Primary von Langenbeck* Palatoplasty

with Levator Reconstruction:

Rationale and Technique

WILLIAM C. TRIER, M.D. THOMAS M. DREYER, M.D. Chapel Hill, North Carolina

In the preceding article, patients undergoing von Langenbeck palatoplasty without reconstruction of the levator veli palatini mus- cles were compared to patients undergoing the identical procedure, but with intravelar veloplasty. Palatoplasty included repair of both hard and soft palate, tension-free approximation of mucoperiosteal and soft palate flaps, and everting suture of nasal mucous membrane and oral mucous membrane from the anterior extent of the palate cleft to the tip of the uvula. No attempt was made to repair an alveolar cleft, if present. The authors concluded that intravelar veloplasty was of signifi- cant value in providing velopharyngeal competency, and in this companion article the rationale and technical details are presented.

Grabb (1971) has given as reasons for proper time for cleft palate repair, whether closing a cleft palate the provision of a the hard or soft palate should be repaired mechanism for normal speech, hearing, first or the entire palate repaired at one dental occlusion, and swallowing and the operation, the type of palatoplasty to be separation of the oral and nasal cavities. performed, and whether a pharyngeal flap Implicit in the attainment of these objec- should be performed at the time of palate tives in palate closure is the requirement closure. for avoiding interference with facial bone A number of factors foster such contro- growth. Although there seems to be gen- versy. One of the major problems is simply eral agreement on the reasons for cleft the definition of "normal speech" and iden- palate closure, there is very little agreement tification of the specific effects on speech on almost all other aspects of cleft palate of the palate repair. When reports of the surgery. There is controversy about the effects of palate repair describe speech merely as "normal," "acceptable," and "un- Dr. Trier is affiliated with the Division of Plastic intelligible," the authors may fail to differ- Surgery, Department of Surgery, School of Medicine, entiate between velopharyngeal incompe- University of North Carolina, Chapel Hill, N. C. tency and speech problems related to other 27514. Dr. Dreyer is in practice in Eugene, Oregon. Address correspondence to: William C. Trier, M.D., factors. In addition, so-called "objective" Division of Plastic Surgery, Wing D, 208H, Medical measures of velopharyngeal competency: School, University of North Carolina, Chapel Hill, N. such as lateral cephalometrograms, cinera- C. 27514, Telephone (919) 966-3080. diography, videofluoroscopy, oral and na- * Blair and Brown (1934) acknowledged that pala- sal endoscopy, and various aerodynamic toplasty performed by raising and suturing together mucoperiosteal flaps elevated through lateral incisions studies have proponents ana opponents, is commonly termed the von Langenbeck palatoplasty. and there are inherent limitations to each They pointed out that it was Dieffenbach in 1828 who of these several methods. first described this technique. It should be stressed Regarding facial growth, some interest- that the Dieffenbach bone flap method of cleft palate ing animal experiments (Kremenak et al. repair is an entirely different technique (Peer, et al, 1964). 1970) suggest the possibility that stripping 254 Trier and Dreyer, PRIMARY PALATOPLASTY 955 of mucoperiosteum from the human max- otitis media found almost universally in illa may result in maxillary deformity. How- children with cleft palate although data ever, such studies are not entirely convinc- indicates this may only be due to effects of ing because of differences in the surgical age (LeWorthy and Schliesser, 1975; subjects, as well as the specific nature of Bumsted and Lusk, 1984). For these rea- the operation performed and the site at sons, as well as to provide a better mecha- which stripping or elevation of mucoper- nism for feeding, palate closure would ide- iosteal flaps is performed. Even the evalu- ally be carried out at the very earliest pos- ation of results of similar operations for sible time. palate closure by different surgeons, and Balanced against these important reasons by even one surgeon over a period of time, for a very early palate closure, however, fail to take into account inter-operator and are the greater difficulties in surgical repair temporal same-operator differences in due to the small size of the oral cavity in an technical details of an operation, surgical infant, a greater likelihood of airway ob- finesse, and, perhaps very important, min- struction in the post-operative period, a ute variations in the site of incisions, degree small blood volume in very small infants of tension in a wound, exact extent of and children and commonly a relatively undermining, and exact suture technique. greater width of the cleft, little affected yet In summary, there is a real need for more by closure of the lip cleft, when present, or precisely defining the standards by which by growth of the palatal shelves. Although the effect of palate repair on speech and admitting to a rather empiric judgment, facial growth can be judged so that more therefore, but believing it to be a reasona- meaningful comparison can be made be- ble compromise, repair is planned for four- tween various techniques of palate closure. teen to sixteen months of age. Anemia and However, it is quite possible that differ- acute upper respiratory infection or other ences in operations are much less important problems may make a delay of surgery nec- than the total quality of the cleft palate essary for a month or two or longer. rehabilitation program with its careful anal- ysis of results and evaluation of particular Choice of Operation surgeons' results by competent speech pa- Rayner (1925), in writing of the opera- thology and dental colleagues. tive treatment of cleft palate, emphasized adequate blood supply, wound closure Time of Operation without excessive tension, freedom from It is generally agreed by speech patholo- infection, and complete de-epithelialization gists and others with a particular interest and eversion of cleft edges. All these basic in oropharyngeal physiology that oropha- principles are important in achieving un- ryngeal movements preparatory to speech complicated wound healing in any site but efforts begin in intrauterine life and that particularly within the mouth. One should these and the babbling and cooing of in- find little disagreement with these technical fants are a very important prelude to the demands. _ normal development of speech (Bosma, Implicit in techniques that meet these 1967; Oller et al, 1976). Recognizable requirements, however, are several impor- speech certainly becomes apparent at about tant details. 1). Provision of adequate relax- the age of two years. For this reason, speech ation and suturing without excessive ten- pathologists recommend palate closure at sion requires sufficient release of palate as early an age as possible (Dorf and Curtin, flaps. In order to achieve sufficient release, 1982; Trost, J.E., 1984). In addition, clin- lateral incisions, elevation of mucoperios- ical reports suggest that restoration of a teal flaps, and occasionally dissection of the more normal palatopharyngeal mechanism greater palatine artery for some distance with an incidental improved mechanism for from the undersurface of the flap, may be Eustachian tube function and protection of required. Release of the soft palate from the Eustachian tube orifice may lessen the the tonsillar pillar may also be required. degree and frequency of episodes of serous The lateral incision must be carried suffi- 256 Cleft Palate Journal, October 1984, Vol. 21 No. 4

ciently anterior to prevent excessive ten- vinced by the work of Veau (1931), Kriens sion in closure of the anterior extent of the (1969, a and b) and Fara and Dvorak palate. 2). No palatal tissue should be dis- (1970) and it does appear logical that a carded. Nasal mucous membrane must be functioning velopharyngeal sphincter dissected from oral mucous membrane to mechanism must be provided as well as permit closure of both layers of tissues; and simple closure of the palatal cleft. In every closure of the oral layer, at least, must be cleft palate, including submucous palatal accomplished with everting vertical mat- clefts, both overt and occult, abnormal in- tress sutures. 3). Repair of a single wound sertion of the levator veli palatini muscles between lateral palatal flaps is inherently into the posterior nasal spine and postero- more secure and less subject to healing medial hard palate can be demonstrated problems than are two or more wounds (Trier, 1983). It is unrealistic to expect converging to a single point, as in the four- separated segments of a muscle sling, teth- flap or three-flap type of repair. ered to bone, to provide any sort of sphinc- In addition to these three technical teric action. Reconstruction of the levator points, the choice of an operation for cleft sling is thus an integral part of palate clo- palate closure is influenced by two other sure. considerations: soft palate length and soft Brief mention should be made of recent palate dynamic function. Estimates of soft enthusiasm by some surgeons for palate palate length have generally been made by closure and construction of a primary pha- oral examination of the palate. Subscribing ryngeal flap. By such policy, unnecessary to the philosphy that "a palate cannot be pharyngeal flaps would have been con- too long" many surgeons routinely perform structed in an least 70% of our present three-flap or four-flap palate closure with series of patients undergoing primary pal- lengthening, elongation, or setback of the atoplasty. An increase in immediate oper- palate, depending upon whether or not the ative morbidity, the greater risk of opera- cleft of the secondary palate is complete or tive mortality, increased nasal airway resist- incomplete. Palate lengthening without ep- ance, additional maxillary growth retarda- ithelial covering of the resulting nasal mu- tion and risks of hyponasality and denasal- cosal defect may provide velopharyngeal ity would have been needlessly added to competency in patients with borderline or the usual risks encountered by patients un- minimal incompetency. However, it seems dergoing primary palatoplasty. illogical that contraction of the secondarily And finally, in choosing the procedure healing wound on the nasal surface would for palate closure, one must consider the not fail to shorten the effective length of relative merits of primary palatoplasty ver- the palate to the extent that lasting com- sus primary veloplasty. Proponents of pri- petency could not be maintained. There- mary veloplasty cite as major justification fore, if lengthening is carried out, plans for for this two-stage palate closure the preven- persistence of this lengthening should in- tion of maxillary deformity and prevention clude reconstruction of the nasal surface of retardation of maxillary growth. There defect with an island palatal mucosal flap are studies that indicate some measurable (Millard, 1962) or a buccal flap (Kaplan, decrease in maxillary growth, but Robert- 1975), or a retrodisplacement of nasal mu- son and Jolleys (1977) suggest that this cous membrane from the nasal surface of decrease is not of clinical Slgmficance to the the hard palate (Cronin, 1957). We are not patient. convinced of the need to lengthen the soft If one can achieve palate closure at an palate whether or not the nasal defect is early stage and in one stage, is there a resurfaced. Furthermore, if the work of significant beneficial effect on the major Kremenak and associates is indeed appli- reason for palate repair, provision of a cable to humans, lengthening of the soft mechanism for normal speech? Although palate certainly results in exposed denuded the data are far from complete, long-term maxillary bone on the oral hard palate sur- speech results in patients undergoing pri- face with potentially deforming effects on mary palatoplasty seem superior to patients the maxillary arch. However, we are con- undergoing delayed hard palate repair, Trier and Dreyer, PRIMARY PALATOPLASTY 257 even when fitted with a speech appliance sure satisfactory medical status of the pa- to cover the temporary hard palate defect tient who is undergoing major surgery. (Cosman and Falk, 1980; Bardach et al., Children with serous otitis media unre- 1984). We have not had many opportu- sponsive to decongestant treatment and nities to examine patients in whom soft with middle ear fluid and retracted tym- palate repair alone has been carried out panic membranes are scheduled for a and in whom a palatal appliance has been myringotomy and insertion of ventilation used as a fixed or removable speech appli- tubes to be carried out immediately follow- ance, but those patients observed have ing induction of anesthesia. Prophylactic speech that is grossly hypernasal with nasal antibiotics (penicillin or a cephalosporin) emission and greater impaired intelligibil- are begun just prior to surgery and contin- ity. They have also had very poor oral ued until the first post-operative day to hygiene secondary to the appliance. Cos- minimize the possibility of wound compli- man and Falk (1980) have called attention cations secondary to infection. Anesthesia to the poor speech results in their patients is enflurane, rather than halothane, to with delayed hard palate repair and they, avoid cardiac irritability. The patient is Fara and Brousilova (1969) and our per- properly positioned and prepared for sur- sonal observations also indicate technical gery. Soft tissue infiltration of 1:200,000 difficulties in performing delayed hard pal- units of epinephrine, with 0.5% lidocaine ate repair. There is certainly an apparent not to exceed 3 micrograms per kilogram and very likely actual increased shortening of body weight, is used to enhance hemo- of the entire palate following a two-stage statis. repair. In addition, the scarring and rigid- SURGICAL TECHNIQUE. The initial inci- ity of the palatal soft tissue, with the de- sion is made transversely across the top of crease in length of palatal tissue, almost the tonsillar pillar just posterior to the max- invariably led to the need for pharyngeal illary tuberosity (Figure la, 1b). The inci- flap construction at the time of hard palate sion then curves anteriorly where soft pal- repair (Reidy, 1962). Fara and Brousilova ate joins maxillary tuberosity and is carried (1969) have not been impressed by the forward exactly at the junction between supposed significant narrowing of the hard palatal mucous membrane and gingival mu- palate cleft as a result of soft palate repair cous membrane to approximately one cen- with or without levator reconstruction, and timeter anterior to the most anterior extent we agree completely. of the cleft in the incomplete cleft palate. This incision is carried to within one half von Langenbeck Palatoplasty with centimeter from the cleft when an alveolar Levator Reconstruction cleft is present. The incision is made at Following is a brief description of a one- right angles to the underlying bone and is stage palatoplasty procedure, the von Lan- carried completely to bone along the entire genbeck palatoplasty with levator recon- length of the incision. struction, that meets all the criteria re- An L-shaped palate elevator is then in- viewed above. The significance of levator troduced just anterior to the maxillary tu- reconstruction is emphasized because that berosity and, being certain that the aspect of the procedure is designed to yield rounded end of the elevator is against a high incidence of velopharyngeal com- tone, and using the bony shelf as a fulcrum, petency. The procedure has been followed the blade of the elevator is used to elevate at the University of North Carolina at the mucoperiosteum from the underlying Chapel Hill by the senior author (W. C. bone to the medial and anterior extent of Trier) since 1976. Between 1967 and 1969 the proposed flap. The elevator is then von Langenbeck palatoplasty without leva- withdrawn from the initial wound and is tor reconstruction had been carried out by reinserted in the transverse incision just the senior author so comparison between posterior to the maxillary tuberosity and the two groups of patients could be made. with the tip of the elevator directly postero- Preoperatively, all necessary examina- medially, the posterior palate tissue is ele- tions and procedures are followed to en- vated. The handle of the elevator is swung 258 Cleft Palate Journal, October 1984, Vol. 21 No. 4

b M ; At +I «

FIGURE la and 1b. Incisions are made transversely across top of tonsillar pillars posterior to maxillary tuberosities and divides palatal from alveolar mucous membrane. Incisions extend to 1 cm. anterior to anterior extent of cleft or within 0.5 cm. of alveolar cleft when present. laterally to carry the tip of the elevator sected in the plane just deep to the visible medial to the greater palatine artery until mucous glands to expose the abnormally it reaches the posterior hard palate. (Care inserted levator muscles. The muscles are . is taken to avoid any blind dissection or exposed anteriorly to their insertion into elevation of the mucoperiosteum medial to the hard palate. The skin hooks are then the maxillary tuberosity in order to avoid moved to retract the levator muscles and injury to the greater palatine artery where the muscles are freed from the thin nasal it emerges from the pterygo-palatine fora- mucous membrane, again to the site of men.) The operator must be aware that the insertion of the levator into the hard palate. foramen, the maxillary tuberosity and the A multiple toothed (Brown-Cushing) for- hamular process of the pterygoid form an ceps then grasps the muscle just posterior equilateral triangle. With adequate eleva- to the hard palate, the insertion of the tion, bleeding will cease promptly and the muscle is divided with scissors, and with same maneuver is repeated on the opposite dissection on oral, nasal and lateral bor- side of the palate. ders, the muscle bundles are dissected free A number 11-bladed scalpel or pointed, until they can be drawn medially and pos- double-edged and angled scalpel blade then teriorly and lie without restriction in a incises the margins of the cleft at the junc- clearly transverse direction (Figures 2a, 2b, tion between oral and nasal mucous mem- 3a, 3b). brane between the tip of the uvula and the At the medial borders of mucous mem- anterior extent of the cleft. If an alveolar brane at the medial edge of the hard palate cleft is present, the incision is carried to the the nasal mucous membrane and oral mu- alveolar cleft. If an alveolar cleft is not cous membrane are separated with a Freer present, or if the palatal cleft is incomplete, septal elevator and mucous membrane is the medial incision is carried around the dissected from the nasal surface of the hard anterior end of the cleft. palate. The angled scalpel blade, or a right Long single skin hooks are then used to angle palate knife is used to incise along elevate the oral mucous membrane just the anterior edge of the cleft so that tears posterior to the posterior edge of the hard in the oral or nasal mucous membrane will palate. Using curved and straight Joseph or not be produced by blind dissection. Davis scissors, mucous membrane is dis- Final dissection is carried out under di-

Trier and Dreyer, PRIMARY PALATOPLASTY 259

FIGURE 2a and 2b. After incisions divide oral from nasal mucous membrane, levator veli palatini muscles are identified, dissected from oral and nasal mucous membrane, and detached from hard palate insertions.

FIGURE 3a and 3b. Levator veli palatini muscles are drawn medially and are sutured so that they overlap each other. rect vision through the lateral incisions by mucoperiosteal flaps from the area of the first raising the flap with the tip of the L- maxillary tuberosity anteriorly is the shaped elevator resting against the bony greater palatine artery. If excessive lateral palatine shelf fulcrum and carefully stretch- restriction of the mucoperiosteal flap still ing the greater palatine vascular bundle does not permit approximation of the flaps from the foramen. Fibrous attachments be- without excessive tension, the vascular bun- tween the mucoperiosteal flap laterally and dle is dissected from the undersurface of the maxillary tuberosity area are divided the flap far enough anteriorly to allow un- under direct vision. The only structure impeded medial movement. If medial now restricting medial displacement of the movement is restricted posterior to the

260 Cleft Palate Journal, October 1984, Vol. 21 No. 4 maxillary tubercle, an elevator or the op- Lateral packs are not used, and after erator's finger can be used to separate soft blood and mucous have been aspirated palate from the tonsillar pillar. from the pharynx, the mouth gag is re- Closure of the nasal mucous membrane moved. A heavy silk suture (0 or 1) is is carried out with simple sutures of 4-0 inserted transversely across the center of chromic catgut tied on the nasal surface. the thickness of the tongue for possible use Closure should be complete from tip of as a traction suture for adequate suctioning uvula to anterior end of cleft, except where or management of the airway in the early an alveolar cleft is present. Closure stops at postoperative period. Arm restraints are the alveolar cleft when an alveolar cleft applied. exists. Following post-anesthetic recovery, clear Levator sling reconstruction is carried liquids are permitted orally and parenteral out by overlapping one levator muscle me- intravenous fluids are continued until oral dially over the other. A mattress suture of fluid intake is adequate. A blenderized diet, 3-0 chromic catgut is inserted through the or diet of similar consistency, is provided mucous membrane and incorporates the for four weeks from the time of operation. levator muscle bundle on the opposite side Patients are most commonly discharged so that traction on these two sutures causes from the hospital on the second post-oper- overlapping of the levator muscles. The ative day. mattress sutures are left untied until clo- Note that no attempt is made to repair sure of the oral mucous membrane is com- an alveolar cleft at the time of primary pleted (Figure 4a, 4b) palatoplasty. Reliable closure of an alveolar Everting interrupted verticle mattress su- cleft cannot be expected at the time of tures of 4-0 polydioxanone, alternated with primary palatoplasty because of inherent simple interrupted sutures of the same ma- technical problems associated with water- terial, are used to approximate the oral tight closure in two layers of a narrow, deep mucous membrane for the entire length of and irregular slit. Damage to tooth buds the palate. Again no effort is made at the and periodontal ligaments with risks for time of primary palatoplasty to close an resulting alveolar deformity seem almost alveolar cleft. certain, as is the need for later bone graft-

FIGURE 4a and 4b. After nasal mucous membrane is repaired, muscle sutures are placed, to be tied after everting closure of oral mucous membrane.

Trier and Dreyer, PRIMARY PALATOPLASTY 261 ing (Boyne and Sands, 1971, 1976). Our at Annual Meeting, American Cleft Palate Associa- colleagues in speech pathology and den- tion, Seattle, May 21, 1984. tistry support this position. BYARS, L. T. Personal communication. CosmanNn, B. anD FALK, A. S. Dalayed hard palate COMPLICATIONS AND RESULTS. There repair and speech deficiencies: a cautionary report, have been no deaths in this personal series, Cleft Palate J., 17: 27-33, 1980. nor have there been any post-operative fis- CRONIN, T. D. Method of preventing raw area on nasal surface tulas, wound infection or wound compli- of soft palate in push-back surgery, Plast. Reconstr. Surg., 20: 474-484, 1957. cations. As reported in the preceding _ arti- DorRF, D. S. AnD CURTIN, J. W. Early cleft palate cle, in the series of 21 patients with von repair and speech outcome, Plast. Reconstr. Surg., Langenbeck (no levator reconstruction) 70: 74-79, 1982. 62% had normal or acceptable speech, 52% DrREYER, T. M. AND TRIER, W. C. A comparison of had adequate palatoplasty techniques. Cleft Pal. J. 21: 251-253, palate function as deter- 1984 mined by aerodynamic studies, and 38% FARA, M. AnD BROUSILOYA, M. Experiences with early had required secondary structural modifi- closure of velum and later closure of hard palate, cation for velopharyngeal incompetency. A Plast. Reconstr. Surg., 44: 134-141, 1969. FARA, M. comparable series of 22 patients undergo- AnD DvORAK, J. Abnormal anatomy of the muscles of palate: pharyngeal closure in ing primary palatoplasty with cleft pal- levator re- ates, Plast. Reconstr. Surg., 46: 488-497, 1970. construction reported 89% of patients ex- GRABB, W. C. General Aspects of Cleft Palate Surgery. amined an average of four years and seven In Cleft Lip and Palate. Edited by Grabb, W. C., months following primary palatoplasty had Rosenstein, S. W. and Bzoch, K. R. Boston: Little, Brown and Company, p. 373, 1971. acceptable or normal speech; 91% had ad- KAPLAN, E. N. Soft palate repair by levator equate muscle closure as demonstrated by aero- reconstruction and a buccal mucosal flap, Plast. dynamic studies; and 11% had required Reconstr. Surg., 56: 129-136, 1975; secondary structural modification for velo- KAPLAN, I., LABANDTER, H., BEN-BASSAT, M., DrEes- SNER, J. AND NACHMANI, pharyngeal incompetency (Dreyer and A. A long-term followup of clefts of the secondary palate repaired Trier, 1984). No patients by von are judged to Langenbeck's method, Brit. J. Plast. Surg., 31: 353- have developed maxillary deformity attrib- 354, 1978. utable to the surgery. KREMENAK, C. R., JR., HUFFMAN, W. C. aAnp Oum, W. H. Maxillary growth inhibition by mucoperios- Conclusions teal denudation of palatal shelf bone in non-cleft Primary von Langenbeck palatoplasty beagles, Cleft Palate J., 7: 817-825, 19070 KRIENS, O. B. Fundamental with levator reconstruction is a safe and anatomic findings for an intravelar veloplasty, Cleft Palate J., 7: 27-36, reliable operation for palate closure. It 1970. presently provides velopharyngeal compe- KRIENS, O. B. An anatomical approach to veloplasty, tency in 89% of patients followed for an Plast. Reconstr. Surg., 43: 29-41, 1969. average of four years and seven months LEWoORTHY, G. W. AND SCHLIESSER, H. Hearing acu- ity before and following primary palatoplasty. after pharyngeal flap procedure, Plast. Reconstr. Surg., 56: 49-51, 1975. MILLARD, D. R. References Wide and/or short cleft palates, Plast. Reconstr. Surg., 29: 40-57, 1962. BARDACH, J., MORRIS, H. L. AND OLIN, W. H. Late MUscrRAvE, R. H. AND BREMMER, J. C. Complications results of primary veloplasty: the Marburg project, of cleft palate surgery, Plast. Reconstr. Surg., 26: Plast. Reconstr. Surg., 73: 207-215, 1984. 180-189, 1960. BLAIR, V. P. AND BROWN, J. B. The Dieffenbach- OLLER, D. K., WIEMAN, L. A., DovyLE, W. J. anp Warren operation for closure of congenitally cleft Ross, C. J. Infant babbling and speech, J. Child palate, Surg. Gynec. Obstetr., 59: 309-320, 19384. Lang., 3: 1-11, 1976. BOYNE, P. AND SANDS, N. R. Secondary bone grafting ONEAL, R. M. Oronasal Fistulas. In Cleft Lip and of residual alveolar palatal defects, J. Oral Surg., Palate. Edited by Grabb, W. C., Rosenstein, S. W. Vol. 3, Feb. 1972. and Bzoch, K. R. Boston: Little, Brown and Com- BOYNE, P. AND SANDS, N. R. Combined orthodontic- pany, pp. 490-498, 1971. surgical management of residual palato-alveolar PEER, L. A., WALKER, J. C. AND MEIJER, R. The cleft defects, Am. J. Ortho., 70:20, 1976. Dieffenbach bone-flap method of cleft palate repair, BOSMA, J. F. Human infant oral function, Chapter 4, Plast. Reconstr. Surg., 34: 472-482, 1964. Symposium on Oral Sensation, Charles C. Thomas, RAYNER, H. H. The operative treatment of cleft- Springfield, 1967. palate. Lancet, 816-817, 1925. BumMsTED, R. M. AND LUsK, R. Palatoplasty and Eusta- REIDY, J. P. The other 20 per cent: failures of cleft chian tube function: a comparative study of primary palate repair, Brit. J. Plast. Surg., 15: 261-270, veloplasty to conventional palatoplasty. Presented 1962. 262 Cleft Palate Journal, October 1984, Vol. 21 No. 4

ROBERTSON, N. R. E. AND JOLLEYS, A. The timing of TrRoST, J. E. Compensatory articulations: error, types, hard palate repair. Paper presented at. Third Inter- patterns and treatment approaches. Presented at national Congress on Cleft Palate and Related Cra- Annual Meeting, American Cleft Palate Associa- niofacial Anomalies. Toronto, June, 1977. tion, Seattle, May 23, 1984. TRIER, W. C. Velopharyngeal incompetency in the VEAU, V. Division Palatine. Paris: Masson and Cie, absence of overt cleft palate: anatomic and surgical 1931. considerations, Cleft Palate J., 20: 209-217, 1983.