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A cleft palate is divided into several types, primarily based on the scope of involvement with the palate. The hard palate is separated into anterior and posterior segments. In cases of complete cleft lip and palate, both hard and soft palates are typically damaged. In isolated cleft palate, only the soft palate may separate. There's also a type where only the uvula splits, appearing as two uvulae, which could be subclinical cleft palate. This often becomes noticeable during speech development, leading to early diagnosis.
The normal upper palate includes the hard palate with bone and the soft palate, which is crucial for function. The soft palate contains six small muscles, but the key ones for speech are the levator veli palatini muscle and the tensor veli palatini muscle. In the cleft state, this transverse pink muscle is separated, presenting a longitudinal appearance. The goal of cleft palate surgery is to adjust this longitudinal muscle to a transverse one.
The white tensor muscle functions in relation to the Eustachian tube closure. The Eustachian tube connects the mouth to the middle ear, so cleft babies have a high chance of middle ear effusion.
The surgery involves using the Z-plasty method to correct the misaligned soft palate muscles and extend the soft palate.
Cleft palate affects feeding and speech for babies. Due to hard palate defects causing nasal-oral communication, milk overflows from the nose during feeding. Additionally, clefts make sucking difficult, and hard palate defects prevent proper sucking. Thus, cleft babies often require specialized bottles post-birth. These bottles feature soft nipples and flexible bodies to allow babies to drink by squeezing the bottle or using nipple sucking.
Besides feeding, clefts impact speech sounds and Eustachian tube function. Abnormal arrangement of soft palate muscles responsible for mouth resonance leads to excessive nasal speech. Regarding Eustachian tubes, due to abnormal muscles controlling the tubes in the soft palate, middle ear effusion becomes common among cleft patients. About 95% of cleft babies experience middle ear effusion issues. Some cleft babies fail newborn hearing tests due to this.
The surgery aims to close the nasal-oral passage caused by hard palate defects, preventing food leakage from the nose, restoring normal mouth function, and realigning muscles for improved speech. For middle ear effusion, while the muscles controlling the Eustachian tube cannot be corrected, the surgery simultaneously involves placing middle ear ventilation tubes by an otolaryngologist to address effusion.
Since clefts affect feeding and speech, why not operate as early as possible? A major issue with cleft palate surgery is its impact on midface growth. Babies are still growing, and early surgery forms scar tissue, naturally affecting development. But clefts also hinder speech learning, so surgery cannot be delayed indefinitely. Worldwide, most cleft centers choose between 9-15 months for babies. We select 9-12 months as a middle ground. This timing minimizes midface growth impact while allowing surgery before speech learning begins. If middle ear effusion or inflammation is present, surgery can be advanced to avoid hearing and learning barriers.
Cleft palate surgery has evolved in hospital history into two methods. Traditional is the two-flap approach, cutting and suturing the separated flaps. However, two-flap's drawback is inability to effectively lengthen the soft palate or recover misplaced muscles. After traditional surgeries, 20-30% of patients had incomplete speech closure. In the 1980s, American surgeon Furlow developed soft palate Z-plasty, and our hospital adopted Furlow's Z-plasty in 2003, greatly reducing incomplete speech closure rates. This means lower chances of needing secondary speech correction surgery.
Cleft palate surgery can repair hard palate defects but has two possible complications. One is poor wound healing at the hard-soft palate junction, resulting in nasal-oral fistula. This occurs more in babies with extensive hard palate defects. Sometimes, hidden infections or bacteria during surgery can cause poor healing. The fistula incidence is about 3%. If present, treatment depends on symptoms; if no issues like nasal leakage, no intervention is needed. Another complication is persistent incomplete speech closure, requiring secondary speech correction. Now, secondary surgery is rare, about 6%.
The Z-plasty allows lengthening the hard palate, improving future speech, and the larger incisions enable better muscle realignment. Currently, our success rate for speech at age 9 is 94%, immediate post-surgery at 97%.
Surgery targets functional improvement without holes or breaks, aiming for complete external appearance. This requires long-term training. Post-surgery, babies often have uvular separation, the so-called "small tongue" state. In learning, one month later, we check and often see "uvular separation." When training in Canada, we learned uvular repair techniques, and since then, no more uvular separation. Current results are nearly normal for many babies; some with good wound healing show no Z-scar.
Regarding post-surgery success in speech: the first criterion is no nasal leakage post-surgery, causing life and social difficulties. Unilateral or bilateral cleft babies may leak from the alveolar ridge due to dentition defects, improving at age 10 with alveolar repair, but general cleft babies should not have nasal leakage.
The second and most important part is speech. Post-repair, speech should not have nasal sounds, meaning certain words shouldn't leak air nasally, like "dad," "brother," "sister." Some speech issues aren't from leakage but poor hearing causing abnormal phonetics, needing speech therapist help and otolaryngology follow-up for hearing confirmation.
Our hospital's Professor Chen Rui advised performing the first surgery myself. The first surgery is crucial. Infant cleft surgery isn't visible externally, seeming repaired, but a poor first surgery lowers future correction chances. From 2018-2023, I performed 298 cleft surgeries, needing only 3 secondary speech corrections.
Basically, isolated cleft babies need periodic follow-up, not just speech, but due to potential midface growth impact from surgery. Cleft surgery varies by cleft size; larger ones require incisions on both hard palate sides, explaining occasional post-surgery asymmetry. Generally, incisions on both sides affect midface growth more. We follow up until adulthood for bone development completion. If future orthognathic surgery or rhinoplasty is needed for midface incompleteness, insurance covers it. Additionally, current one-stage anterior palate suturing makes surgery easier, possibly reducing future midface impact by avoiding bilateral incisions, aiming to minimize hard palate growth effects.
Usually, pre-surgery involves blood tests and chest X-rays to exclude infection risks, with X-rays diagnosing conditions like pneumonia or enlarged thymus. If blood tests and X-rays are clear, we arrange middle ear effusion checks by pediatric otolaryngology. If effusion is diagnosed pre-surgery, during cleft surgery, otolaryngologists place middle ear tubes.
Cleft surgery relates to airways, so post-surgery airways are narrower, and if narrow, we place nasal airways for nasal clearance. No infections two weeks pre-surgery, as they worsen airway obstruction. If nasal tubes are placed, they are removed the next day based on condition. Each baby has an oxygen monitor to ensure breathing stability.
For Pierre Robin babies, post-surgery involves pediatric ICU observation for airways, then transfer to pediatrics.
Post-surgery feeding is another care point. Due to hard palate wounds, standard long nipples cannot be used; we recommend double bottle squeezers to shorten nipple length. Currently, market short-head nipples, so-called natural breastfeeding nipples, can be used immediately post-surgery. If concerned about adaptation, use short nipples pre-surgery. These bottles feature soft bodies and nipples, allowing milk squeezing without sucking.
Post-surgery week one involves cold liquid foods; if wounds are good at one-week follow-up, switch to soft foods. Usually, two weeks post-surgery, wounds stabilize for normal feeding (warm soft baby foods), but avoid hard foods. One month later, fully normal feeding.
Post-surgery feeding is another care point. Due to hard palate wounds, standard long nipples cannot be used; we recommend double bottle squeezers to shorten nipple length. Currently, market short-head, so-called natural breastfeeding nipples, can be used immediately. If concerned about adaptation, use short nipples pre-surgery. These bottles feature soft bodies and nipples, allowing milk squeezing without sucking.
Breastfeeding nipple heads are also recommended by parents, as the first two are too short for some babies; the below breastfeeding bottle is another option. (Some use Pigeon too.)
Recent hospital research on Z-plasty cleft repair. Since Z-plasty suturing started around 2003-2005, and surgery success needs long-term, large cases for rate research. Thanks to several Japanese plastic surgeons learning at our craniofacial center, we conducted long-term, large-patient studies for understanding outcomes.
Two-flap cleft repair vs. Z-plasty cleft repair. Representative is the December 2024 issue in the top plastic surgery journal (PRS), comparing traditional two-flap cleft repair and Z-plasty cleft repair success rates. For 9-year speech success, traditional is 68.3%, Z-plasty 94.6%. For post-surgery nasal-oral fistula incidence, traditional is 9.2%, Z-plasty 0.5%.
Traditional Z-plasty vs. small Z-plasty. Another study compares two Z-plasty types. At our center, there are small Z and traditional Z. This is the June 2024 published article (JPRAS). For 9-year success, groups differ little, traditional Z 92.1%, small Z 90.8%, no statistical difference, but nasal-oral fistula in traditional Z 4.6%, small Z 0.5%. Traditional Z had two babies with airway issues post-surgery, as traditional Z reduces nasopharyngeal airways, and post-surgery swelling easily causes issues.
Due to recent traditional Z causing narrowed airways, with loud snoring, some sitting with respiratory sounds, we started sleep studies for 9-13-year-olds, comparing two Z-plasty airway sleep apnea differences. Sleep apnea is a hot topic recently, as sleep breathing may affect children's physical, intelligence, learning, and relates to obesity.
Currently completed but unpublished research compares two Z-plasty airway volumes, based on 10-year-old computer tomography airway reconstruction. Results show small Z post-surgery airway (repaired soft palate to posterior pharyngeal wall volume) significantly larger than traditional Z, but speech evaluation results no difference.
So based on recent research, surgical methods changed to make nasopharyngeal airways wider post-surgery. Previous methods caused snoring possibly lasting six months or more. Currently, parents report about two weeks. Most babies improve snoring in two weeks, with softer sounds.