IDEAS AND INNOVATIONS

Veloplasty Using the Wave-Line Technique Versus Classic Intravelar Veloplasty

KAI-OLAF HENKEL, M.D., D.D.S. ANN DIECKMANN ORTRUD DIECKMANN, PH.D. JAN-HENDRIK LENZ, M.D., D.D.S GUNDLACH, M.D., D.D.S, M.S.D.

KARSTEN KURT HELMUTH

Objective: A well-known problem in primary surgery of the soft palate is its shortness and the decit of local soft tissue. This article introduces a modication of the primary intravelar veloplasty, allowing lengthening of the soft palate, and compares this alternative technique to the classic intravelar veloplasty. Method: The soft palate wave-line technique adds a wavy incision at the velar cleft margins to the intravelar veloplasty. In 24 patients with complete clefts of the palate, either the newly developed or classic technique was performed. Four years following primary surgery, speech performance and type of breathing were analyzed. Results: Even in wide clefts of the soft palate, repair was easily accomplished using the wave-line technique. Complete closure of the nasal, muscular, and oral layers was achieved, and no postoperative stula was observed. An average lengthening of the soft palate of 56% (range 24% to 83%) was observed immediately following velar repair with the wave-line technique. Speech was signicantly better in the wave-line group (p .05). Furthermore, physiological breathing was observed more often in these patients. Conclusion: Primary repair of clefts of the soft palate using the wave-line technique is straightforward, safe, and easy. On the basis of the present results, this technique seems superior to the classic intravelar veloplasty.
KEY WORDS: cleft palate, intravelar veloplasty, wave-line technique

One common feature of clefts of the soft palate is a decit of soft tissue caused by disturbed embryological development (Limborg et al., 1983; Schumacher, 1983). The absence of well-developed tissue includes the mucosa in the cleft region as well as the velar muscle. Furthermore, there are incorrect insertions of the velar musculature at the posterior shelves of the hard palate (Fara and Dvorak, 1970; Millard, 1980; Kriens, 1997). In early reports, Veau (1931) and Kriens (1969) denied the presence of an aponeurosis posterior to the hard palate. However, more recent studies described the existence of an underdeveloped aponeurosis (Fara and Dvorak, 1970; Kriens,

Dr. Henkel, Dr. Lenz, and Dr. Gundlach are with the Department of Maxillofacial and Facial Plastic Surgery, Rostock University, and A. Dieckmann and Dr. O. Dieckmann are with the School of Logopedics and Speech Pathology, Rostock, Germany. Submitted February 2002; Accepted February 2003. Address correspondence to: Priv.-Doz. Dr. Dr. Kai-O. Henkel, Department of Maxillofacial and Facial Plastic Surgery, Medical School University of Rostock, Strempelstrae 13, 18057 Rostock, Germany. E-mail Kai-Olaf.Henkel@ med.uni-rostock.de. 1

1997). These morphogenetic abnormalities cause a shortness of the soft palate in patients with cleft. Therefore, surgical techniques are aimed at lengthening and correcting repositioning of all three layers of the velum. Intravelar veloplasty as described by Kriens (1997) allows correct reconstruction of the velar muscle, but primary lengthening of velar tissues is limited. Schuchard (1954) attempted some palatal lengthening with Z-plastylike incisions in the soft palate. In recent years the Furlow double-reversing Z-plasty (Furlow, 1986) has become very popular in soft palate repair. The advantage of this procedure is lengthening of soft palate that leads to a better clinical outcome than intravelar veloplasty (McWilliams et al., 1996; Gunther et al., 1998). Although this technique reorients the velar muscles correctly in the transverse position, the resulting overlap of the levator and palatopharyngeus muscle across the midline is not physiologically sound (Huang et al., 1998). The musculus uvulae are also incorrectly placed in the Furlow repair (Huang et al., 1997). Cohen et al. (1991) observed palatal stulas in 10% of patients following the Furlow procedure. These reports pro-

Cleft PalateCraniofacial Journal, January 2004, Vol. 41 No. 1

FIGURE 1 Complete cleft of soft palate: design of the wave-lines.

FIGURE 3 Closure of the nasal layer.

vided the impetus to search for an alternative way to lengthen the velum during cleft palate repair. Pfeifer (1970) described lengthening of the upper lip in patients with cleft by using a wave-line procedure while performing cheiloplasty. Long-term results following primary lifting of the nose and labioplasty in patients with unilateral and bilateral complete clefts by stretching of wavy incisions of the lip cleft edges during the wave-line procedure have been promising (Pfeifer, 1970; Gundlach et al., 1982; Pfeifer et al., 1991; Henkel, 1993). In the present study, Pfeifers approach was combined with the intravelar veloplasty (Kriens, 1997) in patients with complete clefts of the soft palate. The aim of this study was to compare the outcome, especially lengthening of the soft palate, speech, and type of breathing, with the results achieved in other children following intravelar veloplasty. METHOD Participants This investigation was planned as an interdisciplinary prospective clinical trial. In 24 patients with complete clefts of the soft palate, veloplasty was performed at the age of 10 to 12 months (average 11.6 months). The new wave-line technique was carried out in 12 patients (study group), and a con-

ventional intravelar veloplasty was used in the other 12 patients (control group). The selection of these patients was done by randomized criteria in that each patient was assigned to one of the two groups following a previously determined succession. All patients were nonsyndromic patients with unilateral cleft lip and palate. Apart from the type of veloplasty, there was no difference in the treatment protocol between the patients. The same surgeon performed all operations following informed consent by the patients parents. At 4 years of age, the patients surgical and speech data were investigated without prior knowledge of the surgical technique utilized. Procedures Closure of the soft palate using the wave-line technique is depicted in Figures 1 through 4. Initially both sides of the cleft margins are marked by a double-formed wave-line ending in a straight line in the uvula (Fig. 1). The procedure starts with an incision along these lines. The waves in the oral and nasal mucosa are stretched during the surgery, leading to an elongation of the soft palate.

FIGURE 2 Technical sketch. Step 1. Incision in the oral mucosa and dissection of oral mucosa results in a nasally based turn-over ap. Step 2. The intravelar muscles are dissected completely from the posterior shelves of the hard palate.

FIGURE 4 The muscle and oral layers are closed to complete the procedure. Relaxing incisions are seen laterally.

Henkel et al., VELOPLASTY USING WAVE-LINE TECHNIQUE

TABLE 1 Primary Treatment Modalities as Typically Performed in Rostock

Operative Procedure Timing, Age

Labioplasty Veloplasty Repair of the hard palate Primary bone grafting

6 mo 1012 mo 45 y 1113 y

The next step is dissection of the intravelar muscles. Beginning with creation of a nasal based turn over ap from the oral side (dotted area in Fig. 2, rst step), the tensor and levator veli palatini muscles are dissected completely to free them from the oral mucosa on both sides. Furthermore, they are dissected free from the posterior shelves of the hard palate (Fig. 2, second step). This is performed submucosally after both sides are freed from the pterygoid hamulus using lateral incisions (Fig. 4). Complete preparation of the intravelar muscle allows easy rotation of the cleft muscles on both sides into a posteromedial direction. Wound closure is started at the nasal layer (Fig. 3) with absorbable sutures. Suturing the nasal mucosa involves taking up the small turn over aps from the oral mucosa hinged on the nasal mucosa. This is followed by closure of the other muscle layer and nally the oral mucosa. Figure 4 depicts the situation at the end of the procedure. It is very helpful to temporarily suture the uvular base to the posterior pharyngeal wall. This makes elongation of soft tissue easier. Following complete dissection of the tensor and levator veli palatini muscles from the posterior edge of the hard palate, both muscles assume a more cranioposterior position by their own tension because the origin of these muscles are at the base of the skull. Data Analysis

FIGURE 5 Outcome 3 years postoperatively, at age 4 years.

RESULTS The average cleft width amounted to 11.3 mm for the study group and 11.7 mm for the control group, measured at the uvula basis. The wave-line technique enabled lengthening of the velar tissues by an average of 56% (range 24% to 83%). In one patient in the wave-line group (study group), a supercial dehiscence occurred in the oral mucosa but healed secondarily without complications. All other patients healed without complication. Three years following primary surgery no instances of oronasal stula or bid uvula were observed (Fig. 5). All uvulae were normally congured, and scarring of the velum was inconspicuous. Table 2 contains the results of the speech examination. On all parameters measured, patients who underwent the waveline technique (study group) were judged superior to those of the control group (classic intravelar veloplasty). Only 1 of 12 study group patients exhibited compensatory
TABLE 2 Results of Investigation

For every patient, the diameter of the cleft at the uvular basis was measured preoperatively. At the age of 4 years, each patients surgical and speech outcome was evaluated. Wound healing, individual breathing (nasal versus oral type), grimacing, articulation of alveolar sounds /l/, /n/, /d/, /t/, and /z/, /s/, and the Gutzmann /a-I/ test (Garliner, 1989) were analyzed by a speech pathologist. The /a-I/ test was judged positive if a sound difference was observed between speech with an open versus closed nose. This nding is associated with velopharyngeal incompetence. Therefore, a negative /a-I/ test indicated the achievement of velopharyngeal closure. The speech pathologist involved in this study was experienced in the area of cleft and did not know which type of surgery was performed. Both groups received the same followup regarding surgical, logopedic, orthodontic, and ear-nosethroat treatments. Table 1 lists the primary treatment modalities generally applied in Rostock. Chi-square-tests were used for statistical analysis of group differences, with signicance levels set at .05.

Criteria

Wave-Line Technique (Study Group)

Intravelar Veloplasty (Control Group)

Number of patients Width of cleft (mean) Breathing Nose Mouth Grimacing No Yes A-1 test Negative Positive Sounds /l/, /n/, /d/, /t/ Normal Disordered Sounds /z/, /s/ Normal Disordered

12 11.3 mm 8 (67%) 4 (33%) 11 (92%) 1 (8%) 12 (100%) 0 (0%) 6 (60%)* 4 (40%) 6 (60%)* 4 (40%)

12 11.7 mm 4 (33%) 8 (67%) 4 (33%) 8 (67%) 8 (67%) 4 (33%) 3 (25%) 9 (75%) 4 (33%) 8 (67%)

* Two children in the study group were too playful for examination.

Cleft PalateCraniofacial Journal, January 2004, Vol. 41 No. 1

grimacing when speaking, and grimacing was observed in 8 (of 12) control group patients (p .05). The /a-I/ test was negative for all 12 study group subjects and negative for only 8 of the 12 control group subjects (p .05). The production of /l/, /n/, /d/, /t/, and /z/, /s/ was judged to be normal in signicantly more study group subjects than control group subjects (p .05). Nasal breathing was also observed in signicantly more study group subjects (p .1). DISCUSSION In the present study, articulation of /l/, /n/, /d/, /t/, /z/, and /s/ was analyzed in patients with cleft because they are most often adversely affected following cleft palate repair. Labial sounds such as /p/ and /f/ and velar sounds such as /k/ were not included because at the time of investigation, the hard palate cleft had not yet been closed in these patients. The present speech results, obtained 3 years following primary surgery, emphasize the advantages of the wave-line technique in a distinct manner. Intravelar veloplasty with dissection of the muscle from the posterior shelf of the hard palate allows correct positioning of the muscular velar sling. By performing the wave-line technique for reconstruction of the nasal and oral mucosal layers, lengthening of the soft tissue is possible. This modication of the classic intravelar veloplasty (Kriens, 1969) circumvents the well-known limitation to lengthening of the soft palate resulting from scar contracture following straight-line incisions. Stretching of the soft palate can be better realized by utilizing wave-like incisions at the cleft margins. The effect of tissue extension at the soft palate is supported by the tightness of the united cleft muscles. The unied cleft muscles pull in a posterior direction and help to form an articial aponeurosis between the hard palate and muscular velar sling. Finally the modied anatomical situation also supports velopharyngeal function. CONCLUSION Although these results must be considered preliminary, given the relatively small number of subjects evaluated, it may be concluded that the wave-line technique results in effective closure of the soft palate in patients with cleft and offers some advantages when compared with other well-established technique, including closure of the soft palate cleft with local tissue only and without denudation of bone; anatomically normal re-

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