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

Volume 153, Number 2 • Cleft Palate Surgery

palatini tendon. 54 In addition, the senior author (A.K.G.) has modified creation and inset of the Z-plasty flaps to allow more posterior inset of the nasomuscular and oromuscular layers. He also recommends that one consider using buccal fat flaps during Furlow palatoplasty to augment the oronasal mucosal layers for fistula preven tion and dead space obliteration, and prevent relapse with anterior migration of the transposed levator muscles from their restored anatomical alignment. Buccal fat flaps are particularly use ful if there is any evidence of compromise of the nasal or oral mucosal layers during their anterior transposition, as it provides a vascularized layer to improve healing of the compromised tissues and minimize potential fistula formation. 55 Intravelar Veloplasty First described by Veau and modified by Braithwaite and Kriens, 56 this technique involves dissection of the abnormally positioned levator muscles off the posterior edge of the hard palate and suturing the levator muscle edges together at the midline. Over time, there has been a shift to more radical dissection of the levator veli pala tini to reposition the velar sling more posteriorly. Cutting and Sommerlad’s modification involves radical dissection with a microscope, division of the tensor palatini tendon, and repositioning the muscle at the hamulus. 50 Nguyen et al. advo cate for overlapping intravelar veloplasty (IVV) to create a tighter levator veli palatini sling and have shown improved speech outcomes in a ret rospective study when compared with less radi cal techniques. 57 This study was corroborated by Andrades et al. in which the authors showed improved speech outcomes for patients undergo ing radical IVV with two-flap palatoplasty com pared with those undergoing two-flap palatoplasty only. 58 The senior author (A.K.G.) supports radi cal dissection of the levator muscles with overlap ping repair using double-armed mattress sutures to secure the overlapping levator muscles, and transposition of the muscles as far posteriorly as possible until they are abutting on the anterior tonsillar pillars. This technique has the potential to provide physiologic lengthening of the palate with activations of the muscle sling, which is an important adjunct because anatomical palatal lengthening is often not achieved in techniques in which the IVV is used [ see Video 3 (online) ]. Although these radical techniques offer greater levator mobility for repositioning, critics have questioned the scarring and stiffness incurred with radical levator dissections. 59

to closure by way of Z-plasty. Modifications have been made to address this, such as relaxing inci sions, 51,52 mucoperiosteal undermining, and hamulus fracture 53 or division of the tensor veli Fig. 7. Veau-Wardill-Kilner V-Y pushback palatoplasty. ( Above ) Incisions for the Veau-Wardill-Kilner V-Y pushback palatoplasty are designed in similar fashion to the von Langenbeck proce dure, with an additional incision anteriorly connecting the inci sions along the cleft margin and along the posterior border of the alveolus. ( Below ) Bilateral flaps are shifted posteriorly to close the midline palatal defect, and the donor sites anteriorly are left to heal secondarily. [Reprinted with permission from van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyn dromic cleft palate. Plast Reconstr Surg . 2008;121(Suppl):1–14.]

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