Cleft - 3-flap palatoplasty

Considerations

Preparation

Procedure

Sample operative report

Findings:

*** mm midline incomplete palatal cleft

Performed 3-flap palatoplasty with intravelar veloplasty

Procedure in Detail:

The patient was transported to the OR where GETA was induced and time-out was completed. The bed was turned 90 degrees and the patient was draped.

The Dingman retractor was placed, exposing the palate. The midline incomplete (involved a small portion of the hard palate and the entire soft palate) palatal cleft was *** mm at its widest point. The palate was infiltrated with *** ml total of .25% Bupivacaine with 1:200,000 Epinephrine. The incisions were marked in anticipation for the 3-flap palatoplasty. The medial aspect of the uvula was de-epithelialized. Beginning on the left, the marked incisions were completed with the Colorado tip Bovie to the depth of the bone. The Cottle elevator was used to raise the posteriorly based unipedicled flap in the submucoperiosteal plane. The greater palatine artery pedicle was identified and preserved. The dissection was carried out posterior to the pedicle exposing the levator veli palatini, hamulus, and tensor veli palatini. Laterally, the incision was carried around the maxillary tuberosity. The LVP was dissected from both the nasal and oral mucosa. The nasal mucosa was dissected from the floor of the nose. The right sided flap was raised in similar fashion. Lastly, the anterior flap was elevated in the submucoperiosteal plan to the level of the alveolus. Once all three flaps were raised and sufficient medialization was evident, the approximation of the uvula began with 4-0 and 5-0 Chromic in simple interrupter fashion. The nasal mucosa of the soft and hard palate was then approximated with 4-0 Polysorb in simple interrupted fashion. The LVP sling (intravelar veloplasty) was reconstructed, secured with 4-0 Maxon in simple interrupted fashion. The oral mucosa was approximated with 4-0 Polysorb simple interrupted. The anterior aspects of the flaps were secured to the 3rd anterior flap. The lateral incisions were left open; Floseal was placed into this space bilaterally. Every 10 minutes throughout the case the retractor was let down in order to rest the tongue.

Excess Floseal, the upper airway, esophagus, and stomach were suctioned. GETA was discontinued, and the patient was transported to PACU in stable condition. Counts correct.

Post-op

• • Disposition

  • Admit overnight and keep until swallowing well

  • Activity: No-no's x 2 weeks if under age 5 

  • Diet: Clears advance to liquid / purée diet x 2 weeks as tolerated 

  • sippy cup OK

  • No bottle x 2 weeks

• Pain control: Liquid Tylenol and Ibuprofen ATC

  • Unasyn while inpatient then Augmentin x 7 days

  • RTC in 1 week and 3-4 weeks 

Pearls & Pitfalls

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