Incomplete Cleft Palate Repair: Von Langenbeck Converted to Two-flap Palatoplasty with Furlow Double Opposing Z-Plasty

Cleft palate repair was performed. A Dingman mouth gag was placed in the patient’s mouth. Palate was palpated, there was a visible cleft palate involving the soft palate and a portion of the hard palate. We proceed to perform the cleft repair with a von Langenbeck repair anteriorly and Furlow double opposing Z-plasty posteriorly.

The operative area was injected with 1% lidocaine with 1: 100,000 epinephrine, a total of 6cc of local used. The proposed incisions were marked on the palate. The palate was then split through the midline at the junction of the nasal and oral mucosa. Anteriorly we elevated our nasal and oral flaps in a von Langenbeck fashion to close in a straight-line repair. We decided to convert to a two-flap palatoplasty as the palate was very high-arched anteriorly, and visualization was not ideal.

We then dissected posteriorly and planned our double opposing Z-plasty. A posteriorly based myomucosal flap was then incised and elevated on the left-hand side. An anteriorly based mucosal flap was then elevated on the right-hand side. These flaps were retracted laterally with 4-0 Vicryl stay sutures. The nasal midline was then split and that nasal flaps were then developed on the left and right. There was a nasal myomucosal flap based posteriorly on the right, and a nasal mucosal flap based anteriorly on the left.

Once the flaps were developed, they were rotated, and the wound was closed. The nasal layer was closed first by rotating the left sided anteriorly based nasal mucosal flap and the posteriorly based right sided myomucosal flap. Flaps were closed with 4-0 Vicryl in a combination of simple interrupted and running sutures. We then transposed the oral flaps and closed them with 4-o Vicryl in a simple interrupted manner, ensuring there was no tension on the closure.

The hard palate flaps were then closed in the midline with 4-0 Vicryl in a simple interrupted fashion, with intermittent vertical mattress sutures to evert the edges. The uvula was approximated with 4-0 Vicryl in a simple interrupted manner. Lastly, anterolateral tacking sutures were placed between the palatal mucosa and alveolar ridge. This concluded our procedure.

- Repair of physical deformity
- Main objective of cleft palate repair is creation of adequately functioning velopharynx for production of intelligible speech and improvement in swallow function.
- Improvement in eustachian tube function
- Minimize negative effects on maxillary growth pattern.

- Excessively wide palatal defects where there isn’t enough palatal tissue for closure, may consider delaying surgery to allow for increased growth.
- Patients with syndromic disorders, tracheostomies, or mental disabilities consideration should be made as to the benefit of surgery and appropriate timing.

N/A

The patient was placed supine and turned 90 degree away from anesthesia team. A head wrap was placed, and the patient was draped in a standard fashion for operating in the mouth. As the surgery is intraoral, sterilization and sterile draping is not required. An oral ray endotracheal tube is utilized as it allows for placement of the Dingman mouth gag. We recommend a preoperative dose of dexamethasone (0.5 mg/kg, max of 10mg) as well as perioperative antibiotic coverage. The mouth gag is suspended on a stack of rolled tows for our cases instead of the Mayo stand.

Scheduling of palatoplasty is an important consideration in the management of cleft palate patients, surgeries are typically schedule between 10 and 12 months of age, and possibly a little bit later if there is concern for growth, comorbid conditions, and/or airway obstruction. There is no specific preprocedural workup necessary, outside of institutional preoperative anesthesia evaluation. Hemoglobin and hematocrit can be obtained as part of the preoperative workup. Consideration should be placed to the ears as well, as often these children will need myringotomy tubes placed at the time of palatoplasty. Imaging is not necessary in the preoperative evaluation

Embryologically palatal development takes place between 5 and 12 weeks of development. Anteriorly the maxillary prominences grow and push the nasal prominences together in the midline. The fusion of these prominences creates the primary palate. The secondary palate is formed by the fusion of the maxillary prominences starting at the incisive foramen and ending at the uvula. The type of palatal defect is a result of interruption at a certain stage in development.

The incidence of cleft palate alone is about 1:2000, with a female to male predominance. Approximately 40% of cleft palate patients will have an underlying syndrome.
Common Syndromes that may present with cleft palate:
- Van der Woude Syndrome
- Stickler Syndrome
- Pierre Robin Sequence
- 22q11.2 deletion Syndrome
- Treacher Collins Syndrome
- Klippel-Feil Syndrome
- Nager Syndrome

Complications can be subdivided into immediate complication and delayed complications. Immediate complications include hemorrhage, respiratory obstruction, hanging palate, dehiscence of repair or oronasal fistula formation. Late complication typically includes bifid uvula formation, velopharyngeal insufficiency, abnormal speech, and dental malpositioning.

None

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Furlow LT Jr: Cleft palate repair by double opposing z-plasty. Plast Reconstr Surg 1986; 78: 724–736

Koudoumnakis E, Vlastos IM, Parpounas K, Houlakis M. Two-flap palatoplasty: description of the surgical technique and reporting of results at a single center. Ear Nose Throat J. 2012 Mar;91(3):E33-7. doi: 10.1177/014556131209100320. PMID: 22430346.

Ravishanker R. (2006). Furlow's Palatoplasty for Cleft Palate Repair. Medical journal, Armed Forces India, 62(3), 239–242. https://doi.org/10.1016/S0377-1237(06)80010-9