Shown is a VO2 cleft of the soft palate extending the posterior portion of the hard palate. We start by infiltrating the palate to give us turgor, and we make our initial incisions once we have infiltrated using the turgor of our infiltration as countertension. We are now separating the nasal and oral lining and lifting the muscular layer off of the nasal lining. We'll do the same thing on the right side. We'll now incise and pair the nasal and oral layers right to the very tip of the uvula, minimizing our trauma on the uvula. We're now making our lateral relaxing incisions just medial to the alveolar ridge, and we stop when we hit the primary palate because we don't want to dissect into the primary palate with risk of causing further growth restriction. We use the MOLT elevator to raise mucoperiosteal flaps on either side. We then use our reverse beaver blade to continue the incision to the posterior margin of the hard palate. We can then elevate from medial to lateral so as not to disrupt the nasal mucosa, and then from lateral to medial for the mucoperiosteal flaps. Having done this, the levator muscles are now dissected off the nasal mucosa. Having dissected the levator muscles, we're going to use tagging sutures with Vicryl just to pull the anterior mucoperiosteal flaps off of the nasal mucosa so we can better visualize this for a complete nasal mucosal closure. With the oral mucosal flaps stented away, we can now visualize the nasal mucosa nicely. We're going to take the nasal mucosa and use an elevator to elevate this off of the hard palate. The elevator I like is the double-ended pageant, which we just demonstrated. With the nasal mucosa there freed, we can then start bringing it together with interrupted sutures. We like to keep our knots on the nasal side and work our way from anterior to posterior with interrupted Vicryl sutures. Coming right to the very tip of the uvula, we now begin to dissect the levator muscle from the oral mucosa, having previously dissected it from the nasal mucosa. Note that when we do this, we try to stay deep to the minor salivary glands so as to keep the oral mucosa as thick and as viable as possible. Isolating the muscle, we'd like to have minimal minor salivary glands on the muscle itself so we do the least amount of damage. We dissect the right levator muscle as far posteriorly and laterally as possible, coming right to the anterior tonsillar pillars so we get a very posteriorly based oral muscular sling. We are now going to put a double-armed ethabond placed through the belly of the right levator muscle, and this will be for an overlapping repair, which we call vest-over-pants. We now use a similar technique to put a double-armed ethabond suture through the tip of the right levator muscle, and that suture through the tip of the right levator now goes to the belly of the left levator for that pants-over-vest slide. One modification that you can make is use a resorbable suture rather than ethabond, and I've more recently gone to Fibo PDS so that I don't have a permanent suture on the muscle. We can now transpose the left levator muscle superficial to the right levator muscle as a vest-over-pants repair by pulling the two double-armed sutures tightly. Once the vest-over-pants repair is completed, we can imbricate the anterior edge of that muscle overlap just to give a clean muscular sling that rests as far posteriorly as possible abutting on the anterior tonsillar pillars. With the muscular repair completed, we now will complete our uvula repair using simple interrupted sutures, everting edges, and bringing mucosa to mucosa together. Note that we started the uvula repair prior to the muscle imbrication so as to minimize bunching of the uvula. We now complete that uvula repair and blend it in with the remainder of the oral mucosal closure. We use simple interrupted, which is my preference over a mattress suture as there's less ischemia, and with a well-designed simple interrupted technique with eversion, there is good approximation with less tissue used for the closure. Having completed repair of the oral mucosa and the midline, we can now close the lateral relaxing incisions. Note that I use these as access incisions and not relaxing incisions because we like to close them completely and minimize raw surface so as to minimize secondary contracture of the palate.

cleft palate repair

levator muscle repositioning

vest-over-pants technique

uvula repair

surgical suturing techniques