Double- or three-layer appositional technique

The patient is positioned in dorsal recumbency.

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

An incision is made along the medial margin of the soft palate defect on each side to the level of the middle or caudal aspect of the tonsils.

Dorsal and ventral flaps are created on each side by bluntly dissecting the soft palatal tissue using small Metzenbaum scissors.

Nasal flaps are sutured from caudal to cranial with a 5-0 rapidly resorbable monofilament suture material in a simple-interrupted pattern. The knots are located in the nasopharynx or oral cavity.

Oral flaps are sutured in the same manner.

If tension is present along the suture line, partial-thickness (not penetrating the nasal mucosal layer) lateral releasing incisions are made in the oral mucosa the length of the soft palate defect.

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 soft palate.

Note previously successfully repaired hard palate defect.

After creating incisions along the medial margin of the soft palatal defect on each side, sutures are preplaced on the nasal flap.

The nasal flap is sutured in a single-interrupted pattern.

Final result of the midline soft palate defect repaired using the double-layer apposition technique.