September 2019 HSC Section 1 Congenital and Pediatric Problems

Dao & Goudy

This favorably changes the muscle fibers into a more anatomic position while lengthening the palate and retropositioning the levator sling. 14 This technique is primarily used for clefts isolated to the velum and submucous clefts, although some centers routinely incorporate this procedure with most cleft palate repairs. On the oral layer the mucosa is marked, incised, and the Z-plasty flaps are raised with a left posteriorly based myomu- cosal flap and a right anteriorly based thick mucosal flap ( Fig. 5 ). The nasal layer then needs to have a left anteriorly based mucosal flap and a right posteriorly based myomucosal flap to create the opposing Z-plasty ( Fig. 6 ). The nasal mucosal layer incisions should be made with surgical scissors. 15 Closure is done with a 4–0 Vicryl on a PS-4c needle starting with the nasal layer. To avoid ten- sion one may further release the flap segments with a back cut onto the hard palate. Once the nasal layer is closed ( Fig. 7 ), the oral left myomu- cosal flap is rotated and secured with a 3–0 Vicryl through the levator muscle, and the rest of the oral layer is closed ( Fig. 8 ). The uvula is approximated with a horizontal mattress suture. As with the two- flap palatoplasty, a tongue stitch may be used if there is concern for airway obstruction. The Children’s Hospital of Philadelphia modifi- cation of this technique involves bilateral relaxing incisions similar to the von Langenbeck method described next, which results in bipedicled muco- periosteal flaps. The Z-plasty incisions are short- ened to avoid intersection with the relaxing incisions. Also, the right anteriorly based mucosal flap has a more variable angle and length with its tip anterior to the uvula and base just posterior to the hamulus. It has been shown to facilitate a tension-free closure and decrease fistula rates while improving speech outcomes. 16

Fig. 3. Two-flap palatoplasty: closed nasal layer.

on an RB1 needle in an interrupted mattress fashion. Once the nasal layer and levator sling are closed, the oral layer is closed with simple interrupted sutures starting at the base of the uvula and moving anteriorly with 4–0 Vicryl on a TF needle. When the hard palate is reached a switch is made to horizontal mattress sutures and to capture some of the nasal mucosa to obliterate the dead space ( Fig. 4 ). Once completely closed, hemostasis is achieved and microfibrillar collagen hemostatic agent is placed in the open defects laterally. If there is concern for airway obstruction, one may place a tongue traction stitch. Also, if the cleft is more than 2 cm acellular dermal matrix may be used between the nasal and oral layers at the junction of the soft palate and hard palate as reinforcement to reduce fistula formation. Furlow double-opposing Z-palatoplasty The Furlow palatoplasty involves transposing two opposing Z-plasties of the oral and nasal mucosal layers, respectively, with attached levator muscle.

Fig. 4. Two-flap palatoplasty: view of closed oral layer of the hard palate. Horizontal mattress sutures that capture the nasal layer to obliterate dead space.

Fig. 5. Z-palatoplasty: incisions marked. Left posteri- orly based myomucosal flap and a right anteriorly based thick mucosal flap.

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