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The Children’s Hospital of Philadelphia Modification of the Furlow Double-Opposing Z-Palatoplasty

30-Year Experience and Long-Term Speech Outcomes

Li, Cheng-hao Ph.D., D.D.S.; Shi, Jia-yu D.D.S.; Zheng, Qian D.D.S.; Shi, Bing D.D.S., Ph.D.

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Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 429e-431e
doi: 10.1097/PRS.0000000000000157
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Sir:

We read with great interest the recent article entitled “The Children’s Hospital of Philadelphia Modification of the Furlow Double-Opposing Z-Palatoplasty: 30-Year Experience and Long-Term Speech Outcomes” and its accompanying Discussion.1,2 We would like to take the opportunity to further expand on the topic of using V-Y suture in wider clefts and without relaxing incisions in order to reduce high fistula rates.

One out of 500 to 1000 babies are born with a cleft.3 Cleft palate is the most common of these facial clefts. The goal of cleft palate repair is to restore a mechanism for normal speech production, so reconstruction of the continuity of circular muscle in the palate is an important step in the treatment. With publication of Dr. Furlow’s novel original surgical technique, it has been more than 30 years since the first report of cleft palate repair utilizing the double-opposing Z-palatoplasty.4 The double-opposing Z-palatoplasty has been one of the most popular techniques for primary palatoplasty in the world. By using the Furlow repair, the surgeon tries to obtain a good speech outcome by levator muscle repositioning and palatal lengthening, especially for submucosal cleft palate repair and in secondary revision palatoplasty for velopharyngeal insufficiency. In Jackson et al.’s article,1 the authors describe the advantages in great detail. As noted in Kane’s Discussion,2 there are some problem areas when the Furlow method is used in wider clefts and without relaxing incisions. Some areas may present difficulty in obtaining adequate closure, including (1) closure of the left-sided, anteriorly based nasal mucosal flap at the junction of the hard and soft palate and (2) closure of the right-sided, anteriorly based oral mucosal flap.

In particular, young surgeons perhaps are misguided by Furlow’s surgical protocol figures (Fig. 1) and always try to inset and close the oral mucosal flaps, as in the figures. Actually, this protocol is a good choice only for submucosal cleft palate repair and in secondary revision palatoplasty for velopharyngeal insufficiency. The key point of the Furlow method is levator muscle repositioning and palatal lengthening by shortening the soft palatal width (Fig. 2). For a wide cleft palate, it is hard to achieve a tension-free closure without making back-cut or relaxing incision. So some surgeons struggle with tension-free closure to reduce the fistula rate or have concerns regarding the deleterious effects on facial growth with the use of relaxing incisions. In our department, we suggest that, for some cases, the application of V-Y sutures in Furlow double-opposing Z-palatoplasty might be a good choice. In our experience, it should be easy to achieve closure of the nasal mucosal flaps. For the oral mucosal flaps, in order to achieve a tension-free closure, it is not necessary to rotate and inset the muscle flap to the opposing corner; you can just close with the opposing oral mucosal flap with a tension-free suture. Meanwhile, you do not need to extend the right-side oral lateral limb relaxing incision around the maxillary tuberosity at the posterior end of the alveolus to assist with inset of the right-sided, anteriorly based oral mucosal flap if you are worried about the deleterious effects on facial growth (Fig. 3). In addition, with regard to the effect of cleft type on speech outcome, we obtained results similar to those of the Children’s Hospital of Philadelphia, in that patients with Veau type1 and type 2 clefts had significantly worse speech outcomes than patients with Veau type 3 and type 4 clefts using this suture method in Furlow double-opposing Z-palatoplasty. We need more research to confirm this in the Chinese population.

Fig. 1
Fig. 1:
The classic Furlow surgical protocol of the double-opposing Z-palatoplasty. (Reprinted from Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986;78:724–738).
Fig. 2
Fig. 2:
The principle of palatal lengthening by shortening of the soft palatal width in the double-opposing Z-palatoplasty. L, length of soft palate; W, width of soft palate.
Fig. 3
Fig. 3:
Application of V-Y suture in Furlow double-opposing Z-palatoplasty (yellow arrows). You do not need to extend the right-side oral lateral limb relaxing incision around the maxillary tuberosity at the posterior end of the alveolus to assist with inset of the right-sided, anteriorly based oral mucosal flap (pink dotted line).

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Cheng-hao Li, Ph.D., D.D.S.

State Key Laboratory of Oral Disease

West China College of Stomatology

Department of Cleft Lip and Palate Surgery

West China Stomatological Hospital

Jia-yu Shi, D.D.S.

Qian Zheng, D.D.S.

Department of Cleft Lip and Palate Surgery

West China Stomatological Hospital

Bing Shi, D.D.S., Ph.D.

State Key Laboratory of Oral Disease

West China College of Stomatology

Department of Cleft Lip and Palate Surgery

West China Stomatological Hospital

Sichuan University

Chengdu, People’s Republic of China

REFERENCES

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. Kane AA. Discussion: 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;132:623–625
3. Stal S, Hollier L. Correction of secondary cleft lip deformities. Plast Reconstr Surg. 2002;109:1672–1681; quiz 1682
4. Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986;78:724–738

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