which commences by repairing the labial gingiva. We have repaired the labial and palatal gingiva, and the labial gingiva can now be repaired after having excised any epithelial layers between the labial gingival edges. Before repairing the palatal gingiva, we place a monocryl suture coming from the mucoperiosteal flaps. We then come into the nasal mucosa at what we anticipate to be the incisive foramen. This will be the arc of the hard palate, so it has to be carefully placed. This is being done with a 4-ohm monocryl suture. I'm using a P3 needle. After coming through the nasal mucosa at the level of the incisive foramen, we come back through the mucoperiosteal flap to create a mattress suture. The suture is placed. It will not be tied at this time, but rather we will complete the gingival periosteoplasty and anterior gingival closure before tying the monocryl suture to restore the arc to the palate and close the dead space between oral and nasal mucosal layers. Once we have repaired the palatal gingiva separate from the labial gingiva, we can then take the gingiva and repair the palatal and labial gingiva together to complete the palate repair anteriorly and to complete the gingival periosteoplasty. Before closing the lateral defects, we can now tie down our monocryl suture that secures the oral mucosa to the nasal mucosa. Note how it creates a convexity in the arc of the oral mucosa, restoring the arc of the palate. This also eliminates the dead space at the level of incisor foramen between oral and nasal mucosal repairs. With the arc of the palate restored, we can then close the lateral palatal defects. On the greater segment side, we are closing this primarily with interrupted forovicral suture. We now shift to the contralateral or lesser segment side in which we are going to allow the buccal fat pad to line the lateral palatal defect. This minimizes tension on the midline repair. Note that we are doing a unilateral buccal fat pad as we have used the greater segment and its extended gingiva to close the greater segment primarily and shifted the entire palate towards that side such that the lesser segment is then repaired laterally with the buccal fat flap. The buccal fat flap is secured anteriorly to the gingiva on either side. Having secured the buccal fat flap anteriorly, we then imbricate it to the mucoperiosteal flap medially and we will finalize this by imbrication to the gingiva laterally so as to avoid herniation of the buccal fat flap once the child awakes. Upon completion of inset of the buccal fat flap and closure of the lateral palatal defects, we find our repair to be completed with no raw surface and the gingiva complete. Shown is the picture of the anterior palate three weeks postoperatively demonstrating that the left-sided buccal fat flap is beginning to mucosalize. Eight weeks following surgery, we see that mucosalization is complete, the gingiva has healed, and there is no evidence of a buccal fat flap which is completely mucosalized.

palate repair

monocryl sutures

buccal fat flap

gingiva healing

mucosalization