An effect comparison between Furlow double opposing Z-plasty and two-flap palatoplasty on velopharyngeal closure

Abstract

The aim of this study was to compare velopharyngeal closure between patients who underwent Furlow palatoplasty and two-flap palatoplasty. A retrospective review of 88 patients with incomplete palate cleft was performed. 48 patients (17 males; 31 females) aged 2–28 years received Furlow palatoplasty. 40 patients (17 males; 23 females) aged 2–21 years received two-flap palatoplasty. Velopharyngeal function was categorized as adequate, marginal or inadequate. Complications associated with the operation were documented. Statistically significant differences were not found amongst sex distribution, age at operation, follow-up time, and preoperative speech intelligibility. After primary repairs using Furlow and two-flap palatoplasty, the surgeon’s incidence of postoperative palatal fistula was 0%. The complications were not significantly different between the two groups. The authors achieved the lowest reported incidence of postoperative palatal fistulas in primary Furlow palatoplasty. The outcomes of the velopharyngeal closure were better in patients who received Furlow palatoplasty ( P < 0.05). Furlow palatoplasty was more effective than two-flap palatoplasty in obtaining perfect velopharyngeal closure. A probable explanation may be that Furlow palatoplasty can reposition and overlap the divergent palatal muscle and lengthen the soft palate.

Cleft lip and palate are congenital disorders of multifactorial aetiology. The main goal of cleft palate repair is to achieve normal speech and adequate velopharyngeal function with minimal effect on facial growth. The primary objective in the surgical repair of a cleft palate is the development of normal speech. Speech quality remains the most important standard for assessing clinical outcomes and the success of surgical procedures. Many surgical techniques for palate correction have been described. Determining the most effective technique for the surgical repair of palatal clefts continues to cause controversy.

The von Langenbeck palatoplasty described by Bernhard von Langenbeck in the mid-1800s is the oldest procedure, which is still in use today. It does not correct the aberrant muscle of the soft palate. The muscle fibres of the levator veli palatini lie in a transverse orientation in the normal soft palate. Contraction of the levator veli palatini makes the soft palate elevate and recede, and creates a seal against the posterior pharynx. A patient with a cleft palate loses this function as the levator veli palatini fibres lie in an oblique direction and insert on the posterior aspect of the hard palate. The two-flap palatoplasty was refined from the von Langenbeck palatoplasty. The theory of two-flap palatoplasty is similar to that of von Langenbeck palatoplasty, but two-flap palatoplasty can lengthen the soft palate by push-back. Two-flap palatoplasty is used more often, possibly because of its technical ease.

Kriens firstly noted the abnormal position and structure of the levator and that surgery must restore the muscle anatomy. Based on this theory, Furlow designed the double-opposing Z-plasties in 1978 and published the technique in 1986. Two opposing Z-plasties were designed on the oral and nasal mucosal surface. The posterior based flap on each surface was composed of muscle and mucosa, and the anterior surface was composed of mucosa only. Although the most desirable technique for the repair of palatal clefts was still the subject of considerable debate, several small series had suggested that superior speech results could be obtained by using Furlow’s double-opposing Z-plasties. Owing to the technical difficulties of the flaps and concern about postoperative palatal fistula, the Furlow palatoplasty was not used as widely as the two-flap palatoplasty. The purpose of this study was to compare the clinical outcomes of Furlow palatoplasty and two-flap palatoplasty by analyzing velopharyngeal closure and associated complications.

Materials and methods

88 patients with incomplete cleft palate (partial hard and soft cleft palate, and soft cleft palate only) underwent palatoplasty surgically from August 2005 to August 2010 ( Fig. 1 ). They were invited, and agreed, to participate in a retrospective study. They were selected according to the following criteria: no syndromes; no secondary pharyngeal surgery; no cognitive deficiency; no neuromotor dysfunction; no hearing handicap; and incomplete cleft palate. Each subject was assessed by an otorhinolaryngologist who performed a complete ear, nose, and throat examination to exclude nasal and ear pathologies. All patients were followed up for a minimum of 6 months postoperatively for documentation of data. Data including each patient’s general information, type of operation, complications, speech outcome, and cephalometric results were collected.

Fig. 1
Patient numbers from August 2005 to August 2010.

Furlow palatoplasty (Furlow group) was performed in 48 patients (17 males and 31 females) with the age at palatoplasty ranging from 2 to 28 years (mean 7.52 years). The time of the latest follow-up ranged from 0.5 to 5.17 years postoperatively (mean 3.32 years). Two opposing Z-plasties were designed on the oral and nasal mucosal surface. The posterior based flap on each surface composed of muscle and mucosa, and the anterior surface composed of mucosa only. In the majority of cases, the limbs of the Z formed a 60° angle, but in shorter palates the angles were more obtuse. 12 patients underwent the technique described by Furlow. 36 patients underwent a modified technique with the use of lateral relaxing incisions ( Fig. 2 ).

Fig. 2
Furlow palatoplasty. (a) The oral incision. (b) Raising the flaps in the oral layer. The right-sided flap contained the vela palatini muscle bundles. (c) Raising the flaps in the nasal layer. The left-sided flap contained the vela palatini muscle bundles. (d) Suturing the flaps in the nasal layer and shaping the nasal Z shape. (e) Suturing the flaps in the oral layer and shaping the oral Z shape.

Two-flap palatoplasty (two-flap group) was performed in 40 patients (17 males and 23 females) with the age at palatoplasty ranging from 2 to 21 years (mean 8.72 years). The time of the latest follow-up ranged from 0.5 to 5.50 years postoperatively (mean 3.05 years). This was a modification of the von Langenbeck technique in which the incision was made along the cleft margin and the alveolar margin. These were joined anteriorly to free the mucoperiosteal flaps. These flaps were based on the greater palatal vessels. The soft plate was repaired in a straight line. This technique is commonly followed today ( Fig. 3 ).

Fig. 3
Two-flap palatoplasty. (a) The oral incision. (b) Raising the two mucoperiosteal flaps. (c) Suturing nasal mucosa and muscle layer. (d) Suturing oral mucosa.

Table 1 shows the profiles of each group. The decision to use Furlow palatoplasty or two-flap palatoplasty depended on the preference of the surgeon. All operations were performed by experienced surgeons. The age at which the patients received palatoplasty was not significantly different between the two techniques (Student’s t test, P = 0.437). The sex distribution of the Furlow group and two-flap group was not significantly different ( χ 2 test, P = 0.497). The follow-up times of the two groups were not significantly different (Student’s t test, P = 0.310).

Table 1
Clinical information for patients receiving Furlow palatoplasty and two-flap palatoplasty.
Furlow palatoplasty Two-flap palatoplasty P
Number of patients 48 (total) 40 (total)
Male 17 17 0.497
Female 31 23
Age at operation
Range (years) 2–28 2 – 21 0.437
Mean (years) 7.52 8.72
Follow-up time
Range (years) 0.5–5.17 0.5–5.50
Mean (years) 3.32 3.05 0.310

χ 2 test: sex distribution. Student’s t test: age and follow-up time.

The perceptual evaluation of resonance included speech intelligibility, hypernasality, and nasal emission. A sample of each subject’s correlative speech was recorded in a soundproof room using a Sony DAT recorder (55ES) and a Maxell DAT (DM 120) cassette. A CREATIVE HS300 microphone was used. The distance between the lips and microphone was 5 cm. The sample consisted of 5 min of spontaneous speech and a set of specific vocabulary and sentences. The specific vocabulary and sentences were edited by the Cleft Lip and Palate Treatment Center of Peking University. These samples were perceptually judged for intelligibility, hypernasality, and nasal emission by two speech pathologists experienced in judging resonance disorders. Speech intelligibility was expressed as a percentage. According to Sell and Grunwell, a four-point scale was used (1, normal; 2, mild; 3, moderate; 4, severe) to judge the degree of hypernasality. The same scale was used to judge the degree of nasal emission.

Preoperative speech evaluation of each subject was carried out primarily by using perceptual speech intelligibility. The preoperative speech intelligibilities of the subjects between received Furlow palatoplasty and received two-flap palatoplasty were not significantly different (Student’s t test, P = 0.764). All patients were followed up for a minimum of 6 months postoperatively for documentation of perceptual evaluation of resonance including speech intelligibility, hypernasality, and nasal emission. A blind procedure was used whereby all analyses were independently conducted by two examiners. Perceptual evaluations were used to keep the examiners blind to the surgical procedures that had been performed.

The ORTHOPHOS machine (German Sirona Corporation) was used to take cephalometric lateral radiographs. Two cephalometric lateral radiographs were taken at rest and in phonation of / i /, respectively. The pharyngeal depth of the patients was recorded as velar–pharyngeal (V–P) distance. ‘AB’ meant the static V–P distance and ‘AC’ meant the V–P distance of the phonation of / i / ( Fig. 4 ). All patients were followed up for a minimum of 6 months postoperatively for documentation of cephalometric lateral radiographs.

Fig. 4
Cephalometric landmarks: A, midpoint of velar pharyngeal contact (VPC); B, midpoint of pharyngeal side of velar at rest; C, top of pharyngeal side of velar at phonation of / i /; AB, the static V–P distance; AC, the V–P distance of phonation of / i /.

The velopharyngeal function was determined using a combined clinical rating and the above examinations ( Table 2 ). The velopharyngeal functions were categorized as adequate, marginal or inadequate. Adequate and marginal were regarded as successful velopharyngeal closure. The status of velopharyngeal function at the latest follow-up was used for outcome assessment.

Table 2
Combined velopharyngeal competence rating: perceptual speech evaluations and X-ray cephalometric graphs.
Velopharyngeal competence Speech Speech intelligibility X-ray cephalometric
Adequate Normal resonance and normal or mild nasal emission ≥85% The V–P distance of phonation of / i / <4.0 mm
Marginal Slightly hypernasal; mild to moderate nasal emission ≥70% The V–P distance of phonation of / i / <4.0 mm
Inadequate Moderately or severely hypernasal and severe audible nasal emission <70% The V–P distance of phonation of / i / ≥4.0 mm

Statistical analyses of the data were performed with SPSS13.0. For the comparison of the age, follow-up time, preoperative and postoperative speech intelligibility, and the pharyngeal depth of both groups, Student’s t test was performed. For the comparison of the sex of the subjects, speech resonance, and velopharyngeal function of two groups the χ 2 test was applied. P < 0.05 was considered as the level of statistical significance.

Results

The postoperative complications of Furlow palatoplasty and two-flap palatoplasty are given in Table 3 . After primary repairs using Furlow and two-flap palatoplasty the surgeon’s incidence of postoperative palatal fistula was 0%. None of the patients had other complications. There was no obvious difference in postoperative complications between the two groups.

Table 3
Complications after two-flap palatoplasty and Furlow palatoplasty.
Complications Furlow group Two-flap group
Oronasal fistula formation 0 0
Postoperative bleeding 0 0
Infection 0 0
Death 0 0
Malignant hyperthermia 0 0
Pneumonia 0 0
Otitis media 0 0
Dehiscence of the repair 0 0
Airway difficulties 0 0

The results of the speech intelligibility test are given in Table 4 . The postoperative speech intelligibility of Furlow palatoplasty was better than that of two-flap palatoplasty ( P < 0.05). Hypernasality and nasal emission results are presented in Table 5 . The result of the χ 2 test showed statistically significant differences in the presence of hypernasality between the Furlow group and the two-flap group. There were no statistical differences regarding nasal emission.

Table 4
Speech intelligibility outcome of the subjects with Furlow palatoplasty and two-flap palatoplasty ( <SPAN role=presentation tabIndex=0 id=MathJax-Element-1-Frame class=MathJax style="POSITION: relative" data-mathml='X¯±SD’>X¯¯¯±SDX¯±SD
X ¯ ± S D
).
Furlow palatoplasty Two-flap palatoplasty
Preoperative 30.98 ± 11.51 31.67 ± 9.67
Postoperative 84.34 ± 11.75 76.26 ± 12.93
Student’s t test, preoperative: P = 0.764; postoperative: P = 0.003

Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on An effect comparison between Furlow double opposing Z-plasty and two-flap palatoplasty on velopharyngeal closure
Premium Wordpress Themes by UFO Themes