von Langenbeck technique/medially repositioned double-flap technique

The patient is positioned in dorsal recumbency.

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

Two releasing incisions, approximately 2 mm palatal and parallel to the maxillary teeth, are created. The margins of the cleft are tangentially incised to remove the epithelium.

The mucoperiosteum is undermined bilaterally to create two sliding flaps, avoiding trauma to the major palatine arteries.

The two flaps are sutured in the midline in a simple interrupted pattern with 5-0 rapidly absorbable monofilament suture material.

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%).

Narrow midline cleft of the secondary (hard and soft) palate.

Completed cleft repair using von Langenbeck technique on the hard palate. The soft palate is repaired using a double-layer appositional technique  (A detailed description of the technique is available in the dedicated section of the AO Surgery Reference).