Cleft - Furlow Palatoplasty

Indications 

• • Primary palate repair 

  • Palatal lengthening for VPI 

    • 2015 Incidence of velopharyngeal insufficiency and oronasal fistulae after cleft palate repair. 

    • 2015 Furlow palatoplasty for previously repaired cleft palate with velopharyngeal insufficiency.

Considerations

• • Furlow (double opposing Z-plasty) palatoplasty is a soft palate operation 

  • depends on the inward mobilization of the mucoperiosteum

  • Multiple alternative techniques 

  • Bernard Von Langenbeck - first bipedicle mucoperiosteal flaps

  • Schweckendiek staged technique 

  • Veau-Wardill-Kilner three-flap/V-Y "pushback"

  • Salyer and Bardach 2-flap palatoplasty

Timing

• • Controversial

• Most agree repair before development of meaningful speech

• Several historical protocols

  • Early soft palate repair at age 6 months, followed by delayed repair of hard palate at age 6 years

  • Delayed complete repair of the palate at age 12-24 months

  • Complete repair of palate when the patient is younger than 12 months

Procedure

• • Local infiltration: .25% Bupivicaine with 1:200,000 Epinephrine

  • Dingman retractor, throat pack

• Mark incisions

  • The soft palate is divided from the uvula tip to the junction of the hard and soft palates, and the incision is extended approximately 1 cm toward the incisive foramen. The lateral lengths of the oral Z-plasties are drawn to end over the hamuli, which can be palpated with a finger. 

  • The lateral limb of the posteriorly based flap is designed to run from the junction of the hard and soft palates. 

  • The anteriorly based flap is designed to run from the uvula to the hamulus.

• Incise the cleft margin along the visible junction line between the oral and nasal mucosae in the soft palate and exactly on the cleft margin in the hard palate. 

• Mucoperiosteal flaps are elevated through the cleft with a Blair elevator. 

  • Lateral relaxing incisions are not made.

• On the left, the lateral limb incision is made, and the tip of the flap is elevated with a knife. 

• The palatal muscle is detached from the margin of the hard palate. 

  • Along the relatively fibrous cleft margin, the muscle is separated from the nasal mucosa with curved scissors and a No. 15 blade knife as needed. When the dissection reaches a point just medial to the hamulus, the palatal aponeurosis is completely divided. A Freer elevator is then used to separate the palatal muscle from the superior constrictor fibers just lateral to it, freeing the flap for rotation.

  • Complete muscle separation from the nasal mucosa exposes the mucosa for the lateral limb incision of the nasal anteriorly based Z-plasty flap. The incision extends from anterior to the uvula to the tip of the eustachian tube orifice, which is located by dropping the tip of the Freer elevator into it. 

• The right side of the cleft is incised, and the mucoperiosteal flap is also elevated. 

  • Care is taken to elevate the mucoperiosteum around the anterior end of the cleft to separate the oral and nasal mucosae in order to avoid a fistula.

  • On the right side, a lateral limb incision for the anteriorly based oral Z-plasty flap is carried through the mucosa, and the flap is elevated from the underlying muscle. The mucosa is fairly thin along the margin of the cleft, but the dissection is deepened to include minor salivary glands more laterally, making the flap somewhat thicker. The flap base is elevated by joining the subcutaneous plane of the flap dissection with the mucoperiosteal plane along the posterior margin of the hard palate, and mobilization is performed with the Freer and Blair elevators around the greater palatine vessels.

• The nasal right-sided posteriorly based flap is then elevated. The palatal muscles are detached from the hard palate. The eustachian tube orifice is identified. 

• The nasal mucosal incision is made, leaving a free edge in the nasal mucosa. 

• The palatal aponeurosis is divided, exposing the flap's palatal muscle for separation from the superior constrictor fibers lateral to it.

• Closure of the nasal side is then begun with 4-0 Vicryl, suturing the uvular tags with horizontal mattress sutures to minimize notching of the uvula. 

  • The tip of the posterior nasal flap is then inset into the lateral end of the lateral limb on the left side of the eustachian lip, bringing the right palatal muscle across the cleft. The mucosal margins between the uvula and the tip of the flap are then closed. The nasal mucosa flap is then brought across the cleft and inset into the right side in a similar fashion.

• Oral closure with 4-0 Vicryl is then begun by transposing the posteriorly based flap that overlaps the palatal muscles to form the palatal muscle flank. 

  • The anteriorly based flap on the right side is then brought across the cleft. The flap is somewhat difficult to mobilize adequately, and a small back-cut from its lateral end medially around the posterior margin of the alveolus improves mobility and facilitates dissection around the greater palatine vessels. 

  • Horizontal mattress sutures are then used to evert the stiff mucoperiosteum on the hard palate for closure. The closure is carried to the back of the mucoperiosteal incision.

• The throat pack and Dingman are removed.

• The patient's stomach, esophagus, and nasopharynx are gently suctioned.

High-Yield

• How much distance is gained on a Z-plasty based on the the following angles? 

• Superior based pharyngeal flap (pharyngeal flap with lateral side ports) is the best option for correcting VPI when there is good lateral palatal motion but poor medial motion. 

• Sphincter palatoplasty (obturates posterior and lateral wall) is the best option correcting VPI when there is good medial palatal motion with poor lateral motion.

• Palatoplasty with reconstruction of levator is used in patients with cleft palate/submucous clefts.  

• V to Y palate palatoplasty is used to reconstruct cleft palate but does add length to palate.

• Common OR questions

  • Passavant’s ridge

  • Innervation and anatomyt of TVP and LVP 

  • Types of palatoplasty

  • order of recon surgeries and timing (eg alveolus bone graft)

Post-op

• • Disposition: Admit overnight and keep until swallowing well, RTC in 1-3 weeks 

  • Activity: No-no's x 2 weeks if under age 5 

  • Diet: Clears advance to liquid / purée diet x 2 weeks as tolerated 

  • sippy cup ok

  • No bottle x 2 weeks

• Pain control: Liquid Tylenol and Ibuprofen ATC

  • Unasyn while inpatient then Augmentin x 7 days

Links

• • Video: YouTube video Furlow Palatoplasty from Seattle Children's Hospital 

  • eMedicine article Cleft Palate Repair 

  • eMedicine article Plastic Surgery for Cleft Palate

  • eMedicine article Reconstructive Surgery for Cleft Palate