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

Volume 153, Number 2 • Cleft Palate Surgery

velopharyngeal dysfunction through relapsed migration of levator muscles out of their anatomi cal alignment. Hard Palate Repair Techniques The most commonly used techniques in cleft palate repairs that involve the hard palate include von Langenbeck palatoplasty, 39 Veau-Wardill Kilner pushback, 23,40–42 and Bardach two-flap palatoplasty. 43,44 Two-Flap Palatoplasty The most common technique used for one stage repair in a survey reported in 2009 was the Bardach style (two-flap palatoplasty) (Fig. 5) com bined with intravelar veloplasty or the Furlow pal atoplasty. 30 A modification of the von Langenbeck palatoplasty, the Bardach two-flap palatoplasty involves extending the lateral incisions along the anterior aspect of the secondary palate to meet in the region of the incisive foramen, thereby elevating bilateral unipedicled mucoperiosteal flaps from the hard palate and vascularized by the greater palatine arteries. 43 The senior author (A.K.G.) modifies the anterior incision to extend into the alveolar margin, separating the palatal and labial gingival layers at the cleft margin. [ See Video 1 (online) , which displays two-flap palato plasty: part 1. See Video 2 (online) , which displays two-flap palatoplasty: part 2.] This modification allows for gingivoperiosteoplasty on closure of the palate. However, if the patient had a gingivoperi osteoplasty at the time of initial cleft lip repair, one would follow the traditional Bardach tech nique and not reenter the gingiva at the time of cleft palate repair. Modifications by Salyer et al. implemented a bilayer closure of the hard pal ate involving both nasal and oral mucoperiosteal flaps, recreating a functional levator sling with velar muscle dissection and repair, and incorpo rating vomerine flaps to facilitate nasal lining closure. 45 Two-flap palatoplasty is a useful technique for closure of complete unilateral or bilateral clefts. Dissection of mucoperiosteal flaps off the greater palatine artery achieves greater mobility in flap positioning and can close anterior hard palate fistulas in unilateral complete clefts. There is also less denuded bone relative to V-Y push back and less detrimental effects on maxillary growth. Beagle studies conducted by Bardach et al. showed no interference with facial growth. 46,47 This procedure does not, however, have any effect on palatal lengthening and requires a soft palate repair to reposition the velar musculature.

Fig. 5. Two-flap palatoplasty. ( Above ) Incisions for the two-flap palatoplasty are designed along the cleft margin between the oral and nasal mucosa and along the palatal aspect of the max illary alveolus. Incisions are bounded anteriorly by the incisive foramen. ( Center ) Bilateral mucoperiosteal flaps are ( Continued )

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