Keywords palatoplasty - Furlow's Z plasty - intravelar veloplasty
Introduction
Surgical techniques of soft palate repair with zero velopharyngeal insufficiency (VPI)
are still being aimed at. Historically, straight line closure with direct muscle repair,
techniques described as intravelar veloplasty (IVVP), has demonstrated good palatal
muscular sling recreation. But straight line closure of the soft palate has inevitable
contracture which leads to higher incidence of VPI. Furlow's double opposing Z plasty
(DOZ) involves creation of long, narrow thin mucosal flaps with malaligned muscle
approximation and is generally held to be difficult to master. We present a technique
of “hybrid palatoplasty” which borrows from and adds to the existing methods, is robust,
is easy to replicate, and results in normal speech consistently.
Materials and Methods
Retrospective longitudinal clinical study was conducted at our comprehensive cleft
care clinic in a private trust hospital after the institute's ethical committee approval.
Children less than 5 years of age with isolated cleft palate, unilateral or bilateral
cleft lip, and palate who attended the comprehensive cleft care clinic were evaluated
and operated using the “hybrid palatoplasty” technique. One hundred and twenty-three
primary cleft palate cases (group II and III according to Nagpur cleft classification),[1 ] operated between 2014 and 2016, with minimum of 5 years of follow-up were included
in the study, after taking informed consent from parents/guardian. They were followed
up at regular interval and physical examination of palate for evidence of partial
dehiscence or fistula was done. Subjective speech evaluation was done after 3 years
of age by two speech therapists at our institute and reported as per universal parameters
for reporting speech outcomes.[2 ] It was evaluated by direct evaluation, and tele-evaluation using audio and video
recordings. Video-fluoroscopic evaluation was done when there was clinical suspicion
of VPI.
Surgical Procedure
Procedure is started by splitting the cleft margin a few millimeters lateral to the
edge on either side ([Fig. 1 ]). Proximal nasal repair is performed up to the level of posterior nasal spine. In
complete clefts, nasal repair is done up to the junction of posterior and inferior
border of the vomerine bone which can be called as “high vomerine suspension.” The
proximal part of soft palate is consciously moved toward the roof to reduce the resting
gap.
Fig. 1 Schematic diagram showing (left) markings for incision (purple line) and (right)
nasal layer (A ), oral layer (B ), abnormally inserted palatal muscle (C ) and markings for anterior (arrowhead) and posterior stabilization (uvuloplasty -
arrow mark) before nasal Z plasty.
Uvula is then split. Nasal and oral layers of uvula are repaired using interrupted
suture (4-0 monocryl) ([Fig. 1 ]). Same procedure is performed even when the palates are of unequal length. This
stabilizes the central limb of Z plasty between two stable points before designing
the nasal Z plasty ([Fig. 2 ]). First the right side incision is given to develop a posteriorly based mucomuscular
triangular flap dividing all the muscle fibers, aponeurosis, and mucosa for a few
millimeters with the lateral end directed slightly posterior. Muscle is further pushed
posteriorly by developing a plane oral to the aponeurosis for about a millimeter.
This incision to develop the flap is usually less than 5 mm and can be further extended
depending on the size of the mucosal flap on the left side.
Fig. 2 Schematic diagram showing dissected left palatal muscle bundle (arrow mark); stabilized
anterior (A ) and posterior end (B ) before nasal Z plasty (purple line).
On the left side, palatal muscle bundle (confluence of levator, palatoglossus, and
palatopharyngeus) is separated from the aponeurosis which is white in color. The separation
is done using knife to create this plane between the muscle and submucosal glandular
tissue nearer the nasal edge and by blunt dissection more laterally by pushing with
the knife. The mucosal flap so developed contains apart from the mucosa, palatal aponeurosis
laterally and considerable amount of mucosal glands and few muscle fibers medially.
The incision is at right angles to the nasal edge (central limb) and is also close
to the nasal uvular stitch as possible ([Fig. 2 ]). The flap so developed is thick and vascular and one is able to suture without
tension to complete the Z plasty ([Fig. 3 ]).
Fig. 3 Schematic diagram showing transposed anteriorly based nasal Z plasty mucosal flap
with few muscle fiber (A ) and left dissected palatal muscle bundle (B ) sutured to the transposed posteriorly based mucomuscular nasal Z plasty flap (C ) for palatal sling reconstruction.
Muscle which is in the posterior half of the soft palate is then approximated together
as a sling using one or two sutures under vision ([Fig. 3 ]). This takes away the slack of the muscle dissected on the left side and creates
a well-formed palatal sling.
Before oral closure it is usually necessary to give relaxing incisions in the retromolar
area extending onto the molar area ([Fig. 4 ]). The incision is in the grove close to the molar area up to the bone underneath
and is dissected medially by blunt dissection. The greater palatine pedicle need not
be visualized though it is possible to see it at this stage. The attachment of tensor
veli palatini muscle may need to be released by cutting with knife so that the soft
palate can move medially. The junction of hard and soft palate is sutured with a mattress
suture. This is usually the thickest part of the soft palate because of the submucosal
glandular tissue. On the mucosa this is identified by looking for a small dimple.
Fig. 4 Schematic diagram showing markings for small unequal oral Z plasty (green line) with
retromolar relaxing incision extending on the molar region (arrow marks).
Once this is secured, the oral “Z” plasty is planned with about a 60-degree proximal
cut on the left side. This goes through the mucosal gland and a thick flap is elevated
and underneath this the earlier repaired muscle bundle becomes visible. The distal
cut on right side is at right angles, close to the base of uvula and is dissected
off the underlying muscle till it is free to move across. The oral “Z” plasty is then
completed. Design of the flaps is done in such a way that the incisions do not extend
into the relaxing incisions given laterally and leave a small bridge of tissue in-between
as shown in the diagram ([Figs. 4 ] and [5 ]).
Fig. 5 Schematic diagram showing final suture line of the lengthened palate with the transposed
small oral Z plasty (arrow head) and raw area of retromolar incisions (arrow marks).
At completion, any bleeding in lateral relaxing incision is controlled with bipolar
cautery and dead space filled with pieces of Surgicel to ensure that there is no postoperative
ooze. For illustration, preoperative and immediate postoperative image of a case is
presented in [Figs. 6 ] and [7 ]. Intraoperative video of this technique is presented ([Supplementary Video S1 ]).
Fig. 6 Preoperative image showing group II cleft.
Fig. 7 Intraoperative image showing final suture line with “hybrid palatoplasty.”
Supplementary Video S1 Intraoperative video demonstrating the marking, dissection, and suturing of “hybrid
palatoplasty.”
Results
A total of 123 cleft palate patients were studied, which included 39 isolated cleft
palate, 66 complete unilateral cleft, and 18 complete bilateral cleft cases. Age group
at operation was below 1 year (83), up to 2 years (21), and 2 to 5 years (19).
There were 5 fistulae (4%) at the perialveolar area and no bifid uvulae. There was
no dehiscence. Speech was normal in 97.6% of children ([Supplementary Audio S1 ] and [S2 ]) and 2.4% (3 cases) had VPI. Two cases were subsequently operated for VPI and went
on to develop normal speech. Surprisingly, speech was normal even when operated above
1 year of age ([Supplementary Audio S2 ]). Among the VPI cases, one child was operated at 3 years for group II cleft and
two cases were operated at 1 year of age for group III cleft palate ([Table 1 ]).
Supplementary Audio S1 Postoperative audio recording following “hybrid palatoplasty” at 1 year of age.
Supplementary Audio S2 Postoperative audio recording following “hybrid palatoplasty” at 4 years of age.
Table 1
Details of VPI cases post-“hybrid palatoplasty”
Serial no.
Type of cleft
Age at which operated for CP (years)
Age at which VPI correction done (years)
Final speech outcome
Case 1
Group II
3
Yet to be operated
Case 2
Unilateral group III
1
4
Normal
Case 3
Bilateral group III
1
5
Normal
Abbreviations: CP, cleft palate; VPI, velopharyngeal insufficiency.
Discussion
Surgical techniques for cleft palate repair with good speech outcome consistently
are still not obtained. Initially described techniques borrowed tissues from hard
palate and pushed toward the soft palate. This leads to alveolar arch collapse which
requires further intervention. Furlow described DOZ plasty that lengthens soft palate
without borrowing hard palate tissue.[3 ] Several theoretical advantages have been described by this Z plasty like lengthening
of soft palate and avoiding scar contracture.[4 ]
[5 ]
[6 ] Techniques that result in a good palatal length will help achieve good speech outcomes.
Randall et al measured soft palates length and established that length is an important
factor for outcomes of palatoplasty.[7 ] Cephalometric analysis allows us to measure soft palate length at rest.[8 ] Guneren and Uysal analyzed intraoperative and postoperative lengthening of soft
palate in 17 cases operated by Furlow's palatoplasty with a mean follow-up of 4.5
years and demonstrated mean intraoperative and postoperative soft palatal elongation
of 16.11 and 12.47 mm, respectively.[6 ] Chang et al studied 180 primary and secondary cases operated by Furlow's method
and documented immediate postoperative soft palate lengthening of 30.6%.[5 ]
Fistula rates were also analyzed when operated by Furlow's technique in various studies.
Chang et al's study showed 4% oronasal fistula among 108 patients.[5 ] Chen and Noordhoff had 4 oronasal fistulae among 35 operated cases at Chang Gung
Memorial Hospital.[9 ] Losken et al noticed higher fistula rate (35.8%) when majority were operated using
Furlow's, especially among wider clefts and later restricted Furlow's technique only
for clefts with width less than 8 mm and performed Bardach's two-flap palatoplasty
in wider clefts and the fistula rate reduced to 1.6%.[10 ]
Another major component of Furlow's repair was the transverse repositioning of abnormally
attached soft palate musculature.[3 ] But the repositioned muscle is likely to be malaligned and is not directly approximated
to form a proper muscular sling. Good speech being the main aim, good muscle repair
and function is also equally important apart from length of soft palate.
Direct muscle repair with straight line closure has also been scrupulously described
and widely followed.[11 ] Palatine muscle was dissected to various extent by different surgeons and repaired
in IVVP. It was initially described by Braithwaite. The term IVVP was coined by Kriens[12 ] who suggested division of tensor tendon, dissection of velar muscle from hard palate
margin and oral layer but not from nasal lining as it would lead to its sloughing.
Cutting et al described radical IVVP in which he described separating the levator
muscle from both nasal and oral layer after careful dissection of descending palatine
artery.[13 ] Sommerlad modified it further by dissecting soft palate muscles under microscope.[14 ]
Various studies have described the advantages and disadvantages of IVVP.
Bosi et al evaluated immediate and late complications after palatoplasty with IVVP
which showed 16.67% incidence of fistulae and 18.6% incidence of hypernasality incidence.[15 ]
A systematic review was conducted by Timbang et al to compare the speech outcomes
and fistula rates following repair of the cleft palate with Furlow double- opposing
Z-plasty and IVVP techniques. On analyzing 12 studies, the mean failure rates were
higher with IVVP than Furlow's DOZ. The overall oronasal fistula rate was 7.87% in
the Furlow repair group compared with 9.81% in the IVVP group. This difference was
not statistically significant but the difference in the odds of requiring secondary
surgery for VPI in the IVVP group was statistically significant than the Furlow group
(p = 0.03) in unilateral cleft lip–cleft palate.[16 ]
In another comparative study between Furlow's and IVVP by Zietsman et al in 108 patients,
1 out of 34 (2.9%) in the Furlow group and 8 out of 74 (10.8%) in the IVVP group had
fistulas, though the difference was not significant.[17 ]
Various modifications of Furlow's have been described in the literature.[18 ] Nagy and Swennen followed Sommerlad's IVVP with straight line closure on nasal side
and Z plasty on oral side. Two-year follow-up of 25 cases showed good early speech
outcome but lacked long-term follow-up.[19 ]
To combine the advantages of both Furlow's and IVVP technique, “hybrid palatoplasty”
has been designed at our institute. The “hybrid palatoplasty” technique is robust,
easy to replicate, and produces consistent normal speech by borrowing from and adding
to the existing methods:
Z plasties are designed smaller.
Nasal Z plasty contains mucomuscular flap posteriorly; anteriorly based flap is mucosal
with few fibers of muscle to have a robust flap.
On the left side palatal muscle is released from both nasal and oral mucosa and sutured
with opposite palatal muscle to form palatal sling which restores velopharyngeal competence
along with lengthening of soft palate.
Oral Z plasty is purely mucosal on both sides and reverse of nasal Z plasty.
Andrades et al classified IVVP based on various extent of muscle dissection[20 ]:
Type 0: No muscle dissection or suturing of muscle.
Type 1: No dissection, parallel suturing of muscle.
Type IIa: Partial dissection (release from posterior palatal shelf but minimal dissection
from nasal and oral mucosa) creating inverted-U muscle sling.
Type IIb: Partial dissection (dissection from nasal mucosa but not oral mucosa) creating
inverted-V muscle sling.
Type III: Complete dissection creating a transverse muscle sling (radical IVV).
According to this classification, our dissection would be type III on the left side
and type IIb on the right side but it is dissected from oral mucosa and left attached
to nasal mucosa as mucomuscular flap.
Mucosal tear and scaring is less if it is retained as mucomuscular flap rather than
mucosal flap. But good approximation of muscle and palatal sling is also targeted
by dissecting the muscle free at least on one side. Author's “hybrid palatoplasty”
was designed this way taking both the pros and cons of muscle dissection into consideration.
In our study, out of 123 speech recordings available, only 3 had VPI. Among the VPI
cases, one child was operated at 3 years for group II cleft and two cases were operated
at 1 year of age for group III cleft palate (unilateral 1, bilateral 1). As the numbers
are low, further analysis was not possible. Studies in cleft cases have shown that
levator muscle is hypoplastic with more connective tissue and less contractile elements.[21 ] This may be the reason for VPI in spite of good reconstruction of palatine muscular
sling.
Surprisingly, even when operated after 1 year of age, speech was normal for almost
all cases (39/40). We believe creation of good palatal sling and lengthening of soft
palate together helped achieve normal speech even in older children. This observation
has encouraged the author to recommend this surgical technique for children with cleft
palate up to the age of 5 years.
In this study, five patients had fistula. All fistulas occurred in the perialveolar
region not affecting velopharyngeal closure. No fistulas were found in the soft palate
or the junctional area. The cases of fistula and VPI were exclusive of each other.
Conclusion
“Hybrid palatoplasty” yields excellent speech results with minimal surgical complications.
It is simple to replicate when approached in a stepwise manner.
