We thank Dr. Li et al. for their comments in response to our recent article, “The Children’s Hospital of Philadelphia Modification of the Furlow Double-Opposing Z-Palatoplasty: 30-Year Experience and Long-Term Speech Outcomes.”1 The authors raise concern about use of the Furlow technique in wider clefts and without relaxing incisions; they propose a modification to achieve a tension-free closure and thus reduce the risk of oronasal fistula formation and the potentially deleterious effects of relaxing incisions on facial growth. They highlight specific areas of tension where closure can be difficult, namely, at the inset of the anteriorly based nasal and oral mucosal flaps, and they propose a modification (depicted in their Fig. 3) whereby the posteriorly based oral musculomucosal flap is advanced only as far as it will reach without tension and the remainder of the lateral incision is closed in a V-Y fashion. This is performed on the opposing side as well at the inset point of the anteriorly based oral mucosal flap.
Limited use in wide clefts without relaxing incisions is commonly cited as a limitation of the Furlow repair as originally described by Furlow and shown in Li et al.’s Figure 1.2 Our technique at the Children’s Hospital of Philadelphia uses relaxing incisions in all but the most narrow or submucosal clefts, in addition to wide undermining of the hard palatal mucoperiosteum, to accomplish a tension-free closure and allow full transposition of the musculomucosal flaps. As elucidated by the authors in their Figure 2, greater transposition of the soft palatal flaps theoretically results in greater palatal lengthening as well as increased levator muscle overlap and a tighter muscular levator sling, both potentially advantageous for velopharyngeal function. The authors suggestion to use V-Y closure instead of relaxing incisions has the disadvantage of shortening the anteroposterior palatal length, because one is not fully interdigitating the flaps but instead placing sutures that pull the posterior palate toward the front. As described in our article, initially higher fistula rates were observed at our institution; with increased experience came greater recognition of the necessity of wide undermining of the oral mucoperiosteal flaps though relaxing incisions with aggressive mobilization of the vascular pedicles to achieve a tension-free closure. Subsequently, this rate decreased to 2.8 percent over the past 5 years.1
Although continued concerns exist that relaxing incisions have negative effects on midfacial growth, no good studies have demonstrated causality or differentiated between the effects of relaxing incisions versus undermining of the hard palate mucoperiosteum alone. Previous studies from our institution demonstrated no adverse effects on midfacial depth in a cohort of our patients who underwent modified Furlow palatoplasty with and without relaxing incisions (narrow clefts not requiring relaxing incisions), minimal effects on the incidence of anterior crossbites, and no evidence of posterior crossbites after palatoplasty.3,4 Our Le Fort I rate of 14 percent in the cleft population has remained stable over time and is comparable to that of other cleft centers. Certainly, facial growth following the modified Furlow palatoplasty warrants further in-depth study.
Thus, we advocate routine use of relaxing incisions as the means of achieving a tension-free closure. V-Y closure has been used at our institution at the site of the oral mucosal flap inset in situations where this incision has been made too long at the beginning of the procedure or has torn during the dissection, thereby extending it further than desired, or when there remains unacceptable tension at this site; however, it has never been utilized to avoid the use of relaxing incisions. The additional advantage of the Furlow repair is the minimization of overlapping incisions; these points of inset at the tip of the oral flaps are supported by a healthy underlying musculomucosal layer, thus minimizing the risk of fistulization with any delayed healing. Our incision design has evolved from Dr. Furlow’s original description, with a more oblique angulation of the anteriorly based mucosal flap facilitating a more posterior dissection of the nasal musculomucosal flap and a more posterior inset of the oral musculomucosal flap. Illustrations showing this modified design of the incisions can be found in previous publications.5,6
The authors have no financial interest to declare in relation to the content of this communication.
Oksana Jackson, M.D.
David Low, M.D.
Don LaRossa, M.D.
Division of Plastic Surgery
The Children’s Hospital of Philadelphia
Perelman School of Medicine
University of Pennsylvania
1. Jackson O, Stransky CA, Jawad AF, et al. The Children’s Hospital of Philadelphia modification of the Furlow double-opposing Z-palatoplasty: 30-Year experience and long-term speech outcomes. Plast Reconstr Surg. 2013;132:613–622
2. Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986;78:724–738
3. Mayro R, LaRossa D, Randall P, et al. Incidence of posterior dental crossbite after Furlow palatoplasty. April 12, 1997 New Orleans, La Presented at the American Cleft Palate-Craniofacial Association Meeting
4. Wang P, Kirschner RE, Minugh-Purvis N, Randall P, LaRossa D. Relaxing incisions do not adversely affect the A-P midfacial growth in unilateral cleft lip and palate patients. April 16, 1999 Scottsdale, Ariz Presented at the American Cleft Palate-Craniofacial Association Meeting
5. LaRossa D, Jackson OH, Kirschner RE, et al. The Children’s Hospital of Philadelphia modification of the Furlow double-opposing z-palatoplasty: Long-term speech and growth results. Clin Plast Surg. 2004;31:243–249
6. Kirschner RE, Wang P, Jawad AF, et al. Cleft-palate repair by modified Furlow double-opposing Z-plasty: The Children’s Hospital of Philadelphia experience. Plast Reconstr Surg. 1999;104:1998–2010; discussion 2011
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