Single-layer overlapping-flap technique

The patient is positioned in dorsal recumbency.

Maxillary or infraorbital nerve blocks are recommended during a cleft repair.

A modified U incision the length of the palatal defect is made on one side of the defect, 2-3 mm palatal to the maxillary teeth.

To prevent the formation of an oronasal fistula:

• The caudal incision must not lie over the soft palate
• The rostral incision must not be full-thickness over the palatine fissures.

A mucoperiosteal flap is raised using a periosteal elevator. Avoid trauma to the major palatine artery at the caudal aspect of the flap.

The major palatine artery is ligated and transected at the rostral aspect of the flap. Only a partial-thickness flap is created to prevent an oronasal fistula formation when elevating over the palatine fissure. Preserve the flap base because it will act as a hinge when the flap is reflected 180 degrees over the cleft.

A mucoperiosteum incision is made on the cleft's entire length on the other side, perpendicular to the cleft margin.

The oral mucoperiosteum is elevated 8-10 mm away from the cleft margin.

Use stay sutures to manipulate the flap.

The reflected mucoperiosteal flap is hinged over the defect and positioned between the hard palate and the mucoperiosteal flap on the cleft's opposite side. The reflected flap covers the defect and extends approximately 3 mm beneath the opposite mucoperiosteal flap.

If the flap cannot be closed without tension, a releasing incision (dotted line) 2-3 mm palatal to the maxillary teeth is required to close the wound.

The hinged flap is sutured with a horizontal mattress suture pattern without tension using 4-0 rapidly absorbable monofilament suture material. The sutures are preplaced and then tied from caudal to rostral.

The exposed palatal bone, where the hinged flap was harvested, heals by second intention. It takes 3-4 weeks to heal completely.

Small flap dehiscence should be repaired, especially if the dog is showing clinical signs.

If there is tension on the suture line, dehiscence will likely occur.

If dehiscence occurs and the defect is clinically significant, the repair is delayed for 4-6 weeks to allow the tissues to heal.

Multimodal perioperative analgesia is provided by combining opioids and non-steroidal medications. Analgesia is provided for 5-7 days postoperatively.

A broad-spectrum antibiotic is continued for 10-14 days postoperatively depending on the nature, complexity, and duration of the surgical procedure and the presence of complicating factors (e.g., rhinitis).

Postoperative monitoring is required. Evaluate for oral swelling and impaired breathing. The patient is hospitalized overnight, and the surgical site is checked the next day. The surgical site is then evaluated weekly until healing is confirmed (6 weeks postoperatively). Skin sutures in cases of cleft lip repair should be removed 10-14 days postoperatively.

The most common complication is dehiscence. If it occurs and the resulting defect is of clinical significance, then repair is delayed for 4-6 weeks to allow the tissues to heal.

Although the placement of a feeding tube (e.g., esophagostomy or gastrostomy) could be considered, in most cases, oral intake of food can begin following complete recovery from anesthesia. A liquid or a soft blended diet is used for 2 weeks, followed by a slow conversion to a soft diet over the following 2 weeks. Chew toys must be avoided for 6 weeks.

The oral cavity should be carefully rinsed twice daily with an antiseptic oral rinse (e.g., chlorhexidine gluconate 0.12%).

Midline cleft of the hard palate.

Preoperative 3D CT image showing a large bony defect in the area of palatine fissures compared to soft tissue defects.

CT is needed for correct surgical planning to evaluate the size and shape of the bony defect.

Planning of the hinged flap.

Careful manipulation of the flap using stay sutures.

Completed repair of the cleft palate. The overlapping flap technique was used to repair the hard palate's cleft, and the appositional technique to repair the soft palate defect (A detailed description of the technique is available in the dedicated section of the AO Surgery Reference).

Note:

• The major palatine artery being preserved at the caudal aspect of the flap.
• The split-thickness approach on the rostral aspect of the flap to avoid exposure of palatine fissures.