Straight line repair with intravelar veloplasty (IVVP)

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Introduction

The aim of cleft palate repair should be to produce the best possible speech and hearing outcomes but to minimize the detrimental effects of scarring on maxillary growth and function.

Repair of the cleft palate requires an understanding of the normal cleft anatomy. The technique described in this chapter aims to correct the anteriorly orientated cleft muscles to as normal a position as possible, to minimize scarring of the hard palate which may impair maxillary growth, to reduce the burden of care for patient and family by reducing complications and the need for further surgery, and above all to aim to “do no harm”.

The technique was first reported in 2003 following 25 years of development and assessment and has evolved further.

The operation is most effectively performed under an operating microscope. The technique of muscle dissection, using the microscope, is shown in the figures and video which accompany this chapter ( ).

The author’s outcomes, externally assessed, have been well documented.

Aims of surgery

Minimizing the effect of surgery on growth

A major factor responsible for restriction of maxillary growth in patients with clefts (particularly clefts of lip and palate) appears to be the amount of scarring of the hard palate. The aim, therefore, should be to minimize incisions and resulting scars in the hard palate.

Maximizing function for speech and hearing

Velopharyngeal closure depends primarily on the muscles of the soft palate and, most importantly, the levator veli palatini (referred to as the levator in the remainder of this chapter). Retropositioning and reconstruction of the levator is the key to maximizing function for speech. There is growing evidence that this also reduces problems with hearing.

Anatomy

Anatomy of the normal

In the normal palate the levator muscles are united in the midline in the middle 40% of the velum. The anterior third of the soft palate is primarily occupied by the palatal aponeurosis.

Anatomy of the cleft palate

In the cleft palate, the levators are anteriorly inserted into the margins of the cleft, but not into the back of the hard palate as is frequently stated. The palatopharyngeus does reach the posterior border of the hard palate. The aponeurosis is less extensive and the tensor tendon instead inserts into the lateral half of the back of the hard palate.

The cleft palate has been shown to be shorter than the normal palate.

Timing of the operation

The author prefers to repair the cleft palate at the age of 6 months – at about the stage that most babies start babbling and producing consonant sounds. There is good evidence that delay beyond 12 months is detrimental to speech outcomes.

In infants with clefts of lip and palate, the lip is repaired at 3 months with vomerine flap closure of the hard palate at the time of lip repair, and repair of the soft palate at 6 months. At that procedure, a posteriorly based flap of the neomucosa which forms on the vomer can be turned back to aid closure of the nasal layer in soft palate repair.

In patients with bilateral clefts of lip and palate, in which the premaxilla is prominent, and where pre-surgical orthopedics and naso-alveolar molding are not performed, the first operation involves an extended lip adhesion with vomerine flap closure of the hard palate on one side and partial vomerine flap closure on the other side – behind the pre-vomerine suture. This is followed by a second operation at 9 months to repair the soft palate, complete the vomerine closure anteriorly on the incomplete side, and to carry out definitive lip repair with muscle reconstruction, prolabial narrowing, sulcus deepening, and closed nasal correction.

In patients with Robin sequence, the procedure is delayed if there are concerns about postoperative airway, but repaired by 12 months if it is felt safe to do so.

Equipment

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