Overview 

Understanding the cleft palate (CP) 

Cleft palate (CP), as mentioned by Klarity, is an opening in the roof of the mouth seen when the child is born. It’s one of the most common congenital malformations that affects the head and neck area, particularly the face, as evaluated by plastic surgeons. Mostly, cleft palate (CP) came in association with cleft lip (CL), which is an opening in the upper lip, but it could also be an isolated cleft palate or an isolated cleft lip. 

The isolated cleft palate occurs in males more than in females, and one child in every 1,000 is born with a cleft palate worldwide.¹​ The cleft palate is mainly a multifactorial condition with difficulties in recognising if it is a familial inheritance.²​ It’s either part of a syndrome, due to chromosomal abnormalities or exposure of the pregnant mother to some factor, including but not limited; cigarette smoking, alcohol consumption, rubella, nutritional deficiencies, stress, hypoxia and lack of oxygen or anticonvulsants (drugs that prevent seizures).²​ Other factors, like mechanical factors, occur when the tongue’s size is larger than normal and interrupts the closure of the palatal halves (the roof of the mouth is formed by fusion of the two halves of the palatal muscles and bones). 

Diagnosis of an isolated cleft palate is difficult before birth as it’s not visible by prenatal ultrasound, so clinical examination of the child’s palate, mouth and nose immediately after birth is the main method of diagnosis, as mentioned by Klarity. Another method called amniocentesis is used to diagnose this anomaly. Isolated cleft palate could be treated non-surgically by prosthetic devices that close the opening, but it has a rare indication and is limited to those who have a high risk of surgery,² or it is treated surgically by the procedure of palatoplasty. 

What is palatoplasty? 

Palatoplasty, as mentioned by the Cleveland Clinic, is a surgical procedure that aims to repair the defect of the palate by closing the gap or the opening that lies at the roof of the child’s mouth. Its main purpose is to build an oral structure with normal competence, normal hearing, feeding and breathing, also restoring a normal velopharyngeal function without affecting or compromising the growth of the maxilla (the upper jaw).¹​ Palatoplasty should be performed earlier, before the age of 24 months (about 2 years),¹​ with the optimal period of 6 - 18 months.³​ In this period, the surgery has a good outcome regarding speech and hearing development, unlike the late surgery, which will have less effect on the development of the child’s function.¹

What are the types of palatoplasty? 

It has 2 types: 

• Primary palatoplasty 
• Secondary palatoplasty 

Primary palatoplasty 

It’s the main surgery in which the defect is repaired and closed, and needs to be carried out during infancy. 

Secondary palatoplasty 

Additional surgeries that aim to treat the complications of the cleft palate, like improving speech, ear problems or residual defects. 

Surgical techniques of palatoplasty 

Recently, there are 3 main groups of surgical techniques that are used and involve the oral mucosa and its surrounding structures. The choices between them depend on the child’s particular situation. Time of intervention and the type of procedure that will be done in the palatal soft tissues are factors to be considered when planning the surgery¹​. 

The surgery for treating the soft palate takes place in the hospital, according to the Mayo Clinic, under general anaesthesia, so there is no pain. 

Multiple surgical techniques are used, but all of them have the same principle of making incisions in the soft tissues of the hard or soft palate, then repositioning and suturing them together. 

Most common surgical techniques: 

• Tow-flap palatoplasty 
• Furlaw double opposing Z plasty 
• Two-stage palatoplasty 

Two-flap palatoplasty 

This surgical technique consists of creating two flaps (which, according to PubMed, constitutes a piece of tissue that contains a defined blood flow) from the mucoperiosteal layer (the layer that covers the palatal bone) and repositioned and sutured together. 

• Advantages: it's the most used because of its low rate for gap reopening⁴​
• Disadvantages: it restricts the growth of the jaw by forming a scar⁴ 

Furlaw double opposing Z plasty 

In this technique, ‘letter Z’ cuts are made in the soft part of the palate that lies behind the bony part and repositioned and sutured. 

• Advantages: this method was found to make the closure have less tension and prevent the formation of scars, hence allowing the jaw growth⁴ and improving the speech
• Disadvantages: It's a more complex and time-consuming procedure

Two-stage palatoplasty 

This technique performs palatal closure with two separate surgeries performed in separate periods of time. 

• First surgery: it is performed to treat the defect of the hard palate to improve the speech while leaving the hard palate defect open. It should be executed during infancy
• Second surgery: performed around the 4^th to 5^th year to close hard palate defects and aids in minimising the effect of the surgery on the growth of the jaw
• Advantages: it allows an improvement of speech and delays the difficult part of the surgery for years later⁴​​
• Disadvantages: it requires multiple surgeries, and the treatment period is long

Preoperative considerations 

• Taking the medical history 
• Evaluation of the child's health and needs 
• Physical examination 
• Imaging  
• Timing the surgery 

Postoperative considerations 

• Immediate care 
• Management of pain 
• Monitoring of complications 
• Regular check-up 
• Long-term follow-up 
• Performing additional surgeries and treatment of complications, as mentioned by the Mayo Clinic, such as: 
  • Correction of the speaking problems through speech, thereby 
  • Orthodontic treatment for misaligned teeth 
  • Monitoring of the ear to prevent ear infections with a hearing aid if the child undergoes hearing loss 
  • Using special bottles to overcome feeding difficulties 
  • Psychologically, thereby, if the child is experiencing stress due to medical procedures 

Complications of palatoplasty 

• Airway obstruction⁵
• Laryngeal muscle spasm (Constriction of the muscle of the larynx, which results in the lack of ability to breathe well)⁵
• Oxygen desaturation and need for intubation⁵

Less frequently

• Bleeding and hemorrhage⁵
• Nausea and vomiting⁵
• Infection – Mayo Clinic 
• Reaction to anaesthesia – Mayo Clinic 
• Wound reopening (formation of fistula)

Recovery 

After completing the surgery, the child will stay in the hospital for a period that depends on their situation; some of them stay for one to two days and others for longer. During the first days of recovery, swelling, red saliva (bleeding) and more nasal secretions are expected, and the child would feel the stitches in their mouth for several weeks. It should be kept clean with warm water and dried if needed. It will then dissolve by itself, leaving a hard area that will soften with time, according to the Cleveland Clinic. 

Antibiotics and painkillers will be immediately given to the child in the hospital. As mentioned by the Cleveland Clinic, the child will be allowed to eat and drink through cups or special bottles and syringes used to feed the babies. Straws are not allowed during recovery. Over-the-counter pain relievers – like paracetamol and Ibuprofen - may be needed in the first several days after the surgery. The pain may extend for two weeks and will affect the child’s drinking, eating and sleeping. 

FAQs 

What causes cleft palate? 

It’s a combination of multiple genetic and environmental factors, which is a part of a syndrome or due to environmental or lifestyle causes like alcohol, smoking, stress, hypoxia or nutritional deficiencies of the mother. 

How common are cleft palates? 

Commonly, cleft palate doesn't occur alone but with a combination of the cleft lip. The isolated cleft palate occurs in one child in each 1000 births. 

Is detecting cleft palates before birth applicable? 

Detection of cleft palate through paternal ultrasound is challenging, as it is not usually visible. It’s commonly detected through the physical examination immediately after birth by examining the child’s mouth, particularly the roof (the palate) and the nose. 

What is the best age for performing palatoplasty? 

Palatoplasty is better performed in the first year of birth, with an optimal period of 6 to 8 months. 

Summary 

Palatoplasty is the surgery that is performed to repair cleft palate, which is a congenital defect that results in an opening in the roof of the mouth affecting the speech, feeding, hearing and breathing. Cleft palate is mostly diagnosed clinically after birth by examining the baby’s mouth and nose. If detected, the surgery will be carried out in the first two years, particularly during the 6 to 18 months, to achieve an optimal outcome. 

The child may need one or more surgeries to treat the complications. Two-flap palatoplasty, Furlaw double opposing Z plasty and Two-stage palatoplasty are different techniques for palatoplasty, and the choice of them depends on several factors, the most important of which is the time of surgery. 

After surgery, the child is given antibiotics and painkillers and stays in the hospital for at least one or two days. Red saliva and nasal secretion are normal and d and the stitches are expected to dissolve by themselves after several weeks. 

The child should not use a straw and eat or drink through a normal cup or special bottles and syringes.