A Modified 270-Degree Closure Technique to Address the Prominent or Locked-Out Premaxilla in Bilateral Cleft Palate Repair

The bilateral cleft deformity with a prominent or "locked-out" premaxilla presents one of the most challenging repairs in cleft surgery. Despite its relative frequency, traditional hard palate repair techniques fail to fully address this deformity, exposing surgeons and patients to the risk of a large anterior fistula developing when flaps cannot approximate the premaxilla. This greatly increases morbidity for the patient and creates unnecessary challenges during fistula repair or alveolar cleft bone graft later in childhood. The 270-degree closure technique extends the nasal closure 270 degrees around the premaxilla, continuing the hard palate repair through the alveolar clefts. This technique has been performed on 41 patients, with a mean follow-up of 10.8 years. The repair was successful in 93% of patients, with 3 patients developing palatal fistulas, all posterior to the 270-degree closure. The 270-degree cleft palate repair around the prominent premaxilla fills a void in the literature for managing the immense challenge of this deformity. When presurgical orthopedic appliances are not a viable option, this approach can minimize the risk of large or complex fistula formation posterior to the premaxilla.