Cleft Palate Repair Guided by Cleft Gap: An Institutional Protocol Using Modified Asymmetric Short Limb Z-plasty (MASLZ) and Straight-line Repair

No single soft palate repair technique is universally optimal for cleft palate reconstruction; the ideal approach depends on cleft gap width and palatal configuration. Wide-gap clefts incur excessive tension with double opposing Z-plasty, whereas narrow-gap clefts may not require the complexity of intravelar veloplasty (IVV). We developed an institutional protocol selecting the repair technique based on intraoperative cleft gap measurement at the uvular neck: modified asymmetric small limb Z-plasty (MASLZ) for V-shaped gaps ≤ 6 mm, and straight-line repair (SLR) with overlapping IVV for gaps wider or U-shaped palates. Both techniques maximize levator veli palatini muscle overlap, the physiological basis of velopharyngeal competence. In 65 patients with unilateral cleft palate treated by a single surgeon (2015-2023; 34 MASLZ, 31 SLR), fistula formation (1 vs. 5; p = 0.0951) and secondary velopharyngeal insufficiency surgery (2 vs. 6; p = 0.1377) were comparable, and surgical group was not an independent predictor of secondary VPI surgery in multivariable analysis. Consistent palatoplasty outcomes can be achieved through individualized, algorithm-driven technique selection rather than uniform application of a single method.