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Three Flap Palatoplasty

last modified on: Mon, 10/29/2018 - 16:10

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GENERAL CONSIDERATIONS

  1. Three-flap palatoplasty is appropriate when the cleft is bilateral and includes the secondary palate posterior to the incisive foramen. 

OPERATIVE PROCEDURE

  1. Examination of the ears is performed bilaterally. Tympanostomy tubes may be placed if indicated. 
  2. Positioning: The bed is rotated 90 degrees towards the door. All pressure points are padded. The patient's head is positioned in extension off of the end of the Philippine board. The patient is prepped and draped. The Dingman retractor is placed taking care to seat it firmly without damaging the cheeks, lips, teeth or tongue. Retractor is NOT suspended as you might do with a Crowe-Davis.
  3. Throughout procedure it is good practice to release the retractor every 30 minutes to allow tongue re-perfusion
  4. Epinephrine is infiltrated into the palate and allowed time to take effect. 
  5. Incisions: Planned incisions extend from the uvula down the medial cleft mucosa to separate the nasal and oral mucosa (15 blade). Once the blade reaches the incisive foramen the incision extends anteriorly to the contralateral primary palate ending at the alveolus at the approximate location of the canine (colorado needle monopolar). These mucoperiosteal flaps are released from anterior to posterior when the lateral secondary palate mucosa is incised usually with Colorado tip monopolar electrocautery. 
  6. Hard palate dissection: Cold steel or Colorado tip monopolar electrocautery may be used to dissect the mucoperiosteal flaps from the palatal bone from anterior to posterior. Cottle or Woodson elevators are often used to undermine. A gauze may be used to elevate in the region of the neurovascular pedicle emerging from the greater palatine foramen. As the flap is undermined, it is useful to maintain tension using a single hook retractor or a stay suture.  The Von Graefe is used to dissect around the neurovascular bundle and protect it. In order to lengthen and provide mobility to the flap, it is often necessary to further dissect the neurovascular bundle from the mucoperiosteal flap. 
  7. Soft palate dissection: Soft palate muscle remains attached to the oral mucosa while the plane of dissection is carried out between the muscle and the nasal mucosa. Extensive lateral dissection is often necessary to free the mucoperiosteal flap so it can be adequately medialized for a tension free repair. The soft palate musculature should be stripped from their hard palate and periosteal attachments in order to mobilize them for transposition medially to recreate a more physiologic palatal sling. The edges of the primary palate triangle flap are then dissected free from the palate using a cottle and McIndoe in order to provide a cuff of tissue to suture the anterior medial edges of the mucoperiosteal flaps.
  8. Note: If the mucoperiosteal flaps are too narrow transversely due to a wide cleft, the vomer mucosa may be incised, undermined and used as an interposition graft to close the palate. 
  9. Closure: Using 4.0 Vicryl sutures, first the nasal mucosa is closed from anterior to posterior (alveolus to uvula) with care to approximate the raw mucosal edges in an interrrupted tension free fashion. Care must be taken to evert the mucosa nasally with knots on the nasal surface.  Next the soft palate is addressed. The soft palate muscles are transposed medially and sutured together in order to create a functional muscular sling. The oral layer is then closed from posterior to anterior starting at the uvula and progressing towards the anterior flap. Often vertical mattress sutures are used in order to obliterate dead space between the oral and nasal mucosa. Vertical mattress sutures are also preferred to secure the tip of the lateral flaps to the medial edges of the anterior flap. Simple interrupted sutures are used to further tighten all remaining gaps and to finish closure of the anterior triangle. Avitene is then tightly packed over palatal bone into the lateral defects left by the medialized flaps using wet gauze for 2-4 minutes. 
  10. The stomach, oropharynx, nasopharynx, and nasal cavity are gently suctioned. The Dingman is removed. Bacitracin is applied to the lips and the patient is turned back to Anesthesia for extubation.
  11. Armboards should be placed prior to arousal in order to prevent trauma to the palate.

Images

  1. Simplified schematic per Bardach and Salyer 1999 two.flap_.palatoplasty

DICTATION TEMPLATE:

  1. Informed consent was reviewed with the parents.  The patient was then transferred to the operating room.  After a pre-induction checklist, followed by induction and intubation by anesthesia staff, a time-out was performed.   The left ear was examined and cerumen was removed from the canal with a small curette.  A myringotomy incision was made in a radial fashion using a Beaver blade and a VT grommet tube was placed using alligator forcep and fine pick.  Next, the right ear was addressed in a similar fashion.  Drops were instilled and a cotton ball inserted the canal.  The bed was turned 90 degrees.  All pressure points were meticulously padded with reston foam.  The patient was positioned on the Phillipine board and this was postioned such that the head was hanging off in full extension.  The patient was prepped and draped in standard fashion.  The Dingman retractor was placed.  The oral cavity was cleaned with peridex and a toothbrush and suctioned free.  The palate was examined and photodocumentation with the 70 degree telescope obtained.   The proposed incisions were sketched on the palate and the palate injected with 1:200,000 epinephrine.  This was allowed to take effect.  Retraction sutures were placed through either side of the uvula and the medial edge of the uvula trimmed. The incision was made along the oral aspect of the soft palate edges with a 15 blade.  As the hard palate mucosa was encountered, the incision was continued, cheating towards the oral side such that adequate tissue remained to close the nasal mucosa.  Using the colorado needle monopolar, the incision then extended anteriorly across the contralateral primary palate beginning at the incisive foramen and ending at the alveolus at the approximate location of the canine.  The incision was then continued along the alveolus toward the maxillary tuberosity.  This was repeated contralaterally.  Stay sutures were placed at the anterior aspect of each flap.  The mucoperiosteal flaps were then raised anterior to posterior with a cottle elevator until the neurovascular pedicle was encountered at the greater palatine foramen.   The Von Graefe was used to isolate and protect the pedicle while lateral attachments were freed bluntly to increase rotation of the flap medially.  The soft palate musculature was then dissected from the mucosa to facilitate the intervelar veloplasty.  The vomer was then incised in midline and small flaps elevated to facilitate and interposition flap.  The nasal mucosa was closed with 4.0 vicryl suture starting with the bilateral vomer flaps anteriorly and proceeding posteriorly, taking care to invert/oppose the raw edges.  The intervelar veloplasty was then sutured with maxon suture.  Finally, the oral mucosa was closed with vicryl in combination simple interrupted and vertical mattress fashion.  Care was taken to tack the oral mucosa deeply to the nasal flap to eliminate dead space.  All stay sutures were removed.  The wound was irrigated.  Avitene was placed into the lateral pockets of exposed palate bone and pressure held for 3 minutes.  The stomach was then suctioned.  Final photodocumentation was obtained.   This concluded our procedure.  The patient was then turned over to anesthesia for emergence and extubation.  The patient tolerated the procedure well.

POST OPERATIVE CARE

  1. Diet: Strict cup diet for 3 weeks. No straws, spoons, forks or sharp implements. 
  2. Armboards on at all times unless directly in the arms of a parent or guardian. Supervised play. 
  3. Antibiotics for 1 week (amoxicillin; clindamycin if penicillin allergic)
  4. Follow up in 3 weeks

SUGGESTED READING

  1. Salyer and Bardach's atlas of craniofacial & cleft surgery 1998