Background:
The timing of cleft palate closure is a reconstructive challenge in terms of inherent conflict of speech formation vs midface growth. The short palate and paucity of soft tissue can result in cleft palatal fistulas rates of 5-5 percent depending on the technique and the severity of the cleft, with most occurring the posterior alveolar hard palate. We have developed an algorithm to treat large palatal clefts by using the facial artery musculomucosal flap (FAMM) flap as a spacer flap that allows tension free closure of the hard palate while allowing the push back of the soft palate to help decrease the possibility of velopharyngeal incompetence.
Methods:
A total of 21 patients (age range 9 months to 28 years) were followed from 2001 to 2008 (average follow-up: 4.3 years) who received FAMM flaps for closure of palatoschisis.
Group 1 (N=3): Primary cleft palate patients with large palatal surface area (>3cm2) and short velum (>1 cm distance to pharynx)
Group 2 (N=18): secondary cleft palate patients with large fistulas (>4 cm 2) and short or scarred velum (>1 cm to pharynx)
All patients received a FAMM flap that was used as a spacer flap to interposition between the hard and soft palate followed by Von Longenback approach. This allowed for minimal mobilization of the hard palate mucosa and tension free intravelar veloplasty. Speech evaluation and physical exam was performed on regular basis in the cleft center on regular intervals.
Results:
There was one partial loss of a FAMM flap post-operative hematoma resulting in an anterior fistula. There was one lateral suture line dehiscence without a need for further surgical intervention. There were no donor site complications. All patients were reported to have developed normal speech obviating the need for further surgery for their speech.
Conclusion
The FAMM spacer flap acts as a durable vascularized interposition graft that allows simultaneous tension free closure and lengthening of the soft palate without disturbing the hard palate mucosa, thereby maximizing the potential for speech development and midface growth