Salvaging Procedure for Mutilated Cleft Palate by Simultaneous Tongue and Pharyngeal Flap Surgery

Sir: Multiple failed attempts at cleft palate repair leave behind a mutilated palate, with minimal tissue available for closure at a later date. The problem becomes more challenging because of added scarring, which leaves tissue unrelenting. The superiorly based pharyngeal flap has often been used to augment the nasal lining of the scarred, contracted soft palate; similarly, the tongue flap has been used for hard palate closure.1,3 However, a simultaneous pharyngeal flap with tongue flap surgery has never been reported, probably because of expected airway problems.2 A simultaneous pharyngeal flap with tongue flap surgery also lengthens the palate and retains its length postoperatively. Since 2001, I have had six patients with a mutilated and severely compromised palate with little tissue available after previous repairs. These patients had either a completely broken palate with very narrow palatal shelves or a very large anterior fistula with a broken or severely scarred soft palate (Fig. 1). The profiles and other details of these six patients are listed in Table 1.Fig. 1.: Completely broken palate with narrow palatal shelves and scarred, short soft palate.Table 1: Patient Profiles and DetailsDuring the procedures, the paring incision was made on the hard palate 2 to 3 mm away from the edge to create a turndown flap. These flaps were dissected in continuity with the nasal mucoperiosteum of the nasopharynx. Posteriorly, these incisions continued on to the junctional area to the soft palate. As one progresses on the soft palate, the paring incision is moved onto the edges or a little on the nasal side to preserve as much of the oral layer as possible. A superiorly based pharyngeal flap (moderately wide) of adequate length was sutured to the nasal lining of the soft palate. This continued as a repair of the nasal mucoperiosteum of the hard palate. It is essential that this repair be continued anteriorly beyond the alveolus if there is a cleft of alveolus, to prevent retraction of the flap, which may result in a postalveolar fistula. Adequate mobilization of muscles as described by Sommerlad4 will help to approximate the muscles in the center. Occasionally, the tethered, scarred oral layer of the soft palate needed a horizontal incision behind the hard palate to move the oral mucosa medially. An anteriorly based tongue flap of adequate size was raised and the defect was closed primarily. Special attention was given to the most posterior part of the defect while fitting the tongue flap. None of the patients needed blood transfusion. After ensuring that there was no active bleeding, patients were extubated. They were kept in the postoperative recovery room for 4 to 5 hours with pulse oximetry and then transferred to the ward. All these patients were given maintenance intravenous fluid on the day of surgery and encouraged to take sips of water after 6 hours postoperatively. These patients were started on a liquid and semisolid diet from the second day of surgery, and all patients managed to have a semisolid to soft diet by 3 to 4 days. Antibiotics were given only intraoperatively and oral hygiene was emphasized by continuous drinking of water and mouth washes. The tongue flap was divided after 12 to 15 days under local anesthesia (Fig. 2). The cut edge on the palate was cauterized but not sutured. The base of the tongue flap was returned to the tongue. Although we had concerns about the airways, surprisingly, none of the patients had an episode of hypoxia in the recovery room or later. None of the patients has any residual fistula.Fig. 2.: Palate reconstructed by tongue and pharyngeal flap.Of the six patients, we did not have postoperative speech samples for two patients. Of four patients, two did not have any improvement in speech. Two patients had postoperative improvement in speech (nasal emission disappeared), with marginal improvement in articulation. Jyotsna Murthy, M.S., M.Ch., D.N.B. Department of Plastic Surgery Cleft & Craniofacial Center Sri Ramachandra Medical College and Research Institute (Deemed University) Porur, Chennai 600 116, India [email protected] ACKNOWLEDGMENT All patients were operated on for free under the Smile Train Project.