency and establishing a tissue replacement plan.

• 3.

  Reducing overall scar load by using fundamental wound healing principles.

• 4.

  Protecting irreplaceable tissues by using tissue only when you can achieve maximum success.

It is critical to remember that the ACRP is a process not a procedure . For too long we have searched for the one operation that can be used in all cases, and this does work in some surgical specialties. For example, in ophthalmologic lens replacement it can be safely assumed that the lens will be 8 mm in diameter, as that anatomy is essentially always the same. But in cleft surgeries, the only given is that the anatomy will not be the same even within a single Veau classification.

The remainder of the chapter (and Video lecture 21.4.1 ) will describe how this works in different situations, in practice. To do this, we’ll begin with treatment planning in some detail.

Treatment plan development

The overall treatment plan is a 20-year plan that should be done for all patients regardless of cleft type. The overall plan encompasses the anticipated treatments and surgeries necessary to achieve the end goal of a normal face and normal speech at maturity, with no remaining cleft-related issues. Each step and surgery is shared with the patient/family. Smaller clefts will require fewer interventions and larger clefts more, however in both cases, the end result should be the same.

The primary surgical treatment plan addresses what is required during the initial surgery. Every surgical intervention plan has two parts: (1) what is needed to achieve the immediate goal of the specific surgery (i.e., restore a near normal speech engine); and (2) how to achieve the immediate goal without any negative effects on the success of all future surgeries (i.e., don’t damage tissue needed for a future bone graft).

This is quite different from traditional cleft repairs where the most important thought, first and foremost, is to close the cleft hoping that nothing more will be necessary (i.e., the gingivoplasty may obviate a bone graft). This establishes a pattern of reacting , initially to poor speech results and later to facial compression. Compensating speech surgeries and continual facial expansion interventions have become so common they are now considered normal steps in management. This reactionary response in traditional cleft care was a natural development, as reacting to disease is how most of medicine is taught. We react to infection, trauma, or cancer with a treatment, then react to the result of the first treatment with a second treatment.

However, modern pediatrics was the first to move in the revolutionary direction of using treatments to prevent future problems (vaccines, car seats, etc.). A good parallel is seen in pediatric cardiac surgery. Heart surgeons know at the outset that the pump built in infancy will not be sufficient in adulthood. They anticipate natural growth, and the planned treatments move stepwise toward the goal of normal function at maturity. For cleft care to be future focused in this way, the importance of long-term treatment plan cannot be overemphasized. The comprehensiveness and accuracy of the plan ultimately defines each patient’s path and outcome . The overall treatment plan also allows the surgeon to explain to families what will happen over the next 18–20 years, and why each step is necessary. This is vital for families so they can become excellent pre- and postoperative caregivers. And, because each treatment step is designed to facilitate future steps, the overall plan is easily adaptable to incorporate new and better techniques as they are developed.

Remember, the route to improved results is not just in using a buccal flap or any other procedure. The secret to the best result really lies in the process of treatment planning – defining where and why buccal flaps and other tactics are necessary and how they are related to success at maturity.