Dr. Brian Sommerlad

Curriculum Vitae

  • Licenciado en Medicina, Universidad de Sydney (Australia), 1966
  • Especialista en Cirugía Plástica, The London Hospital, Queen Elizabeth Hospital for children y The German Hospital (Inglaterra)
  • Consultor Honorario de Cirugía Plástica, The Royal London Hospital (Inglaterra)
  • Director de los Servicios de Fisuras, Great Ormond Street Hospital for Children / St. Andrews Centre (Inglaterra)
  • Seguidor honorífico del Royal College of Speech & Language Therapists colegio de cirujanos de Sri Lanka
  • Miembro honorífico de la Sociedad Británica de Ortodoncia
  • Anteriormente miembro del consejo asesor sobre estándares clínicos para labio leporiono (CSAG)
  • Autor para la Sección de Cirugía Plástica del Cleft Palate-Craniofacial Journal
  • Co-fundador y Presidente de la asociación de caridad CLEFT
  • Viaja de manera regular con otros cirujanos a Bangladesh, Sri Lanka, Uganda, Irán, Egipto y Kurdistán
  • Consultor Honorario, Servicio Cirugía Plástica, Great Ormond Street Hospital for Children, Londres, Inglaterra



Improving palate repairs is the key to:
  • • Better speech outcomes
  • • Better maxillary growth
  • • Better hearing
This depends on:
  • • Less traumatic surgery on the hard palate
  • • More effective reconstruction of the muscles of the soft palate
Hard Palate

If possible the hard palate should be repaired with marginal incisions. This is possible in about 80% of palate repairs. In clefts of lip and palate, single layer closure of the hard palate at the time of lip repair dramatically reduces the need for more radical hard palate dissection at palate repair.

If necessary, usually in wider clefts, lateral releasing incisions (von Langenbeck repair) are used.

The two flap repair is not necessary for exposure and creates more scarring and, probably, more collapse, crossbite and maxillary retrusion.

The Veau/Wardill/Kilner pushback procedure has not been shown to achieve palate lengthening, frequently results in fistuli which are very difficult to repair, creates crossbite which is difficult to correct orthodontically and significantly impairs maxillary growth.

Soft Palate
Correction of the soft palate musculature requires an understanding of both non-cleft and cleft anatomy.
Surgery is best carried out using an operating microscope.
The essentials of the technique are:
  • • Magnification – ideally the microscope
  • • Lifting of mucous glands from back of the hard palate
  • • Dissection of the oral mucosa from palato-pharyngeus
  • • Mobilisation of the greater palatine NV bundle
  • • Limited lateral releasing incisions if necessary
  • • Dissection by knife – not scissors
  • • Closure of the nasal myo-mucosal layer before muscle dissection
  • • Leaving the para-median mucous glands
  • • Dissection in the plane between the nasal mucosa and levator
  • • Division of the nasal component of the tensor tendon
  • • Splitting of palato-pharyngeus
  • • Non-absorbable sutures to unite muscle – especially the levator
  • • Drainage holes in the nasal layer – if not accidental
  • • Twisted loop mattress suture to appose the oral and nasal layers – in front of the muscle

Secondary surgery (pharyngoplasty) rates are not a good measure of outcome.
Outcome should be assessed:
  • • Independently – in practice from recordings – using accepted outcome measures
  • • Long-term
Submucous cleft palate repair provides the opportunity to assess outcomes early.


Decisions about management of VPI must be made jointly by surgeons and speech pathologists.
“Functional” VPI is managed by speech pathologists.
“Structural” VPI requires surgery.
The aim of surgical management should be to:
  • • Achieve velo-pharyngeal competence
  • • Maintain a good naso-pharyngeal airway
Investigations should include:
  • • Perceptual assessment of speech
  • • Oral examination – but not to make conclusions about palate length
  • • Lateral videofluoroscopy – the most important investigation for assessment of palate length and function
  • • Nasendoscopy – important if pharyngoplasty is being considered
Other investigations which may be useful are:
  • • Nasometry
  • • Dynamic MRI
  • • Nasal/oral airflow/pressure measurements
Surgical options include:
  • A. Surgery to the palate
  • B. Surgery to the pharynx
  • A. Secondary palate surgery
    • 1. Palate re-repair The first surgical option to consider is palate re-repair with retropositioning of the levator. If there is evidence of anterior insertion of the levators and if the palate appears to be of potentially adequate length, this is the procedure of choice
    • 2. If the levator insertion is posterior but the palate is too short, buccinator flap lengthening of the palate may be appropriate
    • 3. If the levator insertion is anterior but the palate appears too short, buccinator flap lengthening can be combined with re-repair
  • B. Surgery to the pharynx
    • 1. Posterior pharyngeal wall augmentation
      • • Injections – not currently
      • • Dermofat grafts – not currently
      • • Cartilage – not currently
      • • Fat injections – not currently
      • • Pharyngeal flap augmentation – modified Hyne’s pharyngoplasty
    • 2. Posterior pharyngeal flap – rarely in sagittal defects
An algorithm will be proposed.