xRead - Treatment of Cleft Lip and Cleft Palate (May 2025)

Plastic and Reconstructive Surgery • February 2024

palate. 10 The secondary palate forms from paired derivatives of the maxillary processes called the palatine shelves. These are initially oriented verti cally posterior to the primary palate and lateral to the tongue. During the eighth week of embryo genesis, the palatine shelves reorient into a hori zontal arrangement cephalad to the tongue and the paired palatine shelves begin to fuse at the midline. This process progresses from anterior to posterior and also allows the primary and second ary palates to fuse with one another. 11 These pro cesses establish distinct oral and nasal cavities, and failure of these processes results in cleft palate. 10 The degree of clefting corresponds to the time in development when fusion was interrupted. 7 Cleft Palate Classification Eighteen classification systems have been pro posed for cleft palate and are largely based on anatomical factors and cleft severity. 12,13 Much like cleft lip, cleft palate may be classified as unilateral or bilateral based on oronasal mucosal continu ity between the palate and the vomer, although this distinction is rarely noted. 14,15 Rather, one of the most common classification schemas for cleft palate is the Veau classification first described in 1931, and founded solely on anatomical distinc tions and deliberately omitting severity to main tain the simplest clinical groupings (Table 1). 12 Although this system is commonly used, it offers less detail than other systems that consider both anatomy and severity. One system that has gained popularity with clinicians across multiple special ties involved in cleft care is the LAHSHAL system, which is a simplified version of the “Striped-Y,” initially proposed by Kernahan and Stark in 1971 and has undergone multiple iterations of modi fications. Similar to the Striped-Y, the LAHSHAL system uses a schematic with letters corresponding to anatomical structures to more tangibly describe the location and extent of clefting (Fig. 3). 13,16 Although each system at its inception was cham pioned by its founders to be adopted widely, there remains a lack of consensus regarding the best classification system, and this poses a challenge

to establishing a shared language for communi cating cleft anatomy, severity, and the subsequent management implied by constellations of these factors. Binary clinical descriptors of cleft severity have also been established, with Bardach describ ing “wide clefts” as those greater than 1.5 cm, and “extremely wide clefts” as those greater than the width of the palatal shelves themselves. 15 Clefts within these categories carry a worse prognosis with respect to velopharyngeal outcomes, fistula rates following repair, and need for secondary surgery. 17 Given the variable size of patients at the time of repair, an absolute cutoff as proposed by Bardach may represent a different relative degree of cleft width among different patients. Instead, the palatal index has emerged as a tool to provide better relative data for a given patient, taking into consideration an individual patient’s total palatal width in relation to the width of their cleft. 18 Fig. 3. The LAHSHAL classification of cleft lip and palate. Classification system for describing the anatomical location of cleft lip and palate defects, in which “L” is the lip, “A” is the alveo lus, “H” is the hard palate, and “S” is the soft palate. (Reprinted with permission from Yao CA, Vartanian ED, Nagengast E, McCullough M, Auslander A, Magee WP. The smile index: part 3. A simple, prognostic severity scale for unilateral cleft palate. Plast Reconstr Surg Glob Open 2021;9:e3870.)

Table 1. Veau Classification of Cleft Palate Veau Classification

Structures Involved in the Cleft

Veau I Veau II

Soft palate

SURGICAL OPTIMIZATION AND TIMING

Soft and hard palate posterior to incisive foramen Soft and hard palate through alveolus unilaterally Soft and hard palate through alveolus bilaterally

Veau III

Preoperative Management The care of patients with cleft palate should ideally begin with prenatal diagnosis and

Veau IV

450e

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