Bipedicled Palatoplasty for Closure of Wide Veau Class II Anterior Palatal Defect: A Case Series

Closure of wide palatal defects poses an operative challenge. Many operative techniques have been described for both soft and hard palatal defects.^1-2 The primary goal of palate repair is palatal lengthening and reorientation of the palatal musculature to achieve velopharyngeal competence.^1-2 While closure of soft palatal defects in wide clefts is typically achieved with utilization of lateral relaxing incisions, a multilayered closure of anterior defects is more challenging. Often, palatal length must be sacrificed to allow for tension-free closure of the repair, especially when the cleft is wide. This can result in poor velopharyngeal functioning and the need for additional speech surgeries.

With the most common and most dreaded complication following palate repair being development of oronasal fistula, the water-tight and tension-free closure of both the oral and nasal layers of the anterior palate is necessary.^1-3 The authors present 2 cases of patients with wide Veau class II cleft palates in which a novel bipedicled anterior palatal flap was utilized for complete and tension-free closure of the palatal defects.

Bipedicled Palatoplasty Technique

After closure of the soft palate utilizing the Furlow palatoplasty technique, attention is turned to the anterior palatal defect. A releasing incision is made along the lingual alveolar ridge, and hard palatal oral mucosal flaps are elevated with 360-degree dissection of the greater palatine neurovascular bundles to achieve maximum central advancement. Instead of completing the anterior palatal repair at the level of the anterior aspect of the cleft, the anterior attachment of the palate is raised in a subperiosteal manner, dissected free, and detached from the anterior palate at the incisive foramen. Dissection is carried posteriorly until the greater palatine neurovascular bundles are encountered bilaterally. The anterior palatal flap is then freely mobile and “U-shaped,” receiving dual blood supply from bilateral greater palatine vessels. It is then sutured together in the midline as a bipedicled mucoperiosteal flap for a tension-free closure of the oral mucosa. Figure 1 demonstrates a schematic of the steps in this technique.

This patient was a 19-month-old male child with Pierre-Robin sequence and a wide Veau class II cleft palate (Figure 2A). The patient was born at 29 weeks’ gestation and had a prolonged stay in the neonatal intensive care unit after birth because of prematurity and neonatal respiratory distress syndrome requiring tracheostomy. Due to the presence of tracheostomy and inability to tolerate capping for a sleep study, a precise diagnosis was delayed until an examination under anesthesia could be performed. Further examination demonstrated severe obstructive sleep apnea, a wide Veau class II cleft palate, and severe glossoptosis relieved with jaw thrust. The patient ultimately underwent mandibular distraction with hope for decannulation and to allow palatal shelves to drop once the tongue was out of the way. Unfortunately, due to the delayed nature of mandibular advancement, the palate remained wide and U-shaped with minimal tissue available for closure.

At the age of 19 months, the decision was made to proceed with palate repair. The preoperative plan was to perform a Furlow palatoplasty with bilateral relaxing incisions and vomerine flaps for closure of the anterior palatal defect. Consent was also obtained for bilateral buccal flaps, should they be necessary. Closure of the soft palate nasal mucosal, muscular, and oral mucosal layers was achieved through Furlow palatoplasty with bilateral von Langenbeck–type relaxing incisions. Closure of the hard palate proved more difficult. The nasal layer was closed with bilateral vomerine flaps as planned; however, closure of the oral layer with the available tissue was a challenge, and a bipedicled anterior palatal flap was employed (Figure 2B-D). In short-term follow-up, this patient has done well and has been decannulated. The lateral areas of the anterior palate were well mucosalized at 3 weeks following surgery. He is active in speech therapy and progressing as expected. He has shown no signs of maxillary growth restriction as of 9 months following surgery. 

Case 2 was a 13-month-old female child with a wide Veau class II cleft palate (Figure 3A). The patient was a born at full term and was brought to the plastic surgery clinic at the age of 13 days for evaluation; subsequent inpatient admission was required because of failure to thrive. Due to concern for Pierre-Robin sequence, a nasoendoscopy was performed that revealed mild glossoptosis. A sleep study demonstrated an apnea-hypopnea index of 5.4. Once a proper feeding regimen was established, the patient was discharged home with close monitoring. At the age of 11 months, the decision was made to proceed with palate repair. The preoperative plan was to perform a Furlow palatoplasty with bilateral relaxing incisions and vomerine flaps for closure of the nasal layer anterior palatal defect. Closure of the soft palate was achieved as planned, but as anticipated, multilayer closure of the wide, hard palatal defect posed a challenge. Vomerine flaps were utilized for closure of the nasal layer. Midline apposition of the oral layer was only achieved with employment of a bipedicled anterior palatal flap (Figure 3B-C). In short-term follow-up, this patient has done well, and the repair has healed without issue. The lateral areas of the anterior palate were well mucosalized at 3 weeks following surgery. She has shown no signs of maxillary growth restriction at 8 months following surgery. She has just begun speech therapy and is progressing as expected.

Complete palatal closure in patients with a wide, U-shaped cleft palate is a challenge. Numerous studies have shown that incidence of fistula development after palatoplasty is higher in patients with wide cleft palates, often due to significant tension on the anterior palatal closure.^2-4 Multiple techniques have been described to offload this tension in order to achieve adequate closure; however, there is no general consensus or gold standard recommendation. Here, a novel technique is presented in which a bipedicled anterior palatal mucoperiosteal flap is raised with complete detachment from the hard palate anteriorly, allowing for water-tight and tension-free closure of very wide hard palatal defects. To the authors’ knowledge, this technique has not yet been described in the literature. The complete release of the mucoperiosteal flap from the hard palate offloads significant tension to allow for adequate medial apposition. Additionally, freeing of all other tissue attachments while leaving this flap bipedicled ensures dual arterial inflow for adequate perfusion. 

Another benefit of this technique is the ability to set back the anterior palatal closure to a more posterior location, preventing inadvertent shortening of the palate that can happen when attempting closure of the anterior palate, thereby hoping to limit negative speech outcomes. While allowing some posterior positioning of the soft palate, this primary closure technique is still limited in the amount of retroposition able to be achieved. 

This report is limited with regard to long-term follow-up to better understand how this repair will affect both speech outcomes and maxillary growth. While any cleft surgeon aims to provide a functional palate repair in terms of speech and mastication while preserving maxillary growth potential, no surgical protocols have yet to completely circumvent the hypoplastic maxilla. The amount to which this specific surgical procedure will limit maxillary and premaxillary growth is unknown at present but is a consideration when proceeding with this method. 

In conclusion, the wide cleft palate remains a challenge for craniofacial surgeons. Lack of a gold standard for palatal closure and significant variability in patient anatomy further complicates an already-difficult problem. Readers are urged to consider this method for anterior palatal closure in patients who have especially wide clefts with limited tissue for oral mucosal closure of the anterior palatal defect. 

Affiliations: ¹Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS; ²School of Medicine, University of Mississippi Medical Center, Jackson, MS

Correspondence: Kathryn W Brown MD; kwbrown@umc.edu 

Disclosures: The authors have no relevant financial or nonfinancial interests to disclose.