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Plastic and Reconstructive Surgery • February 2024

Von Langenbeck Palatoplasty Originally described in 1861, this technique involves repair of an incomplete cleft by elevat ing bipedicled mucoperiosteal flaps (Fig. 6). [ See Video 3 (online) , which displays von Langenbeck palatoplasty.] In comparison to the Bardach two flap palatoplasty, this technique maintains the pal atal soft-tissue attachments to the anterior margin of the alveolus, making it a bipedicled flap. 48 The incisions are created along the edges of the cleft in the midline and lateral relaxing incisions that begin posterior to the maxillary tuberosity and follow the posterior portion of the alveolar ridge. Once both bipedicled mucoperiosteal flaps have been elevated, they are advanced to the midline and repaired primarily. In the original descrip tion, the lateral raw surfaces were left to heal by secondary intention. However, the senior author (A.K.G.) feels that the lateral surfaces should be either closed primarily or covered with a vascular ized tissue layer, such as buccal fat flaps, to mini mize subsequent contracture and maxillary growth restriction. As with the two-flap palatoplasty, this primary hard palate closure is combined with intravelar veloplasty or Furlow double-opposing Z-plasty for complete cleft closure. 49 Veau-Wardill-Kilner (V-Y Pushback) Palatoplasty A modification of the von Langenbeck pala toplasty, this technique is useful for closure of incomplete clefts (Fig. 7). In comparison to the von Langenbeck palatoplasty, the V-Y pushback raises mucoperiosteal flaps off the greater pala tine artery and divides the anterior pedicle. The V-to-Y incision made on the hard palate allows for the mucoperiosteal flaps to be pushed back and positions the levator muscles in a more ana tomical, posterior position. 23 In essence, this tech nique is a modification of von Langenbeck’s with increased posterior palatal lengthening at the expense of wider undermining and increased Fig. 5. (Continued). shown elevated from the hard palate and isolated on their pedicles, the paired greater palatine arteries. The nasal mucosal layer has been closed from the alveolus ante riorly to the tip of the uvula posteriorly. The muscles depicted in shaded gray are no longer inserted on the posterior border of the hard palate, but rather reoriented into anatomical align ment horizontally to recreate the levator sling in the posterior most soft palate. ( Below ) The oral mucosal layer is repaired last to complete the two-flap palatoplasty. [Reprinted with per mission from van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate. Plast Reconstr Surg . 2008;121(Suppl):1–14.]

denuded palatal bone. The outcomes of V-Y pushback techniques have resulted in improved speech outcomes but also adverse facial growth and increased fistula rates. Fig. 6. Von Langenbeck palatoplasty. Incisions for the von Langenbeck palatoplasty are designed similar to the two flap palatoplasty with medial incisions along the cleft mar gin between the oral and nasal mucosa. However, with this approach, the anterior hard palate mucoperiosteum is kept intact, and thus both oral mucoperiosteal flaps are function ally bipedicled. [Reprinted with permission from van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate. Plast Reconstr Surg . 2008;121(Suppl):1–14.] Introduced be Leonard Furlow in 1986, the double-opposing Z-plasty or “Furlow palatoplasty” is a technique used to close cleft palates by way of creating two soft palate Z-plasties that are mir ror images of each other (Fig. 8). 50 [ See Video 4 (online) , which displays Furlow palatoplasty: part 1. See Video 5 (online) , which displays Furlow palatoplasty: part 2.] The posteriorly based oral and nasal flap contain the levator muscle and position the levator sling posteriorly after closure. The palate is lengthened through the central limb of the Z-plasty. This procedure theoretically allows for hard palate closure without relaxing incisions, therefore minimizing denuded bone along the posterior alveolar ridge and maxillary growth restriction. However, given the Z-plasty closure relies on bringing in lateral soft palate tissue, wide clefts are sometimes not amenable Soft Palate Repair Techniques Furlow Palatoplasty

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