Bilateral buccal flaps with double opposing Z-plasty for wider palatal clefts

Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions

PURPOSE OF REVIEW

This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction.

RECENT FINDINGS

Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea.

SUMMARY

Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.

Anatomical Study of Domain Rescue of Palatal Length in Patients With a Wide Cleft Palate: Buccal Flap Reconstruction in Primary Palatoplasty

BACKGROUND

This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty.

METHODS

A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap.

RESULTS

Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6  ±  2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5  ±  2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications.

CONCLUSIONS

Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion.

Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis

OBJECTIVES

In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome.

MATERIALS AND METHODS

A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model.

RESULTS

One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11).

CONCLUSIONS

A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair.

CLINICAL RELEVANCE

Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality.

Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-Analysis

OBJECTIVE

Buccal myomucosal flaps (BMF) anatomically lengthen the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing literature on speech outcome of BMF palatal lengthening.

DESIGN

Three databases were used to identify studies of interest published in English. Studies that did not use standardized speech assessments were excluded. PRISMA checklist was followed, and the risk of bias in the included studies was assessed.

SETTING

Long-term follow up of patients.

PATIENTS

With history of cleft palate presenting with VPI.

INTERVENTION

BMF palatal lengthening.

MAIN OUTCOME MEASURE

Random-effects model meta-analyses were performed for hypernasality, intelligibility, and nasal air emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment.

RESULTS

From the initial 7115 articles, 13 were included in this review. Two of these had a significant patient overlap and a study with a smaller patient population was excluded. All 12 included articles met the National Institutes of Health Quality Assessment Tool criteria. Six retrospective studies evaluated 230 patients and six prospective studies evaluated 181 patients. The most common indications for BMF were large size of the velopharyngeal gap and prior surgery for VPI. Meta-analyses demonstrated effect sizes below zero, confirming the improvement of standardized assessment scores in patients with VPI after BMF palatal lengthening. Egger regressions revealed low risk of publication bias.

CONCLUSIONS

BMF palatal lengthening provides adequate treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.

Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty

Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.

Updates in Cleft Care

Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.

Impact of palatoplasty techniques on tympanic membrane findings and hearing prognosis in children with cleft palate

OBJECTIVE

Children with cleft palate (CP) are at high risk of developing otitis media with effusion (OME) due to Eustachian tube (ET) dysfunction. Palatoplasty has been reported to decrease the frequency of middle ear disease and improve ET function, and although various techniques have been developed, there is no consensus on the differences in the impact of different techniques on the middle ear. The purpose of this study was to determine the differential effects of palatoplasty on middle ear function and hearing.

METHODS

We performed a retrospective observational survey of pediatric patients who underwent palatoplasty for CP between June 2010 and October 2018 at Tohoku University Hospital. Cases were divided into three groups depending on the palatoplasty procedures performed: the push-back palatoplasty group, the two-flap palatoplasty group, and the Furlow double-opposing Z-plasty group. We examined the differences in clinical characteristics between patients who underwent each procedure. The primary outcome variable was tympanic membrane (TM) findings, and the secondary outcome was hearing test results.

RESULTS

Children who underwent the two-flap palatoplasty had a higher tympanostomy tube (TT) insertion rate and a higher total number of TT insertions than those who underwent the Furlow double-opposing Z-plasty or the push-back palatoplasty. The TM retraction rate tended to be lower in the Furlow double-opposing Z-plasty group than in the push-back palatoplasty group or the two-flap palatoplasty group. The hearing test results at the last visit were not significantly different among the three groups.

CONCLUSIONS

Children who underwent the two-flap palatoplasty had a higher rate of TT insertions, potentially increasing the risk of TM perforation. In contrast, the Furlow double-opposing Z-plasty group had a lower tendency for TM regression, possibly due to improved ET function and reduced incidence of OME. It is important to understand the advantages and disadvantages of each technique before selecting one suitable for the child's cleft and arch width. Additionally, it is important to conduct regular follow-up of TM findings and hearing test results even after palatoplasty.

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

BACKGROUND

Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty.

METHODS

A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables.

RESULTS

A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03).

CONCLUSIONS

Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

Buccal Myomucosal Flap Repair for Velopharyngeal Dysfunction

BACKGROUND

Velopharyngeal dysfunction (VPD) is the incomplete separation of the nasal and oral cavities during speech sound production that can persist following primary palatoplasty. Surgical technique used in management of VPD (palatal re-repair versus pharyngeal flap or sphincter pharyngoplasty) is often dictated by the preoperative velar closing ratio and closure pattern. Recently, buccal flaps have increased in popularity in management of VPD. Here, the authors investigate the effectiveness of buccal myomucosal flaps in the treatment of VPD.

METHODS

A retrospective review was performed of all patients undergoing secondary palatoplasty with buccal flaps at a single center between 2016 and 2021. Preoperative and postoperative speech outcomes were compared. Speech assessments included perceptual examinations, graded on a four-point scale of hypernasality, and speech videofluoroscopy, from which the velar closing ratio was obtained.

RESULTS

A total of 25 patients underwent buccal myomucosal flap procedures for VPD at a median of 7.1 years after primary palatoplasty. Patients had significantly increased velar closing postoperatively (95% versus 50%; P < 0.001) and improved speech scores ( P < 0.001). Three patients (12%) had continued hypernasality postoperatively. There were no occurrences of obstructive sleep apnea.

CONCLUSIONS

Treatment of VPD with buccal myomucosal flaps leads to improved speech outcomes without the risk of obstructive sleep apnea. Traditionally, palatal re-repair techniques have been used for smaller preoperative velopharyngeal gaps; however, the addition of buccal flaps allows for anatomical velar muscle correction for patients with a larger preoperative velopharyngeal gap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Effects of two flap palatoplasty versus furlow palatoplasty with buccal myomucosal flap on maxillary arch dimensions in patients with cleft palate at the primary dentition stage: a cohort study

OBJECTIVE

The objective of this study was to evaluate the effect of two flap palatoplasty (TFP) versus Furlow palatoplasty with buccal myomucosal flap (FPBF) on maxillary arch dimensions in children at the primary dentition stage with cleft palate, in comparison to matching subjects without any craniofacial anomalies.

MATERIAL AND METHODS

This study included 28 subjects with an age range of 5-6 years; 10 non-cleft subjects were included in the control group, 9 patients treated with TFP, and 9 patients treated with FPBF. For the included patients, the maxillary models were scanned using a desktop scanner to produce virtual models, and the maxillary dimension measurements were virtually completed. The produced measurements were compared between the 3 groups. Maxillary models of the 28 participants were evaluated.

RESULTS

Statistically insignificant differences were detected between the 3 groups for arch symmetry measurements. Differences were detected in the inter-canine width between the 2 surgical groups and non-cleft group. Both arch length and posterior palatal depth significantly differ while comparing the TFP to the control group, with no differences between FPBF and the non-cleft group.

CONCLUSION

Furlow palatoplasty with buccal myomucosal flap might be considered a better surgical option than two flap palatoplasty for patients with cleft palate while evaluating maxillary arch dimensions at the primary dentition stage as a surgical outcome.

CLINICAL RELEVANCE

This study gives insight into the surgical technique that has limited effect on the maxillary growth and dental arch dimension. Therefore, it decreases the need for orthodontic treatment and orthognathic surgery.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT05405738 ).

Single-stage Palatal Lengthening Using Modified Buccinator Myomucosal and Buccal Fat Flaps

Surgical treatment of velopharyngeal insufficiency (VPI) after primary palatoplasty poses a difficult challenge in cleft care management. Traditional treatment options have shown improved speech outcomes but oftentimes lead to airway obstruction by constriction of the posterior pharynx. The buccinator myomucosal flap is an alternative flap used for VPI correction that re-establishes palatal length and velar sling anatomy by recruiting tissue from the buccal mucosa and buccinator muscle. We present innovative modifications to the original buccinator myomucosal flap by performing the procedure in one stage without a mucosal bridge, incorporating full-thickness buccinator muscle during flap elevation, and placement of bilateral buccal fat flaps. These refinements facilitate wound healing by providing a tension-free closure with both a well-vascularized myomucosal flap and interposed buccal fat flap to prevent scar contracture. Furthermore, no additional surgery is necessary for pedicle division.

Pedicled buccal flaps as a backup procedure for intraoral reconstruction

BACKGROUND

Intraoral soft tissue deficiency and impaired wound beds are common problems after cleft and tumour surgery or after dental trauma. Frequently, limited defects are overtreated with extensive microvascular reconstruction procedures, but pedicled flaps remain useful, as they are simple to harvest, and they provide a reliable outcome. The buccal flap, first described in the 1970s, has been used for palatine lengthening in cleft patients over decades. In the following, we present an expanded indication in cases of palatal fistula, complex vestibulum, exposed bone in orthognathic surgery, and osteoradionecrosis.

METHODS

We conducted a retrospective chart review and report on all buccal flaps harvested in our department within the last 3 years with a follow-up period of at least half a year after flap surgery. Patients of all age groups and treatment indications in which a buccal flap was used were implicated in the evaluation.

RESULTS

Sixteen buccal flaps were performed in 10 patients. The median age at the time of surgery was 42 years, reaching from 12 up to 66 years. Fourteen buccal flaps were used for upper jaw or palatal coverage; two buccal flaps were used in the mandible. In terms of complications (four flaps; 25%), there were two partial flap failures, one wound dehiscence and one wound dehiscence. There were no failures of the remaining mucosal flap islands after pedicle dissection.

CONCLUSION

The buccal flap is a reliable and straightforward approach to challenging intraoral wound beds with soft tissue deficiency. We thoroughly discuss the additional indications for buccal flap surgery, describe the harvest technique, and provide strategies to prevent intra- and postoperative complications.

Quantitative and Qualitative Assessment of Medial Osteotomy of the Greater Palatine Foramen in Wide Cleft Palate Repair

Background:

Repairing of a wide cleft palate faces with several problems, e.g. medialization of palatal flaps, lack of tissue for repair, and fistula formation. We aimed at quantitative and qualitative evaluation of medial osteotomy of the greater palatine foramen for patients with wide cleft palate and its postoperative outcomes.

Methods:

Eight patients 4 males, 4 females with wide cleft palate and the median age of 1.5 year were operated using medial osteotomy of the greater palatine foramen from 2018-2020. In this technique, the osteotomy was carried in the outlet of vascular pedicle medially and posteriorly. This led to more degrees of freedom for the vascular pedicle and a palatoplasty without tension through mucoperiosteal flap movement toward the medial direction.

Results:

After osteotomy and repairing for 8 patients (16 flaps), the mean (SD) length of mucoperiosteal flap pedicle was significantly increased from 2.78 mm to 6.09 mm (P<0.001). All patients were successfully repaired with no major complications, and none of them required any secondary repair. Three weeks postoperatively, all patients showed normal feeding, normal nasal resonance of speech with normal palatal mobility.

Conclusion:

Osteotomy of the greater palatine foramen for the closure of wide palatal clefts showed a good efficiency, quantitatively and qualitatively. The mean length of mucoperiosteal pedicle increased by 3.22 mm (6.44 mm for bilateral) after repairing, which helps to more freely medial movement of the palatal flap and lesser tension across its closure. All patients were successfully improved without any major complications.

Cleft Palate Repair: A History of Techniques and Variations

Orofacial clefting is a common reconstructive surgical condition that often involves the palate. Cleft palate repair has evolved over three centuries from merely achieving anatomical closure to prioritizing speech development and avoiding midface hypoplasia. Despite centuries of advancements, there is still substantial controversy and variable consensus on technique, timing, and sequence of cleft palate repair procedures. Furthermore, evaluating the success of various techniques is hindered by a lack of universal outcome metrics and difficulty maintaining long-term follow-up. This article presents the current controversies of cleft palate repair and details how the history of cleft palate repair has influenced current techniques commonly used worldwide. Our review highlights the need for a global consortium on cleft care to gather expert opinions on current practices and outcomes and to standardize technique classifications. An understanding of global protocols is crucial in an attempt to standardize technique and timing to achieve anatomical closure with optimal velopharyngeal competence, while also minimizing the occurrence of maxillary hypoplasia and palatal fistulae.

An Algorithmic Approach for Deploying Buccal Fat Pad Flaps and Buccal Myomucosal Flaps Strategically in Primary and Secondary Palatoplasty

OBJECTIVE

Recent publications have introduced the use of buccal myomucosal and fat pad flaps to augment palatal repairs with autologous tissue. We propose a workflow for intraoperative decision-making to introduce these adjuncts into standard palatoplasty procedures.

DESIGN/PATIENTS

A retrospective chart review of a single-surgeon series of patients undergoing primary and secondary palatoplasties performed between October 2017 and November 2020 was completed after Institutional Review Board approval.

MAIN OUTCOME MEASURES

Patient demographics, phenotype, operative details, and postoperative complications were recorded.

RESULTS

Fifty-eight patients were included in a review. For those undergoing primary repair, 23.3% underwent a Furlow palatoplasty alone, 46.3% had a Furlow palatoplasty accompanied with acellular dermal matrix (ADM) and/or a buccal fat flap (BFF). A unilateral buccal myomucosal flap (BMMF) with or without augmentation with BFF or ADM was employed in 16.3% of the cases. Fourteen percent required a bilateral BMMF+/- ADM. Fistula occurrence was 2.3% (n = 1). For revisions, 27% underwent only a conversion Furlow palatoplasty, 26% had a conversion Furlow palatoplasty accompanied with ADM and/or a BFF, 33% had a unilateral BMMF or BMMF/ADM, and 14% required a bilateral BMMF+/- ADM.

CONCLUSIONS

In severe phenotypes or complicated cases, buccal fat flaps and myomucosal flaps may be utilized. This approach has mostly replaced the use of ADM over time. An algorithmic approach to palatoplasty allows surgeons to tailor the extent of surgery to the needs of each patient.

Quantitative Evaluation of Palatal Lengthening After Cleft Palate Repair When a Buccal Flap Is Routinely Combined With Furlow's Z-Plasty

INTRODUCTION

The use of a buccinator myomucosal flap in combination with Furlow's Z-plasty during primary and secondary palatal repairs has been proposed by many authors to overcome some of the limitations of Furlow's technique. However, there have been no studies that quantitatively measured the effective palatal lengthening when the buccal flap is added.

PATIENTS AND METHODS

The buccal flap is routinely used during primary palate repair in order to fill the gap between the hard palate and reoriented palatal muscle sling. The soft palatal length was measured in the midline from the posterior edge of the hard palate to the base of the uvula. All patients were measured before starting the surgery and just after palatal closure in the standard position for cleft palate repair.

RESULTS

Seventy-three patients with cleft palate who were candidates for primary repair were included. The mean age at the time of operation was 11.4 ± 3.5 months. The mean preoperative palatal length was 21.36 ± 3.529 mm, whereas the mean postoperative palatal length was 29.64 ± 4.171) mm. The mean palatal length change was 8.29 ± 2.514 mm (P < 0.000).

CONCLUSIONS

The Combined use of a buccinator myomucosal flap with modified Furlow's Z-plasty in primary cleft palate repair has proven effective for palatal lengthening and achieved tensionless closure without the need for relaxing incision. It also provided a pliable soft tissue attachment of the palatal muscles to the hard palate allowing for better muscle function and mobility.

Tissue Augmenting Palatoplasty for the Treatment of Velopharyngeal Insufficiency

PURPOSE

Persistent velopharyngeal insufficiency (VPI) following primary palatoplasty remains a difficult problem to treat. This study evaluates speech outcomes following revision palatoplasty with tissue augmentation using buccal myomucosal flaps (BMF) as an alternative to pharyngoplasty for patients with VPI.

METHODS

A retrospective single-center review of revision palatoplasty with tissue augmentation at a tertiary pediatric hospital Cleft-Craniofacial Center between January 2017 and March 2021 was conducted. Patients with a history of previous palatoplasty, a diagnosis of persistent or recurrent VPI, and comprehensive pre- and postoperative speech evaluations who underwent revision palatoplasty with BMF were included.

RESULTS

Twenty patients met inclusion criteria (35% female, 20% syndromic). Mean age at the time of revision palatoplasty with BMF was 9.7 years. Preoperatively, all patients had stigmatizing speech and received the recommendation for speech surgery; the mean Pittsburgh Weighted Speech Score (PWSS) was 14.3 ± 4.9. The mean postoperative PWSS at the most recent assessment was 4.2 ± 2.3, representing a statistically significant improvement from preoperative scores (P < .001). Mean follow-up time was 8.9 months. Following revision palatoplasty with BMF, only one patient has received the recommendation for further speech surgery. No complications were noted.

CONCLUSION

In patients with VPI following primary palatoplasty, revision palatoplasty with tissue augmentation offers an alternative to pharyngoplasty. This approach preserves dynamic velopharyngeal function, improves speech outcomes, and should be considered an option when treating patients with post-primary palatoplasty VPI.

Modified Buccal Myomucosal Flap Closure of Large Anterior Palatal Oronasal Fistulas

SUMMARY

Large oronasal palatal fistulas can be challenging to reconstruct. The authors present a modified buccal myomucosal flap repair technique and review intermediate-term outcomes. In this technique, large anterior palatal fistulas are closed in two layers. First, apposing nasal turnover flaps of vomer mucosa medially and nasal wall mucosa laterally are approximated. Second, a posteriorly based buccal flap incorporating full-thickness buccinator muscle and overlying mucosa is transposed with interposition of the flap in the retromolar trigone and lateral palate to preserve dental occlusion. Consecutive patient cases performed in low-resource settings were reviewed and outcomes reported. Among eight subjects aged 3 to 22 years, with average defect size of 2.5 cm2 (range, 0.8 to 3.5 cm2), the flap was viable in all cases and required revision or pedicle division in only two patients (25 percent); all patients showed symptom improvement. The modified buccal myomucosal flap shows promising intermediate-term results as a single-stage reconstruction suitable to a wide patient age range, low airway/anesthetic risk, reliable functional outcomes, and low comorbidity.

A novel modification of Bardach's two-flap palatoplasty for the repair of a difficult cleft palate

Bardach described a closure of the cleft utilizing the arch of the palate, which provides the length needed for closure and is most effective only in narrow clefts. Herein, we describe a case where we utilized Bardach’s two-flap technique with a vital and easy modification, done to allow closure of a wide cleft palate and to prevent oronasal fistula formation at the junction of the hard and soft palate, which are otherwise difficult to manage with conventional flaps. The closed palate showed healthy healing, palatal lengthening, and no oronasal regurgitation. We advise using this modification to achieve the goals of palatal repair in difficult cases where tension-free closure would otherwise be achieved with more complex flap surgical techniques, such as free microvascular tissue transfer.

Optimizing speech outcomes for cleft palate

PURPOSE OF REVIEW

Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate.

RECENT FINDINGS

The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics.

SUMMARY

According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.

A Review of and Algorithmic Approach to Soft Palate Reconstruction

Importance

The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity.

Objective

To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review.

Evidence Review

A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded.

Findings

The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases.

Conclusions and Relevance

Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

Occlusion at 5 Years of Age Following Hard Palate Closure With Vestibular Flap

OBJECTIVE

This study aims to assess occlusal relationships and frequency of oronasal fistula at 5 years of age following 2 hard palate closure techniques and to compare results.

DESIGN

Retrospective longitudinal study.

SETTING

Institutional study.

PATIENTS

Study patients included 57 patients with nonsyndromic complete unilateral cleft lip and palate who were consecutively treated. All patients underwent our early 2-stage protocol for palatoplasty, which consisted of soft palate plasty at 1 year of age and hard palate closure at 1.5 years of age. Twenty-nine patients underwent hard palate closure using vestibular flap (VF group) technique (2009-2011) and 28 patients underwent conventional hard palate closure with local palatal flap (LPF group) technique (2006-2008).

MAIN OUTCOME MEASURES

Occlusal relationships were assessed with 5-year-olds' index, and frequency of oronasal fistula was investigated.

RESULTS

Average 5-year-olds' index scores for VF and LPF groups were 3.11 and 3.57, respectively (P < .001). Oronasal fistula occurred in approximately 7% of patients in the VF group and in 18% of patients in the LPF group.

CONCLUSION

Hard palate closure with VF technique may provide better occlusal relationships at 5 years of age than does conventional local closure with the LPF.

Morphology of the Musculus Uvulae In Vivo Using MRI and 3D Modeling Among Adults With Normal Anatomy and Preliminary Comparisons to Cleft Palate Anatomy

PURPOSE

To investigate the musculus uvulae morphology in vivo in adults with normal velopharyngeal anatomy and to examine sex and race effects on the muscle morphology. We also sought to provide a preliminary comparison of musculus uvulae morphology in adults with normal velopharyngeal anatomy to adults with repaired cleft palate.

METHODS

Three-dimensional magnetic resonance imaging data and Amira 5.5 Visualization Modeling software were used to evaluate the musculus uvulae in 70 participants without cleft palate and 6 participants with cleft palate. Muscle length, thickness, width, and volume were compared among participant groups.

RESULTS

Analysis of covariance analysis did not yield statistically significant differences in musculus uvulae length, thickness, width, or volume by race or sex among participants without cleft palate when the effect of body size was accounted for. Two-sample t test revealed that the musculus uvulae in participants with repaired cleft palate is significantly shorter (P = .008, 13.65 mm vs 16.07 mm) and has less volume (P = .002, 51.08 mm³ vs 97.62 mm³) than participants without cleft palate.

CONCLUSION

In adults with normal velopharyngeal anatomy, the musculus uvulae is a cylindrical oblong-shaped muscle lying on the nasal surface of the soft palate, with its greatest bulk located just nasal to the levator veli palatini muscle sling. In participants with repaired cleft palate, the musculus uvulae is substantially reduced in volume. This diminished muscle bulk located just at the point where the palate contacts the posterior pharyngeal wall may contribute to velopharyngeal insufficiency in children with repaired cleft palate.

The use of throat packs in pediatric cleft lip/palate surgery: a retrospective study

OBJECTIVES

Throat packs are commonly used to prevent ingestion or aspiration of blood and other debris during cleft lip/palate surgery. However, dislodgement or (partial) retainment after extubation could have serious consequences. The aim of the present study was to investigate the effect of omitting pharyngeal packing during cleft lip/palate surgery on the incidence of early postoperative complications in children.

MATERIALS AND METHODS

A retrospective study was performed on all children who underwent cleft lip/palate surgery at the Wilhelmina Children's Hospital. This study compared the period January 2010 through December 2012 when pharyngeal packing was applied according to local protocol (group A) with the period January 2013 till December 2015 when pharyngeal packing was no longer applied after removal from the protocol (group B). Data were collected for sex, age at operation, cleft lip/palate type, type of repair, lateral incisions, length of hospital stay, and complications in the first 6 weeks after surgery. Early complications included wound dehiscence, postoperative bleeding, infection, fever, upper respiratory tract infection (URTI), and lower respiratory tract infection (LRTI).

RESULTS

This study included 489 cleft lip/palate operations (group A n = 246, group B n = 243). A total of 39 (15.9%) early complications were recorded in group A and a total of 40 (16.5%) in group B. There were no significant differences (P = 0.902) in complications between the two groups; however, there was a significant difference (P < 0.001) in length of hospital stay between the two groups (group A 3.6 days vs group B 3.2 days).

CONCLUSION

Omitting routine placement of throat packs in cleft lip/palate surgery was not associated with an increased early postoperative complication rate. Therefore, the traditional, routine placement of a throat pack during cleft lip/palate surgery can be questioned.

CLINICAL RELEVANCE

The traditional, routine placement of a throat pack during cleft lip/palate surgery can be questioned.

Buccinator Sandwich Pushback: A New Technique for Treatment of Secondary Velopharyngeal Incompetence

Objective

A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich.

Patients

In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length.

Design

The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist.

Results

Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication.

Conclusion

The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.

The Square Flap Method for Cleft Palate Repair

Objective:

To introduce a new surgical technique for repair of cleft palate using the square flap method.

Design and Setting:

A retrospective analysis of prospectively collected data.

Patients and Methods:

The procedure was performed from 1995 to 2004 in 21 males and 16 females with cleft palates of different types; the patients had a median age of 6.0 years and an average age of 9.4 years (range from 22 months to 23 years). In these patients, the square flap method, consisting of one rhombic flap and four triangular flaps, designed on the soft palate across the defect, was applied to the von Langenbeck procedure. After incisions, the flaps were rotated and advanced, and each flap was inserted into the opposite side and then sutured. The patients were followed from 6 months to 2 years, the velopharyngeal closure was examined by nasopharyngeal fiberscope and/ or x-ray radiography, and a clinical speech evaluation was performed.

Results:

In all cases, no problem of flap viability was encountered and all healed well. The postoperative results were satisfactory without any complications such as dehiscence, perforation, palatal fistula, or functional disturbance. The velopharyngeal closure and clinical speech evaluation were satisfactory, and the effects of the operation were stable.

Conclusions:

The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, and sufficient lengthening of the soft palate.

The Double Opposing Z-Plasty Plus or Minus Buccal Flap Approach for Repair of Cleft Palate: A Review of 505 Consecutive Cases

BACKGROUND

Standard methods of cleft palate repair rely on existing palatal tissue to achieve closure. These procedures often require relaxing incisions, causing scars and growth restriction, and may result in insufficient palatal length and suboptimal positioning of the velar musculature. The Furlow double opposing Z-plasty improves palatal length and repositions the velar musculature; however, relaxing incisions may still be needed. The addition of buccal flaps to the Furlow repair obviates the need for relaxing incisions and allows the Furlow repair to be used in wide clefts.

METHODS

A retrospective review was performed on 505 patients; all patients were treated with the double opposing Z-plasty plus or minus buccal flap approach. Outcomes included nasal resonance, secondary speech surgery, and postoperative complications. A comparison was made between patients treated with double opposing Z-plasty alone and those treated with double opposing Z-plasty plus buccal flaps.

RESULTS

The average nasal resonance score was 1.38 and was equivalent in both the double opposing Z-plasty alone and with buccal flap groups, despite significantly more wide clefts in the buccal flap group (56 percent versus 8 percent). The secondary surgery rate for velopharyngeal insufficiency was 6.6 percent and the fistula rate was 6.1 percent. The large fistula rate (>2 mm) was 2.7 percent.

CONCLUSIONS

The double opposing Z-plasty plus or minus buccal flap approach is a useful alternative to standard palate repairs. Speech outcomes were excellent, even in wider clefts, and postoperative complications were minimal. Buccal flaps allow the benefits of the Furlow repair to be applied to any size cleft, without the need for relaxing incisions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Repair of Oropharyngeal Stenosis With Bilateral Buccal Myomucosal Flaps

Oropharyngeal stenosis (OPS) is a rare postoperative complication of adenotonsillectomy that can be a source of considerable patient distress and morbidity. Circumferential scarring of the soft palate and tonsillar pillars leads to narrowing of the oropharyngeal aperture. This case report describes the novel use of bilateral buccal myomucosal flaps for the repair of postoperative OPS in a 20-year-old woman presenting with dysphagia, odynophagia, dyspnea, and intermittent hypernasal speech. Postoperatively, the patient noted immediate improvement of her symptoms. At 1-month follow-up, she noted complete resolution of her symptoms with no dysphagia, nasal regurgitation, speaking difficulty, dyspnea, or gagging. The buccal flaps were well healed and completely intact, maintaining appropriate height of the tonsillar pillars. The buccal myomucosal flap is an effective tool for numerous palatal and oropharyngeal abnormalities and, as described in this case study, is a reliable, safe, and effective technique that can be considered for the reconstruction of postsurgical OPS.

Tessier No. 3 and No. 4 clefts: Sequential treatment in infancy by pre-surgical orthopedic skeletal contraction, comprehensive reconstruction, and novel surgical lengthening of the ala base-canthal distance

BACKGROUND

Repair of facial clefts implies wide tissue mobilization with multi-stage surgical treatment. Authors propose pre-surgical orthopedic correction for naso-oro-ocular clefts and a novel surgical option for Tessier No. 3 cleft.

METHODS

Two male infants, a Tessier No. 3 cleft (age 7 months) and another Tessier No. 4 (age 3 months), were treated with a modified orthopedic Latham device with additional septo-premaxillary molding and observed to age four years. Tessier No. 3 orthopedic measurements were obtained by image corrected cephalometric analysis. Subsequent repair included tissue expansion on Tessier No. 4 and naso-frontal Rieger flap combined with myocutaneous upper lid flap on Tessier No. 3.

RESULTS

Orthopedic movements ranged from 18.5 mm in bi-planar to 33 mm in oblique analyses. Tissue margins became aligned with platform normalization. Tissue expansion on Tessier No. 4 improved distances from ala base-lower lid and subalar base-lip. The naso-frontal flap combined with myocutaneous upper lid flap on Tessier No. 3 had similar achievement, but also sufficiently lengthened ala base-canthal distance.

CONCLUSIONS

Repairs were facilitated by pre-surgical orthopedic correction. The naso-frontal flap combined with an upper lid myocutaneous flap seems viable as a single-stage option to lengthen ala base-canthal distance to advance repair achievement in unilateral Tessier No. 3.

Modified Palatoplasty Method (Busan Modification) for Incomplete Type Cleft Palate

To achieve ultimate goals of cleft palate repair, levator muscle's appropriate reapproximation is viewed more importantly as of now, rather than simple palatal lengthening. Authors have developed modified version of 2-flap palatoplasty technique for incomplete type cleft palate and conducted follow-up study, including its early complications, speech evaluation, and facial growth measurement. Of the entire patients receiving a surgery from 2002 to 2012, the authors surveyed consecutive 100 cases of nonsyndromic incomplete cleft palate receiving our modified surgeries, and their early postoperative complication occurrence and the progress were monitored. Of them, the authors performed speech evaluation (n = 36) and facial growth measurement (n = 28) for the patients who the authors could follow-up until at least the age of 4.The medical record review has found no single, early postoperative complication requiring immediate treatment. A total of 10 cases showed delayed wound healing, but 7 of them recovered without a special problem and the other 3 showed residual fistula, recording 3% fistula formation rate. Of the 36 pronunciation evaluation cases, average score was 64.2, reaching almost to the full score of 66, but 1 case with the lowest point was found to need a corrective surgery for the clinical velopharyngeal dysfunction. Cephalometric measurement receiving 28 cases showed sella-nasion-A point angle (SNA) of 82.8° ± 3.4°, sella-nasion-B point angle (SNB) of 78.9° ± 3.9°, and a point-nasion-B point angle (ANB) of 3.9° ± 1.9°. In all range of the measurements, no significant statistical difference was found between normal population at that age and the sample group. The authors consecutively performed this modified method (Busan modification) for patients with incomplete cleft palate and consequentially found a lower rate of early postoperative complications. Moreover, relatively excellent long-term results including speech evaluation score and facial growth outcome were proved during 4 years of postoperative follow-up period.

Closure of huge palatal fistula in an adult patient with isolated cleft palate: a technical note

Closure of huge palatal fistula surrounded by fully erupted permanent dentition in the adult patients with cleft is a challenge. Posteriorly based buccinator myomucosal flap is a neurovascular pedicled flap, with inherent nature of thin thickness, saliva secretion, and axial pattern blood supply. Vicinity of donor site to the palate and low donor-site morbidity are the other advantages. It is an ideal choice in such situation. In this article, the details of surgical technique and the effectiveness of this method are presented.

Some modifications of the Furlow palatoplasty in wide clefts--a preliminary report

OBJECTIVES

Authors encounter a large percentage of wide cleft palates while operating in a Third World situation. They define the terms wide clefts and unrepairable clefts in terms of measurement. They describe their technique, which they developed to deal with wide clefts. They describe some previously unreported modifications. They also report the velar lengthening obtained.

METHODS

A total of 77 cases of primary cleft palate repaired with this technique by a single author, during the period May 2006 to February 2009, were selected for the study. These were divided into two groups on the basis of measurements. Group B consisted of all clefts deemed wide or unrepairable. Group A consisted of all other cleft palates. Difference in fistula rate was studied. Velar lengthening was measured in all patients.

OBSERVATIONS

Two fistulae occurred in Group B. The overall fistula rate for the series was 2.6%. The series consisted of 44% wide clefts, which included one case of unrepairable cleft. Lengthening in the velum ranged from 20% to 155%. Statistically significant correlations were found between narrow clefts and age group 0 to 1 year (p = .0094) and Veau Group 4 with wide clefts (p = .0194).

CONCLUSIONS

The Furlow technique as originally described has shortcomings. The authors describe their technique of incorporating the Furlow repair, which enables them to use it as a primary palatoplasty, in a scenario consisting of a large percentage of wide clefts in an older age group, thereby minimizing the fistula rate while increasing palatal length.

Islandized mucoperiosteal flaps: A versatile technique for closure of a wide palatal cleft

BACKGROUND

A variety of surgical methods have been described to repair wide cleft palate; they are all challenging to perform and yield consistently good results. The islandized mucoperiosteal flap, the technique described in the present article, is very versatile because it can close palatal defects of any size without undue tension. Moreover, it provides adequate length and mobility of the soft palate with improved speech and feeding functions without fistula formation.

METHODS

Between 2005 and 2011, 36 patients with wide cleft palate were operated on using islandized mucoperiosteal flaps. This technique involves dissection of the neurovascular bundle from the mucoperiosteal flaps for approximately 1 cm and dissecting the muscle from the posterior edge of the hard palate with intravelar veloplasty. The flaps subsequently become freely mobile in all directions. It can move medially to close palatal defects of any size without tension. In addition, posterior or backward mobilization lengthens the soft palate and renders it freely mobile.

RESULTS

All repairs were successful, with no complications and no patients requiring secondary procedures. All patients regained normal feeding function three weeks postoperatively. All patients showed normal nasal resonance of speech except for two (three and five years of age) who experienced abnormal resonance in the form of open nasality that required regular speech therapy for six months. There was significant improvement and no secondary procedures were required for either.

CONCLUSIONS

A technical modification for closure of wide palatal clefts is introduced. The islandized mucoperiosteal flap, which is a very versatile technique, can close cleft palates of any width without tension, lengthens the soft palate and renders it freely mobile for proper speech functions. Using this technique, good speech and feeding function with no complications were achieved.

The effect of cleft palate repair technique on hearing outcomes in children

OBJECTIVE

Otitis media with effusion causing conductive hearing loss is a problem for many children with cleft palate. This study examines the association between palate repair technique and hearing outcomes in children at 3 and 6 years post-repair.

PATIENTS AND METHODS

Retrospective chart review of patients with all types of cleft palate that were repaired between 2001 and 2006 at a tertiary children's hospital. Exclusion criteria included sensorineural hearing loss, ossicular chain abnormalities, and ear canal abnormalities. The primary outcome was pure tone average (PTA) from 0.5 kHz to 2 kHz.

RESULTS

69 patients (138 ears) were analyzed. 30.4% of left ears and 31.9% of right ears had an abnormal (>20 dB) PTA at 3 years; at 6 years this significantly improved to 13.0% (p=0.008) and 15.9% (p=0.011). Double-reverse z-plasty was associated with the lowest median PTA of 10.0 dB (p=0.046) at 6 years. There was no difference in median PTA between children with and without comorbid diagnoses (such as Pierre Robin Sequence, arthrogryposis) at either 3 years or 6 years (p=0.075, p=0.331). Multivariate model showed that extent of cleft influenced technique choice (p=0.027), but only technique choice was associated with significant differences in PTA and only at 6 years post-repair.

CONCLUSION

The majority of children developed normal hearing by 6 years with palatoplasty and routine tube insertion. Double reverse z-plasty was associated with the best outcome, but is not ideal for hard palate clefts. Randomized controlled trials are needed to elucidate the relationship between technique, middle ear ventilation and time to recovery, irrespective of type of cleft.

Two-stage palatoplasty using a modified Furlow procedure

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.

The Single Z-Plasty for Cleft Palate Repair: A Preliminary Report

Objective

To introduce a surgical technique for the repair of cleft palate with the single and full-thickness Z-plasty method.

Patients and Methods

The procedure was performed from 1999 to 2006 in 34 patients with cleft palate with a median age of 6.0 years (range, 2.0 to 21 years). In these patients, in order to push the soft palate back farther, a single and full-thickness Z-plasty, designed on the soft palate across the defect, was applied to the von Langenbeck procedure. The full thickness of the soft palate was incised after the hard palate was closed by suturing the two mucoperiosteal flaps, and two Z-plasty flaps were formed. The two flaps were then transposed and closed by interrupted suturing of three layers of the palate in proper order, from nasal mucosa, levator muscle to oral mucosa. The patients were followed for 6 months to 3 years, velopharyngeal closure was examined by nasopharyngeal fiberscope and/or x-ray radiography, and a clinical speech evaluation was performed.

Results

In all patients, no problem of flap viability was encountered and all healed well. The postoperative results were satisfactory without any complications such as dehiscence, perforation, or palatal fistula. The clinical speech evaluation was satisfactory, and the effects of the operation were stable.

Conclusions

The technique presented has been effective, having the advantages of palatal closure without tension and with sufficient lengthening of the soft palate.

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

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.

Furlow technique for treatment of soft palate fistula

OBJECTIVE

Fistula of the palate is a common complication of palatoplasty, it leads to nasal regurgitation of fluids and hypernasality of speech. Its treatment is technically difficult due to paucity and fibrosis of palatal tissues. The aim of this study was to evaluate the efficacy of closure of soft palate fistula by using Furlow double opposing Z-palatoplasty.

METHODS

Nineteen patients were subjected for repair of their soft palate fistulas using Furlow Z-plasty. Pre and postoperative speech analysis using auditory perceptual assessment, measurement of nasalance score using nasometric assessment, and measurement of velar movement using flexible nasopharyngoscopy were done.

RESULTS

All cases showed complete closure of their fistulas at first attempt, with no operative or postoperative complications. Recurrence was not recorded in any case after a follow up period of at least 12 months. Significant improvement of speech quality and nasalance score was achieved. Flexible nasopharyngoscopy showed postoperative increase in velar movement which was not significant relative to the preoperative records.

CONCLUSIONS

Treatment of soft palate fistula by using Furlow technique is an effective method as a primary treatment with a high success rate and a good functional outcome.

Cleft palate repair with the use of osmotic expanders: a preliminary report

A new method of cleft palate repair by expansion of tissue by means of osmotic expanders implanted in the first stage of treatment is described. Self-expanding expanders manufactured by OSMED (Ilmenau, Germany) were implanted under the mucoperiosteal layer of the hard palate, on purpose to generate more tissue and provide facility for palate repair performed 24-48h later. Nineteen children aged from 2 to 3 years were operated from January 2004 to 15 April 2005. In clefts<10mm, tissue repair was possible without relaxing incisions. In 11 patients with clefts>10mm, cleft palate repair was more difficult and the outcomes were less favourable. Despite more generous dissection of the neurovascular bundles and other adjunctive measures such as mucosal V-Y plasty [Bardach J, Salyer K. Surgical techniques in cleft lip and palate. Chicago, London: Year Book Medical Publishers, Inc.; 1987.] and suturing of the mucosal grafts at the border of the hard and soft palate, seven 2-4mm fistulae were noted, however. Concluding, in spite of some shortcomings and unacceptable rate of fistula in wide clefts, the above-presented method seems to be an attractive concept. Despite some technical problems related mostly to still tested optimal filling phase, tissue expansion makes palate repair easier, probably without relaxing incisions and bone denudation. Consequently, some adverse effects on facial growth may be reduced. So far, there is no evidence for it, however, and since this is a preliminary report, there is a need for longer observations and larger material.

The Double Transposition Flap for Closure of the Extremely Wide Hard Palate Cleft

Repair of the extremely wide hard palate cleft can be done effectively with a double transposition flap. All cases referred for closure of cleft palates from 1997 to 2005 were considered for this study. Of these, 6 were classified as extremely wide cleft palates thought not to be treatable with standard closure techniques. A double transposition flap was used in each case. All patients tolerated the procedure well; no flap failure or dehiscence was noted; and none has required secondary repair. All patients tolerated an appropriate diet following flap repair. Two patients who were gastrostomy tube dependent preoperatively no longer required gastrosotomy tubes postoperatively.

Residual deformities after repair of clefts of the lip and palate

Every effort should be made to achieve the best possible results at the time of lip and palate repair. Appropriate and extensive evaluation, short- and long-term planning with optimal timing for each procedure, close cooperation with the members of the craniofacial team, selection of the most appropriate technique(s), careful execution, and close follow-up are prerequisites for success. Additional surgical procedures or revisions are required to improve appearance and function and to manage unfavorable results of previous interventions. Such procedures should be also planned carefully, taking into consideration all aspects of the deformity to provide our patients with superior habilitation.

Cleft palate repair: art and issues

Caring for the child with cleft palate requires a multidisciplinary approach that begins with evaluation for other possible congenital anomalies, decisions about timing of repair, and choice of techniques. Postoperative follow-up similarly requires a team approach and should include an otolaryngologist, an orthodontist, and a speech therapist. The art of cleft palate repair has enjoyed a decade rich in new developments. New techniques have been developed, and standard techniques have been refined. Most importantly, the need for prospective, randomized trials to objectively compare surgical techniques has been recognized. Initiation and completion of these trials will improve outcomes for patients with cleft palate repairs.

The quantitative evaluation of palatal elongation after Furlow palatoplasty

PURPOSE

Furlow "double-opposing Z-palatoplasty" (FP) operation lengthens the soft palate by using only soft palate tissues. It is used in cleft palate repair and velopharyngeal incompetence. The aim of this study was to define the importance of the length and ratio of the soft palate elongation after FP.

PATIENTS AND METHODS

This study included 17 patients who were operated on by the same surgeon using FP. The mean follow-up period time was 4.5 years. Preoperative, intraoperative, and late postoperative velar lengths were measured and elongation ratios were calculated.

RESULTS

Mean intraoperative elongation and ratio were 16.11 mm and 69.05%, and mean late postoperative elongation and ratio were 12.47 mm and 55.47%, respectively.

CONCLUSION

Significant and permanent elongation in velar length was obtained using the FP.

Reconstruction of palatal defect using mucoperiosteal hinge flap and pushback palatoplasty

This article describes a simple, new surgical technique to provide a complete two-layer closure of palatal defect resulting from a surgical complication of trans palatal resection of skull base chordoma. The nasal layer was reconstructed with triangular shape oral mucoperiosteal turn over hinge flap based on anterior margin of palatal defect and rectangular shaped lateral nasal mucosal hinge flaps. The oral layer was reconstructed with conventional pushback V-Y advancement 2-flaps palatoplasty. Each layer of the flaps were secured with two key mattress suture for flap coaptation. This technique has some advantages: simple, short operation time, one-stage procedure, no need of osteotomy. It can close small- to medium-sized palatal defect of palate or wide cleft palate and can prevent common complication of oronasal fistula, which could be caused by tension.