Wednesday, April 30, 2025

Return to:  Cleft Lip and Palate Protocols

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Modified Operative Note

Findings
  • Very wide palate cleft: 15.5 mm cleft in a 30 mm wide palate at posterior hard palate
  • Alveolar gap: 4 mm left, 0.5 mm right
  • No touch palatoplasty on hard palate
  • Furlow double-opposing Zplasty palatoplasty of soft palate posteriorly
  • Vomer flaps bilaterally for closure of nasal floors for hard palate
  • Bilateral buccal myomucosal flaps – left to the nasal soft palate and right to the oral hard palate overlying vomer flaps
Operative Report

Informed consent was reviewed with the family. The patient was transferred to the OR and placed in the supine position.

The patient was rotated 90 degrees toward the door and pressure points were padded. The anesthesia team then performed bilateral ultrasound-guided V2 blocks. Please see their procedure note for full details.  He was then prepped and draped in the standard fashion. A 70-degree endoscope was introduced into the oral cavity for appropriate visualization.  Measurements were taken of the cleft with, palate with, and alveolar gaps as noted above.  There was noted to be a residual bridge of tissue posteriorly containing the uvula and bridging the cleft.  The remainder of the straight-line closure from the prior procedure did not persist.  A no touch palatoplasty in hard palate with bilateral buccal flaps was then planned with a Furlow double opposing Z-plasty repair was planned on the soft palate.  The Z flaps were then raised, on the left with the palatal musculature on the oral cavity side, and on the right with the palatal musculature on the nasal cavity side.  The incision was carried anteriorly on the palatal shelves to the level of the alveolar cleft, and a thin free edge of tissue was raised in a submucoperiosteal plane laterally to accommodate flap inset later.

The nasal cavity closure was then undertaken. Vomer flaps were then raised on both sides of the vomer in a submucoperiosteal plane. The vomer flaps were sutured with 4-0 Vicryl suture into the free edge of tissue on the palatal shelves anteriorly to the level of alveolar cleft to separate the nasal cavity from the oral cavity and establish separation between the palatal and labial sides of the alveolus.  Care was taken to evert the mucosal surfaces of the flaps into the nasal cavity.

Attention was then redirected to the palatal Z-plasty.  Due to the large width of the cleft, it was not possible to bring the tips of the Z flaps all the way to the contralateral palatal shelves.  Thus, these were inset with the furthest lateral reach they would accommodate.  A single 4-0 PDS suture was used to imbricate the palatal musculature, and the rest of the Z-plasty closure was undertaken with 4-0 Vicryl suture.  Mucosa from the aforementioned bridge of soft palate tissue at the uvula was utilized to contribute tissue coverage to the Z-plasty closure.

At this point, it was determined that the remaining open cleft and exposed raw surface of the nasal cavity closure would require bilateral buccal flaps to close.  The approximate location of Stensen's duct and the left buccal mucosa was marked, and a buccal flap was then planned.  This was then raised anteroposteriorly in a subbuccinator plane, taking care to leave the buccal fat pad in place.  A similar procedure was then performed in the right buccal mucosa. The left posteriorly based buccal flap was then inset into the posterior portion of the remaining cleft defect using 4-0 Vicryl suture, with the mucosal side reconstituting the nasal floor. The right posteriorly based buccal flap was then inset with 4-0 Vicryl suture as an overlay over vomer flaps used for nasal cavity closure.  The mucosal side was oriented to the oral cavity.  Due to the width of the cleft, the anterior extent of the right buccal flap was not quite sufficient to reach the level of the premaxilla.  A residual area of raw tissue remained exposed in the oral cavity anteriorly.  The buccal flap harvest sites were then closed with 4-0 Vicryl suture. Avitene was packed into the posterior aspects of the buccal flap harvest sites, as well as the exposed raw tissue posterior to the premaxilla.  This completed the procedure.  The patient was then turned over to the anesthesia team for emergence.