Uvuloplasty during soft palate cleft reconstruction

The uvula has been a subject of contradictory observations.[1]Finkelstein Y. Meshorer A. Talmi Y.P. et al.The riddle of the uvula.Otolaryngol Head Neck Surg. 1992; 107: 444-450Crossref PubMed Scopus (34) Google Scholar The aesthetic reconstruction of the uvula during soft palate cleft reconstruction is an important outcome measure from the parents' perspective.[2]Elsherbiny A. Mazeed A.S. Saied S. et al.The significance of uvula after palatoplasty: A new technique to improve the aesthetic outcome.Cleft Palate Craniofac J. 2018; 55: 451-455Crossref Scopus (3) Google Scholar It therefore should be repaired during palatoplasty. The conventional method for uvula repair involves suturing the two hemi-uvulas together, often resulting in a displaced, small, scarred, and contracted uvula. Techniques of uvuloplasty have been described to create a more aesthetically appearing uvula. Khonsari & Ivanov and Rossell-Perry et al.3Khonsari R.H. Ivanov A.L. La chirurgie des fentes labiopalatines en Russie.Rev de Stomatol Chir Maxillofac. 2008; 109: 343-345Crossref Scopus (5) Google Scholar, 4Rossell-Perry P, Olivencia-Flores C, Gavino-Gutierrez AM, et al. A comparative study to evaluate the functional effect of unilateral uvuloplasty after primary palatoplasty. Plast Reconstr Surg, Glob Open; 3. Epub ahead of print 2015. DOI: 10.1097/GOX.0000000000000393.Google Scholar a complete unilateral excision of one hemi-uvula. Khonsari & Ivanov and Ivanov & Agueeva3,[5]Ivanov A, Agueeva L. Veloplasty using single uvular and double-opposing flaps. J Cranio-Maxillofac Surg 2008; 36: ii–xxix.Google Scholar described a technique by placing a de-mucosalised single-layered hemi-uvula anteriorly and into a releasing incision at the nasal side of the opposite hemi-uvula. Two novel techniques of uvuloplasty are presented, utilising an unfolded or a horizontally divided hemi-uvula, thereby creating one aesthetically pleasing uvula, and a lengthened soft palate. The surgical technique for the primary closure of the soft palate cleft is the intravelar veloplasty type III.[6]Bütow K.-W. Engelbrecht H. Naidoo S. Asymmetrical soft palate cleft reconstruction.Int J Oral Maxillofac Surg. 2014; 43: 696-701Abstract Full Text Full Text PDF PubMed Google Scholar The lengths of both sides of the cleft soft palate and the volume of the hemi-uvulas should be assessed before surgery, as the cleft might present an asymmetry in length. The type I uvuloplasty is used for clefts with sides average in length. The hemi-uvula on the slightly shorter side is preserved in its entirety and the straight-line incision of the intravelar veloplasty is stopped anteriorly and perpendicularly to this hemi-uvula, with an extended perpendicular releasing incision into the nasal mucosa. This releasing and extended perpendicular nasal layer incision achieves a more posterior positioning of the hemi-uvula. The unfolded hemi-uvula of the longer side is vertically incised, rotated 90° and sutured as a triangular type of flap (V-Y advancement) into the releasing incision in the V-opening of the nasal layer of the opposite side (Fig. 1). This triangular flap lengthens the shorter side of the cleft soft palate and minimises medio-lateral tension on closure. The type II uvuloplasty is utilised where one side is extensively shorter in length. As with the type I uvuloplasty the hemi-uvula on the shorter side of the cleft is preserved. However, the incision line is extended into the oral and nasal mucosal layers without releasing the submucosa. The hemi-uvula on the longer side is divided horizontally into a superior and inferior half. The superior part of this hemi-uvula is inserted and sutured into the nasal V-shaped incision and the inferior part is inserted into the oral V-shaped releasing incision (Fig. 2). Again, the preserved hemi-uvula is centralised after knotting the palatoglossal-palatopharyngeal muscle-bundle by means of a figure of eight ("pully-type") suture, thereby creating a symmetrical, and aesthetically pleasing result of the soft palate cleft (Figs. 3,Fig 4.)Fig. 3Cleft in soft palate, pre-surgery with 2 hemi-uvulas.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 4Intraoperative, centralizsation of hemi-uvula of the shorter part of the soft palate with tonsillar pillar stitch.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A short releasing incision is placed bilaterally in the antero-superior part of the tonsillar pillar. Long-term resorbable sutures, engaging these incisions are used to avoid temporary tension on the posterior area part of the palate, creating a more V-shaped naso-oral opening of the tonsillar pillars for tension-free healing. Ethics approval not applicable. Informed consent was obtained to use the intraoperative photographs for scientific purposes. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.