Key notes on plastic surgery/Adrian M. Richards

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104 THE HEAD AND NECK
• The flaps are then transposed medially and sutured together in the midline.
• Each flap receives its blood supply from the greater palatine vessels.
• This technique, unlike ‘the push back’, avoids an incision in the anterior portion
of the palate.
• This area is believed to contain important maxillary growth centres.
• Reduced dissection in this site may reduce subsequent facial undergrowth.
Medial von Langenbeck technique
• This is similar to the conventional von Langenbeck repair except that the releasing
incisions are based more medially.
• The bipedicled flaps are therefore not as wide as in the conventional repair.
• Reduced lateral dissection may improve subsequent palatal growth.
Simple repair with no flaps
• In some narrow clefts, it may be possible to elevate mucoperiosteal flaps along
the borders of the cleft and suture them together without the need for lateral
releasing incisions.
• The reduced dissection may improve subsequent palatal growth.
• In order to reduce the width of the cleft and facilitate simple repair, some
authors have advocated repairing the soft palate at the time of lip repair.
• The constraining forces of the musculature of the lip anteriorly and the
soft palate posteriorly narrow the width of the palatal cleft and facilitate simple
repair.
Soft palate
• When repairing the soft palate, it is important to detach abnormal muscle insertions
into the back of the hard palate and reconstruct the normal muscular sling.
• The following techniques are commonly used to repair clefts in the soft palate.
Intravelar veloplasty
• The edges of the cleft are incised and the muscles of the soft palate are released
from the posterior edge of the hard palate and the oral and nasal mucosa.
• The palate is then repaired in three layers:
1 The nasal mucosa
2 The muscle
3 The oral mucosa.
• The lateral extent of the muscle dissection is variable.
• Some authors advocate dissection as far laterally as the pterygoid hamulus.
Furlow technique
• This technique involves lengthening the palate with two opposing Z-plasties.
• The first Z-plasty is based on the mucosa on the nasal surface of the soft palate.
• The second is designed in the opposite direction and is based on the mucosa of
the oral surface of the soft palate.
• The intervening muscle layer is included in the posteriorly based flap of each
Z-plasty.