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NEW CLEFT PALATE REPAIR TECHNIQUE SHOWS PROMISE FOR SIGNIFICANTLY BETTER OUTCOMES

From St. Louis Children's Hospital, Doctor's Digest, written by Pam McGrath, posted June 18, 2012

Albert Woo, MD, Washington University physician and director of pediatric plastic surgery at St. Louis Children’s Hospital, has developed a new surgical technique for cleft palate repair that to date has proven significantly more effective than other procedures commonly used to repair this birth defect.

“There are two primary goals for cleft palate repair. The first is to close the hole in the palate. The second is to correctly position the levator muscle so that the palate functions properly; namely, to separate the mouth from the nose when we speak,” he explains.

Current procedure

Currently the most common procedure for first-time cleft palate repair is the Bardach two-flap palatoplasty. This procedure involves pulling the skin from the side of the palate to the middle and bringing the abnormally positioned levator muscle to the midline.

In 15 – 20 percent of patients undergoing the Bardach procedure, however, the levator muscle proves to be improperly positioned or not functioning properly -- resulting in children having abnormal, hypernasal speech. In some cases, a second surgery called a Furlow palatoplasty can correct the problem.

“This procedure can only be performed if you know that the muscle is in the wrong position, and sometimes we just don’t know where the muscle is located,” says Dr. Woo. “If you are not absolutely confident about the anatomy before you begin, there is no other option for repairing or lengthening the palate. Instead, we are left with other, non-anatomic types of operations.

One example of this involves creating a wall of skin in the back of the throat to try to close off the air that is leaking, thereby resulting in the abnormal speech. This can prove functional, but it results in a palate that is abnormal in appearance. They also have a much higher risk of sleep apnea and other adverse outcomes.”

Over a two-year period, Dr. Woo worked to solve this problem by combining elements of several surgeries, which resulted in the Woo overlapping intravelar veloplasty and oral z-plasty.

Woo Overlapping Intravelar Veloplasty and Oral Z-plasty.

“My surgery involves first dissecting and moving back the muscle to its anatomic location. I then bring the muscle together by overlapping it and tightening it as much as possible,” says Dr. Woo. “The next step is to make a zigzag incision on the roof of the mouth, which lengthens the palate and helps fill the space at the back of the throat that is leaking air.”

To date, Dr. Woo has achieved an 88 percent success rate in operating on children with speech problems, compared to SLCH’s previous experience of a 55 – 60 percent success rate with the Furlow palatoplasty.

In addition, the complication rate with the new technique is 2.5 percent, much lower than the 17 percent typically quoted for the Furlow technique.

Dr. Woo now performs his new surgical approach for both primary and secondary cleft palate repairs. He presented his initial study findings at the American Cleft Palate Association’s national meeting in April.

“Although we will need closer to five or 10 years' worth of data to better assess these children’s speech, our early experience with this new technique demonstrates that it is a safe and effective method for reconstruction of both primary and secondary cleft palate deformities,” says Dr. Woo.

“Hopefully this will significantly reduce the number of children needing to undergo a second surgery to repair their cleft palates.”

Cleft Palate and Craniofacial Institute is oldest in area

Established in 1978 as part of the Division of Plastic Surgery, the Cleft Palate and Craniofacial Institute at St. Louis Children’s Hospital is the oldest center in the area dedicated to the needs of this patient group. Its database exceeds 10,000 patients.

“Our goal is to give each child the best chance for a positive self-image,” says Dr. Woo, who serves as the Institute’s director. “To us, that means providing them with an attractive appearance, intact hearing, understandable speech, useful vision and healthy teeth.”

Among the conditions treated are:
  • Cleft lip and cleft palate
  • The full spectrum of congenital facial and skull problems, including craniosynostosis and hemifacial microsomia; and syndromic conditions
“Among our strengths is the fact that we offer the latest innovations in regard to plastic and reconstructive surgery techniques,” says Dr. Woo. “An example is our ability to correct craniosynostosis endoscopically, which decreases operative time, shortens hospital stay, significantly reduces scars and greatly lessens discomfort and swelling.”

The Institute has the largest comprehensive digital image database of craniofacial deformities, providing opportunities to study the effects of surgery for both clinical and research purposes.

Dr. Woo adds, “Our partnership with pediatric neurosurgery when performing this procedure is an example of the depth of expertise we have available to us as part of a pediatric hospital consistently ranked among the top facilities in the nation.”

“Our highly individualized treatment plans enhance our coordination of care and minimize the number of surgical procedures our patients need. This is extremely important to parents dealing with serious issues involving their children,” says Dr. Woo.

The Institute is an affiliated member of the American Cleft Palate and Craniofacial Association and has been certified by the association as meeting its criteria for care provided to patients by cleft palate and craniofacial teams.
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Copyright 2013 Washington University School of Medicine