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

Mann, Robert J. M.D.; Martin, Matthew D. M.D.; Eichhorn, Mitchell G. M.D.; Neaman, Keith C. M.D.; Sierzant, Charles G. M.D.; Polley, John W. M.D.; Girotto, John A. M.D.

Plastic and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 735e–744e
doi: 10.1097/PRS.0000000000003127
Pediatric/Craniofacial: Original Articles

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.


Grand Rapids, Mich.

From the Spectrum Health Helen DeVos Children’s Hospital, Grand Rapids Medical Education Partners, Michigan State University College of Human Medicine.

Received for publication February 16, 2016; accepted August 24, 2016.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Robert J. Mann, M.D., 230 Michigan Street, Suite 300, Grand Rapids, Mich. 49503,

©2017American Society of Plastic Surgeons