Issues and controversies in the management of cleft palate.

Cleft palate management is complex. There is no current agreement on the appropriate treatment strategy. Extensive disagreement on the pathophysiology, timing of intervention, and techniques of surgical repair have added to the confusion. To provide a comprehensive guide to the management of cleft palate is difficult. However, several main points should be emphasized. Normal speech should be the most important consideration in the therapeutic plan. Growth disturbance should be minimized, but not at the expense of speech impairment, because the facial distortion can be satisfactorily managed with further surgery, whereas speech impairment can often be irreversible. We believe repair of cleft palate to establish a competent velopharyngeal sphincter should be completed from 6 to 12 months of age. This is done early enough to minimize the development of an often irreversible pathologic compensatory speech pattern, but late enough not to increase significantly the surgical risk to the infant. Surgical interventions should be designed to cause minimal disruption of the palate, to decrease the severity of subsequent growth problems. There is a need for well-controlled, prospective studies to establish the validity of the widely different claims of superior results from various techniques. We believe strongly that cleft patients should be managed in a center with a multidisciplinary team. The benefits of these teams have been elaborated. Cleft palate embodies one of the major tenets of plastic surgery, the achievement of an aesthetic result with minimal interference with function. Cleft palate remains a significant and interesting challenge for current and future plastic surgeons.