Innovative Palate Repair
by Albert S. Woo, MD, chief of pediatric plastic surgery, Hasbro Children's Hospital
Cleft lip and palate deformities are the most common congenital anomalies affecting the head and neck, affecting approximately 1 in 690 live births in the United States. Even after cleft palate repair, about 20% of children continue to have abnormal speech characterized by hypernasality and nasal emission, called velopharyngeal insufficiency (VPI). It is thought to be associated with the levator veli palatini muscles of the palate being in the wrong position. Even after surgical correction, however, the speech results have been less than ideal. In such situations, additional surgery is often suggested.
Traditional options have included obstructive, nonanatomic surgeries, such as a pharyngeal flap or sphincter pharyngoplasty. While speech results have generally been positive from these traditional procedures, they also subject young patients to significant risks of obstructive sleep apnea. Surgeons have therefore focused on revising the cleft palate repairs rather than performing these procedures, to minimize the risk of sleep apnea and other complications, while also improving speech.
I recently joined Hasbro Children’s Hospital to lead the Cleft and Craniofacial Center. In 2009, I developed a new cleft palate repair designed to improve speech outcomes in both primary and secondary operations. The results have been nothing short of surprising.
Improvement in Speech for Children who had Undergone Initial Cleft Palate Repair
The Woo Palatoplasty was initially offered as a secondary procedure for children who still had abnormal speech despite having already undergone an initial cleft palate repair in infancy. These results were compared against the Furlow double-opposing Z-plasty technique, which is the most common palatal redo operation performed in the United States.
In nonsyndromic patients, the Woo Palatoplasty achieved 95% success compared to 63% success with Furlow. When the results were refined further to examine only patients considered ideal for the Furlow technique, the Woo Palatoplasty had a 100% success rate compared to 67% with the other procedure. These results were published in Plastic & Reconstructive Surgery in October 2014.
Better Results with Initial Cleft Palate Repair
Spurred by the success, this operation was offered to infants undergoing cleft palate repair for the first time, typically performed around 1 year of age. While roughly 20% of children suffer from VPI with traditional operations, since 2009, none of the nonsyndromic patients who received the Woo Palatoplasty have needed additional surgery.
These dramatic results are thought to be due to the Woo Palatoplasty’s focus on overlapping the palatal musculature, which are thought to be overly long in cleft palate patients. These findings were also published in Plastic & Reconstructive Surgery in July 2015.
Decreased Need for Speech Therapy
In general, approximately 75% of cleft palate patients require some degree of speech therapy, as these children are taught how to use their repaired palates to produce normal speech. A recent study has demonstrated that those who have undergone Woo Palatoplasty had a 57% decrease in cleft-related indications for speech therapy. These findings were recently published in the Annals of Plastic Surgery in March 2017 and described in the January 2017 issue of Plastic & Reconstructive Surgery.
Improved Speech for Cleft Patients
The philosophy of the multidisciplinary cleft team at Hasbro Children’s Hospital is that all children born with a cleft should be able to achieve normal speech, without having to struggle with hypernasality. Our goals are to minimize the number of surgical procedures our patients receive, while also optimizing their final outcomes – not just in speech, but in appearance, growth, function, and development. It is our hope that we can provide a patient-centered, holistic perspective in the care of those born with clefts. This new procedure provides an effective tool to help us achieve these ends.