To the Editor: A 1-year-old girl presented with complaint of nasal regurgitation after eating and was referred to us in 2015. On examination, she was found to have a fistula measuring ∼10 mm in diameter in the central part of the hard palate (Fig. 1). Under general anesthesia, the operation was undertaken. It was similar to what is used for primary repair of the cleft palate and involved radical correction of the cleft muscular abnormality.1 The oral mucosa was incised on the midline, extending slightly into the fistula on the hard palate, and the thin mucosa surrounding the fistula was excised. The mucosal flaps were elevated off the musculature in a plane between mucous glands and muscles, forward to the back of the hard palate, laterally to the hamular process, and posteriorly to the back of the velum. Sharp dissection continued backward medial to the hamulus. The muscle complex (levator and other muscles) was retrodisplaced by holding it with a hook and passed backward to at least the middle third of the velum. The muscle bundles were then sutured across the midline (Fig. 1). To reduce the tension of suturing oral mucosa, lateral incisions were made along the alveolar process. Finally, the oral layer was closed. Eventually, the fistula was completely closed by a 2-layer mucoperiosteal flap. No fistula reoccurred, and sucking function improved during the 1-year follow-up.
Patients with submucosal cleft palate (SMCP) have very thin mucosa in the posterior-medial hard palate, and the poor movement of the mucosa makes it prone to splitting. There is no standard surgery for the repair of SMCP with fistula of the hard palate. Fara2 reported that surgical repair of the defect was a simple matter, and it was far more difficult to successfully deal with the velopharyngeal competence. He suggested closing the fistula with unilateral palatal mucoperiosteal flap and pushing back the soft palate. Cheng and Zhou3 used the Von Langenbeck method to repair the congenital fistula; however, no satisfactory velopharyngeal function was gained. Other palatoplasty, such as a 2-flap or Wardill–Kilner palatoplasty, would have left a large, exposed bone surface in the anterior hard palate, which would negatively affect maxillary growth. In our view, abnormal insertion and discontinuity of velar musculature in SMCP with a hard palate fistula will cause incomplete velopharyngeal closure, which affects speech results. The aims of the surgical treatment for this patient are successful closure of the deformity at the same time as the submucous cleft palate repair and to create possibilities for normal speech development without disturbing maxillary growth. Plastic surgeons should not only close the fistula, but also detach the velar musculature from the posterior margin of the hard palate, retropose the insertion of the levator veli palatine to its physical position, and reconstruct the levator veli palatine sling and increase soft palate functionally to gain velopharyngeal competence.
1. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg
2. Fara M. Congenital defects in the hard palate. Observation of five cases. Plast Reconstr Surg
3. Cheng N, Zhou M. Congenital fistula of the palate. J Craniomaxillofac Surg