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Rules of Engagement in Minimal Blood Loss Palatoplasty Using Saline Hydro Dissection: A Useful Learning Curve for Younger Cleft Surgeons in Manoeuvring Areas of Static Resistance due to Tight Tissue Planes

Minimal blood loss in palatoplasty can be achieved with adrenaline saline hydro dissection, and a good knowledge of key anatomical structures as well as the stubborn areas of static resistance, where dissection is difficult because of fixed tissue planes. With the advent of minimal incision palatoplasty, button-hole and medial-only incision procedures, the amount of blood loss is significantly reduced in most palate operations. The two-stage palate repair also leads to less blood loss and is a popular concept among cleft groups worldwide following the initial promotion by Swedish cleft groups at Gothenburg. The learning curve is reasonable and techniques can be added, as one gains more experience with cleft palate surgeries.


Introduction
Minimal incision palatoplasty is an attractive concept, especially for younger cleft surgeons because of the easy learning curve and very little blood loss. The abstract on minimal blood loss palatoplasty was accepted by the scientific committee as a short oral presentation for the 5 th European Plastic Surgery Research Council, 22 -25 August 2013 in Hamburg, Germany [1].
In this technique, we use a dilute solution of adrenaline in saline for easy dissection of the cleft palate. The recommended maximum dose of epinephrine in combination with lidocaine is 1 to 10 microgram/kg and some have used the upper limit at 30-minute intervals without any side effects; epinephrine without lidocaine admixture can be safely used in the pediatric population [2].
Our preference is to use a dilute solution of 1:500,000 saline adrenaline hydro dissection in all our cases; we have not experienced tachycardia or arrhythmia. Saline hydro dissection with 1:500,000 adrenaline in saline has been advocated to reduce bleeding in older patients. This idea was shared by the craniofacial surgeon with the US International Taskforce on palatoplasty for latecomers at Cleft 2013 when he was invited by Prof Jeffrey Marsh, (Chairman, Cleft 2013) to initiate the online discussions for palatoplasty in latecomers [3].
Minimalist palatoplasty has become a popular procedure, especially in low and middle-income smile missions because it has the advantage of being a relatively easy procedure without any post-operative hypoxemia due to lengthy surgeries in children. As a result, patients rarely face postoperative hypoxemia for long, and there has been no need for re-intubation [4].
The commonly performed procedures with adrenaline saline hydro dissection, to minimize blood loss includes buttonhole incisions, and levator retro positioning along with 2/3 uvular retro positioning [5]. In older children (above 3 -5 years of age and adults) because of the fear of blood loss, we followed the 1944 Schweckendiek 2 stage protocol popularized by Gothenburg, Sweden. In the Swedish study, 55 patients had surgical procedures at Sahlgrenska University Hospital, Gothenburg, Sweden. They found that stage one soft palate repair was beneficial for speech in the long term and improved even before hard palate repair [7].
Our first preference would always be a single-stage palatoplasty using levator and uvula retro positioning, a modified double opposing z plasty along with Langenbeck variants ranging from the minimal incision, buttonhole, or lateral incision two flap procedure in larger palates. The two-stage surgery is also considered, especially in humanitarian missions where adequate facilities may not be available. A recent study by a group in Japan suggested that twostage palatoplasty is advantageous for jaw development. They also found that after the first stage, the palate narrows spontaneously [8].
Rohrich., et al. suggested an earlier timing for soft palate closure at 3 to 6 months, followed by hard palate at 15 to 18 months [9].
We prefer to perform the one stage palatoplasty between 12 to 16 months of age. In a two-stage procedure, we perform the first stage at 6 -7 months and hard palate about one and a half years later. During levator retro positioning, the muscle is oriented in an anatomically correct, horizontal position according to Krien's analysis where he noted that the cleft muscle was oriented sagit-tally and suggested the release of abnormal insertions to a more horizontal position [10].
Despite the lack of consensus between cleft palate surgeons, the intra velar veloplasty and Furlows, with some modifications by different surgeons, have remained the most useful surgeries for speech with good outcomes. Furlow [11] and IVVP [12] with Langenbeck variants, without pushback procedures, have arguably established themselves as near true constants in palatoplasty solutions. Both these procedures have low morbidity rates, improved speech scores, and low re-operation rates. In IVVP [13] we normally follow a more conservative route with less muscle and tissue dissection, focusing more on the levator repositioning. Success outcomes are generally good, and these procedures present an advantage over potentially airway obstructive procedures. The IVVP with its low fistula rate, user-friendly variations, and reasonable learning curve, appears to be a good choice. It is also more anatomically correct in terms of levator repositioning. One might argue that the procedure as a secondary solution may be a belated pointer to IVVP along with a modified double opposing z plasty, as a preferred primary procedure [14].

Materials and Methods
The samples we have chosen for this study from our humanitar-    In the second stage of palatoplasty, we have identified some areas of Resistance Statique (RS), (static resistance, Figure 17) and suggest ways to solve the problems. Static resistance areas are found in the following zones (Table 1).               The muscle fibers and mucosa are gently teased away from the bone with a sharp fine dissector (dental) or blade to release the tense adhesions around.
The bundle is about 5 millimeters from the margin of the arch and can easily be injured since it is tightly held down by periosteum. The bundle is approached from above after raising the mucoperiosteal flap along the mid rugae. The tissue is less vascular and looser here. Saline hydro dissection helps.
The nasal mucosa is tightly adherent and can be gently released using by a fine dissector in a horizontal direction, instead of downwards, which tears the fragile mucosa.
The tight junction along the posteroinferior aspect of the palatal bone can restrict the mobility of the flaps.
Avoid rough handling in this area to prevent holes in the mucosa The cone of periosteum is incised with a blade around the bundle to release the vessel and nerve. Using a 1mm guarded osteotome, a posteromedial palatal ostectomy may be done in very wide palates.
After the mucoperiosteal flap is elevated from lateral to medial, a cuff of medial oral mucosa is taken to give us more tissue on the nasal side.
After hamulus fracture to medialize the muscles, and gentle dissection of the levators, the aponeurosis is incised parallel to the inferior edge of palatal bone with a number 15 blade saline hydro dissection helps here An occasional stalactite of bone may need to be removed medial to the vessel and nerve.
One can avoid tearing the nasal mucosa by staying on the bone, horizontally at all times some divide the tensor tendon as well

Results and Observations
The procedures using hydro dissection, cause minimal bleeding, In two-stage palatoplasty, the first stage makes the second closure easier because of the narrowed palate. Although two flaps can be used for closure, we also find that the hemi palate hinge flap works well. In adults and older children, due to troublesome bleeding, the two-stage procedure becomes a useful addition especially in regions with less than adequate facilities. If an experienced pediatric anesthetist is available and medical infrastructure adequate, the one-stage palatoplasty can be done without any problems.
Identifying the zones of static resistance enabled us to perform better repairs.
The main advantages were ease of closure without tension on the flaps, short operating time, less anesthesia time, and minimal blood loss.

Discussion and Conclusion
Blood loss in palatoplasty can be minimal, especially in Veau 1, 2 cleft palate if minimal incisions are used. The two-stage palate repair can also be used to reduce blood loss, in most cases. However, the Gothenburg protocol is not followed by all surgeons.
Minimal palatoplasty is relatively easy to perform for cleft trainees and leads to tension-free closure with very little blood loss Fistula and velopharyngeal insufficiency rates are comparable to that of other techniques, and theoretical advantages of this technique will be borne out by longer-term follow-up [15]. Cleft palate repair can cause problems postoperatively because of prolonged surgery. have more retrusion of the maxilla than children with smaller clefts [18].
Identifying key areas in palatoplasty helps the cleft surgeon to perform the surgeries with ease and avoid intraoperative complications as well as reduce blood loss. Some of the key areas we have In conclusion, although we are not able to cover many aspects of palatal surgery here, we hope that this paper will help our younger cleft surgeons to gain some experience in the art of cleft palate surgery.