Square Root Palatoplasty: A New Modification of Double Opposing (Furlow) Palatoplasty

Introduction:

 

Double opposing palatoplasty has gained a wide popularity for primary palatoplasty in the US since its first description by Dr.Furlow in 1976. The advantages of Furlow palatoplasty are better repositioning of levator muscle (and formation of functional levator sling), palatal lengthening, tighter nasopharyngeal sphincter and decreased risk of longitudinal scar contracture. However, the desired gain in length is created at the expense of shortening in the transverse axis and therefore, it is difficult to achieve tension-free closure with double opposing palatoplasty in wide clefts. Our aim in this study is to introduce a new modification of Furlow repair to overcome the disadvantages and compare its surgical outcomes with straight line repair.

 

Method:

 In this technique, an incision similar to square root shape is planned in the soft palate. Anteriorly based oral mucosal flap, which forms the transverse axis of the square root sign” is almost 90 degrees to the central limb along the cleft edges. This design allows better mobilization and vascularity of this flap, and prevents accidental tearing of the oral mucosal flap towards its base. Posteriorly based oral myomucosal flap, which forms the smaller “V” of the square root sign, can be easily transposed with this design. The levator veli palatini sling is reconstructed under the operating microscope and a spacer (acellular dermal matrix) is placed between mucosal layer and oral layer.

All patients undergoing primary palatoplasty by a single surgeon over 6 years were retrospectively reviewed. A total of 57 consecutive patients included in the study were divided into two groups: 30 in the modified furlow palatoplasy (MVP) group and 27 in the straight line repair group. Clinical characteristics (age at the time of surgery, sex, cleft type) and surgical outcomes (rate of fistula formation and speech outcomes) were compared between two groups. Speech outcomes are classified into 3 categories: normal speech, hypernasal and hyponasal speech.

 

Results:

Median age of repair at both groups was 8 months. Distribution of sex, cleft type and presence of associated syndromes were similar between the groups. Most common cleft type was Veau 3 (37% in straight line repair group, 40% in MVP group). Speech evaluation was available in 49 patients (85%). Hypernasality was more common in the straight line group than the MVP group (10/23 vs. 6/26, respectively; p=0.02) Fistula rates did not change significantly between two groups (18% in the MVP group vs 23% in the straight line repair group; p=0.67)

 

Conclusion:

Modified Furlow double opposing z-plasty along with levator veli palatini retropositioning followed by a spacer of alloderm placed between the posterior nasal spine and the muscle reconstruction of the levator for primary palatal repairs demonstrated superior perceptual speech outcomes and same fistula rate with primary palatal repair.