Abstract
A two-stage palatal repair using a modification of Furlow palatoplasty is presented. The authors investigate the speech outcome, fistula formation and maxillary growth. In a prospective, successive cohort study, 40 nonsyndromic patients with wide cleft palate were operated on between March 2001 and June 2006 by a single surgeon. 10 patients in the first cohort underwent a Furlow palatoplasty (control group). In 30 patients in the second cohort a unilateral myomucosal cheek flap was used in combination with a modified Furlow palatoplasty (study group). The hard palate was closed in both groups 9–12 months later. The Bzoch speech quality score was superior in the study group, and the hypernasality was significantly reduced in the study group. Overall fistula formation was 0%. At the time of hard palate reconstruction palatal cleft width was significantly reduced. Relative short-term follow up of maxillary growth was excellent. There were no postoperative haematomas, infections, or episodes of airway obstruction. This technique is particularly encouraging, because of better speech outcome, absence of raw surfaces on the soft palate, no fistula formation, and good maxillary growth. Further follow-up is necessary to determine the long-term effects on facial development.
In 1986 Furlow presented a new technique for closure of the soft palate which has gained an increasing number of supporters due to its ability to recreate an effective muscular sling, together with adequate lengthening of the soft palate with better speech outcomes. Disadvantages of Furlow palatoplasty (FP) in reconstructing wide palatal clefts where tension-free closure could not be achieved, has inspired surgeons to modify this technique. The downside of these modifications were the insufficient maxillary growth due to exposure of raw surfaces that were created by medial mobilization of the palatal mucoperiosteal flaps and extensive dissection that caused secondary fibrosis with decreased soft palate mobility, and high-rate fistula formation.
The authors have modified Furlow’s technique in two ways. The first modification which they use in all their palatal repairs, is reuniting the levator muscle with minimal overlap, instead of complete overlap of the myomucosal flaps. The second modification is using a buccal myomucosal flap (BMF) to achieve a tension-free oral layer closure, and avoid exposition of raw surfaces in wider palatal clefts. In these cases one needs to make relaxing incisions and back cuts at the base of the anteriorly based oral layer in order to close the palatal layer in wide palatal clefts. The BMF is a dependable local sensate flap with a well-defined neurovascular pedicle that was originally described by Maeda et al. and Bozola et al. and is currently used by other surgeons, in different ways.
The authors present the modified FP (MFP) with the use of a BMF for the repair of wide palatal clefts in a two stage operation. They compared a group of patients treated with FP and a group treated with the MFP and a BMF. Evaluation was performed on speech outcome and nasality, fistula formation, and short term maxillary growth.
Materials and methods
40 patients with nonsyndromic cleft palate (11 female and 29 male) were operated on between March 2001 and June 2006 by a single surgeon. Table 1 shows the type of cleft and number of patients. Palatal clefts were reconstructed in two stages in all patients. Only patients with a palatal cleft of 9 mm or more, measured at the junction between hard and soft palate were included in this study.
| Control group | Study group | Total | |
|---|---|---|---|
| BCLP | 1 | 6 | 7 |
| CLP | 0 | 1 | 1 |
| CP | 0 | 1 | 1 |
| UCLA + BCP | 0 | 1 | 1 |
| UCLP | 9 | 20 | 29 |
| UCLr + BCP | 0 | 1 | 1 |
| Total | 10 | 30 | 40 |
In the first cohort of 10 patients an FP was used to repair the soft palate (control group). In the second cohort of 30 patients a unilateral BMF was used to achieve a tension-free closure of the oral layer of the soft palate in combination with the MFP (study group). The authors reconstructed the cleft palate in two stages, using FP in the control group, and using MFP in combination with BMF in the study group.
The width of the cleft at the junction of the soft and hard palate varied from 9 to 15 mm in both groups, 12.2 ± 1.8 mm (mean ± SD) for the study group and 10.8 ± 2.0 mm for the control group. The soft palate was closed between 9 and 12 months (10.2 ± 1.2 months) in the study group and between 9 and 15 months (10.8 ± 2.0 months) in the control group. The hard palate was closed in two layers between 18 and 36 months (23.9 ± 6.7 months) in the study group and between 18 and 48 months (37.2 ± 12.8 months) in the control group.
For all nominal variables, the χ 2 test with the Fisher exact test was used to analyse difference between the experimental groups. For the scale variables (i.e. cleft width data) the analyses were done using the t test. For all analyses SPSS 16.0 was used.
Soft palate reconstruction
In Fig. 1 the margins of the cleft and the Z-plasty on the oral side are outlined, as described by Furlow. A dilute solution of adrenaline (1/200,000) is infiltrated into the palate. The cleft margin is incised along the visible junction line between oral and nasal mucosa in the soft palate using a Colorado-tip cautery (Ctc) (Stryker Leibinger GmbH, Freiburg, Germany). This makes the incision fairly easy and under complete haemostasis. On the left side the lateral limb incision is made, the tip of the flap is elevated, and the palatal muscle detached from the margin of the hard palate. The levator veli palatini muscle is separated from the nasal mucosa along the cleft margin. The muscle is then elevated from the nasal mucosa ( Fig. 2 ). The anteriorly based flap is incised in the nasal mucosa, from the base of the nasal surface of the uvula towards the Eustachian orifice ( Figs 3 and 4 ).
On the right side of the cleft, the anteriorly based mucosal flap is elevated from the muscle beneath ( Fig. 5 ). The levator muscle is then identified and separated alongside its length from the nasal mucosa. The lateral limb of the right posteriorly based myomucosal flap is cut a few millimetres from the hard palate, along the levator muscle, and towards the lip of the Eustachian orifice, leaving sufficient nasal mucosa edge for suture placement. This incision frees the flap with its muscle to swing across the cleft and just over the mid-line ( Fig. 6 ). Subsequently the nasal layer is closed. A suture unites the tip of the uvular tags, and while elevated the nasal side of the uvula is closed using a Vicryl 6/0 S-14 (Johnson & Johnson Ethicon, Neuilly, France). The closure of the nasal layer is completed with a Vicryl 5/0 RB1 (Johnson & Johnson Ethicon, Neuilly, France) ( Fig. 7 ). This transposes the right levator veli palatini muscle towards the mid-line. Subsequently the palatal muscle on the left side is dissected from the upper-lying oral mucosa over a distance of a few mm. The tip of the left muscle flap is sutured with a minimal overlap to the right muscle flap with PDS 4/0 II FS-2S. This contrasts with Furlow’s method, where he sutures the tip of one muscle flap to the base of the other one.
