Familial predisposition to flap necrosis after palatoplasty: a case report of two siblings with bilateral cleft palate

Mucoperiosteal flap necrosis is a rare but serious complication following cleft palate repair, often resulting in the formation of oronasal fistulas. Although several factors-such as excessive flap tension, pedicle injury, infection, and hematoma-have been implicated in its pathogenesis, the precise mechanisms remain poorly understood. Herein, we report two nonsyndromic siblings with complete bilateral cleft lip and palate, both of whom developed anterior mucoperiosteal flap necrosis on postoperative day 5 after primary palatoplasty performed with a same two-flap technique incorporating a vomer flap. Neither case involved intraoperative complications, but flap necrosis occurred at the same anatomical site. The underlying cause remains unclear to date. This series raises the question of whether factors beyond surgical technique-such as congenital anatomical variations or genetic predisposition-may contribute to the development of flap necrosis. Recognizing such patient-specific risks may help surgeons anticipate complications in familial cleft cases and better tailored preoperative planning or intraoperative modifications. Further investigations may clarify whether specific subgroups of patients with cleft lip and palate possess an inherent susceptibility to flap necrosis after primary repair.