Medial incision approach in modified small double-opposing Z-plasty for Veau II cleft repair.

An encouraging outcome was described for the use of modified Furlow small double-opposing Z-plasty (sDOZ) using the medial incision (MIsDOZ) approach in repair of Veau type I cleft palate. This retrospective study assessed early results of using extended indication criterion of MIsDOZ for the management of consecutive non-syndromic patients with Veau II cleft palate treated by a single surgeon. Bardach two-flap plus sDOZ (two-flap approach) or medial incision approach with a tension-driven stepwise application of lateral palatal incisions (soft palate only, von Langenbeck type, or two-flap type) were applied. Surgical (age, cleft width, operative time, hospital stay, and complication)- and auditory-perceptual assessment-related data were collected. Two-flap approach (n = 21) demonstrated a significantly (p < 0.001) increased operative time (132.8 ± 12.2 versus 114.8 ± 19.9 min, respectively) and higher use of lateral incisions (100% versus 44.4%) than medial incision approach (n = 27), with no significant (p > 0.05) difference for age at surgery (13.0 ± 6.1 versus 13.6 ± 5.8 months), cleft width (8.5 ± 4.1 versus 8.7 ± 3.8 mm), hospital stay (1.0 ± 0 versus 1.0 ± 0 day), and complication (0% versus 0%) and hypernasality (9.5% versus 7.4%) rates. In conclusion, the medial incision approach for Veau II cleft repair resulted in reduced need for lateral palatal incision with no increase of complication or hypernasality rates.

Assessing the impact of palatal fistula formation and cleft width on speech outcomes following double opposing Z-plasty in patients with cleft palate.

OBJECTIVE: This retrospective study investigated the influence of palatal fistula (PF) formation after double opposing Z-plasty (DOZ) on speech outcomes in patients with cleft palate (CP), focusing on cleft width and palatal length as predictors of velopharyngeal insufficiency (VPI). METHODS: This study included 1117 patients with CP (579 males, 538 females) who underwent DOZ, performed by a single surgeon, between 1988 and 2017. Demographic characteristics, cleft dimensions, history of PF formation, and speech outcomes were investigated. Speech evaluations were performed at a minimum age of five to assess nasal emission, hypernasality, compensatory articulation, intelligibility, necessity for VPI surgery, and speech therapy. Logistic regression analysis was performed. RESULTS: Speech assessments were conducted at the median age of five (interquartile range [IQR], 5-6 years). Overall, 96.5% of patients achieved 'socially acceptable speech' after DOZ. Patients with PF history showed greater cleft width and experienced higher rates of hypernasality, nasal emission, and VPI on videofluoroscopy (VFS) compared to those without PF history (mean, 11.4 mm vs. 7.1 mm; 28.4% vs. 23.6%; 34.8% vs. 14.9%, 38.5% vs. 14.0%, 40.6% vs. 28.3%, respectively; all p < 0.0001). Cleft width was significantly associated with VPI-related speech outcomes in the multivariate logistic regression analysis, affecting both perceptual and VFS-measured outcomes. CONCLUSIONS: A wider CP gap significantly increased the risk of VPI-related speech difficulties after DOZ. Cleft width is a more critical predictor of adverse speech outcomes than the presence of small-to-medium-sized PFs. Patients with a history of PF and wider cleft gaps require targeted interventions and intensified follow-up to effectively manage and improve speech outcomes.

Single vs. Double-Opposing Z-Plasty: Evaluating Their Impact on Palatoplasty Postoperative Outcomes.

BACKGROUND: The double-opposing Z-plasty is a fundamental approach for cleft palate repair. Recently, some surgeons have begun implementing a single Z-Plasty, igniting discussions on the most effective technique for enhancing postoperative outcomes. Consequently, this study sought to evaluate the outcomes of employing single and double Z-plasties within the modified Sommerlad-Furlow technique. METHODS: 116 cleft palate patients undergoing primary surgical repair were divided into two groups: those treated with the Sommerlad-Furlow method using a double-opposing Z-plasty (S.F.2.Z.P. group, n = 58) and those receiving a single nasal Z-plasty (S.F.1.Z.P. group, n = 58). Data on cleft type and width, soft palate length, palatal fistula, and velopharyngeal function were collected. Mann-Whitney test compared the mean values between groups. RESULTS: The S.F.2ZP group demonstrated a statistically significant increase in soft palate length compared to those in the S.F.1ZP group (p = 0.008). However, the S.F.1ZP group demonstrated adequate soft palate length (7.9 ± 2.8 mm) compared to the S.F.2ZP group (9.3 ± 2.8 mm). The velopharyngeal function was good in both groups, with no significant differences (P = 0.52). While the proper velopharyngeal closure was 81% in the S.F.1ZP group and 87.9% in the S.F.2ZP group, velopharyngeal insufficiency was 10.3% and 5.2%, respectively. The rates of persistent palatal fistula were 5.2% in the S.F.1ZP group and 3.4% in the S.F.2ZP group, with no significant differences found between both groups (P = 0.64). CONCLUSIONS: There were no significant differences in crucial outcomes such as velopharyngeal function and the incidence of persistent palatal fistulas, indicating the effectiveness of both techniques. While the double-opposing Z-plasty demonstrated a statistically significant increase in soft palate length, the a nasal Z-plasty demonstrated adequate soft palate length which sufficiently enables effective velopharyngeal closure. These outcomes suggest that a single Z-plasty is both effective and easy to perform, making it a valuable surgical approach for achieving the desired outcomes.. CLINICAL RELEVANCE: The current study suggests that although the soft palate may not be as elongated with nasal Z-plasty alone compared to the double Z-plasty, it sufficiently enables effective velopharyngeal closure.

Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study.

BACKGROUND: The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center. METHODS: A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included. RESULTS: A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0. CONCLUSION: Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula.

Preoperative Velopharyngeal Closure Predicts Hypernasality Outcomes of Secondary Furlow Double-Opposing Z-Plasty.

OBJECTIVE: To determine if preoperative velopharyngeal closure percentage (VCP) is predictive of successful Furlow double opposing Z-plasty (DOZP) and subsequently determine the optimal velopharyngeal closure cutoff for successful DOZP. DESIGN: Retrospective study. SETTING: Tertiary academic center. PATIENTS: 110 patients with repaired cleft lip and palate having hypernasality treated with DOZP. INTERVENTIONS: Speech videofluoroscopy images were used to obtain the preoperative VCP and other measurements. MAIN OUTCOME MEASURES: Changes in hypernasality scores using the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM) rating system were used as the primary outcome measure. A successful DOZP was defined as a postoperative hypernasality score of ≤ 1 or an improvement of 2 or more scores from baseline. A receiver operating characteristic (ROC) curve was calculated to determine preoperative VCP cutoff. RESULTS: There were 110 patients who underwent DOZP for treatment of velopharyngeal insufficiency. Of these patients, 94 (85%) had successful surgery as determined by their postoperative CAPS-A-AM hypernasality score. Preoperative VCP was a statistically significant predictor of successful DOZP (P < .0001). The ROC curve with Youden index (J) determined a cutoff (c*) of 55% preoperative VCP or greater to optimize surgical success rate. Grouping by preoperative VCP showed that surgical success increases directly with preoperative VCP, and patients with low VCP had above a 50% success rate in reducing hypernasality scores. CONCLUSIONS: Preoperative VCP was significantly associated with improved hypernasality ratings postoperatively. A preoperative VCP of ≥55% may be used to help predict success of Furlow palatoplasty treatment. Patients with lower VCP can still benefit from secondary DOZP.

A Single Institution 19 Year Comparison of Furlow and Straight Line Palatoplasty Techniques in Bilateral Cleft Lip and Palate.

OBJECTIVE: This study aims to compare patients' speech correcting surgery and fistula rates between the Furlow and Straight Line (SLR) palatoplasty techniques when combined with greater palatine flaps for complete bilateral cleft lip and palate (BCLP) repair. DESIGN: This was a single-center IRB approved retrospective cohort study. SETTING: This study took place at an urban tertiary academic center. PATIENTS, PARTICIPANTS: All patients with BCLP anomalies that underwent repair between January 2003 and August 2022 were included. Patients with index operations at an outside institution or incomplete medical charting were excluded. INTERVENTIONS: A total of 1552 patients underwent palatoplasty during the study period. Of these, 192 (12.4%) met inclusion criteria with a diagnosis of BCLP. MAIN OUTCOME MEASURES: Primary outcomes of this study included rate of fistula and incidence of speech correcting surgery. Secondary outcomes included rate of surgical fistula repair. RESULTS: One hundred patients underwent SLR (52.1%) and 92 Furlow repair (47.9%). There was no significant difference in fistula rates between the SLR and Furlow repair cohorts (20.7% vs. 15.0%; p = 0.403). However, SLR was associated with lower rates of speech correcting surgery when compared to the Furlow repair (12.5% vs. 29.6%; p = 0.011). CONCLUSIONS: This study compares the effect of Furlow and SLR on speech outcomes and fistula rates in patients with BCLP. Our findings suggest that SLR resulted in an almost three times lower rate of velopharyngeal dysfunction requiring surgical intervention in patients with BCLP, while fistula rates remained similar.

Simultaneous Furlow Palatoplasty and Tonsillectomy for the Treatment of Velopharyngeal Insufficiency and Tonsillar Hypertrophy.

OBJECTIVE: To determine whether performing tonsillectomy at the time of Furlow palatoplasty for the treatment of cleft palate related velopharyngeal insufficiency (VPI) incurs increased surgical complications or compromises speech outcomes. DESIGN: A retrospective review of patients who had Furlow palatoplasty and the outcomes of surgery in the treatment of cleft palate related VPI. SETTING: A single academic center between January 2015 and January 2022. PARTICIPANTS: Patients with submucous cleft (SMC) palate or patients with prior straight line primary palatoplasty presenting with VPI. INTERVENTIONS: Simultaneous conversion Furlow palatoplasty and tonsillectomy. MAIN OUTCOME MEASURE(S): Primary outcome measures include preoperative and postoperative Modified Pittsburgh Weighted Speech Scale (mPWSS), and postoperative surgical complications. RESULTS: Eight patients (25%) underwent Furlow palatoplasty and concomitant tonsillectomy, while 24 patients (75%) underwent Furlow palatoplasty alone. A significantly lower median postoperative mPWSS score, corresponding to better velopharyngeal function, was reported for patients in the Furlow-tonsillectomy group (0, IQR 0-0) compared to the Furlow only group (1, IQR 0-9, p = 0.046). No surgical complications were encountered in either group. Five patients (20.8%) in the Furlow only group required subsequent surgery for persistent VPI. No patients in the Furlow-tonsillectomy group required additional surgical treatment for VPI (0%, p = 0.16). CONCLUSIONS: Tonsillectomy at time of Furlow palatoplasty is utilized in patients with both VPI and baseline tonsillar hypertrophy to lessen the risk of postoperative obstructive breathing. Tonsillectomy performed concurrently with Furlow palatoplasty is safe, without increased risk of surgical complications, and does not compromise post-Furlow palatoplasty speech outcomes.

A predictor of a postoperative fistula after double-opposing Z-plasty in bilateral cleft lip and palate patients.

Furlow double-opposing Z-plasty (FDOZ) as primary palatoplasty for the bilateral cleft lip and palate (BCLP) closure often leads to a palatal fistula formation in cases with wide clefts. We examined the utility of the calculated maximum closable cleft width to determine the feasibility of a direct palatal closure without lateral incisions. In this retrospective study, we analyzed consecutive patients with a BCLP who were treated for 5 years from 2009. In sixty-three BCLP patients, the following dimensions were measured preoperatively: an actual distance between maxillary tuberosities (Actual X); actual cleft height, calculated from the line joining the maxillary tuberosities to the cleft edge (Actual Y); and actual cleft width at the hard-soft palate junction (Actual Z) and calculated maximum cleft width requiring a direct closure (CMZ). Six months postoperatively, the relationships between the fistula occurrence and actual Z/CMZ were examined. Median values (interquartile range) of Actual X, Y, and Z and CMZ were 35.0 (33.0-39.0) mm, 7.0 (6.0-8.0) mm, 10.0 (8.0-11.0) mm, and 4.6 (2.7-5.7) mm, respectively. The median age at operation was 8.0 (7.0-17.0) months. Fistulae at the hard-soft palate junction developed postoperatively in three cases with more than a 10-mm cleft width (4.76%). A receiver operating characteristic (ROC) curve analysis indicated that actual Z was a better predictor of a postoperative fistula formation than CMZ. An actual cleft width was a better predictor of the fistula occurrence than a calculated maximum cleft width after FDOZ for a BCLP repair. The low fistula rate of FDOZ suggested that FDOZ could be used to close the palate with less than a 10-mm cleft width.

A procedure combining double opposing Z-plasty with buccal flap and skin graft for a cleft palate patient with short palate.

Cleft palate patients with a short palate are sometimes encountered and it is difficult to achieve effective primary palatoplasty and good speech in these cases. Our purpose was to establish an effective palatoplasty for a cleft palate patient with Randall type III short palate. Buccal musculomucosal flap on the nasal side and skin graft on the oral side were performed, along with double opposing Z-plasty. Speech improved postoperation. This procedure brought the nasopharyngeal area closer to the normal anatomical state. In terms of disadvantages, the procedure is rather complicated and depends on the engraftment rate.

Surgical indication of Furlow palatoplasty to treat submucous cleft palate.

This study investigated the effects of Furlow palatoplasty on children with submucous cleft palate (SMCP) and identified surgical indications by comparing SMCP and control patients. Twenty-three SMCP children (average age 28.9 months) who were nonsyndromic and underwent surgery between April 2010 and December 2016 were included. Facial computed tomography (CT) was performed preoperatively and at least 1 year postoperatively after a language test. Facial CT measurements were taken for 140 children aged 0-6 years without deformities (control group). Later surgery was associated with more severe nasality. In the coronal view, the difference in the maxillary tuberosity before and after surgery was 3.8 mm (p < 0.05). The height and width of the palatal arch (HNP and WNP) were well maintained (p > 0.05), whereas the angle of the levator veli palatini muscle (ALM) increased (p < 0.05). The nasopharynx was close to normal postoperatively. The distance between the medial pterygoid plates, the HNP, and the WNP were larger in SMCP patients preoperatively (p < 0.05), but these differences disappeared after surgery (p > 0.05). The ALM in SMCP patients was narrower preoperatively, but became flatter postoperatively (p < 0.05), indicating the repositioning of the levator muscle, with improvement of the velopharyngeal function. Furlow palatoplasty is indicated if the HNP and WNP values are larger, and the ALM value is less, in patients with SMCP than in those without.

Double-Opposing Z-Plasty for Secondary Surgical Management of Velopharyngeal Insufficiency Following Primary Furlow Palatoplasty.

OBJECTIVE: The present study investigates the efficacy of performing a "palate rerepair" utilizing a double-opposing z-palatoplasty (DOZ) following primary Furlow palatoplasty. DESIGN: Retrospective study. SETTING: Tertiary referral academic center for craniofacial surgery. PATIENTS: 15 consecutive patients who presented with velopharyngeal insufficiency (VPI) after primary Furlow palatoplasty. MAIN OUTCOME MEASURES: All subjects were evaluated using the perceptual speech assessment (PSA) scale. Criteria for inclusion in the study were (1) velopharyngeal gap size on phonation of 7 mm or less and (2) lateral wall motion at least 40% normal. RESULTS: Mean PSA score was 7.13 + 3.31 (range 3-13) preoperatively, and decreased to 1.80 + 2.83 (range 0-11; P < .001 vs baseline) 3 months or more after surgery. A sphincter pharyngoplasty was performed as a tertiary procedure in 2 patients due to persistent nasal air emission. There was no symptomatic airway compromise following secondary or tertiary management in all patients. Presence of a cleft lip, lateral wall motion, and velopharyngeal gap size did not impact outcomes. CONCLUSIONS: We have demonstrated that a DOZ performed secondarily is anatomically possible following Furlow palatoplasty and can restore function of the levator muscle despite significant scarring following primary repair. This approach respects anatomic principles of palatoplasty without eliminating the possibility for extrapalatal procedures should velopharyngeal competence not be achieved.

The effect of age at surgery and compensatory articulation on speech outcome in submucous cleft palate patients treated with double-opposing Z-plasty: A 10-year experience.

BACKGROUND: Submucous cleft palate is a congenital deformity that may present as velopharyngeal insufficiency. The degree of anatomical abnormality varies widely among patients and does not predict severity of symptom. We present our 10-year experience treating submucous cleft palate patients with double opposing z-plasty and explore the effect of age at surgery and compensatory articulation on speech. METHODS: Preoperative assessment included intraoral examination, nasoendoscopy, and perceptual speech evaluation. Age, gap size, and severity of hypernasality were assessed to determine the timing and type of surgery. A retrospective study of 74 submucous cleft palate patients undergoing double-opposing z-plasty from 2005 to 2016 by a single surgeon (Baek RM) was conducted. Double opposing z-plasty was modified to fully release all abnormal insertions of the levator veli palatini muscle. Postoperative velopharyngeal function was measured and statistical analyses were performed. RESULTS: The ages of patients at surgery ranged from 11 months to 19 years. Postoperatively 87 percent of the patients achieved velopharyngeal competency and 13 percent had remaining mild hypernasality. Age was a significant factor in predicting speech outcome, and patients receiving surgery prior to the age of 5.5 years had a higher normalization rate. Compensatory articulation did not have an impact on postoperative hypernasality. There were no cases of postoperative hyponasality or airway problems. CONCLUSION: Satisfactory speech outcome was achieved with the authors' protocol and modification of the double-opposing z-plasty. A comprehensive assessment of patient age, intraoral findings, severity of hypernasality, and gap size, is necessary for proper treatment of submucous cleft palate patients.

Velopharyngeal Dysfunction Evaluation and Treatment.

Velopharyngeal dysfunction (VPD) can significantly impair a child's quality of life and may have lasting consequences if inadequately treated. This article reviews the work-up and management options for patients with VPD. An accurate perceptual speech analysis, nasometry, and nasal endoscopy are helpful to appropriately evaluate patients with VPD. Treatment options include nonsurgical management with speech therapy or a speech bulb and surgical approaches including double-opposing Z-plasty, sphincter pharyngoplasty, pharyngeal flap, or posterior wall augmentation.

Redo double-opposing Z-plasty is effective for correction of marginal velopharyngeal insufficiency.

OBJECTIVE: Double-opposing Z-plasty (DOZ) of the Furlow method has been successfully used for the correction of marginal velopharyngeal insufficiency (VPI) by reconstructing the levator muscle and lengthening the soft palate. For a recurrent or residual marginal VPI, it was questioned whether redo DOZ could be applied to correct the problem and minimize surgical morbidity. This study reported the outcome of the redo DOZ. MATERIALS AND METHODS: The DOZ procedure was the method of choice for marginal VPI in the authors' center. To evaluate the effectiveness of the redo operation, patients with cleft palate with or without cleft lip treated from 2005 to 2014 were reviewed. Inclusion criteria were non-syndromic patients who underwent the second DOZ for the correction of marginal VPI. Clinical information, speech assessment, and nasopharyngoscopic findings were reviewed. RESULTS: The velopharyngeal function was improved from marginal to adequate in all 13 patients either subjectively or objectively. The resonance became normal in nine patients after the surgery, and the change was statistically significant. Preoperative audible nasal emission improved in four out of five patients. Complications were minor or transient including one patient with snoring. No patient complained of airway or sleep problems. CONCLUSION: Although the levator muscle sling might be disturbed by the redo DOZ procedure, the surgery was effective in correcting the residual VPI with low morbidity.

Influence of preoperative velar closing ratio and lateral wall movement on outcomes of Furlow palatoplasty for velopharyngeal incompetence.

Currently, there is no consensus regarding how to determine the optimal surgical procedure for a patient with velopharyngeal incompetence (VPI) post-primary palate repair. The purpose of the present study was to assess the effect of preoperative velar closing ratio (VCR) and lateral wall movement (LWM) on nasal emission and hypernasality after Furlow double-opposing Z-plasty. A retrospective analysis involving patients with VPI post-primary palatoplasty whose VPI was treated with double-opposing Z-plasty by a single surgeon was performed. Ten consecutive patients with VPI postpalatoplasty were reviewed. Videonasendoscopy, videofluoroscopy and perceptual speech examinations were performed preoperatively and postoperatively. VCR improved from an mean of 0.5 preoperatively (range 0.1 to 0.95) to 0.9 postoperatively (range 0.55 to 1.0). Postoperative mean LWM was 0.5 (range 0.3 to 0.9), unchanged from preoperative ratings. A trend toward an inverse relationship between preoperative VCR and improvement in hypernasality and resolution of nasal emission was observed. No relationship was noted between the degree of preoperative LWM and mean improvement in hypernasality. However, patients with worse preoperative LWM experienced better resolution of nasal emission postoperatively.

Il n'y a pas de consensus pour déterminer l'intervention chirurgicale optimale chez un patient présentant une insuffisance vélopharyngée (IVP) après une réparation palatine primaire. La présente étude visait à évaluer l'effet du ratio de fermeture vélaire (RFV) et de mouvement des parois latérales (MPL) sur l'émission nasale et l'hypernasalité après une plastie en Z en double opposition selon Furlow. Les chercheurs ont procédé à une analyse rétrospective de patients qui avaient subi une palatoplastie primaire et qui présentaient une IVP traitée par un chirurgien par une plastie en Z en double opposition. Ils ont examiné dix patients consécutifs ayant une IVP après leur palatoplastie. Ils ont effectué une vidéo-endoscopie nasale, une vidéo-fluoroscopie et des examens orthophoniques perceptuels avant et après l'opération. Le RFV s'est amélioré d'une moyenne de 0,5 avant l'opération (plage de 0,1 à 0,95) à une moyenne de 0,9 après l'opération (plage de 0,55 à 1,0). Le MPL moyen après l'opération était de 0,5 (plage de 0,3 à 0,9), identique aux mesures préopératoires. Les chercheurs ont observé une tendance inversement proportionnelle entre le RFV préopératoire, l'amélioration de la nasalité et la résolution de l'émission nasale. Ils n'ont pas remarqué de relation entre le degré préopératoire de MPL et l'amélioration moyenne de l'hypernasalité. Cependant, les patients dont le MPL était plus prononcé avant l'opération présentaient une meilleure résolution de l'émission nasale après l'opération.

Teaching Furlow palatoplasty: the sticky note method.

OBJECTIVE: The double-opposing Z-plasty (Furlow palatoplasty) procedure is a well-established method for palate repair in children. We propose a simple and easily accessible sticky note model to demonstrate the lengthening in palatal anatomy afforded by this technically challenging procedure. METHODS: Our model involves creating a lengthened three-dimensional representation of the Z-plasty through making specified incisions and rearrangements of the palatal layers. The sticky note model was made a total of 20 times and length of the palate model pre and post Z-plasty was measured. RESULTS: The average length of the palate pre-procedure was 72 mm. The average length of the palate post procedure was 78.9 mm, showing an increase of 6.9 mm (9.6%). CONCLUSION: Our model provides an accurate and valuable educational tool that will aid in the visualization and understanding of the Furlow palatoplasty procedure.