Repair of cleft palate by rotation–transposition of the two
mucoperiosteal flaps: can this reduce the incidence
of postoperative fistula?
Ashraf Hussein Abbas
Received: 16 August 2010 / Accepted: 18 September 2010 / Published online: 7 October 2010
Abstract Successful primary closure of cleft palate is the
only prophylaxis against postoperative fistula. Many factors
are accused of causing fistula, but the most important factor
is the repair under tension. We tried in this work to rotate
one of the mucoperiosteal flaps backward (90–180°) to fill
the midline gap at the point of maximum tension. The other
flap is then transposed medially to fill the anterior gap of
the cleft. This work was conducted in the Plastic Surgery
Unit in Suez Canal University Hospital from March 2007 to
March 2010. Forty-eight patients were operated on using
with the modified technique. Fistula occurred in one patient
(2.1% of patients). With the simplicity of this procedure
and its success rates we recommend this method as an
alternative to the standard von Langenbeck cleft palate
repair especially with wide cleft palate or when there is
much tension when suturing the oral mucosa.
Keywords Cleft palate
Modified von Langenbeck
The incidence of cleft lip with or without cleft palate has
increased to about one in 600–1,000 live births, making it
the most common congenital birth deformity [1, 2]. Isolated
cleft palate shows a relatively constant ratio of 0.45–0.5/
1,000 births .
The difficulty in cleft palate closure relates to achieving
tensionless closure. Although primary closure of the cleft
palate is possible now, in almost all cases, the problem of
postoperative cleft fistulae persists .
No single technique is satisfactory in the management of
post-repair fistulas. Attempts at closure of these fistulas
have been associated with failure rates around 37%, and
even as high as 65% in some series, increasing with the
second or further trials [5–11].
It was found that the width of the cleft palate has a
bearing on the occurrence of postoperative palatal
fistula formation. Width of 10 mm or more have a
statistically significant risk of fistula formation [8, 10,
Although fistulae may occur anywhere along the line of
the cleft, they most commonly occurs at the junction of the
hard and soft palate and the anterior portion of the cleft [6,
The list of surgical techniques used in palatal cleft
closure is extensive. Every surgeon incorporates his own
modification [3, 10, 16, 17]. In 1861, Bernard von
Langenbeck was credited with pioneering the first bipedicle
mucoperiosteal flaps for palate closure. Almost every repair
undertaken today is influenced by this important contribu-
tion [1, 18, 19].
We suggest that the major causes of occurrence of fistula
in traditional von Langenbeck technique are:
1. Deficient tissues in the midline of the repair.
A. H. Abbas (*)
Plastic Surgery Unit, Suez Canal University,
Eur J Plast Surg (2011) 34:279–283