Scand J Plast Reconstr Hand Surg 28: 199-205, 1994

MINIMAL INCISION PALATOPHARYNGOPLASTY

A Preliminary Report

Mario. Mendoza,’ Fernando Molina,’ Cesare Azzolini’ and

Antonio Ysunza Rivera2

From the Departments of lPlastic Surgery and 2Phoniatrics, Hospital “Dr. Manuel Gea Gonzalez”,
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Mexico City, Mexico

(Submitted for publication May 13, 1993)

Abstract. A new palatopharyngoplasty which allows
good muscular reorientation as well as elongation of
the soft palate with minimal morbidity and scarring
has been developed, and 66 selected patients under-
went the procedure during the period September
1989 to March 1993. The most important findings
were reduced operative bleeding, good length and
mobility of the soft palate, and minimal scarring. A
total of seven fistulas (11%) developed. Twenty-
For personal use only.
maxillary growth. During the last two decades
in our cleft palate clinic we have used the
Wardill-Kilner palatoplasty with simultaneous
posterior pillars pharyngoplasty (25). In a pre-
vious report the incidence of velopharyngeal
insufficiency after palate closure in patients
operated before the age of 18 months was 12%,

three patients (mean age 6 years and 2 months at the
time of operation) underwent nasopharyngoscopy
and multiview videofluoroscopy; velopharyngeal
insufficiency was evident in only four (17%). Dental
casts were obtained in 14 patients (mean age at the
time of the operation 1 year, 3 months) who were
followed up for a maximum period of two years. N o
postoperative orthodontic treatment was required
and the width and harmony of the dental arch were
maintained in all cases.
Key words: palatopharyngoplasty, palatoplasty,
velopharyngeal insufficiency, hypernasality, articu-
lation defects, dental arch alterations, fistulas.
but this incidence increased appreciably as the
age of the patient at the time of the palatoplasty
increased (30).
The incidence of dental arch anomalies was
35%, lateral crossbite and transverse maxillary
collapse being the most common.
Here we report our experience during the
past three years with a new technique of pal-
atopharyngoplasty . The procedure allows good
muscular reorientation as well as elongation
of the soft palate with minimal morbidity and
scarring.

Cleft lip and palate is the most common cranio-
facial malformation. Fogh Andersen in 1964
(8) reported an overall incidence of 1.47/1000
live births. In that report cleft lip alone com-
prised 21% of all cases, and cleft palate, either
as an isolated deformity or in association with
cleft lip, was the most common malformation
(79%).
Palatoplasty is one of the most commonly
debated topics among plastic surgeons, and the
two most common points of disagreement are
the appropriate time for palate closure and the
technique to use (29). These factors influence
the functional result of cleft palate surgery
including both velopharyngeal function and
PATIENTS A N D METHODS
In the period September 1989 to March 1993 a new
technique for palatopharyngoplasty including mini-
mal incisions was used in 83 patients. The study
group includes 66 patients who have been followed
up for longer than three months and who had clefts
affecting the primary and secondary palates (Table
1).
Forty of the patients were male and 26 were
female. The age at the time of palatal repair ranged
from 8 months to 26 years (mean 4 years, 11 months).
The patients were followed up for periods ranging
from four months to three and a half years (mean 1
year, 11 months).
All the patients were visited regularly by senior
surgeons from the cleft palate team other than the
one who had done the operation. A careful intraoral
examination was made to assess palate length, scar-

01994 Scandinavian University Press. ISSN 0284-4311 Scand J PIast Reconstr Hand Surg 28
 200 M. Mendoza et al.
T a b l e I . Distribution of patients according to type of cleft
Type of cleft No (%) of patients
Complete unilateral primary and secondary 12 (18)
Complete bilateral primary and secondary 3 (5)
Complete secondary 27 (41)
Incomplete secondary 24 (36)
Total 66 (100)
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ring, mobility, and the absence or presence of
fistulas. Patients were asked whether liquids or semi-
solid fluids leaked into the nose.
The patients whose speech had already developed
had a phoniatric evaluation by trained speech path-
ologists in the department of phoniatrics to assess
nasality and articulation. No tests of reliability of
the observers’ judgment were made. Twenty three
patients underwent nasopharyngoscopy and multi-
view fluoroscopy and these were videorecorded and
evaluated as reported by Golding-Kushner et al.
(13).
The patients also had a periodic orthodontic exam-
ination which included direct inspection of the
superior dental arch and in 14 cases sequential dental
casts were made. The evaluation of the form of the
For personal use only.
associated craniofacial malformations other than the
cleft were excluded.
Surgical technique
Under general anesthesia with an oral endotracheal
tube, a Dingman mouth gag was inserted and the
operating area was infiltrated with lignocaine 1%
and adrenaline 1/100000. Seven to 10 minutes later
an incision was made on the medial border of the
cleft at the junction of the oral and nasal mucosa
starting at the most anterior part of the cleft and
continuing until it reached the border of the posterior
pharyngeal pillars (Fig. la). A n angled elevator was
inserted and the oral mucoperiosteal flaps were
released anteriorly and laterally u p to the alveolar

dental arch has up to now been subjective. Specific
measurements, also of anteroposterior growth, will
be collected and will be reported only when an
adequate period of time has passed to show that the
results are reliable.
We classify palatal clefts into three grades accord-
ing to the width of the cleft measured at the junction
of the hard and soft palates. Grade I is a cleft with
an amplitude less than the width of each palatal shelf;
grade I1 has an amplitude equal to the width of the
lesser palatal shelf and grade 111 indicates a cleft with
an amplitude greater than each shelf.
Only patients who presented with grade I and
grade I1 clefts were included in the study. Patients
with neurological developmental disorders or with
ridge. The nasal mucosa was raised in the same way;
as much of the lateral nasal wall was included as was
necessary to reach the midline. If the cleft included
the primary palate, the mucosa of the vomer was
dissected subperiosteally in continuity with the nasal
flap. Great care was taken in dissecting the greater
palatine artery; it was freed gently (Fig. lb) to allow
it to elongate and free the flaps so that they would
close without tension. Complete dissection of these
structures allowed the identification of the posterior
edge of the palatal bones. The oral flaps were sep-
arated with a skin hook and, under direct vision, the
anomalous muscular insertions on the palatal shelves
were released beginning medially and continuing
until the pterygoid hamulus was reached (Fig. lc);

Fig. 1. Minimal incisions palatopharyngoplasty. ( a ) The incisions. ( b )Careful dissection around the area of
the greater palatine artery is necessary to obtain complete liberation of the mucoperiosteal flaps. (c)
Anomalous muscle insertions are freed from the posterior palatal shelves up to the pterygoid harnulus to
obtain reorientation, retropositioning, and end to end suture of the muscles. ( d ) Complete closure of the
cleft with no raw areas.

Scand J Plasr Reconstr Hand Surg 28

 Minimal incision palatopharyngoplasty 201
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Fig. 2. Incomplete cleft of the secondary palate in a 26 year old patient. ( a ) Preoperatively, and ( b ) 15
months after the operation. The only scar is in the midline, and postoperatively he developed normal
speech.

at this point the ligament of the muscle tensor veli
palatini was carefully freed. At the soft palate the
muscles were dissected up to the uvula and the initial
portion of each posterior pharyngeal pillar. Once it
had been confirmed that all the structures could
reach the midline without tension the nasal mucosa
was sutured leaving the knots on the nasal side. The
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the first stage (operatively and immediately
postoperatively) bleeding, local oedema and
the ease of operation were evaluated. Oper-
ative bleeding was considerably reduced, par-
ticularly in older patients. It was roughly half
that of palatoplasties that included lateral

muscular layer was then repaired. beginning with

the palatopharyngeal muscle and then the uvula,
rebuilding the normal raphe of the soft palate by
reorienting, retropositioning, and suturing the fibres
of the tensor and levator palatini muscles at the
midline. This myorrhaphy automatically elongated
the soft palate (Fig. Id). Finally the oral mucosa was
closed, everted, and kept in complete apposition of
its borders to avoid fistulas, especially at the junction
of the hard and soft palate.
RESULTS
The results were evaluated in three stages. In
incisions. None of the patients had any res-
piratory difficulty as a result of oropharyngeal
oedema. All patients were discharged the same
day or the day after the operation.
Surgical skill is required for this technique,
because access to anatomical structures is
limited, particularly around the area of the
greater palatine artery and the pterygoid
humulus. In the second stage (three months
later) the following variables were assessed
clinically: length and motion of the operated

Fig. 3. Complete grade I cleft of the primary and secondary palate. ( a ) Preoperatively, and ( b ) nine months
postoperatively. This patient presented developmental articulation errors which were corrected by speech
therapy. Nasopharyngoscopy and multiview videofluoroscopy showed no sign of velopharyngeal insuf-
ficiency.

Scund J Plus! Reconslr Hand Surg 28

 202 M. Mendoza et al.
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Fig. 4. Complete grade I1 cleft of the secondary palate. ( a ) Preoperatively. ( b ) 10 months after minimal
incision palatopharyngoplasty. (c) Dental cast taken 10 months after the operation which did not show any
alterations of the dental arch. There was no crossbite, and no orthodontic treatment was given.

palates, the quantity and quality of scars, and
the presence of fistulas. The clinical inspection
of the operated palates showed that overall
length and mobility were good. Scarring was
minimal, the only one being located in the
midline. This meant that the palates hardly
looked as if they had been operated on (Figs.
2, 3, 4a and b).
There were seven fistulas (11%). Four of
them (6%) were anterior (postalveolar) and
three ( 5 % ) at the junction of the hard and soft
palate. All fistulas were less than 3 mm.
In the third stage (late postoperative period)
velopharyngeal function and maxillary arch
alterations were evaluated.
The group of patients operated on between
the age of 9 and 18 months, have normal
Scand J Plast Reconstr Hand Surg 28
speech. This was assessed by a group of sur-
geons and speech pathologists. Two of them
(8%) have velopharyngeal insufficiency.
The 35 patients who had already learned to
speak had their nasality and articulation
assessed clinically.
It was assumed that all patients were hyp-
ernasal before the operation because of vel-
opharyngeal insufficiency caused by the cleft.
After minimal incision palatopharyngoplasty
hypernasality was detected in only six patients
(18%). Hypernasality was rated as mild in two
cases (6%), moderate in three patients (9%),
and severe in only one patient (3%). Five had
compensatory articulations (14%), and eight
showed developmental articulation errors
(23%). Five cases (14%) had both com-

Table 11. Description of the four patients with velopharyngeal insuficiency
Case Age at the time
No Type of cleft of operation
1 Complete unilateral 11,7
primary and secondary
2 Complete secondary 2,6
3 Complete secondary 3,6
4 Incomplete secondary 66
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* Reported by Golding-Kushner et al. (13).
pensatory and developmental articulation
errors. All these patients received speech
therapy.
Twenty three patients (mean age at the time
of operation 6 years, 2 months) who had no
misarticulations (n = 17) or in whom articu-
lation errors had already been corrected
( n = 6), had nasopharyngoscopy and multiview
videofluoroscopy. These studies showed that
only four cases (17%) had velopharyngeal
For personal use only.
insufficiency (Table 11).
For the orthodontic evaluation, sequential
dental casts were obtained in 14 patients (mean
age at the time of operation 1 year, 3 months).
These patients were followed up for a maximum
period of two years and the width and harmony
of the dental arch were maintained in all cases
(Fig. 4c).
DISCUSSION
A modern approach to cleft palate surgery
includes the closure of the fissure with the sep-
aration of the oral and nasal cavities, and also
the attainment of good velopharyngeal function
without obstruction of the airway, as well as
normal growth of the maxillary arch. Several
types of palatoplasty have been reported (2,6,
12, 16, 21-24, 26, 32-34). Although they can
all be used to close the cleft of the palate though
with a variable incidence of fistulas (4),their
results as far as speech outcome and maxillary
growth are concerned have not shown that one
procedure is better than any other.
The reported incidence of velopharyngeal
insufficiency after palatoplasty varies from 10%
(12) to 80% (1) depending on the surgical tech-
nique and the age of the patient at the time of
Minimal incision palatopharyngoplasty 203
Percentage of
velopharyngeal
Hypernasality insufficiency
Severe 20
Moderate 10
Moderate 10
Moderate 25
the operation (1, 3, 5, 7, 12, 14,23,27-31, 35,
36). The best results have been reported after
elongating procedures with adequate muscular
reconstruction done before the age of 18
months (12, 23, 30, 31).
The myorrhaphy which lengthens and reori-
ents the muscle fibres can be achieved in two
ways: suturing the muscles in the midline after
freeing of their anomalous insertions (18), or
transposing triangular musculomucosal flaps
(12, 23).
The incidence of reported maxillary and
occlusal disorders as a result of cleft palate
surgery is highly variable (10, 11, 14, 15, 17,
20, 27) and one of the factors involved is the
amount of scarring on the palatal shelves (9,
15, 17, 20). The procedures that use backward
sliding of the mucoperiosteal flaps may elongate
the palate, but the raw areas that they leave
cause scar contracture of the soft and bony
tissues. The Schweckendiek protocol, in which
the cleft of the palate was closed in two stages
(26) , did not describe its advantages clearly.
Though in some reports delayed closure of the
hard palate showed better maxillary growth
(27), the incidence of velopharyngeal insuf-
ficiency was high (1, 5, 7). Our technique chal-
lenges the need for lateral incisions to close the
cleft of the palate, reduces blood loss, and
leaves minimal scarring. Because care was
taken not to damage the perialveolar vessels,
bleeding was appreciably reduced and we oper-
ated in an almost bloodless field.
The muscles of the soft palate were carefully
freed from their abnormal insertions and trans-
posed backwards to elongate the soft palate.
We believe that the elongation should be mainly
by reorientating, transposing medially, and
Scand J Plast Reconstr Hand Surg 28
 204 M . Mendora et al.
retropositioning of the muscles of the velum,
and not only by sliding mucoperiosteal flaps.
In the study group 17% of the patients who
were evaluated by nasopharyngoscopy and
multiview videofluoroscopy showed velo-
pharyngeal insufficiency. This percentage was
lower than that reported by our group in
1988 (30) when Wardill-Kilner palatoplasty
with simultaneous Sanvenero Rosselli pharyn-
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goplasty had been done in patients older than
three years.
Using minimal incisions the only scar was
located in the midline, far away from the
alveolar ridge. The absence of raw areas
avoided scar contracture. No patient has shown
transverse maxillary collapse or crossbite. N o
orthodontic treatment has been used in any of
them.
Though we are aware that maxillary retrusion
is also due to early repair of the lip (19), we
hope that midface retrusion in the study group
will not be evident in a long term follow up.
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The limitation of the technique was that it was
not applicable to all types of cleft palate, and
patients were selected depending on the width
of the palatal cleft. The classification presented
was easy and reliable. It correlated the factors
that limit the closure of a cleft: the tissue defi-
ciency with the tissue availability. Prudent
selection of cases allows good results and the
maintenance of a low incidence of fistulas.
Attempts to close clefts in which the available
tissues are not sufficient are avoided. Perhaps
the use of presurgical orthodontics or of hard
palate tissue expansion will make the technique
applicable to wide (Grade 111) clefts in the
future.
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Correspondence to:
Dr. Mario Mendoza Arellanes
Department of Plastic Surgery
Hospital General “Dr. Manuel Gea Gonzalez”
Calzada de Tlalpan 4800
14000 Mexico, D.F.
Scand J Plasr Reconsrr Hand Surg 28