TWO-FLAP PALATOPLASTY:

BARDACH'S TECHNIQUE
JANUSZ BARDACH, MD

The two-flap palatoplasty technique, which I described for the first time in 1967, allows for complete closure of
the palatal cleft, with two-layer closure in the area of the hard palate and three-layer closure of the soft palate.
Using this technique, many palatal clefts can be closed without leaving bare bone exposed lateral to the
mucoperiosteal flaps in the area of the hard palate. Precise dissection of the muscles of the soft palate from the
posterior edge of the bony palate and from the nasal periosteum allows for increased mobility as well as
lengthening of the soft palate. Several key steps of this technique are presented in this paper. The results of
our clinical studies revealed that normal speech production is achieved in approximately 75% to 80% of patients.
Oronasal fistulas were found on the average of 5.2% in patients with all types of palatal clefts.

KEY WORDS: two-flap palatoplasty; mucoperiosteal flaps

In 1967, I described the principles and the surgical tech- palate, and three-layer closure (nasal mucosa, mus-
nique of two-flap palatoplasty. 1 I reported that in many cles, and oral mucosa) of the soft palate.
patients, palatal clefts could be closed without leaving 3. Closure of the palatal cleft with no tension in the area
bare bone exposed lateral to the mucoperiosteal flaps. of the h~rd and soft palate. Tension-flee closure pre-
I hypothesized that various angulations of the palatal vents dehiscence and oronasal fistulas.
shelves and, more importantly, the downward rotation of 4. Special attention must be paid to two-layer closure of
the mucoperiosteal flaps in the area of the hard palate the anterior portion of the cleft to prevent oronasal
make it possible to both close the cleft and cover the bare fistulas.
bone lateral to the mucoperiosteal flaps. The geometric 5. Tight approximation of mucoperiosteal flaps from the
analysis I performed with Nosal 2 in 1985 provided the nasal layer with the mucoperiosteal flaps from the oral
theoretical basis for the possibility of simultaneous clo- layer prevents dead space from occurring between the
sure of the palatal cleft and bare bone lateral to the mu- layers and provides for better and faster healing.
coperiosteal flaps in the area of the hard palate. In cases 6. Dissection of the muscles of the soft palate from the
of wide clefts, complete closure of bare bone may be dif- posterior edge Of the hard palate, and from the peri-
ficult to obtain and other measures must be taken. osteum on the nasal side, allows the soft palate to be
Over the years, I perfected the two-flap palatoplasty lengthened, and a muscle sling to be created.
technique, adding various details. I first described the 7. In my opinion, there is no need to enter Ernst's space
technique in the English literature in 1984. 3 The most or to fracture the hamulus. These steps do not add to
recent and full description is presented in the 2nd Edition the success of palatoplasty. On the contrary entering
of the Surgical Techniques of Cleft Lip and Palate. 4 Ernst's space may extend the healing time.
I would like to emphasize that experimental and clini- 8. Construction of a palatal sling adds to an adequately
cal studies do not support the widespread misconcep- functioning soft palate, which is essential for normal
tions about the detrimental effect of palatoplasty on facial speech production.
growth, s'6 My clinical observations and studies, as well 9. In wide clefts when a large area of bare bone is ex-
as my experimental studies, provide evidence that two- posed, loose sutures can be used to decrease this area.
flap p a l a t o p l a s t y d o e s n o t i n t e r f e r e w i t h facial The remaining bare bone must then be covered with
growth.7,8,9,10,11 Avetine or Oxycel.

PRINCIPLES OF
TWO-FLAP PALATOPLASTY STEPS TO AVOID
1. Complete closure of the entire palatal cleft performed 1. Transverse incisions of the nasal mucoperiosteum
in one surgical procedure. along the posterior edge of the bony palate to lengthen
2. Two-layer closure (nasal and oral layers) of the hard the soft palate (This leaves an extensive raw area on
the nasal surface)
From the University of Iowa, Iowa City, IA. 2. Fracturing the hamulus and/or dislocation of the ten-
Address reprint requests to Janusz Bardach, MD, Professor Emer- don of the tensor muscles
itus of Plastic Surgery, The University of Iowa. Iowa City, IA 52242.
Copyright 9 1995 by W.B. Saunders Company 3. Extension of the lateral incisions into Ernst's space
1071-0949/95/0204-0001 $5.00/0 4. Severing the neurovascular bundle

Operative Techniques in Plastic and Reconstructive Surgery, Vol 2, No 4 (November), 1995: pp 211-214 211
TIMING OF TWO-FLAP PALATOPLASTY

The type and severity of the palatal cleft determines the

timing for surgical repair. I repair clefts of the soft palate
only or clefts of the hard and soft palate at approximately
9 to 12 months of age. I repair unilateral and bilateral
complete palatal clefts associated with clefts of the lip and
alveolus at 12 to 18 months of age.

SURGICAL TECHNIQUE OF
TWO-FLAP PALATOPLASTY
/
The first step of the operation involves designing the in- (
cisions at the cleft margins for creation of the mucoperi- I
osteal flaps. The wider the palatal deft, the larger the
margin of mucoperiosteum that must be left at the medial
edge of the palatal cleft on the oral side. This strip of \

mucoperiosteum at the palatal edge will be turned down-

ward and used w h e n closing the nasal layer.
As shown in Figure 1, the incision starts along the me-
dial margin of the soft palate--the line between the oral
and nasal mucosa. With this incision, the muscles on Fig 2. Undermining of the mucoperiosteal flaps (Reproduced
both sides are exposed. The incision is carried up to the with permission from Salyer K, Bardach J: Atlas of Cranio-
9tip of the divided uvula. Incisions on the hard palate facial and Cleft Surgery. Raven Press, 1996. Copyright Raven
follow the design of the mucoperiosteal flaps that will be Press).
raised.
The next step, as illustrated in Figure 2, is to under- down, I can raise the upper portion of the mucoperiosteal
mine the mucoperiosteal flaps on the oral side. I start flap.
undermining by inserting a Woodson elevator into the I then perform the blunt dissection with a roll of gauze
lateral incision and slipping it between the bone and peri- to finish undermining the flap at the posterior edge of the
osteum until it reaches the incision at the medial edge of hard palate. The neurovascular bundle and the greater
the cleft. By moving the Woodson elevator up and palatine foramen are identified. Using a dull hook, the
neurovascular bundle is lifted, and its main trunk is par-
tially dissected from the mucoperiosteal flap to obtain
greater mobility of the flap (Fig 3).
The nasal mucoperiosteum is widely undermined us-
ing a sharp periosteal elevator (Figs 4 and 5). The mus-
cles of the soft palate are then completely released from
their attachments at the posterior edge of the hard palate
and from the periosteum on the nasal side, to be redi-
rected downward and medially, which lengthens the soft
palate and permits creation of a muscle sling.
As shown in Figure 6, closure of the nasal layer of the
palatal cleft begins at the alveolar ridge. It is closed us-
ing 4-0 chromic sutures with knots tied at the nasal sur-
face. These interrupted sutures are run from the alveo-
lus to the tip of the uvula. The muscles of both sides are
sutured together to improve the coordinated movements
of the soft palate. Closure of the muscles will proceed
from the tip of the uvula forward to assure their proper
alignment in the changed position.
Following muscle closure, closure of the oral mucosa
takes place in the area of the soft palate, illustrated in
Figure 7. I like to use vertical mattress sutures that go
through both the oral mucosa and muscle. By doing so,
I avoid leaving chromic sutures in the soft palate. In the
Fig 1. Design of the incisions for two-flap palatoplasty (Re- area of the hard palate, vertical mattress sutures are used
produced with permission from Salyer K, Bardach J: Atlas of to bring the oral and nasal layers close together. This
Craniofaclal and Cleft Surgery. Raven Press, 1996. Copyright prevents leaving a dead space between the layers. The
Raven Press). mattress sutures are inserted first through the oral mu-

212 JANUSZ BARDACH

 Fig 5. Undermining of the mucoperiosteal flap on the nasal
side (Reproduced with permission from Salyer K, Bardach J:
Atlas of Craniofacial and Cleft Surgery. Raven Press, 1996.
Copyright Raven Press).

Fig 3. Partial dissection of the neurovascular bundle from

the mucoperiosteal flap. It allows for greater mobility of the
flap and for tension-free closure of the palatal cleft. (Repro-
duced with permission from Salyer K, Bardach J: Atlas of
Craniofacial and Cleft Surgery. Raven Press, 1996. Copyright
Raven Press),

Fig 6. Closure of the nasal layer (Reproduced with permis-

sion from Salyer K, Bardach J: Atlas of Craniofacial and Cleft
Surgery. Raven Press, 1996. Copyright Raven Press).

osteum. When tied, these sutures bring both layers

Fig 4. Dissection of the muscles of the soft palate from the
posterior edge of the hard palate and from the periosteum on
close together. This type of closure has proven to be
the nasal side (Reproduced with permission from Salyer K, essential in avoiding oronasal fistulas, especially in the
Bardach J: Atlas of Craniofaclal and Cleft Surgery. Raven anterior palate and between soft and hard palates.
Press, 1996. Copyright Raven Press). After complete closure of the palatal cleft, it is impor-
tant to assess the area of bare bone exposed lateral to the
coperiosteum, then through the nasal mucoperiosteum, mucoperiosteal flaps (Fig 8). In the majority of cases, it
again through the nasal mucoperiosteum on the other is possible to close gaps or to approximate the margins to
side, and finally turned back through the oral mucoperi- facilitate healing in the area. If complete closure of the

TWO-FLAP PALATOPLASTY: BARDACH'S TECHNIQUE 213

 Fig 8. Complete closure of the palatal cleft and closure of the
lateral incisions (Reproduced with permission from Salyer K,
Bardach J" Atlas of Craniofacial and Cleft Surgery. Raven
Press, 1996: Copyright Raven Press).

Fig 7. Mattress sutures are used to approximate the nasal

dach l, Salyer K (eds): Surgical Techniques in Cleft Lip and Palate.
and oral layers (Reproduced with permission from Salyer K, Chicago, IL, Year Book Medical, 1987, pp 192-197
Bardach J: Atlas of Craniofacial and Cleft Surgery. Raven 3. Bardach J: Unilateral cleft palate repair, in Gates GA (ed): Current
Press, 1996. Copyright Raven Press). Therapy in Otolaryngology--Head and Neck Surgery, 1984-85.
Philadelphia, PA, BC Decker, 1984, pp 350-355
4. Bardach J, Salyer K: Surgical Techniques in Cleft Lip and Palate, (ed
g a p s c a n n o t b e a c h i e v e d b e c a u s e of excessive t e n s i o n , I
2). St Louis, MO, Mosby-Yearbook, 1991
r e c o m m e n d r e d u c i n g the area of e x p o s e d b o n e b y u s i n g 5. Herfert O: Fundamental investigations into the problems related to
loose s u t u r e s a n d c o v e r i n g t h e e x p o s e d b o n e w i t h A v e t - cleft palate surgery. Br J Plast Surg 11:97, 1958
ine or O x y c e l to s t i m u l a t e h e a l i n g of the d e n u d e d area. 6. Kremenak CR: Animal experimental studies on the effects of cleft
T h e r e s u l t s f r o m o u r clinical s t u d i e s -9 12 s h o w e d t h a t palate surgery on maxillary growth. J Jpn Cleft Palate Assoc 19:191-
202, 1994
n o r m a l s p e e c h p r o d u c t i o n is a c h i e v e d in a p p r o x i m a t e l y
7. Bardach J, Roberts DM, Klausner EC: Influence of two-flap palato-
7 5 % to 80% of p a t i e n t s . O r o n a s a l fistulas w e r e f o u n d o n plasty on facial growth in rabbits. Cleft Palate J 16:402-411, 1979
the a v e r a g e of 5.2% in p a t i e n t s w i t h all t y p e s of palatal 8. Bardach J, Mooney M, Bardach E: The influence of two-flap palato-
clefts. T h e f e w e s t n u m b e r of fistulas w e r e f o u n d in p a - plasty on facial growth in beagles. Plast Reconstr Surg 69:927-936,
tients w i t h unilateral c o m p l e t e palatal clefts (1.8%). 9"1~ 1982
9. Bardach J, Morris H, Olin W, et al: Late results of multidisciplinary
T h e g r e a t e s t n u m b e r of fistulas w e r e f o u n d in p a t i e n t s
management of unilateral cleft lip and palate. Ann Plast Surg 12:
w i t h bilateral clefts (8.3%). 11 P a t i e n t s w i t h cleft p a l a t e 235-242, 1984
o n l y h a d a rate o f 4.5%. 12 , 10. Morris H, Bardach J, VanDemark D, et al: Results of two-flap palato-
plasty with regard to speech production. Eur J Plast Surg 12:19-24,
1989
11. Bardach J, Morris H, Olin W, et ah Results of multidisciplinary
REFERENCES management of bilateral cleft lip and palate at the Iowa Cleft Palate
Center. Plast Reconstr Surg 89:419-432, 1992
1. Bardach J: Rozszczepy Warqi Gornej i Podniebienia. Warszawa, 12. Morris HL, Bardach J, Olin W, et al: Results of multidisciplinary
Panstwowy Zaklad Wydawnictw Lekarskich, 1967 treatment results for patients with isolated cleft palate. Plast Recon-
2. Bardach J, Nosal P: Geometry of the two-flap palatoplasty, in Bar- str Surg 92:842-851, 1993

214 JANUSZ BARDACH