September 2019 HSC Section 1 Congenital and Pediatric Problems

Gingivoperiosteoplasty and Alveolar Bone Grafting

is made. When making the incision along the cleft margin medially it is important to stay 1 mm to 2 mm toward the oral mucosa to ensure a suitable mucosal flap for a tension-free nasal closure. After the incision is complete attention is turned to raising palatal flaps in a subperiosteal plane until there is complete exposure of the hard-soft palate junction, taking care to identify and preserve the greater palatine artery ( Fig. 2 ). The greater palatine neurovascular bundle that supplies each flap is encountered and preserved while the foramina fascia should be released to assist with medial advancement of the flap. Osteotomies may also be made through the posterior foramina of the hard palate in significantly wide cleft palates (>20 mm) while meticulously avoiding injury to the bundle itself. Starting medially the abnormal le- vator muscle attachments are released from their attachment at the posterior edge of the hard palate and cleft margin. The nasal mucosa is also raised off of the superior surface of the hard palate and extended into the soft palate. Muscle fibers are released laterally until the hamulus and tensor veli palatini muscle are seen. One must check all flaps (nasal mucosa, musculature, and oral layer) for adequate length. Vomer flaps are elevated on one side only in a unilateral cleft palate but bilater- ally in bilateral cleft palates to decrease the tension on the nasal layer closure. The nasal layer of the uvula is then closed with horizontal mattress sutures using a 4–0 Vicryl on a TF needle. The remainder of the nasal layer is then closed with simple interrupted sutures using a 4–0 Vicryl on a PS-4c needle burying the knots on the nasal layer ( Fig. 3 ). If there is excessive ten- sion on the nasal closure, the central sutures are placed after the muscle layer is approximated to decrease tension. The levator muscle is sutured to create an intravelar veloplasty with a 3–0 Vicryl

extension, unless the patient has a syndrome associated with spinal abnormalities. Intubation is with either a standard endotracheal tube or a right angle endotracheal tube that is secured in the midline to the chin. Patients with midface hy- poplasia and micrognathia may be difficult to intu- bate before surgery and experience postoperative airway obstruction; therefore, it is important for the surgical team to communicate concerns and discuss postoperative airway management. Tega- derms are used for eye protection. The surgical bed is rotated at least 90 " from the anesthesiolo- gist. Intravenous antibiotics are administered, sur- gical site is draped, a Dingman mouth retractor ( Fig. 1 ) is used to achieve adequate visualization, and the palate is injected with 1% lidocaine with 1:100,000 epinephrine. Surgical Techniques The main principles of palatoplasty consist of a tension-free and multilayered closure with reposi- tioning of the velar muscle sling. Several tech- niques along with modifications exist, and the most commonly performed options are described next. Two-flap palatoplasty The two-flap palatoplasty is a widely used tech- nique that is indicated for the closure of complete unilateral and bilateral clefts of the primary and secondary palate. This technique permits easy exposure of the soft tissue musculature that allows release of anomalous attachments of the levator veli palatini to complete an intravelar veloplasty and reorient the levator sling horizontally. Incisions are marked from the tip of the uvula medially along the cleft margin toward midline of the alveolus. The alveolar ridge is then followed posteriorly to the end of the alveolus where a small releasing incision

Fig. 2. Two-flap palatoplasty: raised palatal flaps in the subperiosteal plane with preserved greater pala- tine neurovascular bundles bilaterally.

Fig. 1. View of cleft palate before incision using a Dingman mouth retractor.

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