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Plastic and Reconstructive Surgery • February 2024

migration of the velar sling, minimal donor-site morbidity, and minimal raw surface, which prevents scar contracture. It has shown promising results in treatment of common palatoplasty complications including fistula and VPI. 69–74

COMPLICATIONS

Airway Compromise Early postoperative complications following primary palatoplasty relate to upper airway com promise. Airway compromise is more common in syndromic cleft palate and other associated con genital anomalies, and prolonged operative times leading to significant edema. 75 Management depends on the severity and cause of airway obstruction and ranges from positional changes to airway control with reintubation. 75 Fistula Formation Successful palatal surgery is measured by com prehensible speech outcomes and continuity of the repair. Oronasal fistula following palatoplasty is a common complication with a varying reported inci dence in the literature. A meta-analysis by Bykowski et al. estimated the true fistula rate at approxi mately 5%, with half of the reported fistulas occur ring at the junction of the soft and hard palate. 76 Predictive risk factors include cleft type, surgical technique, age at operation, and syndromic clefts. 77 Symptomatic fistulas require surgical management, with treatment options varying from local flaps (mucoperiosteal flap, buccal myomucosal flap) to free flaps (radial forearm free flap), depending on the size and location of the fistula. 78,79 Speech Impediment Normal speech articulation following primary palatoplasty requires dynamic and synchronized movement of the velopharyngeal sphincter. VPI is the result of improper velopharyngeal closure and can have a negative impact on speech, pro ducing a pattern of speech that is hypernasal with weak consonant production. 80 VPI is a relatively common occurrence following primary cleft pal ate repair, and the reported rate of surgical cor rection for VPI is 20% to 30%. 80,81 Formal speech evaluation is required for diagnosis and aids in presurgical decision planning by evaluating the velopharyngeal closure pattern. Correction can be performed with a variety of techniques includ ing primary or secondary Furlow palatoplasty, sphincter pharyngoplasty, pharyngeal flap, and buccal myomucosal flaps. 80

traditional palatoplasty techniques, and one ret rospective study found closure of hard palate with vomer flaps compared with two-flap palatoplasty to have less adverse effect on maxillary growth and incisor overjet. 67 Buccal Myomucosal Flap The buccinator myomucosal flap is an intra oral, pedicled flap that has been increasingly used for palatal lengthening to correct postpalatoplasty VPI, but it has also been implemented as an adjunc tive procedure in primary palatoplasty. Jackson et al. demonstrated use of a unilateral buccinator myomucosal flap placed at the posterior hard pal ate during primary palatoplasty to increase the length of the velum, with excellent reported speech outcomes and fistula rates. 68 The advantages of the buccal myomucosal flap include anatomical length ening of the soft palate and prevention of anterior Fig. 10. Vomer flap. ( Above ) Anatomy of the palate and vomer in the presence of a midline cleft of the hard palate and the anticipated incisions for a vomer flap indicated by the red lines . ( Below ) Vomer mucoperiosteal flaps elevated from either side of the vomer bone and sutured to the nasal layer of palatal muco periosteal flaps. Also shown is a midline straight-line repair of the oral layer of the palatal mucoperiosteal flaps for a final repair consisting of two layers.

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