No Longer a Pain in the Neck: The Use of an Operating Microscope for Cleft Palate Closure

Cleft palate repair is an intricate and difficult operation positionally for a craniofacial surgeon.  Historically, use of loupe magnification and a headlight can cause significant strain to the surgeon’s neck and, at times, subpar optics for both the operator and the assistant.  The use of an operating microscope was first advocated by Sommerland in 2003.[i]  By using the operating microscope for cleft palate closure in addition to modifying the classic Z-plasty repair, we offer the following surgical pearls:

1. Use of the scope offers improved ergonomics for the surgeon and assistant by allowing for straight in-line back and neck posture with excellent visualization of the surgical field for the entire surgical team.
2. By rotating the viewfinder 90 degrees and utilizing the assistant port, there is direct line of sight to the anterior-most aspect of the palate without compromising surgeon position.
3. The available zoom and focus improves the ability to isolate and repair the levator veli palatani muscle.
4. Modifying the Z-plasty flaps, specifically narrowing the musculomucosal flap and widening the mucosal-only flap, allows for decreased tension along the repair while maintaining adequate vascular supply to the flaps.
5. The use of an Alloderm spacer anterior to the muscular repair allows for decreased contracture to the hard palate and for an unimpeded contraction of the muscle.

Photos and videos are used to illustrate these technical pearls.

[i] Sommerland BC.  “The Use of the Operating Microscope for Cleft Palate Repair and Pharyngoplasty.”  Plast. Reconstr. Surg.  Nov 2003.  112 (6): 1540-41.