Cleft Palate Surgery: Evolving Surgical Techniques and Reconstructive Principles for Oronasal Fistula and Velopharyngeal Dysfunction: A Narrative Review

Background Despite more than a century of surgical innovation, no single palatoplasty technique has demonstrated consistently superior outcomes across the spectrum of cleft palate phenotypes. Objective This review examines the historical evolution of cleft palate reconstruction and contemporary evidence relating operative techniques, technical modifications, and reconstructive adjuncts to oronasal fistula (ONF) and velopharyngeal outcomes. Methods A narrative literature search of PubMed/MEDLINE, Scopus, the Cochrane Library, and Google Scholar (January 1990-March 2026) incorporated original clinical studies, systematic reviews, meta-analyses, and landmark reports, with evidence from primary palatoplasty, symptomatic submucous cleft palate, secondary velopharyngeal surgery, and fistula reconstruction considered according to clinical setting. Results Across a heterogeneous evidence base, favorable outcomes were associated with restoration of the levator sling, tension-minimized multilayer closure, preservation of vascularity, adequate tissue recruitment, and adaptation of reconstruction to cleft morphology. The independent contribution of these principles remains uncertain because the evidence is predominantly observational and heterogeneous. Conclusions Successive palatoplasty techniques therefore appear to represent different strategies for addressing shared reconstructive constraints rather than competing solutions with uniformly superior outcomes. This updated synthesis integrates established reconstructive principles with contemporary evidence on ONF, velopharyngeal outcomes, cleft morphology, and tissue deficiency to provide an outcome-oriented framework for individualized cleft palate reconstruction.