Operative Technique in Plastic Surgery – Kevin C.Chung

TECH FIG 16 • V-Y mucosal flap with use of dermal
allograft for augmentation.
Excision and Reconstruction of Lower Lip Fullness With
Acellular Dermal Allograft14
■ A large central V-shaped mucosal flap is designed with the apex in the
midline of the inferior gingivobuccal sulcus. The lateral arms of the flap
include ellipses that excise the lip pits.
■ The pits and tracts are fully excised, and the orbicularis oris muscle is
reconstructed.
■ To restore fullness to the lower lip, an acellular dermal allograft, structural
fat grafting, or autogenous dermal fat grafts are utilized to create a natural
shape for augmentation (TECH FIG 16).
■ This is placed under the V-shaped mucosal flap and sutured into place with
4-0 Vicryl sutures at each commissure.
■ The mucosa is closed as a V-to-Y advancement flap with chromic sutures.
PEARLS AND PITFALLS
Etiology of
deformities
■ Some secondary cleft lip deformities are intrinsic to the disease.
■ Others are iatrogenic from the primary repair. Care must be taken to
create a balanced lip and nose with release and repositioning of the
lower lateral cartilage on the cleft side and complete reconstruction of

the orbicularis oris muscle sling at the first operation to minimize the
risk of iatrogenic deformities.
Analysis
■ Accuracy in analyzing the problem is essential. One must identify the
underlying anatomic cause of the deformity in order to accurately
reconstruct it.
■ Assess the entire lip/nose complex in planning your reconstruction.
■ Assessment must include all tissues from the underlying bony
skeleton, mucosa, muscle, skin, cartilage, and soft tissue.
The repair
must
match the
deformity.
■ Minor deformities may be addressed with minor scar revisions and
insertion of triangular flaps.
■ A more complex deformity involving multiple elements is best
treated by a complete revision of the lip and nose repair.
Mucosa
excess
■ This may often be resolved by direct excision.
Mucosa
deficiency
■ A minor deficiency of the central tubercle may be addressed by
creation of a laterally based vermilion triangular flap, which can be
inset in the central tubercle medially.
■ A larger deficiency of lip soft tissue can be treated by various
techniques including autologous structural fat grafting, autologous
dermal fat graft, or allograft.
Abbe flap
■ An Abbe flap is best used to reconstruct a deficiency of all tissues of
the central lip unit—philtral skin, vermilion, muscle, and mucosa.
■ This treats the most severe forms of lip notching that cannot be
addressed adequately by local flaps and augmentation alone.
Lip pits
■ The entire pit and epithelialized tract must be excised.
■ Reconstruction requires repair of the orbicularis oris muscle and
reconstruction of the mucosa to achieve a natural lower lip contour.
POSTOPERATIVE CARE
■ Antibiotic ointment is typically applied to the incision until it is healed.
■ Patients often may resume their usual diet.
■ With young children, elbow restraints may be used to keep the child from
putting the hands in the mouth or traumatizing the incision.
■ Special care is taken to optimize cutaneous scar healing after surgery.
■ When cutaneous absorbable sutures are used, we ensure that they have
absorbed by 4 to 5 days postoperatively. We apply diluted hydrogen peroxide
to them several times daily to speed this process along to avoid track marks

from the sutures.
■ Permanent sutures are removed within 5 days after surgery to avoid scarring.
■ Once the wound margins have healed, silicone tape is applied to the scar. It is
changed every few days and used continuously for approximately 3 months.
■ Patients and families are educated on techniques in scar massage and
avoidance of sun exposure for the first year after surgery.
■ If hypertrophy is noted in the early postoperative period, consideration is
given to applying steroid-impregnated tape or performing steroid injections
with triamcinolone.
OUTCOMES
■ Outcomes after correction of secondary deformity are usually good.
■ Depending on the severity of the deformity, asymmetry or contour
abnormalities can be persistent.
■ The degree of residual deformity and patient level of concern typically dictate
whether additional revision surgeries are recommended.
COMPLICATIONS
■ Inadequate correction of the deformity may be caused by an incorrect
diagnosis and treatment plan, such as performing a minimal excision when a
complete revision is necessary.
■ Hypertrophic scarring is possible, and attempts are made to minimize it as
described.
■ Wound dehiscence and infection are rare.
■ Intraoperative complications such as bleeding or anesthesia concerns are rare.
REFERENCES
1. Sitzman TJ, Coyne SM, Britto MT. The burden of care for children with
unilateral cleft lip: a systematic review of revision surgery. Cleft Palate
Craniofac J. 2016;53:84-94.
2. Rogers CR, Meara JG, Mulliken JB. The philtrum in cleft lip: review of
anatomy and techniques for construction. J Craniofac Surg. 2014;25:9-13.
3. Li W, Steinbacher DM. Unilateral cleft lip revision with conversion to the
modified inferior triangle. Plast Reconstr Surg. 2015;136:
353e-361e.
4. Mulliken JB. Double unilimb Z-plastic repair of microform cleft lip. Plast
Reconstr Surg. 2005;116:1623-1632.

5. Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation
technique. Plast Reconstr Surg. 2005;116:61-71.
6. Jones CM, Morrow BT, Albright WB, et al. Structural fat grafting to improve
reconstructive outcomes in secondary cleft lip deformity. Cleft Palate
Craniofac J. 2017;54(1):70-74.
7. Attar BM, Haghighat A, Naghdi N, et al. Acellular dermal graft in secondary
cleft lip deficiencies: assessment of results with a reproducible quantitative
technique. J Craniofac Surg. 2016;27:313-316.
8. Lee SW, Kim MH, Baek RM. Correction of secondary vermilion notching
deformity in unilateral cleft lip patients: complete revision of two errors. J
Craniomaxillofac Surg. 2011;39:326-329.
9. Cannon B, Murray JE. Further observations on the use of the split vermilion
bordered flap. Plast Reconstr Surg. 1953;11:497-501.
10. Cutting CB, Warren SM. Extended Abbe flap for secondary correction of the
bilateral cleft lip. J Craniofac Surg. 2013;24:75-78.
11. Van der Woude A. Fistula labii inferioris congenital and its association with
cleft lip and palate. Am J Hum Genet. 1954;6:244-256.
12. Mutaf M, Sensoz O, Ustuner ET. The split-lip advancement technique
(SLAT) for the treatment of congenital sinuses of the lower lip. Plast Reconstr
Surg. 1993;92:615-620.
13. Chen CH, Liao HT, Shyu VB, Chen PK. Inverted-T lip reduction for lower lip
repair in Van der Woude syndrome: a review and comparison of aesthetic
results. Int J Oral Maxillofac Surg. 2013;42:
198-203.
14. Bozkurt M, Kulahci Y, Zor F, et al. Reconstruction of the lower lip in Van der
Woude syndrome. Ann Plast Surg. 2009;62:451-455.

7
CHAPTER
Delayed Hard Palate Repair
in UCLP Patients
Jan Lilja
DEFINITION
■ In UCLP patients, the cleft palate will lead to speech difficulties.
■ Poor ventilation of the Eustachian tubes results in a high incidence of hearing
problems due to middle ear infection.
■ Early surgery on the palate may result in reduced maxillary growth.
■ Late surgery on the palate may result in aberrant speech.
ANATOMY
■ The palate can be thought of as an anterior bony part limited by the dental arch
and a posterior mobile part where muscles, oral mucosa, and nasal mucosa are
important functional structures.
■ The anterior palate (hard palate) is a horseshoe-formed bony structure concave
toward the mouth and convex toward the nose where it forms the nasal floor.
Both sides are covered by mucosal epithelium.
■ The muscles in the posterior part (soft palate) will act on the soft palate and
produce tension, lifting, or lowering of the soft palate. Lifting of the soft palate
is most important and is accomplished by the levator veli palatini muscles. In
speech, the soft palate should be lifted as far back as the posterior pharyngeal
wall and be able to stop airflow through the nose in order to produce distinct
pronunciation of certain sounds.
PATHOGENESIS
■ In a complete cleft of a unilateral cleft lip and palate, a cleft separates the lip,
the alveolar bone, and the hard and soft palate. The lateral incisor on the cleft
side is usually missing in both deciduous and permanent dentition. The cleft

separates the hard palate lateral to the vomer, establishing a cleft side and a
noncleft side in the hard palate where the vomer is attached to the noncleft side.
The soft palate is separated in the midline, but the cleft side is usually smaller.
■ Feeding is often difficult for the child because there is an opening between the
oral and nasal cavity. Food may pass into the nasal cavity and sucking is
compromised because adequate negative pressure cannot be achieved during
breast-feeding.
■ In the soft palate, the muscles are not attached to each other; the muscles
follow an anteroposterior direction along the cleft edges. Some of the muscles
are attached to the posterior edge of the hard palate on both sides of the cleft.
■ This morphological aberration impairs development of speech and hinders
ventilation of the Eustachian tube.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ The diagnosis of a patient with complete unilateral cleft lip and palate is
usually made by clinical examination.
■ Photographs taken from anterior, lateral, and inferior views can be taken to
document the condition.
■ In some centers, plaster casts are made from both upper and lower jaws.
■ Postoperatively, the patients are followed on a regular basis with photos,
speech evaluation, cephalometric assessment, and plaster casts.
■ When needed for evaluation of velopharyngeal incompetence (VPI),
nasendoscopy and videofluoroscopy can be used.
SURGICAL MANAGEMENT
■ There are numerous protocols for operating on the palatal cleft in patients with
complete cleft lip and palate. These protocols differ in procedure and timing.
■ Early surgery of the soft palate is a prerequisite for good speech, but
combined with closure of the hard palate, it will produce reduction of
maxillary growth.
■ Closure of the whole palate at an older age will give less problems with
maxillary growth but may give more problems with impaired speech.
■ When delayed hard palate repair is performed in UCLP patients, soft palate
closure is performed early to promote speech, and hard palate closure is
delayed until 2 years of age to promote growth. The palatal closure is
continued over to the oral side, where a pushback procedure can be done
within the soft palate.

■ Closure of the soft palate with a posteriorly based vomer flap will result in
anchorage of the anterior part of the soft palate to the base of the vomer flap.
■ This part of vomer is situated at the insertion of the vomer to the cranial base.
The direction of the soft palate will therefore be posterior-upward, resulting in
reduction of the openings toward the nose.
■ This may explain the favorable speech results in our patients, improving the
posterior positioning of the levator muscles and thereby reducing VPI.
Positioning
■ The patient is positioned supine on the operating table.
■ A shoulder roll is placed, serving to tilt the head backward to facilitate
visualization.
T E C H N I Q U E S
■ Soft Palate Repair
■ Incisions begin around the posterior part of the maxillary tuberosities and
then follow a zigzag route at the posterior border of the hard palate (TECH
FIG 1A).
■ A posteriorly based vomer flap is dissected, which does not reach the
vomero-premaxillary suture anteriorly. The base of the flap lies at the
junction of the vomer with the cranial base (TECH FIG 1B).
■ Mucosal flaps in the soft palate are raised by blunt dissection. The hamulus
is identified but not broken (TECH FIG 1C).
■ The insertions of the velar muscles and the nasal mucosa at the posterior
border of the hard palate are cut (TECH FIG 1D).
■ A flap with the muscles attached to the nasal layer is then dissected free and
mobilized.
■ The palatal muscles, including the levators, are then reconstructed to a
transverse course at the level of the opening of the Eustachian tube (TECH
FIG 1E).
■ The vomer flap is raised, and the nasal layer of velum can be closed
anteriorly to the level of the muscular sling by use of the vomer flap. In this
way, the vomer bone is connected to the anterior velum (TECH FIG 1E).

TECH FIG 1 • Soft palate closure. A. The incisions
follow a zigzag line between the soft and hard palate.
A posterior vomer flap is dissected, which has its base
at the posterior-cranial part of the vomer. B. Both
sides of velum are divided into two layers: the oral
mucosa and the nasal mucosa. C. The muscles
including the nasal mucosa are cut at the border of the
hard palate. D. The muscles are redirected to a
transverse course, sutured together medially in a
posterior position, and also attached anteriorly to the
backward-turned vomer flap. E. The muscles and the
raw surface of the vomer flap are covered by the oral
flaps, which are pushed in a medial-posterior
direction.
■ Hard Palate Repair

■ Incision lines are made for a flap on the noncleft side using palatal
mucoperiosteum. The flap is based on the vomer (vomer flap). On the cleft
side, an incision is made at the cleft border (TECH FIG 2A).
■ The vomer flap is raised leaving a raw bone surface on the noncleft side
(TECH FIG 2B).
■ Suturing starts on the oral mucosa, going into the pocket between the bone
and the mucoperiosteum. The needle catches the vomer flap from the
mucosal side, coming out on the raw side, going back to the mucosal side and
thereafter into the pocket and out on the mucosal side. Therefore, the knots
are tied on the mucosal side (TECH FIG 2C).
TECH FIG 2 • Repair of a residual cleft in the hard
palate. A. Incision lines. On the noncleft side, the
incision goes into the flat medial part of the palate. On
the cleft side, the incision is made at the cleft border
between the oral and nasal mucosa. B. The vomer
flap is raised. It contains some oral mucosa leaving a
raw bone surface in the medial part of the palate on

the noncleft side. Sutures are put to bring the vomer
flap into the incision on the cleft side. C. The vomer
flap is brought into the pocket between bone and
mucoperiosteum on the cleft side. Suturing starts on
the oral mucosa going into the pocket between the
bone and the mucoperiosteum. The needle catches
the vomer flap from the mucosal side, coming out on
the raw side and then going back to the mucosal side
and thereafter into the pocket and out in the mucosa.
Pulling the suture will bring the vomer flap into the
pocket between the bone and the mucoperiosteum.
Four or five sutures are placed. D. The vomer flap
sutured in place. E. The mucoperiosteum on the cleft
side is sutured to the vomer flap in order to ensure
good attachment.
■ Four to five such sutures are placed.
■ Pulling the suture will bring the vomer flap into the pocket between the
bone and the mucoperiosteum (TECH FIG 2D).
■ When the vomer flap is well positioned under the mucoperiosteum of the
cleft side, sutures are tied, keeping the vomer flap in place and also covering
the residual cleft with a one layer closure (TECH FIG 2E).
■ Additional sutures are put at the border of the cleft, keeping the raw surface
of the vomer flap attached to the raw surface of the mucoperiosteum on the
cleft side, thereby ensuring good healing (TECH FIG 2E).
PEARLS AND PITFALLS
Diagnostic studies
■ Nasendoscopy and videofluoroscopy are reserved
postoperatively for cases demonstrating persistent VPI
following palate repair.
Rationale for
■ Delayed hard palate repair is done to optimize both speech
and palatal growth.

delayed hard palate
repair
■ Soft palate closure is performed early to promote speech.
■ Hard palate closure is delayed until 2 y of age to promote
growth.
Posteriorly based
vomer flap for soft
palate closure
■ Base of the flap lies at the junction of the vomer with the
cranial base and does not extend anteriorly to the vomero-
palatine suture.
■ Results in anchorage of the anterior part of the soft palate
to the base of the vomer flap
■ Improves the posterior positioning of the levator muscles
and thereby reducing VPI
Soft palate repair
■ Insertions of the velar muscles and the nasal mucosa at the
posterior border of the hard palate are cut.
■ The nasomuscular flaps are reconstructed to a transverse
course at the level of the opening of the Eustachian tube.
■ The nasal layer of the nasomuscular flap is connected
anteriorly to the vomer flap.
Hard palate repair
■ Closure is performed with a mucoperiosteal vomer flap
raised from the noncleft side and sutured to the
mucoperiosteum at medial edge of the cleft side.
■ Lateral mucoperiosteal dissection is avoided to minimize
subsequent restriction of maxillary growth.
Outcomes
■ Long-term outcomes for both speech and growth have not
been surpassed by any other surgical procedure for palate
closure.
OUTCOMES
■ Long-term growth and speech outcome are excellent in patients with two-stage
palatoplasty with early soft palate repair and delayed hard palate repair.1,2
■ Results from growth studies and speech evaluation have not been surpassed by
any other surgical procedure for palate closure.
REFERENCES
1. Friede H, Lilja J, Lohmander A. Long-term, longitudinal follow-up of
individuals with UCLP after the Gothenburg primary early veloplasty and
delayed hard palate closure protocol: maxillofacial growth outcome. Cleft
Palate Craniofac J. 2012;49(6 suppl):649-656.
2. Lohmander A, Friede H, Lilja J. Long-term, longitudinal follow-up of
individuals with unilateral cleft lip and palate after the Gothenburg primary

early veloplasty and delayed hard palate closure protocol: speech outcome.
Cleft Palate Craniofac J. 2012;49(6 suppl):657-671.

8
CHAPTERFurlow Palatoplasty
T. Guy Thorburn
DEFINITION
■ Furlow Palatoplasty is widely used technique for repair of either cleft palate
(CP) or submucous cleft palate (SMCP). It can also be used in revision palate
repair. Some surgeons who routinely use a Sommerlad repair for complete CP
will instead use a Furlow for SMCP.
■ The technique is based on the concept of lengthening the soft palate by use of
“Double-opposing Z-plasties.” This involves mirror-image Z-plasties to the
oral and nasal layers while also retropositioning and reconstructing the levator
muscle mechanism by keeping the levator palatini muscle on each side
attached to the limb of the Z-plasty that moves posteriorly (FIG 1).1
■ Randall has described a variation for wider CP that involves using
Langenbeck-type lateral releasing incisions to relieve the tension on the oral Z-
plasty (FIG 2).2
ANATOMY
■ The key functional issue in CP or SMCP is that the levator muscle mechanism
is not in continuity on the two sides. In addition, the fibers become tethered to
the posterior border of the hard palate. Successful functional palate repair
therefore requires repair of the “levator sling” as well as just closure of the
tissues across the cleft.
■ The tethering to the hard palate seems to be an equal problem in differing
types of cleft, whether unilateral or bilateral cleft lip and palate, cleft palate
only, or SMCP.
■ Tip: the oral layer of the soft palate is more elastic than the nasal layer, and
the elasticity increases as you move from the hard palate–soft palate junction

toward the uvula. This means that the oral layer Z-plasty will tend to inset
better with slightly wider flaps (closer to 80–90 degrees), whereas for the nasal
layer, 60 degrees is sufficient. On the oral layer, the tissue elasticity is even
greater in the posterior part of the palate, so the posterior limb is best designed
slightly wider (around 90 degrees) as it will narrow after incision.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The initial assessment of the newborn with a cleft involving a palate would
usually be alongside a pediatrician and will include:
■ Pregnancy and birth history (including information from any antenatal
testing), gestation, birth weight, and Apgar scores.
■ Initial assessment of cleft type and any related anomalies, including any
airway concerns suggesting Robin sequence.
■ Medical history, drug history, and allergy history.
■ Family history of clefts, other major health problems, or anesthetic problems
and any genetic diagnosis.
■ Feeding history including bottle type (eg, squeezy bottle, free flow,
Haberman, etc.), current weight, maximum percentage weight loss and
number of days to regain birth weight, and volume/duration/frequency of
feeds.
■ Physical examination to assess the upper airways, cleft type, cleft width, and
how much deficiency there is of surrounding tissues, as well as any related
anomalies or dysmorphic features. The pediatrician would then complete a
fully newborn examination, looking in particular for related health issues such
as cardiac, respiratory, renal, or neurological signs.
FIG 1 • Schematic diagrams of the Z-plasties of both

oral and nasal layers before and after inset.
FIG 2 • The variation described by Randall utilizing
lateral releasing incisions (von Langenbeck) for wider or
more complete cleft palate.
IMAGING
■ No routine preoperative imaging is required for typical clefts. For older
children presenting with SMCP or velopharyngeal incompetence (VPI),
assessment with a speech lateral videofluoroscopy helps to assess the position
of the levators and relative size of the soft palate to the size of the pharynx.
■ Standardized preoperative clinical photos should be taken as these are
invaluable when assessing outcomes many years later.
SURGICAL MANAGEMENT
Preoperative Planning
■ A key aspect of successful cleft palate repair is in optimizing the patient prior
to surgery. A pediatrician is a crucial member of the Cleft team. Although there
is much discussion of age at palate repair, different team protocols vary from
around 3 months old to 15 months or more. Very young babies will tend to be
more susceptible to airway compromise around the time of surgery. Delaying
repair until much older and speech has developed has been associated with
poorer speech outcomes, particularly related to articulatory errors.
■ Tip: our team protocol is for palate repair around 8 to 12 months (corrected
for prematurity), but our emphasis is much more on ensuring the child is well

and thriving in the run-up to surgery. If they are not growing along their
expected percentiles (with growth plotted on the appropriate chart for
syndromic children), then we would want to address this before surgery. We
will also routinely postpone for about 4 weeks if children have upper
respiratory tract infections. By following this approach, we have seen a
significant reduction in fistulae and concerns with speech function.
■ Routine blood tests or cross match samples are not required, unless the child is
known to have a specific risk factor.
■ For children, with cardiac or respiratory problems, an up-to-date
echocardiogram or sleep study may be relevant.
Positioning
■ A south-facing Rae uncuffed or microcuffed tube is used. The taping of the
tube needs to be secure but avoiding taping the mouth closed or limiting
access. Taping in a V shape along the line of the mandible avoids displacing
the tapes when the gag is opened.
■ The child is placed supine on a warming blanket, with the head at the very end
of the operating table. A large horseshoe gel head ring is placed under the
shoulders and around the head to provide support without overextending the
neck.
FIG 3 • Applying a sticker across the head drapes as a
warning that the throat pack is in place, so that the
drapes cannot be removed without first removing the
sticker.

■ A head drape is applied, and the face is prepped.
■ Tip: we use a clear plastic drape [3M Steri-Drape Fluoroscope Drape 90 ×110
cm] over the trunk, which allows the anesthetist to see their endotracheal tube
and circuit without disturbing the surgical field. We avoid any adhesive drapes
near the endotracheal tube as these have the potential to catch and dislodge the
airway.
■ The table is tilted to a slight head-up position. An operating microscope is
used for the procedure. The height of the table is adjusted once the microscope
has been brought in to place (adjusted according to whether the surgeon prefers
to sit or stand).
■ A modified Dingman mouth gag is placed.
■ A throat pack is placed, and a marker sticker put across the drapes as a
reminder to ensure it is removed at the end. The sticker is placed so that the
drapes cannot be removed without needing to disturb the warning sticker (FIG
3). The throat pack is also included in the scrub nurse count as an additional
precaution.
■ The nose and mouth are rinsed with aqueous chlorhexidine solution.
Approach
■ The width of the cleft is measured, and any unusual features are noted.
■ The incisions are marked with pen and ink. Depending on tissue condition and
tension, the limbs of the oral Z are usually about 8 to 10 mm long. The angles
are usually 80 to 90 degrees (slightly wider on the limb in the posterior soft
palate) (FIG 4).
■ Tip: for a right-handed surgeon, the oral layer Z is typically marked with the
posteriorly based limb (where the muscle remains attached to the flap but has
to be dissected from the nasal layer) on the left. This will tend to give the
easiest access to the hardest part of the dissection.

FIG 4 • Oral layer markings for a standard Furlow
palatoplasty. Note the angles of the Z are wider than for
the skin, approaching 80 to 90 degrees.
T E C H N I Q U E S
■ Hard Palate
■ Levobupivacaine or bupivacaine long-acting local anesthetic with adrenaline
1:100 000 is infiltrated and left about 7 to 8 minutes for vasoconstriction
(TECH FIG 1A). The injection is used to help hydrodissect the hard palate
subperiosteal layer.
■ Tip: Steri-Strips are placed to protect the corners of the mouth from abrasion
by instruments (TECH FIG 1B).
■ The incision is begun along the cleft margin (or in the midline for a SMCP
or rerepair).
■ For clefts involving the hard palate, incise carefully down to the bone along
the margin of the hard palate and 3 to 5 mm past the hard palate–soft palate
junction and elevate subperiosteally with a raspatory or Warwick-James
elevator. Be careful approaching the posterior nasal spine as the tissues are
more adherent here, and it is easy to tear the oral layer if there is a tethered
salivary gland at this point. Switching between 15 blade and raspatory is
usually necessary. Tip: for incising the margin of the rest of the soft palate
and back to the uvula, a 12 blade tends to be easiest.
■ Depending on the cleft type, it may be necessary to raise vomer flaps to help

close the nasal layer without tension.
■ After raising the vomer flaps, elevate the nasal layer off the hard palate
(again in a subperiosteal plane) with a raspatory or dental flat plastic.
TECH FIG 1 • A. Infiltration of local anesthetic with a
Luer-lock syringe, using the infiltration to hydrodissect.
B. Steri-Strip “cat’s whiskers” to protect the oral
commissures during the procedure.
■ Oral layer
■ A skin hook is placed on the left margin of the cleft, where the incision has
been marked to create the posteriorly based flap. Using the skin hook to
tension, a 15 blade is used to incise the oral layer and muscle, down to the
nasal layer (which is left intact) (TECH FIG 2A).
■ The muscle is then freed carefully from the nasal layer with the 15 blade
and/or dissecting scissors. Keeping tension on the muscle toward the midline
(rather than posteriorly or superiorly) makes this dissection easier without
buttonholing the nasal layer.
■ The muscle is freed off the nasal layer out toward the hamulus, so it is
dissected more laterally than the extent of the oral layer incision.
■ On the right side, the opposite flap is raised in a similar way but leaving the
muscle intact on the nasal layer (TECH FIG 2B,C).
■ Tip: after incising the leading edge of the posteriorly based oral flap and
elevating the anteriorly based flap, then applying topical 1:1000 adrenaline
on neuro patties provides excellent vasoconstriction and facilitates the

subsequent dissection (TECH FIG 2D,E).
TECH FIG 2 • A. Incising the oral layer posteriorly
based flap (the muscle and mucosa flap on the left
side of the palate). B. Raising the oral layer anteriorly
based flap (the mucosa-only flap on the right side of
the palate). C. Spread dissection with scissors can be
very useful for identifying the plane between the
muscle and the mucosal flap. D,E. After the initial
dissection of the oral layer, topical 1:1000 adrenaline
helps with the next stage of dissection by
vasoconstricting. First, neurosurgical patties are
placed in the wound to keep the solution in the desired
area, and then 1 mL of 1:1000 adrenaline solution is
dripped onto the patties.
■ Nasal layer

■ To make access easier for the stage, a stay suture can be used to hold the oral
flaps out of the way if the surgeon prefers, or the assistant can use a dental
flat plastic or skin hook to do this (TECH FIG 3A).
■ The nasal Z-plasty is a similar size to the oral layer. The angles are usually
just over 60 degrees.
■ On the nasal layer, the Z-plasty is a mirror image of the oral layer Z-plasty.
At this stage, the muscle is present and attached to the nasal layer on the right
side, while on the left, the nasal layer has already been dissected bare.
■ A skin hook in the margin on the right side is used to place tension toward
the midline. The posteriorly based flap is then raised by incising the nasal
layer and muscle together with a 15 blade and/or dissecting scissors (TECH
FIG 3B). The nasal layer is kept adherent to the muscle (TECH FIG 3C).
■ Tip: when incising the muscle/nasal layer on the right, plan to keep a rim of
the tensor aponeurosis tissue intact. This makes it much easier to inset the
contralateral flap during closure.
■ As with the muscle on the oral layer, it is necessary to free the muscle more
laterally than the limit of the nasal layer incision.
■ Once the posteriorly based flap is fully mobilized, hold it across to the
opposite side to check the position of the nasal layer–only flap (TECH FIG
3D).
TECH FIG 3 • A. The longitudinal incision in the nasal
layer. Note the effectiveness of the adrenaline, making

it much easier to see the correct planes. B. Incising
the posteriorly based nasal layer flap (the muscle and
mucosa flap on the right of the palate). Gentle traction
of the muscle bulk toward the midline, as opposed to
lifting or posteriorly, allows clean incision with either
scissors or 15 blade. C. As the flap is incised and
retropositioned, the levator muscle (marked) comes
into view on the nasal aspect of the other muscle
fibers. D. Designing the flap in order to leave a rim of
the tensor aponeurosis (marked) makes subsequent
suturing of the flaps much easier. E. After checking
the position with the right sided flap, the anteriorly
based nasal layer flap is incised (the mucosa-only flap
on the left side of the palate). F. Position of flaps at
rest before inset. Assuming correct design of the flaps,
they will tend to want to move toward their new
positions, and the palate is already visibly lengthened.
■ Then incise the anteriorly based nasal layer flap on the left side (TECH FIG
3E, F).
■ Closure
■ Start with the inset of the nasal flaps—it is usually easier to begin by
insetting the posteriorly based flap. A resorbable monofilament suture is
used, preferably with a round or tapercut needle to avoid inadvertent tears of
the mucosa. We use 5-0 Monocryl plus on the nasal layer and 4-0 Monocryl
on the oral layer (TECH FIG 4A,B).
■ Option: although this technique provides good overlap of the muscle mass
on two sides, it is worth noting that the two levator muscles are not directly
opposed or joined. Some surgeons therefore choose to directly suture the
levators as well. In this situation, first complete inset of the nasal layer. Then
a 5-0 nylon suture is placed through the levator muscle which is visible on
the underside of the left oral layer flap. The oral flap is then held out to

length to allow placement of the suture to pick up the levator muscle on the
right side (TECH FIG 4C). This muscle is lying out of direct sight on the
deep aspect of the muscle that is attached to the nasal layer on the right side
(TECH FIG 4D).
■ The oral flaps are then inset. McGregor corner sutures combined with
Barron sutures to the flap edges allow the avoidance of knots or ischemic
areas at the distal ends of the oral mucosal flaps (TECH FIG 4E). If the oral
flaps appear too tight, they can be inset a little short with a raw area left
laterally.
■ The local anesthetic is topped up.
■ The throat pack is removed.
TECH FIG 4 • A. The nasal layer flaps are inset first;
the rim of tensor aponeurosis makes suturing the
nasal layer easier. B. The position of the nasal layer
flaps after inset is complete. C. With inset of the nasal
and oral layer posteriorly based flaps, the levator
mechanism has been retropositioned. But in the
classic Furlow, the two levator muscles are not directly

connected, which can give an asymmetric lift of the
palate. Therefore, some surgeons prefer to place
permanent nylon mattress sutures directly connecting
the two halves of levator. D. A schematic diagram of
the soft palate in cross section to show the layers of
the oral and nasal Z-plasties and the inset of the
levator mechanism. E. The position of the oral layer
flaps after inset is complete.
■ Alternative: Z-Plasty with Intravelar Veloplasty
■ It is possible to use a hybrid of a Sommerlad and a Furlow approach. This
can be particularly useful in SMCP.
■ Preparation, draping, and hard palate are the same as above.
■ The oral layer is raised as per a Sommerlad repair but is marked out a Z-
plasty as for a Furlow repair.
■ Incision and retraction of the Z-plasty flaps can give easier access for the
muscle dissection (radical intravelar veloplasty) which is the same as for a
Sommerlad repair.
TECH FIG 5 • The marking for the nasal layer Z-plasty
at the base of the uvula in the hybrid procedure.
■ The muscle is dissected off the nasal layer on both sides.
■ A Z-plasty is then made in the posterior 1/3 of the nasal layer (in a mirror

image of the oral layer Z-plasty) (TECH FIG 5).
■ Tip: a principle of Z-plasties is that increased length is achieved by
redistributing tension in a lateral direction. Therefore, placement of the Z-
plasty on the posterior 1/3 of the nasal layer, toward the base of the uvula,
means that the lateral tightening achieved by the process of insetting the Z-
plasty also tightens the velopharyngeal port.
■ The muscles on the two sides are sutured with three 5-0 nylon mattress
sutures, aiming to pick up both the levator muscle and the tougher tensor
aponeurotic tissue with each bite. The knots must be tied very carefully to
allow the ends to be cut extremely short.
■ The oral layer is then closed with inset of the Z-plasty.
PEARLS AND PITFALLS
Timing of
surgery
■ Careful optimization of the baby prior to surgery is important;
good growth following percentile lines is a useful indicator—a
thriving baby at the time of surgery is more important than a
specific age.
Shared
airway
■ As with all “shared airway” surgery, it is important for the
anesthetist and surgeon to communicate well with each other—the
WHO checklist and team brief are very useful for this.
Operating
microscope
■ The routine use of the operative microscope for palate repair gives
excellent lighting and visualization of the operative field. It is also
very helpful for giving trainees a better view and involvement, as
well as reducing the strain on the surgeon’s neck.
Postoperative
elevation
■ Nursing the baby “head-up” in the recovery room and on the ward
after surgery is helpful for reducing postoperative swelling—
cuddling the baby over the parent’s shoulder tends to give ideal
positioning.
POSTOPERATIVE CARE
■ Topping up the local anesthesia with a long acting agent at the very end of the
operation is useful for postoperative comfort and feeding.
■ Nurse the baby with head elevated.
■ Babies can be offered feeds straight away once they are awake.

■ Monitor airway and saturations especially over the first night after surgery.
OUTCOMES
■ The main outcome measures for cleft palate repair are fistula rate, structural
speech problem rate, need for secondary surgery, and impact on maxillary
growth.3
■ There has been a systematic review comparing Furlow with straight-line
repairs. This shows considerable variation in outcomes according to the cleft
type. The average fistula rate ranged from 2.6% to 11.6% with different cleft
types. The hypernasality rate (indicating structural speech problems) ranged
from 8.9% to 18.5%, and the secondary surgery for speech rate ranged from
0% to 11.4%. There is a lack of data on the effect of maxillary growth from
Furlow repairs, even though that was a starting focus in Furlow original
description.4
COMPLICATIONS
■ Infection, significant bleeding, and transfusion are all rare after palate surgery.
■ Airway compromise is a potential risk especially in babies with Robin
sequence and in younger/smaller babies.
■ Fistula is reported to have a lower incidence than in some other techniques of
palate repair in some series, but there is wide variation between series, and the
extent and width of the cleft palate play a major factor in the fistula rate.
■ Speech problems—whether VPI or “cleft type characteristic” articulatory
errors.
REFERENCES
1. Furlow LT. Cleft palate repair by double opposing Z-plasty. Plast Reconstr
Surg. 1986;78(6):724-738.
2. Randall P, LaRossa D, Solomon M, Cohen M. Experience with the furlow
double-reversing Z-plasty for cleft palate repair. Plast Reconstr Surg.
1986;77(4):569-576.
3. Sitzman TJ, Allori AC, Thorburn G. Measuring outcomes in cleft lip and
palate treatment. Clin Plast Surg. 2014;41(2):311-319.
doi:10.1016/j.cps.2013.12.001.
4. Timbang MR, Gharb BB, Rampazzo A, et al. A systematic review comparing
Furlow double-opposing Z-plasty and straight-line intravelar veloplasty
methods of cleft palate repair. Plast Reconstr Surg. 2014;134(5):1014-1022.

doi:10.1097/PRS.0000000000000637.

9
CHAPTER
von Langenbeck
Palatoplasty
Kathryn V. Isaac and David K. Chong
DEFINITION
■ Cleft palate is the failure of fusion of the palatal shelves during embryological
development.
■ There are many surgical techniques used for cleft palate repair. The repair
technique chosen varies depending on the type of cleft palate and beliefs
regarding facial growth and speech repercussions1.
ANATOMY
■ Embryologically, the cleft may affect the primary or/and secondary palate.
■ Anatomically, the cleft is defined according to the involvement of the hard and
soft palates.
■ A complete cleft of the palate is defined as a cleft involving both the primary
and secondary palates. Hence, a complete cleft involves the soft palate and the
hard palate.
■ The Veau classification (FIG 1) provides a clinically useful description of the
cleft type according to the involvement of the alveolus, the hard palate, and the
soft palate. It guides selection of the surgical treatment.2
■ The von Langenbeck palatoplasty is most commonly employed for incomplete
cleft palates, where the primary palate is unaffected (ie, soft palate and hard
palate to incisive foramen) or where the primary palate was previously repaired
(commonly with a superiorly based vomerine flap at the time of lip repair).1,3
■ Von Langenbeck palatoplasty is less commonly used to repair isolated clefts
of the soft palate (Veau I) and mostly employed to repair clefts of the soft
palate and secondary palate [hard palate posterior to the incisive foramen
(Veau II)].

■ This technique may also be modified for complete clefts and is named a
hybrid procedure.4 This hybrid procedure employs the bipedicled von
Langenbeck flap on the greater segment and a unipedicled flap on the lesser
segment. It is not used for the treatment of submucous clefts.
■ Additionally, the von Langenbeck technique of a bipedicled mucoperiosteal
flap may be used for the repair of fistulae located in the hard palate or
junction with the soft palate.
PATHOGENESIS
■ The etiology of cleft palate is multifactorial: environment, teratogen exposure
(alcohol, anticonvulsants, steroids, diazepam), nutrition, maternal infections
(rubella, toxoplasmosis), and genetics.
■ Cleft palate repair restores anatomical closure between the oral and nasal
cavities.
■ An unrepaired cleft palate may result in impaired breathing, feeding, speech,
and hearing.
NATURAL HISTORY
■ Orofacial clefting is the most common craniofacial birth defect, occurring in
1:750 live births.5
■ The incidence of cleft palate alone is 1:2000, with a female-to-male ratio of
2:1.
■ The incidence of cleft palate in combination with cleft lip is greater,
estimated at 1:1000 with a reverse gender ratio.
■ In the population of children with cleft lip and/or cleft palate (CL+/−P),
approximately 50% will have CLP, 30% to 35% CP, and 15% to 20% CL.
FIG 1 • Veau classification of cleft palate types. I. Cleft
of soft palate only. II. Cleft of secondary hard and soft
palates. III. Unilateral cleft extending through secondary

hard and soft palate, through right or left primary palate,
and through the alveolar process. IV. Bilateral cleft
through secondary hard and soft palate, through
bilateral primary palate and bilateral alveolar processes.
■ Approximately 40% of CP patients will have a syndrome, and 15% of CLP
will have a syndrome.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The diagnosis of a cleft palate is made by prenatal ultrasonography or by
physical examination at birth and in early infancy. A detailed assessment is
made of the child’s breathing, feeding, growth, and development.
■ Airway assessment must exclude the presence of sleep apnea and micro-
/retrognathia.
■ Assessment of growth and weight is key to identify and monitor feeding
difficulty, gastroesophageal reflux, and the use of feeding aids
(Haberman/Pigeon teat).
■ Hearing and middle ear function must be assessed and treated early by an
otolaryngologist.
■ The plastic surgeon should define the cleft palate type according to the
anatomic structures involved, the laterality, width of the palate, and the
presence/absence of a cleft lip.
■ Also, the child should be assessed for associated anomalies suggestive of a
syndrome: craniofacial dysmorphism, airway compromise, cardiac defects,
ocular and auricular abnormalities, and musculoskeletal anomalies. A genetics
referral is suggested if suspicious for a case of syndromic cleft palate.
DIFFERENTIAL DIAGNOSIS
■ Syndromic cleft palate
■ Van der Woude syndrome
■ Stickler syndrome
■ Robin sequence
■ 22q11.2 deletion syndrome
■ Treacher Collins syndrome
■ Nager syndrome
■ Ectrodactyly-ectodermal dysplasia

■ Klippel-Feil syndrome
NONOPERATIVE MANAGEMENT
■ It is very uncommon not to repair a cleft palate.
■ If the child is unable to undergo surgical treatment secondary to airway
concerns or medical fitness, a palatal obturator may be considered.
■ Such patients should be reassessed on a regular basis (at least annually), as
they may become sufficiently stable for delayed surgical correction of the
cleft palate.
SURGICAL MANAGEMENT
■ Cleft palate repair is ideally performed between 9 and 12 months of age, with
the infant weighing greater than 8 kg.
■ Airway and middle ear disease assessment is performed and treated prior to or
simultaneously with cleft palate repair.
■ Risks of the procedure are hemorrhage/hematoma, airway compromise, wound
dehiscence, infection, oronasal fistula, flap necrosis, velopharyngeal
insufficiency, and reduced midfacial growth.
■ The main objectives of the cleft palate repair are:
■ To separate the oral and nasal cavities
■ To reposition to the velar musculature for restoration of the velopharyngeal
sphincter, in particular the reconstruction of the levator muscular sling
■ To improve Eustachian tube function
■ To minimize detrimental effects on subsequent maxillary growth
■ The goals of the palatoplasty are to improve feeding and speech.
■ The main steps of the procedure are:
■ Marking and elevation of bipedicled mucoperiosteal flaps off the hard palate
■ Dissection and separation of the nasal mucosa, velar musculature, and oral
mucosa
■ Careful dissection of pedicles (greater palatine artery)
■ Tension-free closure of nasal mucosal layer
■ Reconstruction of the velopharyngeal sphincter with repositioning of the
levator sling
■ Recreation of the uvula
■ Closure of the oral mucosal layer
Preoperative Planning

■ With the patient anesthetized, the width of the cleft is measured at the junction
of soft and hard palate. The width of the cleft is important to predict difficulty
of the cleft palate repair and anticipated amount of dissection required for
closure.
■ The von Langenbeck technique provides less flap mobilization relative to
other techniques (two-flap palatoplasty). Thus, this technique is best reserved
for narrow clefts.
Positioning
■ The patient is positioned supine with shoulder roll to allow neck extension. An
oral Rae tube, with the circuit directed caudally, is carefully taped centrally.
Corneas are protected with eye tapping.
■ Access and visualization of the entire palate are very important and cannot be
understated. It is especially important to ensure visualization from the uvulae
to the anterior extent of the palate.
■ It is essential for the surgeon to ensure positioning is correct prior to
scrubbing. This will facilitate the procedure.
■ The surgeon should have a headlight or lighted instruments for optimizing
visualization in the confined space and a skilled attentive assistant.
■ It is advantageous to have a bed that has Trendelenburg positioning capability.
Some surgeons stand to perform palate surgery from below, but having the
baby’s head supported with the surgeon seated operating upside down provides
the best exposure and is the preferred position by most surgeons.
Approach
■ The aim of cleft palate surgery is tension-free closure of the palate oral and
nasal mucosal layers and restoration of the velopharyngeal muscular sphincter.
■ Difficulties anticipated include:
■ Access
■ Lighting
■ Bleeding obscuring visualization
■ Surgical approaches differ with regard to the amount of dissection performed
to achieve tension-free closure and muscle repositioning.
■ Critical step is adequate exposure and dissection of tissues to provide comfort
for the operating surgeon to achieve tension-free closure.
■ Oral layer mobilization is largely dependent on careful mobilization of the

greater palatine artery from its periosteal sleeve.
■ Nasal layer mobilization is largely dependent on careful mobilization of the
mucosa as a sheet from its dense bony attachments.
T E C H N I Q U E S
■ Markings
■ Carefully insert an intraoral gag and a throat pack (it is the surgeon’s
responsibility to insert and remove).
■ Mark the incision lines:
■ Along the medial edges of the cleft from the uvulae to the anterior extent
of the cleft at the primary palate
■ Laterally at the junction of the hard palate and maxillary alveolus,
extending from the posterior maxillary tubercle anteriorly to the level of the
canine tooth (TECH FIG 1).
■ Inject local anesthetic with adrenaline into the hard palate and soft palate
(average of 8 mL).
■ The vasoconstrictive properties reduce blood loss and enhance visual field.
■ Local anesthetic also facilitates hydrodissection of the mucoperiosteal flaps
off of the hard palate and tissue expansion for ease of layer dissection in
the soft palate.
■ Wait 8 minutes or until injection sites stop bleeding.

TECH FIG 1 • Incision markings of a von Langenbeck
palatoplasty for cleft of the secondary palate.
■ Elevation of Oral Mucoperiosteal Flaps
■ Perform incisions with needle tip cautery to reduce bleeding. Use a skin
hook on the uvula or stay sutures for countertraction.
■ Incisions, flap elevation, and pedicle dissection are done similarly on both
the greater and lesser segments.
■ Begin with lateral incisions: from the retromolar trigone along the junction
of the alveolus and palate with diathermy down to the bone and slightly
angled medially so as to avoid injury of developing teeth.
■ For the medial incisions, palpate the posteromedial edge of the hard palate
before incising to ensure the incision medially will be onto the bone (hard
palate) as you can inadvertently cut into the nasal layer and do a “double cut”
that reduces the available tissue for nasal layer closure (TECH FIG 2A).
■ Oral palatal mucosa is susceptible to tearing so dissect continuously along
the entire length of the lateral incision toward the cleft to elevate the
mucoperiosteal flaps.

■ Avoid “tunneling” as this can cause tearing of the hard palate mucosa due
to dense periosteal attachments.
■ Use a periosteal elevator to raise the mucoperiosteal flaps from lateral to
medial beginning at the anterior extent of the incision (TECH FIG 2B).
■ Dissect from anterior to posterior along the hard palate in sweeping motions
toward the greater palatine foramina and posterior limit of the hard palate.
TECH FIG 2 • A. Incision of medial edge of cleft
beginning at posterior-medial border of the hard
palate, separating oral and nasal mucosal layers. B.
Dissection of oral mucoperiosteal flaps.
■ Isolation of Greater Palatine Vessels
■ As you approach the greater palatine artery at the posterolateral edge of the
hard palate, the vessel becomes visible on the undersurface of the flap. The
visibility of the pedicle is limited with this bipedicled flap technique. Given
the difficulty in visualization, the amount of dissection of the pedicle may be
limited. Knowledge of the pedicle location will enable you to gently and
circumferentially release the dense periosteal attachments around the pedicle.
■ A surface landmark for the pedicle is the dimpling in the mucosa near the
posterior edge of the hard palate. This represents the dense periosteal
attachments of the pedicle.
■ Start laterally, and then work circumferentially around the foramina, staying

on the bone and taking care not to dissect into the artery or the leash of veins
surrounding it.
■ Staying on the bone during pedicle dissection is very important and
rewarding for there are tethering ligaments that insert into the oral mucosa.
■ Dissection directly off the bone facilitates the circumferential release of
these ligaments, which otherwise make it exceedingly easy to tear the oral
mucosa and injure the pedicle.
■ Spreading of dissecting scissors parallel to the vascular pedicle will help to
release some dense periosteal attachments; this should be done with care not
to avulse the vessel.
■ Previous hydrodissection during local anesthetic injection will also aid in
finding the bloodless plane between the oral layer mucosal glands and the
muscular layer.
■ Complete circumferential pedicle dissection is achieved once the periosteal
sleeve is released behind the greater palatine foramina, and the flaps can be
mobilized toward the midline.
■ It is critical for the surgeon to anticipate the location of the pedicle and
appreciate the careful dissection to be completed with limited visibility,
mainly using the lateral approach to perform the release.
■ Once sufficiently mobilized, retract the flaps out of the surgical field with
stay sutures, and secure to the intraoral gag/retractor.
■ Dissection and Separation of the Oral Mucosa,
Nasal Mucosa, and Muscle
■ Oral mucosa dissection: under magnification, dissect in the plane between
oral mucosal glands and the muscle layer posteriorly in the soft palate from
the edge of the bony palate to the uvula.
■ Nasal mucosa dissection:
■ Mobilize the nasal mucoperiosteal layer with care, beginning on the lesser
segment of the cleft. This requires the gradual and wide dissection of this
continuous sheet of nasal mucosa, which is firmly attached to the hard
palate along its medial and posterior edges, along the nasal surface of the
bony palate and the medial surface of the medial pterygoid plate.
■ The elevation of the nasal layer anteriorly on the greater segment will
necessitate elevation off the vomer.

■ The nasal mucosa is even more unforgiving than the oral mucosa. Once a
tear occurs, it is easy to propagate. Resist the temptation to tunnel before a
whole edge has been liberated.
■ To liberate the dense attachments of the medial hard palate, a Mitchell
trimmer double-ended elevator or a similar blunt edged instrument is used.
■ The dissection starts at the cleft margin, scraping the oral surface of the
bone until the edge of the nasal mucosa starts to be defined.
■ As the edge of the hard palate becomes apparent, elevate the nasal
mucoperiosteum widely off the entire extent of the medial aspect of the
hard palate.
■ The judicious use of needlepoint diathermy on low setting can help to
elevate firmly attached areas that are not easily released with the Mitchell
trimmer.
■ Once the edge of the nasal mucoperiosteal flap is defined, slide the trimmer
around the corner of the hard palate onto the nasal surface of the bone staying
right on the bone. If the edge is sufficiently liberated, sweep anteriorly and
posteriorly to liberate the entire sheet off the nasal surface.
■ If a portion of the edge is still attached, resist further sweeping until
releasing the portion that remains tethered to prevent a tear.
■ This dissection is continued to the posterior nasal spine.
■ At this juncture, there are always muscle attachments.
■ Release these aberrant velar muscle attachments with needlepoint
diathermy.
■ Continue dissection along the nasal surface following the posterior edge of
the bone cephalad and lateral toward the medial surface of the medial
pterygoid plate.
■ Release the nasal mucoperiosteum directly off the bony surface of the medial
surface of the medial pterygoid plate with careful dissection of the fibrous
attachments.
■ Be patient and careful during the release of this densely adherent portion of
the nasal mucosa working posteriorly and cephalad along the pterygoid
plate and palatine bone.
■ Confirm complete release by directly visualizing the plane of the medial
surface of the medial pterygoid plate.
■ If further release is required, the origin of the tensor veli palatini along the
medial pterygoid plate may be severed to improve mobilization.

■ The sheet of mucosa should now be freely mobile as one continuous sheet
posteriorly and along the anterior medial hard palate.
■ Attention is then turned to the greater segment.
■ The dissection of the nasal mucoperiosteal flap is identical posteriorly
along the hard palate cleft margin.
■ Anteriorly, at the bony junction of the vomer and bony palate, the nasal
mucoperiosteum is raised in continuity with the vomerine periosteum. This
vomerine flap is raised cephalad directly off the bone and in continuity with
the periosteum of the nasal surface of the hard palate.
■ In a cleft of the secondary palate only, the caudal edge of the vomer is
located in the midline of the two hard palate shelves.
■ The caudal vomer is incised in the midline and nasal mucoperiosteal flaps
raised off each side of the vomer.
■ Both vomerine flaps are used for closure of the nasal lining anteriorly; each
vomerine flap is secured to the ipsilateral hard palate nasal mucoperiosteal
flap.
■ As you close the nasal lining from anterior to posterior, you will continue
beyond the vomerine flaps and directly approximate nasal lining from the
palatal shelves.
■ Closure of Nasal Mucosa
■ Nasal layer closure is then commenced once assurance that the repair is
tension free by checking that both sides are sufficiently liberated (TECH FIG
3).
■ Meticulous closure is executed with knots tied on the nasal side.
■ Small wedges are excised at the base of the oral surface of the uvula to assist
closure.
■ Place eversion sutures during the closure of the uvulae to prevent notching
or bifidity.
■ It is helpful to pare the musculus uvulae into a nasal and oral component
during dissection so that musculus uvulae can be included in the suture
closure of both oral and nasal layers of the uvula to further strengthen the
closure.

TECH FIG 3 • Closure of nasal mucosal flaps from
anterior extent of cleft to the uvula.
■ Dissection of the Muscle and Intravelar Veloplasty
■ With the nasal layer completely closed, proceed with the muscle dissection
and reconstruction of the velopharyngeal sphincter.
■ Three steps are critical for muscle repositioning:
■ Identification and separation of levator veli palatini (LVP)
■ Velar musculature dissection and release from its attachments to the cleft
margin and hard palate shelf
■ Velar musculature repositioning and repair
■ Deep to the muscles inserted into the back of the bony hard palate, the LVP
inserts abnormally at the cleft margin in the anterior half of the velum.
■ Using a scalpel, sharply dissect the velar muscle layer off the nasal mucosa
along the cleft margin. This is done with a paramedian incision lateral to the
nasal mucosal closure line through the muscle until nasal mucosal surface is

identified.
■ It is easiest to separate the muscle layer once the nasal mucosa has been
repaired to give a “trampoline” effect, providing tactile feedback and
countertraction during this careful dissection.
■ The bulk and breadth of the muscle widen as you dissect laterally. This is
analogous to the changing depth of a swimming pool, with a shallow end
(paramedian) becoming deeper as one progressively dissects laterally.
■ The velar musculature is raised off the nasal mucosa and separated from the
tendinous fibers of the tensor veli palatini (TVP). This separation is done
laterally along the hard palate shelf at the junction of “salmon pink” velar
muscle fibers and tendinous fibers of the TVP.
■ The velar musculature is further dissected until it can be freely mobilized
to lie parallel to the posterior hard palate margin and overlying the
contralateral velar muscle bundle.
■ You have completed the levator dissection when the “salmon pink”-colored
longitudinal fibers of the levator are identified emerging from the skull
base and the entire dissected muscle is free to be reoriented to a more
functionally effective position in the posterior half of the soft palate.
■ The dissection of the velar musculature is performed on both sides.
■ Repair the muscles, and reconstruct the levator muscular sling by suturing
the muscles and securing with multiple sutures, knots facing the nasal
surface.
■ Ensure proper hemostasis is achieved.
■ Closure of the Oral Mucosa
■ Close the oral layer beginning with stay sutures placed anteriorly and
progressing posteriorly toward the uvulae with horizontal mattress sutures.
There is no attempt of push-back of the flaps for lengthening with a V-Y
closure (TECH FIG 4).
■ During oral layer closure, place some full-thickness sutures through both the
oral and nasal layers just posterior to the hard palate shelf (anterior to muscle
repair) to help obliterate the dead space and position the muscle repair.
■ Place interrupted simple sutures between each of the mattress sutures.
■ Attempt to minimize raw bone exposure by closing palatal flaps to the
alveolus wherever possible.

■ Recheck for adequate hemostasis, irrigate, and remove throat pack.
■ If concerned for airway during postoperative period, consider
nasopharyngeal tube insertion and a tongue stitch. Note that a tongue stitch is
rarely used in our practice.
TECH FIG 4 • Closure of oral mucosa after
medialization of the bipedicled flaps.
PEARLS AND PITFALLS
Headlight and
positioning
■ Good lighting and access to the palate are important
Pedicle dissection
■ Visibility of the greater palatine foramina is limited. The
release is accomplished with careful and near-

circumferential dissection from the lateral approach.
Complete the dissection from the medial approach.
Hemostasis
■ Ensure meticulous hemostasis throughout the case to
optimize visualization.
■ Judicious use of needlepoint diathermy.
■ Failure to do so may result in airway compromise, flap
necrosis, and wound dehiscence.
Use needlepoint
diathermy to make
hard palate incisions
■ Controls bleeding and persisting ooze.
Work on broad front
■ Avoid tunneling during dissection.
Patience and
precision during
dissection especially
around palatine
foramina
■ Bleeding obscures view, and careless dissection risks
injury to pedicle and vascularity of the flap.
Handle tissues with
care
■ The nasal mucosa is especially susceptible to tears.
Inset palatal flaps
with stay sutures to
help control closure
■ Helps to put the most difficult sutures anteriorly with
stay sutures to judge closure and maintains good
exposure.
Do not attempt
closure until all
layers are sufficiently
mobilized
■ Prevents tearing.
■ If sutures are prematurely placed, further attempts to
mobilize tissue are more likely to result in tears.
Prematurely suturing may also result in tears if tension is
still present.
Oronasal fistula
■ Critical to achieve adequate tissue dissection, perfect
approximation, and apposition of tissue layers with
meticulous suture technique to prevent fistulae.
POSTOPERATIVE CARE
■ Nasopharyngeal tube as required.
■ Remove tongue stitch in recovery if used.
■ Analgesia to reduce blood pressure and distress (24 hours of intravenous
opioids).

■ Encourage feeding.
■ Postoperative visit in 4 weeks.
OUTCOMES
■ Primary von Langenbeck palatoplasty with levator reconstruction provides a
reliable repair and good speech outcomes with 89% of patients having
acceptable or normal speech.
■ Velopharyngeal insufficiency necessitated surgical correction in 11% of
patients.
■ The fistula rate of a cleft palate repair with a bipedicled flap technique is
10.2% (95% CI, 6.3% to 15%) according to a systematic review of
international data.6
■ There was an observed trend toward higher fistula rates with bipedicled
compared to unipedicled flap technique.
■ The effect of palatoplasty on maxillary facial retrusion is controversial.
Inherent maxillary growth deficiency, secondary scarring from palatal flap
elevation, and timing of repair are all contributing factors to midfacial
retrusion. Deleterious growth has been shown to be greatest in patients treated
by Veau push-back technique.7
■ Further long-term studies are required to compare the effect of palatal flap
technique on maxillary growth restriction.
COMPLICATIONS
■ Bleeding is a feared complication as it may lead to an emergency with airway
obstruction and respiratory compromise. Additionally, hematoma may lead to
compression of the pedicle or flap, with resultant flap necrosis, wound
dehiscence, and oronasal fistulae.
■ To prevent this complication, vigilant hemostasis is an absolute necessity, and
adequate postoperative analgesia avoids stressing the repairs.
■ Airway obstruction may occur in the absence of hemorrhage, and a tongue
stitch or nasopharyngeal tube may assist in preventing obstruction in infants at
risk.
■ Flap necrosis is rare and avoidable with careful dissection and release of the
periosteal sleeve of the greater palatine pedicle.
■ Infection and wound dehiscence leading to oronasal fistulae are detrimental.
■ A small fistula secondary to delayed wound healing may heal with
conservative measures.

■ Failure of closure may necessitate reoperation with re-elevation and closure
of oral and nasal flaps, as well as possible augmentation using local flaps
and/or biologic adjuncts.
REFERENCES
1. von Langenbeck B. Weitere Erfahrungen im Gebiete der Uranoplastik mittels
Ablosung des mucosperiostalen Gaumenuberzuges. Arch Klin Chir. 1864;5:1-
70.
2. Wallace AF. A history of the repair of cleft lip and palate in Britain before
World War II. Ann Plast Surg. 1987;19:266-275.
3. Trier WC, Dreyer TM. Primary von Langenbeck palatoplasty with levator
reconstruction: rationale and technique. Cleft Palate J. 1984;21:254-262.
4. Gillett DA, Clarke HM. The hybrid palatoplasty: a preliminary report. Can J
Plast Surg. 1996;4(3 suppl):157-160.
5. van Aalst JA, Kolappa KK, Sadove M. CME article: nonsyndromic cleft
palate. Plast Reconstr Surg. 2008;121(1 suppl):1-14.
6. Hardwicke JT, Landini G, Richard BM. Fistula incidence after primary cleft
palate repair: a systematic review of the literature. Plast Reconstr Surg.
2014;134:618e-627e.
7. Lee YH, Liao YF. Hard palate repair technique and facial growth in patients
with cleft lip and palate: a systematic review. Br J Oral Maxillofac Surg.
2013;51:851-857.

10
CHAPTERSommerlad Palatoplasty
T. Guy Thorburn
DEFINITION
■ Cleft palate repairs can be broadly classified into straight-line repairs (such as
the Sommerlad technique) vs Z-plasty repairs (such as the Furlow technique).
■ Otto Kriens proposed the intravelar veloplasty based upon his work on the
anatomy of the cleft palate.1
■ Sommerlad then developed this dissection into a more radical procedure and
popularized the technique.
■ The underlying principle is identification and retropositioning of the soft
palate muscles, before connecting the levator muscle mechanisms from the two
sides of the soft palate.
ANATOMY
■ The key functional issue in CP or SMCP is that the levator muscle mechanism
is not in continuity on the two sides. In addition, the fibers become tethered to
the posterior border of the hard palate.
■ Successful functional palate repair therefore requires repair of the “levator
sling” as well as closure of the tissues across the cleft.
■ The tethering to the hard palate seems to be an equal problem in differing
types of cleft: whether unilateral or bilateral cleft lip and palate, cleft palate
only, or submucous cleft palate.
■ The key functional muscle is the levator palatini, but the surrounding
muscle/aponeurotic tissue is kept in continuity to allow more reliable tissue
handling and retropositioning and subsequent suturing.
■ Of note, the levator sits on the nasal aspect of the soft palate and so becomes
visible only when the dissection is well underway.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The initial assessment of the newborn with a cleft involving a palate would
usually be alongside a pediatrician and includes:
■ Pregnancy and birth history (including information from any antenatal
testing), gestation, birth weight, and Apgar scores.
■ Initial assessment of cleft type and any related anomalies, including any
airway concerns suggesting Robin sequence.
■ Medical, drug, and allergy histories.
■ Family history of clefts, other major health problems, or anesthetic problems
and any genetic diagnosis.
■ Feeding history, including bottle type (eg, squeezy bottle, free flow,
Haberman), current weight, maximum percentage weight loss and number of
days to regain birth weight, and volume/duration/frequency of feeds.
■ Physical examination to assess the upper airways, cleft type, cleft width and
how much deficiency there is of surrounding tissues, as well as any related
anomalies or dysmorphic features. The pediatrician would then complete a
fully newborn examination looking in particular for related health issues such
as cardiac, respiratory, renal, or neurological signs.
IMAGING
■ No routine preoperative imaging is required for typical clefts. For older
children presenting with SMCP or velopharyngeal incompetence (VPI),
assessment with a speech lateral videofluoroscopy helps to evaluate the
position of the velum during phonation and relative size of the soft palate to the
size of the pharynx.
■ Standardized preoperative clinical photos should be taken as these are
invaluable when assessing outcomes many years later.
SURGICAL MANAGEMENT
Preoperative Planning
■ A key aspect of successful cleft palate repair is optimizing the patient prior to
surgery. A pediatrician is a crucial member of the cleft team.
■ Although there is much discussion of age at palate repair, different team
protocols vary from around 3 months old to 15 months or more.
■ Very young babies will tend to be more susceptible to airway compromise
around the time of surgery.

■ Delaying repair until much older and speech has developed has been
associated with poorer speech outcomes, particularly related to articulatory
errors.
■ Our team protocol is for palate repair around 8 to 12 months (corrected for
prematurity), but our emphasis is much more on ensuring that the child is well
and thriving as surgery approaches.
■ If the child is not growing along his or her expected centiles (with growth
plotted on the appropriate chart for syndromic children), this should be
addressed before surgery.
■ We routinely postpone for about 4 weeks if children have upper respiratory
tract infections.
■ By following this approach, we have seen a significant reduction in fistulae
and concerns with speech function.
■ Routine blood tests or cross match samples are not required, unless the child is
known to have a specific risk factor.
■ For children with cardiac or respiratory problems, an up-to-date
echocardiogram or sleep study may be relevant.
Positioning
■ A Rae uncuffed or microcuffed tube is positioned in the midline and secured to
the lower face.
■ The taping of the tube needs to be secure but avoiding taping the mouth
closed or limiting access. Taping in a V shape along the line of the mandible
avoids displacing the tapes when the mouth gag is opened.
■ The child is placed supine on a warming blanket, with the head at the very end
of the operating table.
■ A large horseshoe gel head ring is placed under the shoulders and around the
head to provide support without overextending the neck.
■ A head drape is applied, and the face is prepped.
■ The table is tilted to a slight head-up position.
■ An operating microscope is used for the procedure. The height of the table is
adjusted once the microscope has been brought into place (adjusted according
to whether the surgeon prefers to sit or stand).
■ A modified Dingman mouth gag is placed.
■ A throat pack is placed, and a marker sticker put across the drapes as a
reminder to ensure it is removed at the end.

■ The sticker is placed so that the drapes cannot be removed without needing to
disturb the warning sticker.
■ The throat pack is also included in the scrub nurse count as an additional
precaution.
■ The nose and mouth are rinsed with aqueous chlorhexidine solution.
FIG 1 • Marking the incisions at the margin of the cleft.
Approach
■ The width of the cleft is measured. The extent of the cleft and any unusual
features are noted.
■ The incisions are marked with pen and ink (FIG 1).
■ Depending on the extent and shape of the anterior edge of the cleft, either a
horseshoe shape or a triangular flap can be marked anteriorly.
■ The line of the incision in the soft palate can be identified by the pale line
where the nasal mucosa meets the oral mucosa along the margin of the cleft.
■ For very wide clefts, lateral von Langenbeck incisions can be marked at the
outset, or these can be decided later in the procedure after the closing tension
around the hard palate-soft palate junction is apparent.
■ Tension is a factor of the soft tissue cleft width, the width of the lateral
shelves of the palate, the elasticity of the tissue, and how vertical the shelves
were sitting (which gives a “drawbridge effect”).
T E C H N I Q U E S

■ Hard Palate
Incisions and Dissection
■ Levobupivacaine or bupivacaine long-acting local anesthetic with adrenaline
1:100 000 is infiltrated and left about 8 minutes for vasoconstriction.
■ The injection is used to help hydrodissect the hard palate subperiosteal
layer and the vomer flaps if these are being used (TECH FIG 1A)
■ The incision is begun along the cleft margin (or in the midline for a SMCP
or rerepair).
■ For complete clefts of the palate, it is usually easier to start with the
posterior two-thirds of the hard palate extending across the hard palate-soft
palate junction, then to move on to the very anterior portion of the cleft,
and finally to move on to the posterior soft palate and uvula (TECH FIG
1B).
■ For clefts involving the hard palate, use a no. 15 blade to incise carefully
down to the bone along the margin of the hard palate and 3 to 5 mm past the
hard palate-soft palate junction and elevate subperiosteally with a periosteal
elevator or Warwick-James elevator (TECH FIG 1C,D).