Journal of Plastic Surgery and Hand Surgery

ISSN: 2000-656X (Print) 2000-6764 (Online) Journal homepage: http://www.tandfonline.com/loi/iphs20

Isolated cleft palate requires different surgical

protocols depending on cleft type

Anna Elander, Christina Persson, Jan Lilja & Hans Mark

To cite this article: Anna Elander, Christina Persson, Jan Lilja & Hans Mark (2017) Isolated cleft
palate requires different surgical protocols depending on cleft type, Journal of Plastic Surgery and
Hand Surgery, 51:4, 228-234, DOI: 10.1080/2000656X.2016.1235579

To link to this article: https://doi.org/10.1080/2000656X.2016.1235579

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JOURNAL OF PLASTIC SURGERY AND HAND SURGERY, 2017
VOL. 51, NO. 4, 228–234
http://dx.doi.org/10.1080/2000656X.2016.1235579

ORIGINAL ARTICLE

Isolated cleft palate requires different surgical protocols depending

on cleft type
Anna Elandera, Christina Perssonb, Jan Liljaa and Hans Marka
a
Institute of Clinical Sciences, Department of Plastic Surgery, Sahlgrenska Academy, University of Gothenburg, Sweden; bInstitute of
Neuroscience and Physiology, Division of Speech-Language Pathology, Sahlgrenska Academy, University of Gothenburg, Sweden

ABSTRACT ARTICLE HISTORY

A staged protocol for isolated cleft palate (CPO), comprising the early repair of the soft palate at 6 Received 22 September 2015
months and delayed repair of the eventual cleft in the hard palate until 4 years, designed to improve Revised 25 July 2016
maxillary growth, was introduced. CPO is frequently associated with additional congenital conditions. Accepted 18 August 2016
The study evaluates this surgical protocol for clefts in the soft palate (CPS) and for clefts in the hard Published online 29 Septem-
ber 2016
and soft palate (CPH), with or without additional malformation, regarding primary and secondary surgi-
cal interventions needed for cleft closure and for correction of velopharyngeal insufficiency until 10 KEYWORDS
years of age. Of 94 consecutive children with CPO, divided into four groups with (þ) or without () Isolated cleft palate;
additional malformations (CPS þ or CPS  and CPH þ or CPH), hard palate repair was required in 53%, malformation; soft and hard
performed with small local flaps in 21% and with bilateral mucoperiosteal flaps in 32%. The total palate
incidence of soft palate re-repair was 2% and the fistula repair of the hard palate was 5%. The total
incidence of secondary velopharyngeal surgery was 17% until 10 years, varying from 0% for CPS  and
15% for CPH, to 28% for CPS þ and 30% for CPHþ. The described staged protocol for repair of CPO
is found to be safe in terms of perioperative surgical results, with comparatively low need for second-
ary interventions. Furthermore, the study indicates that the presence of a cleft in the hard palate and/
or additional conditions have a negative impact on the development of the velopharyngeal function.

Introduction morphology, and only 10% of patients had to undergo

The isolated cleft palate (CPO) is usually described as a
homogenous group of clefts. There are various anatomical
variations in size and configuration, of course, such as
whether the cleft is in the soft palate only (CPS) or both the
hard and soft palates (CPH). Moreover the isolated cleft pal-
ate is frequently associated with other additional congenital
conditions (þ) [1]. Different surgical techniques can be used
to repair the cleft, most of them aiming for a one-stage
repair. To date there has been no consensus as to the best
surgical protocol.
In Gothenburg, the Wardill-Kilner pushback technique was
long used to repair all kinds of palatal clefts, including CPO
[2]. This technique is a one-stage closure using a pushback
procedure of bilateral mucoperiosteal flaps, leaving denuded
bone areas in the anterior and lateral parts of the hard palate
for secondary healing, with scar formation that contracts the
upper dental arch, which has been shown to restrict the
maxillary growth with negative impact on the facial profile
and dental occlusion for both complete and CPO clefts [3–6].
Aiming for improved maxillary growth, the Wardill-Kilner
technique was, therefore, abandoned for complete unilateral
cleft lip and palate (UCLP) in 1975, in favour of a two-stage
procedure for palatal closure. The new protocol included an
early soft palate repair at 6–9 months, followed by a delayed
hard palate closure at the age of mixed dentition (7–9 years).
This protocol showed improved results regarding facial
orthognathic surgery to correct a maxillary growth aberration
judged to be untreatable with orthodontic treatment alone
[7]. Furthermore, the SNA angle describing maxillary prog-
nathism was closer to normal (76.8) and significantly larger
than when using Wardill-Kilner (72.9) [3] and von
Langenbeck (74.2) [8], while the maxillary length was also
significantly longer than when using von Langenbeck
(49.5 mm vs 46.0 mm) [8].
For CPO, the Wardill-Kilner technique showed a similar
negative impact regarding constricting scars in the hard pal-
ate affecting the dental arch [4,5,9,10], which was why it was
abandoned. Instead, a similar protocol was introduced for
CPO in 1987, including the same soft palate repair as used
for UCLP at 6 months. Any cleft in the hard palate was left
for closure at 4 years. An evaluation of this protocol per-
formed by Friede et al. [5] in 2000 to judge maxillary growth
at 5 years of age was encouraging, as a significantly better
occlusion was found in children with CPS in comparison to
when the Wardill-Kilner technique was used. From an ortho-
dontic perspective, these results support the introduction of
this strategy for CPO. The children’s speech was also eval-
uated at age 5, which showed that 35% were rated to have
an impaired velopharyngeal function (VPI) [11]. The sub-
group of children with CPS  performed best (0% VPI), fol-
lowed by the sub-groups with CPH (31% VPI), CPS þ (44%
VPI), and CPH þ (77% VPI). These results indicate that speech

CONTACT Hans Mark hans.mark@vgregion.se Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenberg, Sweden
ß 2016 Acta Chirurgica Scandinavica Society
 JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 229

outcomes not only depended on the surgical technique, but the cleft margins, at the junction between the oral and nasal
also on the presence of a cleft in the hard palate and mucosa to the tip of the uvula (Figure 1). Small bilateral oral
whether the cleft was in conjunction with a malformation. flaps were raised from the posterior part of the hard palate
However, further investigation of older children is needed. at each side of the cleft. At the border of the soft palate the
The primary aim of the present study is to describe and blunt and sharp dissection continued, dividing the oral
evaluate a surgical protocol for soft palate repair and hard mucosa from the muscles, which were kept attached to the
palate closure for different types of CPO, with or without nasal mucosa as one layer. The incision posterior to the max-
additional conditions, until 10 years of age. illary tuberosities was widened by blunt dissection and the
hamulus was identified, but not broken. The oral flaps were
Patients and methods mobilised posteriorly and medially until they could reach the
midline without tension. The tensor insertions and the nasal
Subjects mucosa were dissected free from the posterior part of the
Between 1987–1993, 105 consecutive children with CPO are palatal shelf and released by a cut through the nasal mucosa
known to have been treated using this protocol at the going lateral then posterior, enabling the levator muscles
and the nasal layer to be rotated posteriorly and medially
Department of Plastic Surgery, Sahlgrenska University
towards the midline, to be reconstructed about 1 cm poster-
Hospital, in Gothenburg, Sweden, of whom 94 children
ior to the hard palate, leaving an anterior defect in the nasal
(57 girls and 37 boys) were retrospectively followed until
layer. Both the nasal layer, including the levator muscles, and
10 years of age. (Of the 11 children excluded from the study,
the oral layer were sutured in the midline with mattress
five had moved away from the area, five had passed away,
sutures using 4–0 Dexon or Vicryl and the uvula with 5–0.
and one had been operated on in the early period using the
For CPS, the anterior tips of the oral flaps were not pulled
Wardill-Kilner technique at the behest of the surgeon.) Of
forward, attempting to cover the exposed bone of the palatal
those 94 children, 42 (45%) had a CPS and 52 (55%) had a
CPH, where CPH was defined as all children needing repair
to the hard palate in a separate procedure. No submucous
clefts were included. In 40% of the children (38/94), the pres-
ence of other malformations could be identified for both CPS
(17/42) and CPH (21/52). The definition of malformations was
the presence of any kind of additional malformation affecting
the heart, limbs, or urogenital region or neuropsychiatric
problem, or if the cleft was part of a syndrome [12].

Surgical protocol
The soft palate repair was performed at 6 months of age,
leaving the eventual cleft in the hard palate open as a
residual cleft to be repaired in a secondary procedure at
4 years of age. General anaesthesia was used in combination
with infiltration with Xylocaine 0.25% with adrenaline 1:200
000 of surgical area. All patients had pre-operative antibiotics
with cloxacillin during both procedures. There was a total of
five surgeons performing soft palate repairs in the period in
question, all of whom had different experience of the
method—indeed, two surgeons operated on only two cases
each. During the early period all surgeons were allowed to
operate, whereas during the last period only two surgeons
performed the operations. Meanwhile, the number of sur-
geons performing the residual cleft closure was two. All chil-
dren had splints and were prevented from moving freely; the
food regime was a full liquid diet for the first 5 days, then a
soft diet for the subsequent 5 days.

Repair of the soft palate
In repairing the soft palate, the incision started posterior to
the maxillary tuberosities, continued medially on the poster-
ior part of the hard palate shelves, going posterior to the pal-
atine vessel to the lateral border of the cleft on the palatal
shelf. When reaching the cleft, the incision continued along
Figure 1. Schematic illustration of soft palate closure in a cleft in the Soft pal-
ate only. (a) Cleft in the soft palate. (b) Incision line posterior to the tuber of
the alveolar ridge, continues in medial-anterior direction. The incision continues
medial-posterior behind the major palatine vessel and turns to a medial anterior
direction until it meets the incision at the cleft border. (c) Oral mucosal flaps
raised and muscular insertions to the hard palate are cut, the muscles are
moved posteriorly near the Eustachian tube. (d) Muscles are sutured in a poster-
ior position. (e) Oral layer closed covering muscles leaving raw bone surface
anteriorly.
230 A. ELANDER ET AL.
shelves, but were fixed by some sutures to the posterior
edges of the hard palate, achieving a pushback of 1 cm
(Figure 1). For CPH, the two-layer repair of the soft palate
bridged over the cleft from the sides without any anchorage
in the anterior direction (Figure 2); however, a posteriorly
based vomer flap was raised and turned over and sutured
between the nasal flaps if possible, which anchored the soft
palate to the vomer (Figure 3).
Repair of the residual cleft
The nasal layer was closed using the same technique for
both small and large clefts. An incision was made along the
border of the residual cleft. At the anterior and posterior
ends of the cleft V-shaped flaps were raised from the oral
side. The nasal mucosa was dissected free from the palatal
Figure 2. Schematic illustration of soft palate closure in a cleft in the soft and
hard palate. (a). Cleft in the soft and hard palate. (b) Incision line posterior to
the tuber of the alveolar ridge. Then medial in a zigzag fashion behind the
major palatine vessel until it meets the incision at the cleft border. Oral mucosal
flaps are raised and muscular insertions to the hard palate are cut the muscles
are moved posteriorly near Eustachian tube. (c) Muscles are sutured in a poster-
ior position. (d) Oral layer closed covering muscles leaving an opening anteriorly
in the hard palate.
Figure 3. Schematic illustration soft palate closure in a cleft in the soft and hard palate and a vomer flap. (a) Cleft in the soft and hard palate. Incision line posterior
to tuber of the alveolar ridge. Then medial in a zigzag fashion behind the major palatine vessel until it meets the incision at the cleft border. Oral mucosal flaps are
raised and muscular insertions to the hard palate are cut and muscles are moved posteriorly near the Eustachian tube. A posteriorly based vomer flap is raised and
introduced between the muscular bundles. (b) Muscles are sutured together and to the vomer flap in a posterior position. (c) Oral layer closed covering muscles
leaving an opening anteriorly and a raw bone surface on the vomer.
shelves and the V-shaped flaps were turned over into the
defect, facilitating the suturing and closure of the nasal layer.
By one or two sutures brought through the nose, the nasal
layer could be mobilised by traction into the nasal cavity. For
closure of the oral layer, two different principles were used
depending on the size of the cleft. For small clefts, the oral
layer was closed with two bipedicle flaps raised from the
medial half of the palatal shelf and brought over the defect
and sutured; the residual cleft was, thus, closed in two layers
(Figure 4). Wider clefts required bilateral mucoperiosteal
flaps. Since children at the age of 4 have developed molars,
mucoperiosteal flaps were raised after dento-gingival mar-
ginal incisions from behind the tuber area anterior to the
region of the deciduous lateral incisor, where the incisions
went medially to the anterior part of the circumferential inci-
sion around the residual cleft in the palate. The flaps were
sutured with mattress sutures in the midline and could in
most instances be repositioned back into their original pos-
ition and sutured along the neck of the teeth without leaving
denuded bone for secondary healing. The closure of the cleft
defect was, thus, achieved by a hanging bridge principle
(Figure 5).
Secondary pharyngeal surgery
The indications to perform surgery were based on perceived
problems with speech according to the family and velophar-
yngeal insufficiency, perceptually assessed by an experienced
speech-language pathologist and verified by videofluoro-
scopy or nasendoscopy. Surgical correction for velopharyng-
eal insufficiency was performed using a velopharyngeal flap
in all cases but one (in that patient a secondary intravelar
veloplasty was performed instead. All velopharyngeal flaps
were superiorly based and sutured into the soft palate either
in the nasal layer or tucked in between the nasal and oral
layer through an incision along the posterior edge of the soft
palate cranially of the uvula.
Statistics
The mean ± SD and range are given for the different varia-
bles. Student’s t-test was used for comparison; p < .05 was
considered significant.
 JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 231

Figure 4. Schematic illustration of closure of a small residual cleft. (a) Small residual cleft in the hard palate. (b) Two bipedicular flaps are raised, nasal layer dis-
sected free and sutured. (c) Oral layer closed.

Figure 5. Schematic illustration of closure of a large residual cleft. (a) Large residual cleft in hard palate with incision lines made along the neck of the teeth in the
gingival pocket. No tissue is left near the teeth. Incision continues to the second incisor where it turns to a medial-posterior direction. It will meet the incision from
the opposite side close to the residual cleft. The incision continues around the residual cleft leaving flaps anterior and posterior. (b) The nasal layer is closed using
nasal mucosa dissected free and the anterior and posterior turnover flaps. (c) Oral layer closed. Note, minimal raw surfaces between the mucoperiosteal flaps and
the teeth.

Table 1. Data from soft palate repair and residual cleft closure. reoperation due to bleeding and no blood transfusions were
Soft palate repair Residual cleft closure given. No patient stayed for intensive care observation over-
(n ¼ 94) (n ¼ 50)
night. The hospital stay after residual cleft closure ranged
Mean age, months (min-max) 7.7 (4.5–33.5) 49 (24–83)
HSP 7.6 (4.5–27) from 3–9 days.
SPO 7.7 (5–33.5) The total incidence of fistulas needing repair was 5%. Of
Mean weight, kg 7.6 – the 50 patients operated on for residual cleft closure, postop-
HSP 7.4
SPO 7.7 erative fistulas were diagnosed in seven patients, of whom
Bleeding, ml; min-max 14 (5–70) 28 ± 27 five needed reoperation due to significant problems (10%),
Reoperation due to bleeding 4 patients – while in the other two patients the fistulas were without sig-
Postoperative intensive care 4 patients –
Hospital stay, days (min–max) 7.8 (4–11) 5 (3–9) nificance. Two of the fistulas needed repair after local flap
Postoperative dehiscience 2 partial separations 7 fistulas closure and three after closure by use of mucoperiosteal
Dehiscience needing reoperation 2 5
flaps, giving a similar rate for secondary surgery due to
impaired healing of 10% for both principles used for residual
cleft closure.
Results The total incidence of secondary velopharyngeal surgery
The demography and surgical data associated with the soft was 17% until age 10. The incidence varied according to two
and hard palate repair are given in Table 1. The mean sur- factors: the presence of a cleft in the hard palate or add-
gery time for soft palate repair was 71 minutes. In total, a itional conditions as described in Table 2. In the group with
vomer flap was raised and sutured into the nasal layer in 22 no additional conditions CPH had a significantly higher fre-
out of 94 children (24%), all CPH; four out of 94 children quency of secondary velopharyngeal surgery (15%) than SPO
needed intensive care postoperatively, one after reoperation (0%). Children with an additional condition had a significantly
due to bleeding, and three due to respiratory problems diag- higher incidence of secondary velopharyngeal surgery com-
nosed prior to surgery or during anaesthesia for surgery. The pared to the whole CPO group, and indeed to the CPS sub-
hospital stay after soft palate repair ranged from 4–11 days. group.
Partial postoperative separations of the soft palate occurred
in two children, which required reoperation (2%). No com-
Discussion
plete separations occurred.
In total, 53% needed repair of a residual cleft in the hard There are many techniques for cleft palate repair and the
palate, 21% by use of small local flaps and 32% by the use ultimate protocol is yet to be identified. For various reasons,
of bilateral mucoperiosteal flaps. No patients needed it is still the case that each surgeon advocates his or her
232 A. ELANDER ET AL.
Table 2. Velopharyngeal flap surgery performed until age 10 years in the cleft
groups with malformations present or not. Level of statistical significance
between HSP vs SPO and between no malformation vs malformation.
All iCP (n ¼ 94) HSP (n ¼ 52)
All iCP (n ¼ 94) 16 (17%) 11 (21%)
No malformation (n ¼ 56) 5 (9%) 5 (15%)
Malformation (n ¼ 38) 11 (29%)† 6 (30%)
p < .05;
†p < .05.
own. Many studies have been published, but to date the sci-
entific quality has been low due to the study design – includ-
ing mixed groups with respect to cleft types, small numbers
of patients, and a mixture of clefts with or without additional
conditions – which, combined with different ages, different
timings of the surgical protocol, and the fact that almost all
reports are retrospective, makes valid scientific conclusions
impossible.
In the present study, soft palate repair was timed to take
place at 6 months, since early surgery was considered to
be beneficial for speech development, a hypothesis that now
seems supported [13]. Earlier repair was tried at our unit, but
at lower ages (3–4 months) and with other complicating con-
ditions, respiratory problems needing advanced postopera-
tive care were more common. The mean age for soft palate
repair in this study was, thus, 7.7 months, and from the peri-
operative data it may be concluded to be safe.
A positive aspect of the present protocol is that it concen-
trates on the soft palate repair, facilitating muscle repair and
the posterior transition of the soft palate. Furthermore, the
two-stage protocol for CPH in this study enables an individu-
alisation regarding the hard palate closure depending on the
size and extent of the cleft. The reason for introducing a
vomer flap if possible is that it helps to lengthen and close
the nasal layer, and anchors the soft palate to the vomer.
Characteristic for the soft palate repair is that the muscles
are kept undissected from the nasal mucosa, and the reposi-
tioning of the muscles is achieved by dissecting and releas-
ing the nasal layer from the posterior part of the hard palate,
enabling it to be closed in the midline by moving it posterior
to the level of the Eustachian tube opening. The fact that
the closure is in one layer only in the anterior part was not
thought a problem, and this procedure might be beneficial
for the lengthening and function of the soft palate, indicated
by the rather low occurrence of velopharyngeal flaps found
in the sub-group CPS without additional malformations in
this study (Table 2). Further analysis of speech outcomes is
needed to support this hypothesis though.
In the present study, 17% of the patients have had sec-
ondary pharyngeal surgery at 10 years of age, and later fol-
low-up may increase this figure. Our findings that CPS had a
lower frequency of pharyngeal flaps than CPH was supported
by Brunnegård and Lohmander [14], who report that none of
the children with a cleft in the soft palate had required a
pharyngeal flap, while 8% of the children with CHP operated
on with a two-stage procedure similar to ours had one at 10
years of age. The reported incidence of secondary pharyngeal
surgery in CPO when using a one-stage protocol varies, prob-
ably depending on more factors than the surgical technique
used. One possibility is that the size of the cleft is a factor
[15], as also reported here. Marrinan et al. [15] have pub-
lished different incidences of pharyngeal flaps for CPS and
SPO (n ¼ 42)
CPH, reporting 9% and 25%, respectively, when using von
5 (12%)
0 (0%) Langenbeck and Wardill-Kilner techniques. Nyberg et al. [16]
5 (28%)† reported a higher number of velopharyngeal flaps at age 5
among children with CPH (30%) compared with children with
CPS (3%). Andersson et al. [17] reported 10 years after pri-
mary surgery an overall incidence of pharyngeal flaps of
14%; and, the larger the cleft, the higher the incidence,
amounting to 42% for HSP. In this group, all children with
additional malformations were excluded.
One thing that speaks in favour of the present protocol is
that it seems to result in a significantly better width of the
maxillary dental arch at the level of the first deciduous
molars by 2.5 mm in CPS, as indicated by data on patients
from the present cohort regarding palatal growth and dental
occlusion at 5 years, compared to when the Wardill-Kilner
technique was used [4,5]. There was, thus, less need for
orthodontic treatment. One possible explanation for the bet-
ter growth is less scarring of the hard palate as compared to
when the hard and soft palate are moved posteriorly as one
unit, which has been reported by others too [9,10].
Furthermore, when comparing children from this cohort at 5
years who had their cleft in the hard palate repaired with
large mucoperiosteal flaps, to those who could be closed by
local flaps, the former had a significantly narrower maxillary
dental arch width by a mean value of 1.4 mm [5].
Against a two-stage protocol for CPH is the fact that chil-
dren with CPH will need two surgical interventions – in the
present study, 48% of patients. However, in order to properly
evaluate the two-stage procedure, the various outcomes – all
primary and secondary surgical interventions, need for ortho-
dontic treatment and speech therapy, and not least the final
speech result – must be analysed and compared to one-
stage procedures. In the present study, we present the load
of surgical interventions until the age of 10. A drawback with
a one-stage approach is that the same technique is used
regardless of the presence of a cleft in the hard palate or not
[2,10]; consequently, children with CPH were treated with
unnecessary wide mucoperiosteal flaps and large undermin-
ing, since it impacts negatively on the maxillary growth.
Another one-stage technique for palatal closure in CPO
patients, presented by Sommerlad [18], combines minimal
hard palate dissection with radical repositioning of the velar
musculature and tensor tenotomy. Fistulas occurred in 12%
of the CPO clefts, as opposed to a fistula frequency of 5% in
the present study. However, this technique is being investi-
gated in the TOPS (timing of primary surgery) trial, and more
will be reported in future.
After closure of the hard palate, seven fistulas occurred, of
which five needed a reoperation (only 5% of the entire
group), which is in the same low range as has been reported
by others [10,19,20]. Fistulas are common in palatal repairs
and vary from low numbers up to more than 50% [20]. A fre-
quency of 50% means in reality that two procedures are
used in half of the patients – meaning a two-stage procedure
– but with a more complicated situation for surgical repair,
since fistulas involve more scarring. Against this, a residual

cleft has intact surrounding tissue and is subsequently easier
to close, which speaks in favour of a two-stage protocol
for CPH.
Delayed closure of a cleft in the hard palate after early
soft palate closure has shown that the palatal shelves con-
tinue to grow medially, reducing the residual cleft, until 3
years [21]. However, this does not seem to occur in ICP clefts.
The palatal shelves in CPO patients have continuous growth
before soft palate closure, but this growth seems to stop
after this surgery [21,22]. This implies that there is no residual
cleft reduction to be expected. On the other hand, during
growth of the child, the whole hard palate and the dental
arch grow, giving larger dimensions of the palatal shelves in
relation to the residual cleft, making it easier to close without
leaving denuded bone for secondary healing. In the present
study the residual cleft closure was performed at 4 years,
which might be too long to wait, since the speech evaluation
at 5 years has shown in a previous study that 46% of
CPH þ patients had retracted oral articulation [11]. Therefore,
the residual cleft closure should preferably be performed at
an earlier age, but without affecting the dental arch.
The isolated cleft palate is one of the three main cleft sub-
groups; each having its own special characteristics, the cleft
sub-groups should be regarded as distinct entities. The inci-
dence of additional conditions varies between them, with the
highest for the CPO sub-group. In a large European study
based on 6 million births in 16 countries, 54.8% of clefts were
isolated, with no other anomalies present, 18.0% were associ-
ated with multiple congenital anomalies, and 27.2% were in
recognised conditions [1]. Of the children who underwent sur-
gery in the present study, 40% had a syndrome (e.g. 22q11
deletion syndrome and Stickler syndrome), other malforma-
tions affecting the heart, limbs, urogenital region, or neuro-
psychiatric problems. In the present study, we chose to
separate all children who did not have other conditions from
those who did, since we wished to evaluate surgical techni-
ques for soft palate repair and the effect of malformations or
syndromes separately. These related conditions might have an
additional impact on articulation and velopharyngeal function
than that of the cleft, as structural deficits such as deep phar-
ynx [23], as well as muscle weakness, hypotonia [24], and
hearing impairment [25] might be present.
The impact of additional conditions was high in this study,
indicated by the higher incidence of secondary pharyngeal
surgery in both CPS þ and CPHþ, in comparison to children
with CPS  and CPH. Consequently, secondary pharyngeal
surgery was needed in 9% of the total CPO  group, where
no additional conditions were presented. When additional
conditions were detected in patients with CPO, the incidence
for secondary pharyngeal surgery increased significantly from
9% to 29%. In the patients with CPH þ there was no signifi-
cant difference regarding the need for speech surgery (28%)
compared to those with CPS þ (30%). Therefore, it may be
deducted that cleft size was less important for speech devel-
opment than the effect of the associated malformations.
One strength of the study is the comparatively large
group of CPO [19]. However, after identifying the four sub-
groups (CPS and CPH, both with and without other malfor-
mations) the numbers get smaller. Sub-grouping is needed,
JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 233
though, due to differences in characteristics and in order to
gain a better understanding of the outcome data.
To sum up, our primary goal with this individually staged
protocol for CPS and CPH – to achieve better maxillary growth,
with at least the same or better speech outcomes – seems to
be reached. However, follow-up until adulthood is needed to
confirm this. Furthermore, the results indicate that, by closing
the hard and soft palate separately, the effect on maxillary
growth for the majority of CPO patients is reduced. Thus, large
mucoperiosteal flaps could be applied when necessary, mean-
ing in 30% of CPH, instead of in all CPO.
Conclusion
In conclusion, the described staged protocol for the repair of
CPO, including the techniques for soft and hard palate repair,
are safe regarding perioperative surgical results. The need for
secondary interventions for fistula repair or speech-improving
surgery is comparatively low. Furthermore, the study indi-
cates that the presence of a cleft in the hard palate and/or
additional malformation or syndromes have a negative
impact on the development of the velopharyngeal function.
Disclosure statement
The authors report no conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
References
1. Calzolari E, Bianchi F, Rubini M, et al. Epidemiology of cleft palate
in Europe: implications for genetic research. Cleft Palate Craniofac
J 2004;41:244–9.
2. Elander A, Lilja J, Friede H, et al. Surgical treatment of cleft palate:
27 years' experience of the Wardill-Kilner technique. Scand J Plast
Reconstr Surg Hand Surg 1993;27:291–5.
3. Enemark H, Bolund S, Jorgensen I. Evaluation of unilateral cleft lip
and palate treatment: long term results. Cleft Palate J
1990;27:354–61.
4. Friede H, Persson E-C, Lilja J, et al. Maxillary dental arch and occlu-
sion in patients with repaired clefts of the secondary palate.
Influence of push back palatal surgery. Scand J Plast Reconstr Surg
Hand Surg 1993;27:297–305.
5. Friede H, Enocson L, Mo €ller M, Owman-Moll P. Maxillary dental
arch and occlusion in repaired clefts of the secondary palate: influ-
ence of surgical closure with minimal denudation of bone. Scand J
Plast Reconstr Surg Hand Surg 2000;34:213–18.
6. Kim T, Ishikawa H, Chu S, et al. Constriction of the maxillary dental
arch by mucoperiosteal denudation of the palate. Cleft Palate
Craniofac J 2002;39:425–31.
7. Friede H, Lilja J, Lohmander A. Long-term, longitudinal follow-up
of individuals with UCLP after the Gothenburg primary early velo-
plasty and delayed hard palate closure protocol: maxillofacial
growth outcome. Cleft Palate Craniofac J 2012;49:649–56.
8. Semb G. A study of facial growth in patients with unilateral cleft
lip and palate treated by the Oslo team. Cleft palate. Craniofac J
1991;24:1–21.
9. Jacobsson O, Ponten B. Closure of the cleft palate in one or two
stages: the surgical methods. Scand J Plast Reconstr Surg Hand
Surg 1990;27:149–55.
10. Helio€vaara A, Rintala A, Ranta R. One-stage closure of isolated cleft
palate with the Veau-Wardill-Kilner V to Y pushback procedure or
the Cronin modification. I. Comparison of operative results. Scand
J Plast Reconstr Surg Hand Surg 1993;27:49–54.
234 A. ELANDER ET AL.
11. Persson C, Elander A, Lohmander-Agerskov A, So €derpalm E.
Speech outcomes in isolated cleft palate: impact of cleft extent
and additional malformations. Cleft palate. Craniofac J 2002;39:
397–408.
12. Shprintzen RJ, Siegle-Sadewitz VL, Amato J, Goldberg RB.
Anomalies associated with cleft lip, cleft palate, or both. Am J
Med Genet 1985;20:585–95.
13. Willadsen E, Enemark H. A comparative study of prespeech vocal-
izations in two groups of toddlers with cleft palate and a noncleft
group. Cleft Palate Craniofac J 2000;37:172–8.
14. Brunnegård K, Lohmander A. A cross-sectional study of speech in
10-year-old children with cleft palate: results and issues of rater
reliability. Cleft Palate Craniofac J 2007;44:33–44.
15. Marrinan EM, LaBrie RA, Mulliken JB. Velopharyngeal function in
nonsyndromic cleft palate: relevance of surgical technique, age at
repair, and cleft type. Cleft Palate Craniofac J 1998;35:95–100.
16. Nyberg J, Raud Westberg L, Neovius E, et al. Speech results
after one-stage palatoplasty with or without muscle reconstruc-
tion for isolated cleft palate. Cleft palate. Craniofac J
2010;47:92–102.
17. Andersson EM, Sandvik L, Tordal IB, Åbyholm F. Pharyngoplasty
after primary repair of clefts of the secondary palate. Scand J Plast
Reconstr Surg Hand Surg 2010;44:26–30.
18. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr
Surg 2003;112:1542–8.
19. Winters R, Carter JM, Givens V, St Hilaire H. Persistent oro-nasal fis-
tula after primary cleft palate repair: minimizing the rate via a
standardized protocol. Int J Pediatr Otorhinolaryngol 2014;78:
132–4.
20. Becker M, Hansson E. Low rate of fistula formation after
Sommerlad palatoplasty with or without lateral incisions: an ana-
lysis of risk factors for formation of fistulas after palatoplasty.
J Plast Reconstr Aesthet Surg 2013;66:697–703.
21. Owman-Moll P, Katsaros C, Friede H. Development of the residual
cleft in the hard palate after velar repair in a 2-stage palatal repair
regimen. J Orofac Orthop 1998;59:286–300.
22. Rintala AE, Ranta R. Spontaneous narrowing of the palatal cleft
during the first year of life: a quantitative study. Scand J Plast
Reconstr Surg Hand Surg 1987;21:35–8.
23. Ruotolo RA, Veitia NA, Corbin A, et al. Velopharyngeal anatomy in
22q11.2 deletion syndrome: a three-dimensional cephalometric
analysis. Cleft Palate Craniofac J 2006;43:446–56.
24. Zim S, Schelper R, Kellman R, et al. Thickness and histologic and
histochemical properties of the superior pharyngeal constrictor
muscle in velocardiofacial syndrome. Arch Facial Plast Surg
2003;5:503–10.
25. Flynn T, Persson C, Moller C, et al. A longitudinal study of hearing
and middle ear status of individuals with cleft palate with and
without additional malformations/syndromes. Cleft Palate
Craniofac J 2014;51:e94–101.