Piezoelectric Palatine Foraminotomy in Wide Cleft Palate Repair: A New Approach for Safe Neurovascular Pedicle Mobilization

Introduction: Surgical repair of large cleft palates is challenging and is associated with high postoperative fistula rates. Midline tension is a critical factor in fistula formation. Foraminotomy enables increased medial mobilization of the palatal flaps, particularly in cases in which standard palatal closure would otherwise result in excessive midline tension; however, this procedure carries a risk of neurovascular pedicle injury and subsequent flap necrosis. In this study, we present our surgical technique for piezoelectric palatine foraminotomy to facilitate palatal flap mobilization and tension-free closure in large cleft palate repair. Methods: Seventeen patients with wide cleft palates (≥15 mm cleft width; Veau class II-IV) who underwent primary palatoplasty with piezoelectric foraminotomy between 2017 and 2020 were reviewed. All procedures were performed by a single senior surgeon. The piezoelectric device equipped with a sinus lift tip was used to enlarge the palatine canal via controlled removal of the posteromedial bony wall, allowing tension-free medial mobilization of the neurovascular pedicle. Postoperative outcomes including fistula formation, flap necrosis, and neurovascular complications were assessed over a minimum 12-month follow-up period. Results: No intraoperative or postoperative neurovascular pedicle injury, flap necrosis, or wound infection was observed. Oronasal fistula developed in 3 patients (17.6%), all with Veau class III or IV clefts, located at the hard palate-soft palate junction. Conclusions: Piezoelectric osteotomy for palatine foraminotomy is a feasible, controlled, and soft tissue-preserving technique that may enhance the safety of neurovascular pedicle mobilization in wide cleft palate repair.