Square-root Palatoplasty: Comparing a Novel Modified-Furlow Double-opposing Z-palatoplasty Technique to Traditional Straight-line Repair

Abstract

The purpose of this study was to introduce a modification of the Furlow double-opposing Z-plasty (DOZ)-the square-root palatoplasty (SRP)-and critically evaluate outcomes compared to children who underwent straight-line repair (SLR).

Methods: A retrospective review was performed of all nonsyndromic children undergoing primary cleft palate closure either by SRP or SLR at our institution between 2009 and 2017. Outcomes of interest included rates/location of oronasal fistula, secondary surgery, speech delay/deficits, resonance, nasal air emission (NAE), articulation errors, and velopharyngeal function. Logistic regression was used to assess for the effect of surgery type on outcomes while controlling for Veau cleft type, age, and gender.

Results: Seventy-eight patients were included; 46 (59%) underwent SRP, and 32 (41%) underwent SLR. The mean follow-up was 4.07 years. When compared to SLR, children who underwent SRP were less likely to have oronasal fistula [odds ratio (OR) 4.8, P = 0.0159], speech delay/deficits (OR 7.7, P < 0.001), NAE (OR 9.7, P < 0.001), articulation errors (OR 10.2, P < 0.001), or need for secondary speech surgery (OR 13.2, P < 0.0002). Patients who underwent SRP were also more likely to have normal resonance (78.26% versus 43.75%, respectively; P = 0.0043) and good VP function (84.78% versus 56.25%, respectively; P = 0.0094).

Conclusions: This study describes and evaluates outcomes following a modified-Furlow DOZ technique-the SRP. After adjusting for Veau classification, age, and gender in nonsyndromic children, SRP is associated with significantly less speech delay/deficits, NAE, articulation errors, and need for secondary speech surgery when compared to children who underwent SLR.

Fig. 1.

Velopharyngeal function following SRP versus SLR. Thirty-nine children (84.78%) in the SRP group demonstrated good VP function, whereas five (10.87%) and two (4.35%) had fair and poor VP function, respectively. In the straight-line group, by contrast, 18 (56.25%) had good VP function, six (18.75%) fair, and eight (25%) poor. These differences were statistically significant (P = 0.0094).

Fig. 2.

Intraoperative photograph and diagram demonstrating markings for the SRP (A); for orientation, the posterior-most cleft margin is at the top of the photograph (uvula partially obscured by endotracheal tube), whereas the alveolus is at the bottom of the photograph and partially covered with the limbs of a Dingman retractor. For comparison, the red lines represent the mirror-image Z-plasty incisions as originally described by Furlow, designed with approximately 60° angles. Note that the 90° component in SRP is chosen based upon pliability annotated with white arrow. The base of the narrow triangular flap annotated with white arrow, is selected in a spot between the hamulus and base of the uvula, which allows for rotation of the soft palatal flap upon inset. The image (B) represents a simple schematic comparing marking/incisions for classic Furlow repair (thick red lines) and SRP (thick green lines); the stippled blue lines represent the hard–soft junction, while the thin red lines within the hard palate (anteriorly) represent incisions for elevation of mucoperiosteal flaps and posterior alveolar releasing incisions, respectively. The numbers and corresponding thin green arrows illustrate the change in degrees between Furlow’s traditional flap design and the SRP: 60° to 90° (1 to 2) and 60° to 30° (3 to 4). The red stars denote the area where there is a limited bridge of tissue that supplies the mucosa, which can easily be cut across or compromise blood supply to the edge of the flap due to the narrow base; by widening one flap to 90° the blood supply to the mucosa-only flap is increased, while the same holds true when narrowing the contralateral flap to 30° (increasing the distance from the posterior alveolar releasing incision).

Fig. 3.

Intraoperative photograph, taken using the operating microscope, following approximation of the levator muscles with previously placed retention sutures and closure of the soft palate nasal mucosa. Alloderm is then placed above the nasal mucosal layer and secured to lateral musculature and the posterior border of the hard palate. For orientation, the muscle transposition and repair is immediately posterior to the Alloderm (marked with M and annotated with transverse white lines; the O represents suture placement) and the uvula (albeit slightly obscured with the endotracheal tube) is marked with U; inferior to the Alloderm is the hard palate, marked with H. The double-sided arrow in the right side of the image denotes the space between the muscle repair after retropositioning and the posterior shelf of the hard palate, over which the Alloderm is placed. Finally, the hard palate mucoperiosteal flaps are brought into the midline and closed with mattress sutures, enveloping the dermal matrix as shown in Figure 2.