Complete Secondary Cleft Palate Repair

The incisive foramen divides the primary palate from the secondary palate. Either may occur in the complete or incomplete forms. Although anatomically distinct, they are commonly occur together.

Steps in the Procedure

1. The palate is exposed with a Jennings or Dingman mouth gag or cheek retractors

2. A 2-0 silk suture is placed through the tongue to act as stay sutures to pull the tongue forward. Alternately, the tongue is retracted out of the operative field using a tongue retractor.

3. The internal pterygoid muscle is identified as a marker for the plane of mobilization of the soft palate.

4. A #15 scalpel is used to incise the mucosa and periosteum medial to the alveolar ridge.

5. The incision is curved laterally (outwards toward the lips) at the posterior end of the alveolar ridge.

6. The incision is continued posteriorly to a position in the plane of the uvula.

7. A mucosal/periosteal flap is raised via blunt dissection with a nasal freer the entire length of the incision.

8. Care must be taken to not break through the mucosa at the cleft edge anteriorly.

9. The mucosal/periosteal flap is raised posteriorly to expose the tensor veli palatini muscle with care being taken to not disrupt the posterior palatine vessels.

10. The internal pterygoid muscle and tendon is exposed at the posterior edge of the raised mucosal/periosteal flap and the space medial is opened widely using blunt dissection and displacing the tonsils and tonsillar pillars medially.

11. Blunt dissection with the nasal freer or sharp dissection with a #15 blade is performed to separate the flap from the palatine bone near the origin of the pterygoid muscle.

12. The edge of the hamulus is identified by palpation and exposed with the internal pterygoid muscle serving as a landmark.

13. Some surgeons fracture the hamulus using a small osteotome to release tension on the tensor veli palatini muscle, although this is controversial as it may lead to damage to the eustachian tube and impair function.

14. A #15 scalpel is used to separate the soft palate from the posterior edge of the hard palate.

15. The area of dissection is packed with gauze and the identical steps listed above are performed on the contralateral (opposite) side.

16. A 5-0 Dermalene stay suture is placed through the uvula and gentle tension is placed on it.

17. A #17 scalpel is used to make an incision along the medial margin of the cleft

18. The edge of the hard palate is identified with sharp dissection to develop the layers of the oral mucosa and nasal mucosa.

19. The edge of the soft palate is identified with sharp dissection to develop the layers of the oral mucose, nasal mucosa, and the middle muscle layer.