Bart Nierzwicki¹ and Thaer Daifallah²

¹Private Practice, Millennium Surgical, Chicago, Illinois, USA

²Department of Oral and Maxillofacial Surgery, University of Missouri–Kansas City, Kansas City, Massouri, USA

A means of repairing congenital palatal defects utilizing nasal and oral mucoperiosteal flaps to achieve complete palate closure and velopharyngeal competence with minimal impact of maxillary growth.

Indication

1. Hard and soft tissue defects of the palate

Contraindications

1. No absolute contraindications
2. Relative contraindications include medical comorbidities which preclude the use of general anesthesia

Anatomy

Muscles of soft palate:

1. Levator palatini
2. Tensor palatini
3. Palatopharyngeus
4. Palatoglossus
5. Musculus uvulae

Bardach Two-Flap Palatoplasty Technique

1. The patient is placed supine on the operating table and orally intubated with a RAE endotracheal tube.
2. The neck is carefully hyperextended for better visualization of the palate and alveolar process.
3. The oral cavity and face are prepped with povidone–iodine and draped.
4. A Dingman or similar retractor is inserted to allow complete exposure of the palate from the uvula to the anterior maxillary alveolus.
5. Methylene blue on a 30G needle tip is used to mark the proposed incision sites adjacent to the cleft defect.
6. Local anesthetic containing a vasoconstrictor is infiltrated into the upper lip vestibule, alveolar cleft, hard palate, soft palate, and vomer mucoperiosteum.
7. Nasal cavities are packed with oxymetazoline-soaked cottonoids.
8. Incisions are initiated with a #15c blade immediately adjacent to the cleft at the junction of the nasal and oral mucosal lining within the soft and hard palate bilaterally. The incisions originate at the posterior aspect of the cleft and extend anteriorly to the junction of the palatal and alveolar mucosa (Figure 26.1, Case Report 26.1). A second incision is initiated at the junction of the hard palate and the maxillary alveolus. This incision originates at the termination of the first incision and extends posteriorly around the maxillary tuberosities bilaterally.
9. Along the entire length of the cleft, a cottle elevator is used to elevate a full-thickness mucoperiosteal flap separating the nasal mucosa from the oral mucosa. Care is taken to preserve the greater palatine vascular pedicle.
10. Once elevated, the oral mucosal flaps are retracted laterally with 4-0 silk sutures (Figure 26.2, Case Report 26.1). Fibrous attachments around the vascular pedicle are freed, and the abnormal attachments of the levator palatini and tensor palatini muscle area are released bilaterally from the palatine bones.
11. The nasal lining is freed from the palatine bone, and the levator palatini muscle is freed from the nasal and oral lining. Judicious use of bipolar cautery is utilized for hemostasis.
12. A vomer flap is elevated to allow for a tension-free closure of the nasal mucosa. The vomer mucoperiosteum is split asymmetrically, and it is elevated from the anterior edge of the cleft and extends to the junction of the hard and soft palate.
13. The hard palate extent of the cleft is repaired with a two-layer closure. The soft palate extent of the cleft is repaired with a three-layer closure. The nasal lining of the hard palate and soft palate is primarily closed using 5-0 Monocryl interrupted and running sutures (Figure 26.3, Case Report 26.1). For wide clefts where primary closure of the nasal mucosa cannot be achie/>
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