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Chapter 22
Furlow Palatoplasty for the Treatment of
Velopharyngeal Insufficiency
Mark E. Boseley
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Army, the
Department of Defense, or the U.S. government.
LTC(P) Boseley is a military service member. This work
was prepared as part of his official duties. Title 17 U.S.C.
105 provides that “Copyright protection under this
title is not available for any work of the United States
Government.” Title 17 U.S.C. defines a “United States
Government work” as a work prepared by a military
service member or employee of the United States
government as part of that person’s official duties.”
Abstract
The double-reversing Z-plasty, or Furlow palatoplasty, was
first described in 1978 by Dr. Leonard Furlow. This tech-
nique is particularly helpful when treating children with
velopharyngeal insufficiency secondary to a submucous
cleft palate or short soft palate. The Furlow palatoplasty can
also be utilized to close narrow overt clefts of the secondary
palate. The aim of this chapter is to better define the role of
this surgical technique to treat velopharyngeal insufficiency.
The chapter will include published speech results and a step-
by-step description of the procedure.
Dr. Furlow first described the double-reversing Z-plasty
technique for repair of soft palate clefts in 1978.1 This
approach was designed to increase palate length and to
also create an intact muscular sling. The velopharyngeal
sling is made up of the following muscles: the palato-
glossus, palatopharyngeus, tensor veli palatini, levator
veli palatini, and the musculus uvulae. The levator veli
palatini is particularly important in providing upward
motion of the soft palate. The Furlow palatoplasty can
also be a useful surgical procedure in children with
velopharyngeal insufficiency (VPI) secondary to a sub-
mucous cleft or a short soft palate. A submucous cleft
palate is diagnosed when the levator muscles are found
to be in a sagittal orientation on flexible nasendoscopy
(seen as a notch on the nasal side of the soft palate).2
The double-reversing Z-plasty reorients these muscles
into an anatomically correct transverse position. The
Z-plasty technique also increases the length of the soft
palate, which can improve closure through its ability to
contact the posterior pharyngeal wall. Speech results
when a Furlow palatoplasty is performed for a diagno-
sis of velopharyngeal insufficiency have been mixed in
the literature. One of the largest studies reported on a
group of 148 consecutive patients who were diagnosed
with a submucous cleft palate found that 72% had
improved speech following surgery. However, only
19% of children who had less than a 50% closure of the
velopharyngeal gap size on phonation had resolution
of their symptoms. The conclusion reached was that
children with large velopharyngeal gaps should have
a sphincter pharyngoplasty performed in conjunction
with the Furlow palatoplasty.3 Results in children with
the diagnosis of velocardiofacial syndrome seem to be
less successful, with one recent study reporting only
45% of 22 patients with VPI having improved speech
following the Furlow procedure.4
Surgical Indications
The Furlow palatoplasty should be considered for chil-
dren with VPI secondary to a submucous cleft palate.
This can be detected as a midline notch on the nasal sur-
face of the soft palate on nasal endoscopy, which would
be indicative of sagittal orientation of the levator veli
palatini muscles. The clinician should be advised that if
the resting velum gap size does not decrease by greater
than 50% on phonation, the Furlow palatoplasty might
not completely resolve the patient’s symptoms. In such
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Video Atlas of Cleft Lip and Palate Surgery
cases, this procedure can be used in combination with
a sphincter pharyngoplasty (either concurrently or
staged). The Furlow palatoplasty may also be consid-
ered in children diagnosed with velocardiofacial syn-
drome (VCFS) when surgery is contemplated for VPI.
These children can sometimes have medialized carotid
arteries, making pharyngeal surgery more difficult.
Surgical Equipment and Tools
• Dingman mouth gag
• Gentian violet for marking proposed incisions
• 60-degree Potts scissors
• Langenbeck elevator
• Angled and straight needle holders
• Mucosal hook
• Cushing forceps
• Headlight
Anesthesia
• Midline endotracheal tube — Oral Rae® or
armored tube preferred to prevent “kinking”
during the course of the procedure
Surgical Procedure (Video of Furlow
Palatoplasty for Velopharyngeal Insufficiency)
1. We routinely administer one dose of dexametha-
sone (0.5 mg/kg, maximum of 12 mg).
2. We place the patient on a shoulder roll and suspend
the Dingman retractor from a mayo stand. Placing
the child in Trendelenburg position can sometimes
aid with visualization.
3. The proposed mucosal incisions are marked with
a marking pen or gentian violet using a 25-gauge
needle. The ideal angle for the limbs of the Z-plasty
is 60 degrees, which increases the length of the
midline palatal incision by 75% (Figure 22–1). If
one uses an angle of 45 degrees, the midline pala-
tal incision length increases by 50%; the length
increases by 25% if the angle is 30 degrees.
4. The proposed incision is injected with either 0.5%
or 1% lidocaine with 1:100,000 epinephrine.
5. An incision is made with a 15-blade or Colorado™
needle through the mucosa on the patient’s right
side, from the bottom edge of the cleft laterally
toward the hamulus (for right-handed surgeons) to
create a superiorly based mucosal flap (Figure 22–2).
Figure 22–2. First cuts for a right-handed surgeon. (Repro-
duced with permission from Boseley M, Bevans SE. Double-
reversing Z-plasty [Furlow palatoplasty]; Hartnick CJ, Hansen
MC, Gallagher TQ, eds. Pediatric airway surgery. Adv Otorhi-
nolaryngol. 2012;73:145–148. Copyright 2012 Karger [Basel,
Switzerland].)
Figure 22–1. Intraoperative view of proposed mucosal incisions.
Furlow Palatoplasty for the Treatment of Velopharyngeal Insufficiency
287
This mucosal flap can be raised with a combina-
tion of sharp and blunt dissection. The 60-degree
Potts scissors and Langenbeck elevator work well
for this purpose. Care must be taken to minimize
trauma to this flap, since it can be quite thin. Alter-
natively, a left-handed surgeon could consider
making an incision on the left side, from the bot-
tom of the cleft laterally toward the hamulus on the
left. This alteration in technique provides better
access for those who are left-handed for the most
difficult part of the procedure (elevating muscle
from the nasal mucosa). The key take-home point
is that the posterior-based flaps contain the levator
muscles.
6. A second incision is then made with a 15-blade
through the mucosa and the levator musculature
on the patient’s left side (Figure 22–3). This incision
extends from the hard–soft palate junction laterally
toward the hamulus to create an inferiorly based
mucosa and muscle flap. The mucosa and muscle
flap can then be raised in an inferior direction, tak-
ing care not to disrupt the nasopharyngeal mucosa
on the posterior surface.
7. Angled scissors are then used to make the opposing
Z-plasty incisions (Figure 22–4). On the patient’s
right side, this incision is through the levator mus-
cle and nasopharyngeal mucosa. On the patient’s
left side, this incision is through the nasopharyn-
geal mucosa only.
8. The nasal side Z-plasty is closed by first suturing
the right-sided inferiorly based levator muscle and
nasopharyngeal mucosal flap to the cut surface of
the nasopharyngeal mucosa on the left side with
3-0 or 4-0 chromic suture (Figure 22–5).
9. The superiorly based left-sided nasopharyngeal
mucosal flap is then inset by suturing it to the
superior surface of levator muscle described in the
previous step, and to the cut undersurface of the
right-sided oral mucosal flap with 3-0 or 4-0 chro-
mic suture.
10. The oral side Z-plasty is then closed by first sutur-
ing the left-sided inferiorly based oral mucosal and
Figure 22–3. Intraoperative view of first cuts and flap eleva-
tion for a right-handed surgeon.
Figure 22–4. Second cuts for a right-handed surgeon. (Repro-
duced with permission from Boseley M, Bevans SE. Double-
reversing Z-plasty [Furlow palatoplasty]; Hartnick CJ, Hansen
MC, Gallagher TQ, eds. Pediatric airway surgery. Adv Otorhi-
nolaryngol. 2012;73:145–148. Copyright 2012 Karger [Basel,
Switzerland].)
288
Video Atlas of Cleft Lip and Palate Surgery
levator muscle flap to the cut surface of the oral
mucosa on the left side with 4-0 Vicryl™ suture.
11. The right-sided superiorly based oral mucosal flap
is sutured into place with 4-0 Vicryl™ suture (Fig-
ures 22–6 and 22–7).
Postoperative Considerations
• Care must be taken to prevent trauma to
the repair. This might involve use of arm
restraints during the postoperative period
if the child has a propensity to put his/her
fingers in the mouth.
• Avoid the use of sippy cups and straws for
approximately 3 weeks after surgery.
• Solid foods should be of a pureed consistency
for 3 weeks following surgery.
• We usually give oral antibiotics for 5 to 7 days
following surgery.
Figure 22–5. First layer closure of nasal mucosa and levator
muscles. (Reproduced with permission from Boseley M, Bevans
SE. Double-reversing Z-plasty [Furlow palatoplasty]; Hartnick
CJ, Hansen MC, Gallagher TQ, eds. Pediatric airway surgery. Adv
Otorhinolaryngol. 2012;73:145–148. Copyright 2012 Karger
[Basel, Switzerland].)
Figure 22–6. Final closure of oral mucosa. (Reproduced
with permission from Boseley M, Bevans SE. Double-reversing
z-plasty [Furlow palatoplasty]; Hartnick CJ, Hansen MC, Gal-
lagher TQ, eds. Pediatric airway surgery. Adv Otorhinolaryngol.
2012;73:145–148. Copyright 2012 Karger [Basel, Switzerland].)
Figure 22–7. Intraoperative view of completed procedure.
Furlow Palatoplasty for the Treatment of Velopharyngeal Insufficiency
289
Complications
• Early complications include tongue edema
from prolonged retraction, palatal dehiscence,
fistula, or necrosis of the distal ends of the
palatal mucosal flaps.
• Late complications include snoring or
obstructive sleep apnea and worsening of the
speech result over time.
Pearls and Pitfalls
• Adequate hemostasis is extremely important
in order to visualize the surgical plane of
dissection.
• The anterior-based mucosa flap can be quite
thin and should be handled delicately. We
have found that staying in a plane just above
the levator musculature ensures that this flap
does not become too thin.
• The oral flaps should be closed with the least
amount of tension possible. This sometimes
results in areas that are not completely
covered by oral mucosa. Another pearl to
avoid dehiscence is to make a back cut in the
mucosa near the hamulus to decrease the
tension on the mucosal flap.
• If a fistula occurs after the procedure that
does not close after a period of observation,
AlloDerm® (LifeCell Corporation) can be
considered as an allograft to close the defect.
References
1. Furlow LT. Cleft palate repair by double opposing
Z-plasty. Plast Reconstr Surg. 1986;78:724.
2. Rudnick EF, Sie KC. Velopharyngeal insufficiency: cur-
rent concepts in diagnosis and management. Curr Opin
Otolaryngol Head Neck Surg. 2008;16:530–535.
3. Perkins JA, Lewis CL, Gruss JS, Eblen LE, Sie KC. Furlow
palatoplasty for management of velopharyngeal insuffi-
ciency: a prospective study of 148 consecutive patients.
Plast Reconstr Surg. 2005;116(1):72–80.
4. Rottgers SA, Ford M, Cray J, Smith D, Kinsella C, Grun-
waldt L, et al. An algorithm of Furlow palatoplasty to
the treatment of velocardiofacial syndrome — associated
velopharyngeal insufficiency. Ann Plast Surg. 2011;66(5):
479–484.
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291
Chapter 23
Posterior Pharyngeal Wall Augmentation
Colleen F. Perez and Matthew T. Brigger
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Army, the
Department of the Navy, the Department of Defense,
or the U.S. government.
LT Perez and CDR Brigger are military service mem-
bers. This work was prepared as part of their official
duties. Title 17 U.S.C. 105 provides that “Copyright
protection under this title is not available for any
work of the United States Government. Title 17
U.S.C. defines a “United States Government work”
as a work prepared by a military service member or
employee of the United States government as part of
that person’s official duties.
Abstract
Several methods exist for augmenting the posterior pharyngeal
wall to improve speech in children with mild velopharyngeal
insufficiency (VPI). Posterior pharyngeal wall augmenta-
tion is particularly useful for patients with a small central
velopharyngeal gap. Techniques include raising a superiorly
based posterior pharyngeal wall flap to create bulk or plac-
ing an autologous or nonautologous implant through a direct
incision or injection into the posterior pharyngeal wall. Mate-
rials described include cartilage, fat, fascia, silicone, acellular
dermis, polytetrafluoroethylene, and calcium hydroxylapatite
(CaHA). The perioperative considerations and techniques for
posterior pharyngeal wall augmentation are described.
The goal of posterior pharyngeal wall augmentation is
to allow for better soft palate contact in velopharyn-
geal closure. The concept involves displacing the pos-
terior pharyngeal wall anteriorly in such a way that
it provides an easily reached contact point for the soft
palate, allowing an adequate velopharyngeal seal to
prevent nasal air escape during oral phonemes. The
procedure has been described using a superiorly based,
rolled, posterior pharyngeal wall flap as well as autol-
ogous and nonautologous implant materials. Implant
materials have been delivered through direct mucosal
incisions as well as via injection. Implant materials
described include cartilage, fat, fascia, silicone, acel-
lular dermis, polytetrafluoroethylene, and calcium
hydroxylapatite (CaHA).1–5
Injection pharyngoplasty to improve speech was
described as early as 1902 with the use of paraffin, but
migration led to mediastinitis, and its use was aban-
doned.6 Teflon was also used with good results in
the past but an unclear safety profile and migration
of the implanted material led to decreased use over
the years. Calcium hydroxylapatite (CaHA) has
demonstrated safety and efficacy over 24 months in
properly selected patients and is the senior author’s
choice of implant material.7 In patients with mild
velopharyngeal insufficiency (VPI) and a small cen-
tral velopharyngeal gap or touch closure that can-
not withstand transvelar pressure, posterior wall
augmentation by injection pharyngoplasty is an eas-
ily performed procedure that can reduce the mor-
bidity associated with more extensive surgery.
Posterior pharyngeal wall augmentation by
means of a superiorly based pharyngeal flap has been
described. Similar to other pharyngeal procedures, a
central flap is raised from the posterior pharyngeal
wall. The flap is then rolled on itself to provide ade-
quate tissue bulk and improve closure. Many surgeons
have abandoned the use of a rolled pharyngeal flap as
outcomes for moderate to large gaps appear to be infe-
rior to that of sphincter pharyngoplasty and pharyn-
geal flaps; yet the morbidity is similar. In children with
small velopharyngeal gaps, the use of a rolled pharyn-
geal flap has been supplanted by the use of implants as
described previously. The rolled pharyngeal flap tech-
nique is briefly detailed in the following primarily for
historical purposes.
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Video Atlas of Cleft Lip and Palate Surgery
Surgical Indications
Posterior pharyngeal wall augmentation is indicated
for mild VPI with touch closure or functional VPI dur-
ing conversational speech as well as the presence of a
small central velopharyngeal gap. A thorough review
of preoperative nasendoscopy should be performed to
allow adequate assessment of the location of air escape
as well as to identify landmarks to target the augmen-
tation site intraoperatively. Patients with sagittal closure
patterns benefit most from augmentation. It is important
to evaluate for lateral wall motion as this is necessary
to control nasal escape. Children with lateral air escape
tend to have outcomes that are poor likely secondary
to medial migration of the implant intraoperatively. The
resorption properties of the planned injection material
should be considered as well. A high level of suspicion
for velocardiofacial syndrome and coexistent cardiac
abnormalities should be maintained with consideration
for possible medialization of the carotid arteries.
Surgical Equipment and Tools
• Mouth gag
• 120-degree endoscope with a palate retractor
• 0-degree endoscope (for transnasal injection)
• 25-gauge needle
• Injection material
Anesthesia
• In children, posterior pharyngeal wall
augmentation is performed under general
anesthesia via endotracheal intubation.
• Alternatively, transnasal injection
pharyngoplasty may be performed under local
anesthesia in carefully selected older patients.
Surgical Procedure
Injection Pharyngoplasty
(Video of Injection Pharyngoplasty)
1. We routinely administer a dose of prophylactic
antibiotics prior to the start of the case.
2. We routinely administer one dose of dexametha-
sone dosed according to weight to aid with post-
operative recovery from anesthesia.
3. Preoperative nasendoscopy is reviewed to identify
location of velopharyngeal gap in relation to the
Eustachian tube orifices and regional anatomy for
desired implant injection.
4. The patient is positioned supine in the Rose posi-
tion with a shoulder roll as necessary for neck
extension, and the mouth gag is inserted.
5. The posterior nasopharyngeal wall is evaluated
and palpated to identify pulsations associated with
anomalous vasculature.
6. A 120-degree endoscope with a palate retractor is
used for visualization (Figure 23–1).
7. Augmentation material is injected into the poste-
rior pharyngeal wall target sites by transnasal or
transoral insertion of the needle to the depth of
bone contact and then withdrawing approximately
2 mm. The senior author prefers CaHA as an injec-
tion material, and generally places 2 to 4 mL into
the retropharyngeal space.
8. The material is injected under direct visualization
to provide sufficient bulk as determined from the
preoperative nasendoscopy and intraoperative
exam (Figure 23–2).
9. Alternatively, in older children and adults, a direct
transnasal injection can be performed utilizing a
0-degree endoscope through one nostril and the nee-
dle passed through the contralateral nostril. Local
anesthesia is obtained with topical 4% lidocaine
with oxymetazoline to provide vasoconstriction.
Superiorly Based, Rolled Pharyngeal Flap
1. Preparation and positioning are identical to steps 1
to 6 as described for injection pharyngoplasty.
Figure 23–1. Intraoperative view of posterior pharyngeal wall
prior to injection.
Posterior Pharyngeal Wall Augmentation
293
2. The posterior pharyngeal flap width is estimated
to be the distance between the posterior tonsillar
pillars with the inferior extent at the midpoint of
the tonsillar fossa.
3. Flap length is estimated as the distance of the free
edge of the soft palate to the posterior pharyngeal
wall.
4. Proposed incision lines are injected with 1% lido-
caine with 1:100,000 units of epinephrine.
5. Lateral incisions are made down to the preverte-
bral fascia, and the flap is elevated from the infe-
rior portion superiorly into the nasopharynx to the
level of the natural velopharyngeal closure.
6. The inferior edge of the flap is sutured with 3-0 Vic-
ryl™ suture to the prevertebral fascia at the base
of the flap effectively rolling the flap onto itself
and augmenting the posterior pharyngeal wall
(Figure 23–3).
7. The remaining defect on the posterior pharyngeal
wall is reapproximated with 3-0 Vicryl™ suture.
Postoperative Considerations
• Children undergoing injection
pharyngoplasty may be discharged home
on the day of surgery. Historically, children
undergoing rolled pharyngeal flaps are
observed overnight.
• Postoperative antibiotics are continued for
1 week.
• Postoperative evaluation is performed at 1 to
2 weeks.
• Postoperative speech therapy may commence
immediately following injection pharyngoplasty
and in approximately 1 month if a rolled
pharyngeal flap is performed.
Complications
• Complications following injection
pharyngoplasty are minimal. Patients with
associated craniofacial anomalies or large
velopharyngeal gaps are more likely to
experience treatment failure. Speech therapy
may be employed in cases of persistent
VPI. However, if symptoms persist beyond
3 months postoperatively, then a revision
pharyngoplasty may be necessary, which has
not proven to be a problem with CaHA.
• If a foreign body reaction were to develop,
then removal becomes necessary.
• Migration of implant material could require
surgical revision or more invasive procedures.
In our experience, no postoperative infections
Figure 23–2. Intraoperative view of injection under direct
visualization.
Figure 23–3. Schematic of configuration for rolled pharyngeal
flap. Reproduced with permission from Willging JP. Velopharyn-
geal insufficiency. In: Bluestone CD, Rosenfeld RM, eds. Surgical
Atlas of Pediatric Otolaryngology. Hamilton, Ontario: BC Decker;
2002:416.
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Video Atlas of Cleft Lip and Palate Surgery
have developed; however, all patients
are counseled to the possibility of local
and potentially systemic infection in the
retropharyngeal space.
• Patients and/or caretakers are counseled
regarding the off-label use of commercially
available injection materials as well as a
theoretical risk of embolization of injection
material via pharyngeal plexus venous
vasculature.
Pearls and Pitfalls
• The ideal candidate for posterior pharyngeal
wall augmentation has mild VPI with a small
central velopharyngeal gap.
• Several materials exist for injection
pharyngoplasty, including autologous and
nonautologous implant materials.
• High clinical suspicion should be maintained
for associated craniofacial anomalies, and a
thorough exam of the posterior pharyngeal
wall should be conducted for anomalous
vasculature. If velocardiofacial syndrome
is suspected, a preoperative CT scan with
contrast should be obtained to evaluate for
medialized carotid arteries.
• Posterior wall augmentation is easily
performed without the morbidity associated
with more extensive pharyngeal flaps.
Patients may expect to be discharged home
the same day.
• Complications include persistent VPI, foreign
body reaction, and implant migration and
resorption that could lead to the need for
further procedures.
References
1. Willging JP, Cotton RT. Velopharyngeal insufficiency.
In: Pediatric Otolaryngology. Bluestone CD, Stool SE,
Alper CM, eds. 4th ed. Philadelphia, PA: Saunders; 2003:
1789–1799.
2. Lando RL. [Transplant of cadaveric cartilage into the
posterior pharyngeal wall in treatment of cleft palate.]
Stomatologiia (Mosk). 1950;4:38–39.
3. Bluestone CD, Musgrave RH, McWilliams BJ, Crozier
PA. Teflon injection pharyngoplasty. Cleft Palate J. 1968;5:
19–22.
4. Blocksma R. Correction of velopharyngeal insufficiency
by Silastic pharyngeal implant. Plast Reconstr Surg. 1963;
31:268–274.
5. Sipp JA, Ashland J, Hartnick CJ. Injection pharyngo-
plasty with calcium hydroxyapatite for treatment of vel-
opalatal insufficiency. Arch Otolaryngol Head Neck Surg.
2008;134:268–271.
6. Eckstein M. Ueber Subkutane and Submucosen Hartparaf-
finprosthesen. Berl Klin. 1902;39:315–316.
7. Brigger MT, Ashland JE, Hartnick CJ. Injection pharyngo-
plasty with calcium hydroxyapatite for velopharyngeal
insufficiency: patient selection and technique. Arch Oto-
laryngol Head Neck Surg. 2010;136:666–670.
295
Chapter 24
Revision Velopharyngeal Surgery
J. Paul Willging
Abstract
Surgical correction of velopharyngeal insufficiency is effec-
tive in the majority of cases, with improvement in resonance
occurring in over 98% of cases and normal resonance accom-
plished in over 90% of cases. At the end of 3 to 6 months of
therapy, an objective assessment of the surgical results should
be obtained to determine the success of the operation. Surgi-
cal repairs should be evaluated for their location within the
velopharyngeal sphincter. It is the author’s opinion that sur-
gical revision in cases of airway obstruction should be under-
taken. Multiple reasons exist for persistent velopharyngeal
insufficiency. It is possible to “redo” a pharyngeal flap or
sphincter pharyngoplasty. Often, less involved secondary
revision procedures can be performed with excellent results.
Surgical correction of velopharyngeal insufficiency
(VIP) is effective in the majority of cases, with improve-
ment in resonance occurring in over 98% of cases and
normal resonance accomplished in over 90% of cases.
Speech therapy should be utilized postoperatively to
maximize the functional results of any surgical inter-
vention. At the end of 3 to 6 months of therapy, an
objective assessment of the surgical results should be
obtained to determine the success of the operation. If
abnormal resonance or nasal air emission is identified,
nasopharyngoscopy should be performed to visualize
the function of surgical repair and determine the etiol-
ogy for the persistent problem.1,2
Surgical repairs should be evaluated for their loca-
tion within the velopharyngeal sphincter. Flaps that are
too low allow air to escape around the flap. Ports that
are too large cannot be completely closed by medial
movement of the lateral pharyngeal walls. Asym-
metrical lateral wall motion, or a flap that is skewed
to one side, may demonstrate air leakage on just one
side of the velopharyngeal sphincter. Sphincter pha-
ryngoplasty repairs may continue to escape laterally
if the lateral fornices are not medialized sufficiently,
or centrally if the posterior pharyngeal wall is not suf-
ficiently augmented. If the lateral ports are too small,
airway obstruction may develop.3 If airway obstructive
symptoms persist beyond 3 months, it is unlikely that
improvement will spontaneously develop in the near
future. It is the author’s opinion that surgical revision
in cases of airway obstruction should be undertaken.
Continuous positive airway pressure (CPAP) may tem-
porize the problem but the child will be technology
dependent for long periods of time.
It is possible to “redo” a pharyngeal flap or
sphincter pharyngoplasty. There is sufficient laxity in
the surrounding tissue that a second procedure can
be accomplished. Closure of the donor sites may be
slightly more difficult but generally not problematic.
Often less involved secondary revision procedures can
be performed with excellent results.
Injection Pharyngoplasty
See Chapter 23 and Video on Injection Pharyngoplasty
Velopharyngeal Port Augmentation.
Surgical Indications
• Inadequate closure of the velopharyngeal
port(s).
• Small gaps along the posterior pharyngeal wall.
• Touch closure of the velopharyngeal
mechanism that cannot withstand increased
intraoral pressure.
• Could be used as an initial or revision
procedure.
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Video Atlas of Cleft Lip and Palate Surgery
Surgical Equipment and Tools
• Shoulder roll
• Headlight
• Crowe-Davis or Dingman mouth gag
• Metal tongue blade
• Injectable materials
• DeFlux®
• Hydroxylapatite
• Hyaluronic acid
• Collagen
• Autologous fat
• There are no papers at this point reporting
the long-term results of the use of
injectable materials for the correction of
VPI. In a personal communication with
Sheligh Cofer, MD (Mayo Clinic), she
reports continued success with DeFlux® in
patients evaluated 2 years out from their
procedures. My experience with the other
materials is that they generally resorb
within 3 to 6 months.
Anesthesia
• General endotracheal anesthesia with an
oral RAE® tube.
• Ketorolac given intravenously at the
conclusion of the procedure improves
postoperative pain.
Surgical Procedure
Preparation
• A video of the nasopharynx during connected
speech is viewed immediately before the
operation to determine the level of attempted
velopharyngeal closure. Anatomic landmarks
are identified on the video that can be used to
locate the site requiring augmentation.
• The material to be injected must be available.
Medical-grade Teflon carries the risk of
infection, granuloma formation, inferior
displacement over time4, or theoretically
embolization.5 It is no longer available.
Collagen products are available from
manufacturers. Little experience exists in their
use in the posterior pharyngeal wall. Care
must be taken to ensure no allergies exist
before injections are performed. Homologous
fat may be injected, and can be harvested
from the abdomen or buttock. The amount of
absorption and the viability of the tissue are
variable, and the need for repeat procedures
should be discussed with patients and
families.
Deflux® is a material used for the
correction of ureteral reflux. It is FDA
approved for use for this indication in
children. If it is readily available, it is easy to
use with a 25-gauge needle.
• Perioperative antibiotics should be
administered intravenously before the start of
the procedure.
Procedure
1. The patient is positioned on a shoulder roll to
maintain hyperextension of the neck.
2. Mouth gag is inserted, and the patient is placed
into suspension.
3. The posterior pharyngeal wall is visualized and
palpated to identify any significant vessels in the
operative field. The internal carotid arteries may be
medialized in velocardiofacial syndrome patients.
4. Suction catheters are placed transnasally and
brought out through the mouth to symmetrically
retract the soft palate.
5. Landmarks identified on the video localize the
exact site of nasopharyngeal escape. These land-
marks are identified in the surgical field.
6. The injection material is instilled into the area
identified as needing augmentation (Figures 24–1
and 24–2). A single needle puncture per injection
site is important to minimize the amount of mate-
rial escaping during the injection. The material is
injected into the submucosa. It is resting on the
surface of the underlying muscle and creates a
bulge at the injection site. Injections may be into the
posterior pharyngeal wall, the lateral pharyngeal
walls, or the soft palate margin.
7. A metal tongue blade is pushed against the pos-
terior pharyngeal wall immediately inferior to the
injection site. This creates a broad barrier to dis-
placement of the injected material in an inferior
direction.
8. The augmentation material is slowly injected
onto the prevertebral fascia. Generally, 1 to 2 cc of
material are injected at each site. Overcorrection is
necessary — generally 50% additional material is
required.
Revision Velopharyngeal Surgery
297
9. After the material has been deposited, the needle
should not be removed for an additional minute
to allow the pressure in the tissues to disperse,
thus minimizing the amount of material expelled
through the injection puncture site (Figure 24–3).
10. Additional sites are injected as required.
Postoperative Considerations
• The patient is discharged home from the
recovery room.
• Postoperative antibiotics should be given for a
period of 1 week.
• DeFlux® creates an intense inflammatory
reaction, leading to neck stiffness and pain.
Ketorolac given at the end of the procedure
smooths the postoperative recovery.
Figure 24–1. Diagram showing posterior pharyngeal wall augmentation.
Figure 24–2. Submucosal injection of material.
298
Video Atlas of Cleft Lip and Palate Surgery
Additional antiinflammatory medications
(ibuprofen) are more effective than
acetaminophen. Narcotics are not necessary.
• Patients return for a postoperative check at 3
weeks.
• Evaluation of the functional results of the
procedure is obtained at 3 months.
Complications
• Infections of the injection material.
• Failure to adequately augment the area of
deficiency.
• Airway obstruction from overzealous
augmentation.
Pearls and Pitfalls
• Overcorrection is necessary.
• Slow injections are required to control the
flow of the material into the tissue. Firm
pressure below the injection site prevents
inferior migration of the material.
• The DeFlux® syringe has a Luer-lock
attachment for the needle but there is a
pressure fitting between the Luer-lock device
and the barrel of the syringe. With increasing
pressure, the device may separate causing
wastage of injection materials.
Velopharyngeal Port Revision
Reduction in the Size of the Port
Surgical Indications
• Continued VPI following placement of a
pharyngeal flap through an incompetent
lateral port.
• A low flap with air escape around the flap.
Surgical Equipment and Tools
• 1 ml 1% lidocaine with 1:100,000 units
epinephrine
• Beaver® blade scalpel
• 3-0 Vicryl™ suture
Anesthesia
• General endotracheal anesthesia with an
RAE® tube.
Surgical Procedure (Video of Velopharyngeal
Port Reduction)
Preparation
• A video of the nasopharynx during connected
speech is viewed immediately before the
operation to determine the level of attempted
velopharyngeal closure. Anatomic landmarks
are identified on the video that can be used to
locate the site requiring augmentation.
• The patient is positioned on a shoulder roll to
maintain hyperextension of the neck.
Procedure
1. Mouth gag is inserted and the patient is placed into
suspension.
2. Suction catheters are placed transnasally and
brought out through the mouth to symmetrically
retract the soft palate.
3. The inferior aspect of the pharyngeal flap is infil-
trated with 1% lidocaine with 1:100,000 units epi-
nephrine to affect vasoconstriction. One ml or less
is used to minimize distortion and swelling of the
surrounding tissues.
4. An incision is made along the inferior and lateral
attachment of the pedicle of the flap on the poste-
rior pharyngeal wall (Figure 24–4). The incision is
carried down to the prevertebral fascia.
Figure 24–3. Final result of narrowing the velopharyngeal port.
Revision Velopharyngeal Surgery
299
5. The flap is elevated bluntly in a superior direc-
tion, such that it resides within the velopharyngeal
sphincter (Figure 24–5).
6. The lateral ports are inspected. With elevation
of the flap, the ports will be smaller. Additional
narrowing of the ports is possible by advancing
mucosa into the resulting donor site below the
newly elevated flap (Figure 24–6). With forceps,
the mucosa within the velopharyngeal ports is
manipulated to determine what direction of pull
will narrow the port. Sometimes the mucosa infe-
rior to the port needs to be pulled superiorly to nar-
row the port. Trial and error will demonstrate the
correct maneuver. Overcorrection is necessary, as
30% relaxation of the tissue can be expected.
7. The mucosal advancement flaps are sutured into
position with 3-0 Vicryl™ sutures.
Postoperative Considerations
• The patient is discharged home from the
recovery room.
• Postoperative antibiotics should be given for a
period of 1 week.
• Patients return for a postoperative check at
3 weeks.
• Evaluation of the functional results of the
procedure is obtained at 3 months.
Complications
• VPI may persist.
• Hyponasality or obstructive breathing may
occur if lateral port stenosis occurs.
Figure 24–4. Incision made along the inferior aspect of the
pedicle of the pharyngeal flap.
Figure 24–5. Prevertebral fascia is exposed, and the flap is
elevated superiorly.
Figure 24–6. Advancement of adjacent mucosa from the
velopharyngeal port into the donor site defect to close the
donor site and narrow the port.
300
Video Atlas of Cleft Lip and Palate Surgery
Pearls and Pitfalls
• Most cases of failure of closure of the
velopharyngeal ports are associated with
a flap in a low position. Raising the flap
improves the ability of the lateral walls to
contact the flap.
• Overcorrection of the lateral ports is essential
to long-term success. The tissue will relax
over time leading potentially to further nasal
air escape.
Increasing the Size of the Velopharyngeal Port
Surgical Indications
• Airway obstruction secondary to stenosis of
the velopharyngeal port(s).
• Hyponasal resonance.
Surgical Equipment and Tools
• Crowe-Davis mouth gag
• Suction catheters
• McCrea dilators
• Beaver® blade scalpel
• 3-0 Vicryl™ suture
Anesthesia
• General endotracheal anesthesia with an
RAE® tube.
Surgical Procedure (Video of Velopharyngeal
Port Enlargement)
Preparation
• Preoperative nasopharyngoscopic evaluation
during connected speech has identified the
lateral port(s) that requires revision.
• The patient is positioned on a shoulder roll to
maintain hyperextension of the neck.
Procedure
1. Mouth gag is inserted, and the patient is placed
into suspension.
2. A suction catheter is passed transnasally through
the stenotic port. If it is difficult to pass, a dilator can
be passed through the eye of the suction catheter
into its lumen, and the dilator can be manipulated
through the port. Traction on the suction catheters
will tense the port and allow better visualization
of the port and determination of the reason for the
stenosis.
3. Inspection of the port will determine why the port
is narrow (Figure 24–7). There frequently is a band
on the posterior pharyngeal wall that creates a
ledge, narrowing the port. Dividing the ledge will
open the port.
4. A Beaver® blade is used to make a V-shaped wedge
in the scar tissue that is narrowing the port. The inci-
sion removes the obstructing material (Figure 24–8).
5. The revision is carried out bilaterally if necessary.
6. The resulting defect is left to granulate (Figure 24–9).
Postoperative Considerations
• The patient is discharged home from the
recovery room.
• Postoperative antibiotics should be given for a
period of 1 week.
• Patients return for a postoperative check at
3 weeks.
• Evaluation of the functional results of the
procedure is obtained at 3 months.
Complications
• Airway obstruction or hyponasality may persist.
• Velopharyngeal insufficiency may develop if
the ports are made too large.
Figure 24–7. Narrow velopharyngeal ports causing airway
obstruction.
Revision Velopharyngeal Surgery
301
Pearls and Pitfalls
• Injection of lidocaine with epinephrine makes
it difficult to determine how much tissue
should be removed to improve the airway.
Minimal bleeding is encountered even
without the injection.
• Stents are not necessary postoperatively.
References
1. Kummer AW, Curtis C, Wiggs M, Lee L, Strife JL. Com-
parison of velopharyngeal gap size in patients with
hypernasality, hypernasality and nasal emission, or nasal
turbulence (rustle) as the primary speech characteristic.
Cleft Palate Craniofac J. 1992;29:152–156.
2. Croft C, Shprintzen R, Rakoff S. Patterns of velopharyngeal
valving in normal and cleft palate subjects: a multi-view
videofluoroscopic and nasendoscopic study. Laryngoscope.
1981;91:265–271.
3. Hogan V. A clarification of the surgical goals in cleft pal-
ate speech and the introduction of the lateral port control
(l.p.c.) pharyngeal flap. Cleft Palate J. 1973;10:331–345.
4. Smith J, McCabe B. Teflon injection in the nasopharynx
to improve velopharyngeal closure. Ann Otol Rhinol Lar-
yngol. 1977;86:559–563.
5. Borgatti R, Tettamanti A, Piccinelli P. Brain injury in a
healthy child one year after periureteral injection of Tef-
lon. Pediatrics. 1996;98:290–291.
Figure 24–8. Resection of obstructing tissue from the poste-
rior aspect of the port.
Figure 24–9. Resulting enlargement of the velopharyngeal
port.
(Trang không có chữ)
303
Index
Note: Page numbers in bold reference non-text material.
A
Adenotonsillar hypertrophy, 274
Adjacent palatal mucosal shelves, 232–233, 233
Advancement flaps
bilateral cleft lip repair using, 88, 91
buccal, 155, 155–156
Airway
assessment of, 10–11
difficulties associated with, 13
oral, 12
Alar base, 169
Alar base flap suspending sutures
for bilateral cleft lip repair, 92, 93, 95
for unilateral cleft lip repair, 67, 69, 69–70
Alar base transfixion sutures, for unilateral complete
cleft lip repair, 70, 70–71
“Alar creep,” 54
Alar hooding, 169
Alar lobule notching, 225
Alare, 53
Allogenic grafts, for nasoalveolar cleft repair, 147
Alveolar cleft
bone graft, 185
palatal fistula with or without extension to. See
Palatal fistula with or without alveolar cleft
extension
Anesthesia. See also General anesthesia; Local anesthesia
bilateral cleft lip repair, 86
bilateral complete cleft palate repair, 125
Furlow palatoplasty, 286
nasoalveolar cleft repair, 148
revision cleft lip repair, 206
revision cleft palate repair, 230
secondary cleft lip rhinoplasty, 166
soft palate cleft repair, 134
submucous cleft palate repair, 134
unilateral cleft lip repair. See Unilateral cleft lip
repair, anesthesia for
Anterior palatal fistula with or without alveolar cleft
extension
adjacent palatal mucosal shelves, 232–233, 233
anteriorly based tongue flaps, 237, 238–239, 239
buccal finger/rotational flap for, 234–236, 235–236
buccally advanced tissue for, 233–236
combination flaps for, 239
direct buccal advancement flap for, 234, 236
island flap, 236–237
lateral sliding flap, 236
nasal layer closure, 231, 231–232
oral layer closure, 232–239
overview of, 231
Anterior-based mucosa flap, 289
Anteriorly based tongue flaps, 155, 237, 238–239, 239
Anthropometry
applications of, 54–55
definition of, 53
direct, 53
indirect, 53
landmarks used in, 53–54
measurements used in, 54
nose, 53, 53–54
B
Bilateral cleft lip
classification of, 82–83
columellar deficiency in, 82
complete, 5
description of, 4, 7, 81
difficult laryngoscopy in, 10
extent of, 82
illustration of, 5
Le Fort osteotomy modifications in, 190, 190–193
nasal deformities associated with, 166, 167, 168, 170
nasoalveolar molding appliance for, 43, 44, 47, 82,
84, 85
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Video Atlas of Cleft Lip and Palate Surgery
Bilateral cleft lip (continued)
nasolabial anthropometric measurements, 55
nonsurgical columella lengthening in, 44, 45
striped “Y” classification for, 82, 83
Bilateral cleft lip repair
active appliances for, 85
anesthesia for, 86
complications of, 98, 98–99
contraindications, 82
equipment and tools for, 86
goals of, 83–84
hypertrophic scars after, 98
indications for, 82
lip dehiscence after, 98
local anesthesia for, 88–89, 97
multidisciplinary approach to, 99
overview of, 81–82
pearls and pitfalls of, 99–100
postoperative considerations for, 95, 97–98
presurgical orthopedic care, 84–86
residual cleft lip deformities after, 202, 202–204
results of, 95–97
revision surgery
Type II, 209
Type III, 210, 213–215
Type IV, 223, 223–224
secondary rhinoplasty after, 172–175, 173–175
surgical procedure for
advancement flaps, 88, 91
alar base flap suspending sutures, 92, 93, 95
anesthesia, 86
endotracheal tube placement, 86
final closure of, 94–95, 96
Hamdan sliding V-cheiloplasty technique, 92, 92
labial dissection, 89–91, 89–91
lip closure, 91–94, 92–94
local anesthesia, 88–89, 97
markings, 87, 88
mucosal flaps, 88, 90, 92
nasal dissection, 91
patient positioning, 86
philtral ridges, 88
preoperative photographs, 87
prolabial flap, 87–89
rhinoplasty, 92, 94, 94–95
vermilion border flaps, 94, 213
surgical safety checklist for, 87
timing of, 86
wound infections after, 98, 99
Bilateral complete cleft palate
anatomy of, 113, 124, 124
repair of
anesthesia for, 125
complications of, 129–130
endotracheal tube for, 125
equipment and tools for, 124–125
goals for, 123
greater palatine artery injury in, 129
indications for, 123–124
intravelar veloplasty for, 129
pearls and pitfalls of, 130
postoperative considerations for, 129
surgical procedure for, 125–129
timing of, 124
vomer flap for, 127–129, 128
Bilateral nasoalveolar cleft, 144–145
Biofeedback, 252
Blood transfusion, emergency, 37
Buccal advancement flap, 155, 155–156, 234, 234, 236
Buccal finger/rotational flap, 156, 157, 234–236,
235–236
Bupivacaine, 12, 61
C
Calcium hydroxylapatite, 291
C-flaps, 94, 95, 220, 225–226
Cheilion, 54
Children, 250–252
Chondrocutaneous flap, 171
Cine magnetic resonance imaging, 249
Cleft lip
anatomic abnormalities associated with, 58
bilateral. See Bilateral cleft lip; Unilateral cleft lip
repair
classification of, 4–5, 4–6, 59
complete. See Complete cleft lip
embryology of, 3–4
functional anatomy of, 6–7
incidence of, 3, 9, 183
microform, 58
Millard’s classification of, 59
nasal deformities associated with. See Nasal
deformities
residual deformities of. See Residual cleft lip
deformities
revision repair of. See Revision cleft lip repair
secondary rhinoplasty. See Secondary cleft lip
rhinoplasty
unilateral. See Unilateral cleft lip; Unilateral cleft lip
repair
Cleft palate
bilateral. See Bilateral complete cleft palate
classification of, 4–6
Index
305
complete. See Complete cleft palate
embryology of, 3–4
feeding issues caused by, 249–250, 252
functional anatomy of, 6–7
incidence of, 3, 9, 183
incomplete. See Incomplete cleft palate
oral deficiencies associated with
description of, 257
maxillary constriction, 257–259, 258
vertical dimension, 257–258
revision repair of. See Revision cleft palate repair
soft palate. See Soft palate cleft
submucous. See Submucous cleft palate
unilateral. See Unilateral complete cleft palate
Columella
deficiency of, in bilateral cleft lip, 82
deformity of, 201
highest point of, 53
nonsurgical lengthening of, 44, 45
retracted, 225
Columellar base flap, 64
Complete cleft lip
bilateral, 4–5
definition of, 58
description of, 4–5
unilateral. See Unilateral cleft lip, complete
Complete cleft palate
bilateral. See Bilateral complete cleft palate
description of, 4, 6
Continuous positive airway pressure, 295
Cortico-cancellous blocks, 190, 192
Craniofacial abnormalities, 10
Craniofacial syndromes, 278
“Crash” cart, 28, 28, 33–34
Crista philtri inferior, 54
Crista philtri superior, 54
Crossbite, bilateral, 258
Cul-de-sac test, 248
Cupid’s bow
deformities of
asymmetry, 199–200, 203, 207, 215
Z-plasty for, 206
description of, 62, 64, 81
D
Dermabond, 224, 226
Dexamethasone, 11–12, 270
Difficult laryngoscopy, 10
Dingman retractor, 279
Direct anthropometry, 53
Distraction osteogenesis, 184
Double-reversing Z-plasty. See Furlow palatoplasty
Down-fracture, 190, 191
E
Electronic medical records, 20
Embryology, 3–4
Emergency response protocol, for surgical outreach
initiatives
“crash” cart, 28, 28, 33–34
equipment portability, 28, 28–29
location-specific adaptability, 29
overview of, 25, 27
sample, 31
site-specific checklist, 35
team member roles, 36–37
workflow and team communication, 29
Endotracheal tube
for bilateral cleft lip repair, 86
for bilateral complete cleft palate repair, 115, 125
description of, 11
for soft palate cleft repair, 134
for unilateral cleft lip repair, 62
End-tidal CO2 monitors, 23
Epinephrine, 61
External nasal nerve block, 12, 61, 62, 76, 89
Extubation, 12
F
Facial development, 3
Facial nerve block, 61, 62
Feeding, 249–250, 252
Fiberoptic intubation, of general anesthesia, 11
Fistula
anterior palatal. See Anterior palatal fistula with or
without alveolar cleft extension
mid-hard palate fistula with extension to the
junction of the hard and soft palate, 239–241
nasoalveolar cleft repair, 146
soft palate, 241–242
Flexible nasoendoscopy, 249
Frontonasal prominence, 3
Functional anatomy, 6–7
Furlow palatoplasty
anesthesia for, 286
anterior-based mucosa flap, 289
complications of, 289
description of, 266, 266
equipment and tools for, 286
history of, 285
indications for, 285–286
306
Video Atlas of Cleft Lip and Palate Surgery
Furlow palatoplasty (continued)
pearls and pitfalls of, 289
postoperative considerations for, 288
submucous cleft palate repair using, 132–133, 139,
139–140
surgical procedure for, 286–288, 286–288
G
General anesthesia. See also Anesthesia
emergence and extubation from, 12
induction of, 11
maintenance of, 11–12
unilateral cleft lip repair, 61–62
Gingivoperiosteoplasty, 48
Global Smile Foundation
description of, 17
emergency “crash” cart used by, 28, 28, 33–34
emergency response protocol of, 27, 35–37
mission planning by, 17
quality assurance guidelines of, 24–25, 26–27
site survey by, 19
staffing requirements, 18–20, 21
team members, 18–20, 21
Greater palatine artery
injury to
in bilateral cleft lip repair, 110
in bilateral complete cleft palate repair, 129
in soft palate cleft repair, 141
in submucous cleft repair, 141
in unilateral cleft lip repair, 120
island flap based off of, 238
Greater palatine foramen, 117
GSF. See Global Smile Foundation
Gunter diagram, 173, 177–178
H
Hamdan sliding V-cheiloplasty technique
for bilateral cleft lip repair, 92, 92
for unilateral cleft lip repair, 58, 67–69, 68–69, 75, 218
Hamulus, 116, 116–117, 135
Heminasal width, 54
Herman modification, of lateral sliding flap, 156, 158
Horizontal osteotomy, 188
Hydration, 10
Hyponasal speech, 256
Hypoplastic mandible, 10
I
Incisive foramen, 5
Incomplete cleft lip, unilateral, 5, 58, 74–76, 77–78
Incomplete cleft palate
definition of, 58
description of, 4, 6, 106
repair of
anesthesia for, 107
complications of, 110
equipment and tools for, 106
goals for, 105
greater palatine artery injury during, 110
indications for, 106
pearls and pitfalls of, 110–111
postoperative considerations, 110
surgical procedure for, 107–110
timing of, 106
von Langenbeck technique for, 107–110, 108–110
Indirect anthropometry, 53
Induction, of general anesthesia, 11
Infants, speech and resonance disorders in, 249–251
Infraorbital nerve block, 12, 61, 62, 76, 89
Injection pharyngoplasty, 292, 292–293, 295–298
Interdomal sutures
bilateral complete cleft lip, 94, 94
revision cleft lip surgery, 219–220
unilateral complete cleft lip, 69, 70
Intermediate rhinoplasty
definition of, 164–165
surgical procedure for, 166–167
Internal carotid artery, 133
International surgical outreach initiatives. See Surgical
outreach initiatives
Intraoral air pressure, 248
Intraoral appliances, 60
Intravelar veloplasty, 109, 118, 119, 129, 138
Intravenous fluids, 12
Island flaps
anterior palatal fistula with or without alveolar cleft
extension treated with, 236–237
palatal, 153–155, 154
L
Labial dissection, for bilateral cleft lip repair, 89–91,
89–91
Labiale superius, 54
Language development, 250–251
Laryngeal mask airway, 11
Laryngoscopy, 10
Lateral crus recurvature, 170
Lateral mucosal flap, 66
Lateral palatal flaps, 152–153, 153, 233
Lateral releasing incision, 153
Lateral sliding flap, 156, 158, 236
Index
307
Latham appliance, 84, 85
Le Fort osteotomy
in cleft patient with alveolar cleft bone graft, 185
description of, 184
modifications to
in bilateral cleft patient, 190, 190–193
in unilateral cleft patient, 185–186, 186–189
in noncleft patient, 184
LeMesurier, Arthur Baker, 57
Levator veli palatini, 7, 126, 263, 277
Lidocaine, 12
“Lift-obturator,” for velopharyngeal insufficiency, 256,
257
Lip
anthropometric points of, 53, 54
embryology of, 3–4
formation of, 4
Lip adhesion, 60, 84
Lip asymmetry, 199
Lip dehiscence
after bilateral cleft lip repair, 98
after revision cleft lip repair, 225
after unilateral cleft lip repair, 79
illustration of, 200, 202, 203
Lip taping, 60
Local anesthesia. See also Anesthesia
bilateral cleft lip repair, 86, 88–89, 97
description of, 12
external nasal nerve block, 12, 61, 62, 76, 89
infraorbital nerve block, 12, 61, 62, 76, 89
revision cleft lip repair using, 226
unilateral cleft lip repair, 61, 62, 64, 76, 76–77
M
MacKay-Kummer Simplified Nasometric Assessment
Procedures test, 248
Magnetic resonance imaging, of velopharyngeal
insufficiency, 249, 265
Maintenance, of general anesthesia, 11–12
Mask ventilation, 10–11
Maxilla
constriction of, 257–259, 258
growth of, 257
Maxillary alveolus cleft repair. See Nasoalveolar cleft
repair
Meatal obturator, for velopharyngeal insufficiency,
256, 256, 261
Medial mucosal flap, 64, 64
Medial palatine prominence, 3
Medical missions
case selection for, 22–23, 26
emergency response protocol for
“crash” cart, 28, 28, 33–34
equipment portability, 28, 28–29
location-specific adaptability, 29
overview of, 25, 27
sample, 31
site-specific checklist, 35
team member roles, 36–37
workflow and team communication, 29
on-call schedule for, 29
operative care, 23–24, 27
patient screenings, 20–22, 22, 26
perioperative stage of, 20–24, 26–27
photographic documentation of patients, 20–21
planning of, 17, 17–24
postoperative stage of, 24, 27
preoperative stage of, 18–20, 26
quality assurance guidelines, 24–25, 26–27
site selection for, 18, 20, 26
site visit for, 18, 19, 26
team members
selection of, 18–20, 21, 27
standardization of roles for, 29–30, 36–37
Microform cleft lip, 58
Millard’s rotation advancement flap, 57, 64
Mucosal flaps, for bilateral cleft lip repair, 88, 90, 92
Mulliken, John B., 82
Multiview fluoroscopy, 249
N
NAM. See Nasoalveolar molding appliance
Nasal air emissions, 248
Nasal deformities
bilateral, 167, 168, 170
in bilateral cleft lip, 166
description of, 55
illustration of, 164
residual, 197, 198
secondary cleft lip rhinoplasty for. See Secondary
cleft lip rhinoplasty
types of, 58–60, 59
unilateral, 167–168, 168
in unilateral cleft lip, 165
Nasal mirror, 248
Nasal stents, 44–45, 45, 47, 272, 275
Nasal tip projection
deformity of, 202, 204
graft of, 168
Nasal tip rhinoplasty, 223–224
Nasal turbulence, 248
Nasal valve, for velopharyngeal insufficiency, 256–257
308
Video Atlas of Cleft Lip and Palate Surgery
Nasoalveolar cleft repair
adjunctive orthodontics with, 147–148
anatomy of, 143
anesthesia for, 148
bilateral, 144–145, 156
categories of, 144
early secondary, 144
equipment and tools for, 148
fistulae after, 146
goals of, 143
graft options, 147
indications for, 144–148
late secondary, 144
postsurgical orthodontic care, 148
presurgical orthodontic care, 147–148
primary, 144
surgical procedure for
anteriorly based tongue flaps, 155
autogenous cancellous bone grafts, 148, 149
bed preparation for bone graft, 149–151, 150
bone graft placement into alveolar defect, 151,
151
buccal advancement flap, 155, 155–156
buccal component of oral mucosal layer, 155–156
complications of, 156
lateral palatal flaps, 152–153, 153–154
lateral sliding flap, 156, 158
nasal layer closure, 149–151, 150
palatal component of oral mucosal layer, 152–155
palatal island flaps, 153–155, 154
pearls and pitfalls of, 156, 158–159
postoperative considerations, 156
steps involved in, 148
tension-free flaps for closure of oral mucosal
layer, 152, 152
timing of, 144
Nasoalveolar molding appliance
adjustments to, 44
alveolar segment misalignments, 48
benefits of, 48
bilateral cleft lip treated with, 43, 44, 47, 82, 84, 85
caregiver compliance with, 48
complications of, 46–48
design of, 42–43, 84
fabrication of, 42–43
gingivoperiosteoplasty and, 48
illustration of, 42, 85
impression technique for, 42, 43
insertion of, 43–44
nasal stent system, 44–45, 45
nasal symmetry using, 226
objective of, 41–42
outcomes of, 85
parental compliance with, 48
primary maxillary incisor eruption caused by, 48
soft tissue complications of, 46–47
taping of, 43–44
unilateral cleft lip and palate treated with, 43, 44,
46, 60
Nasoendoscopy
speech and resonance disorders evaluated using,
249, 252
velopharyngeal sphincter evaluations, 265
Nasolabial anthropometry. See Anthropometry
Nasometry, 248–249, 252
Nasopharyngeal mucosal flap, 287
Nasopharyngoscopy, 269, 275, 279
Nerve block
anesthetic use of, 12, 61, 62
facial, 61, 62
Nonsteroidal antiinflammatory drugs, 12
Nose
anthropometric points of, 53, 53–54
deformities of. See Nasal deformities
rhinoplasty of. See Rhinoplasty
Nostril bases, 202, 204
Nostril stenosis, 225
Notching, secondary, 199
Nutrition, 10
O
Obstructive sleep apnea, 265, 278, 282
Obturator prosthesis, for velopharyngeal
insufficiency, 255–256, 256, 259, 259
Operating room
fire in, 36
medical/surgical emergency in, 37
oxygen failure in, 36–37
Oral airway, 12
Oral motor exam, for speech and resonance disorders,
248, 250
Orbicularis oris
deficiency of, 199, 199, 202, 203
description of, 90, 92
sutures of, 221
Orthognathic surgery
alveolar cleft, 184
bone grafting with, 184
complications of, 194
equipment and tools for, 184
indications for, 183–184
Le Fort osteotomy. See Le Fort osteotomy
pearls and pitfalls of, 194
Index
309
postoperative considerations, 193–194
preoperative considerations, 184
prevalence of, 183
secondary cleft lip rhinoplasty and, 164
skeletal maturation considerations, 184
surgical imaging before, 184
timing of, 183
treatment planning for, 183
Overclosure, in vertical plane, 258
P
PACU. See Post anesthesia care unit
Palatal fistula with or without alveolar cleft extension,
anterior
adjacent palatal mucosal shelves, 232–233, 233
anteriorly based tongue flaps, 237, 238–239, 239
buccal finger/rotational flap for, 234–236, 235–236
buccally advanced tissue for, 233–236
combination flaps for, 239
direct buccal advancement flap for, 234, 236
island flap, 236–237
lateral sliding flap, 236
nasal layer closure, 231, 231–232
oral layer closure, 232–239
overview of, 231
Palatal island flaps, 153–155, 154
Palatal lifting prosthesis, for velopharyngeal
insufficiency, 256, 257, 261, 261
Palate
formation of, 4
normal development of, 3–4
soft. See Soft palate
Palatoglossus, 277
Palatopharyngeal obturators, 265
Palatopharyngeus, 277
Palatoplasty
Furlow. See Furlow palatoplasty
speech development evaluations after, in infants,
250
Paré, Ambrose, 57
Periosteal elevator, hamulus position identified using,
116, 116–117, 137
Pharyngeal bulbs, 265
Pharyngeal flap, superiorly based
adenotonsillar hypertrophy caused by, 274
anesthesia for, 270–271
complications of, 274–275
description of, 242
equipment and tools for, 270
indications for, 269–270
nasal stents, 272, 275
nasopharyngoscopy before, 269, 275
pearls and pitfalls of, 275
placement of, 270
postoperative considerations, 273–274
sphincter pharyngoplasty versus, 277
surgical procedure for, 271–273, 271–274
suturing of, 273, 273
velopharyngeal insufficiency treated with, 266,
269–275, 270–274
Pharyngoplasty
injection, 292, 292–293, 295–298
sphincter. See Sphincter pharyngoplasty
Philtral tubercle, 202, 203
Philtrum, 202, 202
Pierre Robin sequence, 10–11
Post anesthesia care unit
description of, 12
fire in, 36
medical/surgical emergency in, 37
oxygen failure in, 36–37
Posterior pharyngeal wall augmentation, 266, 266,
291–294, 292–293, 297
Posteriorly based tongue flaps, 241
Postoperative care, 12–13
Preoperative evaluation, 9–11
Presurgical orthopedics
history of, 41–42
nasoalveolar molding. See Nasoalveolar molding
appliance
Primary palate, 3
Prolabial flap, 87–89, 202, 203, 215
Prolabium, 202, 204
Pterygoid plate fracture, 188
Q
Quality assurance, for surgical outreach initiatives,
24–25, 26–27
R
Residual cleft lip deformities
asymmetric Cupid’s bow, 199, 199–200, 203
bilateral cleft lip repair, 202, 202–204
columella, 201
lip asymmetry, 199
lip dehiscence, 200, 202, 203
nasal deformities with, 197
revision repair for. See Revision cleft lip repair
surgical classification system for, 197, 198
Type I, 198, 206–207, 206–207
Type II, 198, 207–209, 208–209
310
Video Atlas of Cleft Lip and Palate Surgery
Residual cleft lip deformities (continued)
Type III, 198, 209–215, 211–215
Type IV, 198, 215–224, 216–224
unilateral cleft lip repair, 199–202, 199–202
Resonance development, 250
Resonance disorders. See Speech and resonance
disorders
Respiratory infection, 10
Revision cleft lip repair
anesthesia for, 206
complications of, 225
contraindications for, 205
equipment and tools for, 205–206
goals for, 205
indications for, 205
linear excision for, 207
lip dehiscence after, 225
local anesthesia for, 226
pearls and pitfalls of, 225–226
postoperative considerations, 224–225
preoperative planning for, 199
presurgical orthopedic care, 205
principles of, 205, 205
residual cleft lip deformities. See Residual cleft lip
deformities
surgical classification system for, 197, 198
timing of, 205
Type I, 198, 206–207, 206–207
Type II, 207–209, 208–209
Type III, 209–215, 211–215
Type IV, 215–224
V–Y flap for, 206–207, 207
Z-plasty for, 206, 206
Revision cleft palate repair
anesthesia for, 230
anterior palatal fistula with or without alveolar cleft
extension
adjacent palatal mucosal shelves, 232–233, 233
anteriorly based tongue flaps, 237, 238–239, 239
buccal finger/rotational flap for, 234–236, 235–236
buccally advanced tissue for, 233–236
combination flaps for, 239
direct buccal advancement flap for, 234, 236
island flap, 236–237
lateral sliding flap, 236
nasal layer closure, 231, 231–232
oral layer closure, 232–239
overview of, 231
complications of, 243
equipment and tools for, 230
indications for, 229–230
isolated soft palate fistula, 241–242, 242
mid-hard palate fistula with extension to the
junction of the hard and soft palate, 239–241,
240
overview of, 229
pearls and pitfalls of, 243
postoperative considerations, 242–243
surgical procedure for, 230–242
two-layer closure, 229, 243
Rhinoplasty
in bilateral cleft lip repair, 92, 94, 94–95
nasal tip, 223–224
secondary cleft lip. See Secondary cleft lip
rhinoplasty
in unilateral cleft lip repair
complete, 66, 66, 69–74, 70–74
incomplete, 75–76
Rolled pharyngeal flap, 291–293, 293
Rotation flap, 64
Rule of 10’s, 60
S
Salpingopharyngeus, 277–278
Secondary cleft lip rhinoplasty
age of patient, 163
algorithm for, 168–169
anesthesia for, 166
bilateral, 172–175, 173–175
case studies of, 168–178, 169–178
complications of, 179
equipment and tools for, 165–166
Gunter diagram used in, 173, 177–178
indications for, 163–165
infection risks, 179
orthognathic procedures before, 164
pearls and pitfalls of, 179
postoperative considerations, 179
primary rhinoplasty versus, 163
surgical procedure for, 167–168
in unilateral cleft lip, 168, 170, 171–172, 172
Secondary palate, 3
Septal deviation, 201
Septorhinoplasty, 175
Shield graft, for tip projection correction, 168
Simonart band, 58
Skeletal maturation, 184
Sleep-disordered breathing, 278, 282
Sliding V-cheiloplasty technique (Hamdan)
for bilateral cleft lip repair, 92, 92
for unilateral cleft lip repair, 58, 67–69, 68–69, 75
Soft palate
isolated fistula of, 241–242, 242
Index
311
mid-hard palate fistula with extension to the
junction of the hard and soft palate, 239–241,
240
Soft palate cleft
anatomy of, 131, 132
overt, 132
repair of
anesthesia for, 134
complications of, 141
equipment and tools for, 134
goals for, 133
indications for, 133–134
intravelar veloplasty for, 138
palatal incisions, 137, 137
pearls and pitfalls of, 141
postoperative considerations, 140
straight-line closure technique for, 131, 133
surgical procedure for, 134–138, 135–138
timing of, 133–134
Speech
articulation assessments, 251
development of, 250
Speech aid prosthesis, for velopharyngeal
insufficiency, 255–256, 256
Speech and resonance disorders
biofeedback for, 252
in children, 250–252
in infants, 249–251
instrumental assessment of, 248–249, 252
intraoral air pressure assessment, 248
magnetic resonance imaging of, 249
multiview fluoroscopy of, 249
nasal air emissions assessment, 248
nasal turbulence assessment, 248
nasoendoscopy of, 249, 252
nasometry of, 248–249, 252
noninstrumental assessment of, 247–248, 252
oral motor exam for, 248, 250
overview of, 247
surgery for, 251, 253
therapy for, 251, 253
in toddlers, 250
videofluoroscopy of, 249, 252
vocal loudness parameters for, 248
vocal quality assessments, 248
Speech-language pathologist, 247, 269
Sphincter pharyngoplasty
advantages of, 281
anesthesia for, 278
complications of, 282
description of, 266, 266, 277, 295
equipment and tools for, 278
indications for, 278
pearls and pitfalls of, 282
pharyngeal flap versus, 277
postoperative considerations, 282
surgical procedure for, 279–281
Stomion, 54
Stomodeum, 3
Subalare, 53
Submucous cleft palate
anatomy of, 132, 132
description of, 114
repair of
anesthesia for, 134
complications of, 141
equipment and tools for, 134
Furlow palatoplasty, 139, 139–140
goals for, 133
indications for, 133–134
pearls and pitfalls of, 141
postoperative considerations, 140
timing of, 133–134
Von Langenbeck technique for, 139, 139
velocardiofacial syndrome and, 132
velopharyngeal insufficiency associated with, 132
Subnasale, 53
Superiorly based nasopharyngeal mucosal flap, 287
Superiorly based pharyngeal flap
adenotonsillar hypertrophy caused by, 274
anesthesia for, 270–271
complications of, 274–275
description of, 242
equipment and tools for, 270
indications for, 269–270
nasal stents, 272, 275
nasopharyngoscopy before, 269, 275
pearls and pitfalls of, 275
placement of, 270
postoperative considerations, 273–274
surgical procedure for, 271–273, 271–274
suturing of, 273, 273
velopharyngeal insufficiency treated with, 266,
269–275, 270–274
Surgery
airway complications of, 12
bilateral cleft lip repair. See Bilateral cleft lip repair
general anesthesia for. See General anesthesia
nasoalveolar molding therapy before, 46. See also
Nasoalveolar molding appliance
orthognathic. See Orthognathic surgery
speech and resonance disorders treated with, 251,
253
timing of, 9
312
Video Atlas of Cleft Lip and Palate Surgery
Surgery (continued)
unilateral cleft lip repair. See Unilateral cleft lip
repair
velopharyngeal insufficiency treated with, 265–266,
266
Surgical outreach initiatives
case selection for, 22–23, 26
emergency response protocol for
“crash” cart, 28, 28, 33–34
equipment portability, 28, 28–29
location-specific adaptability, 29
overview of, 25, 27
sample, 31
site-specific checklist, 35
team member roles, 36–37
workflow and team communication, 29
on-call schedule for, 29
operative care, 23–24, 27
patient screenings, 20–22, 22, 26
perioperative stage of, 20–24, 26–27
photographic documentation of patients, 20–21
planning of, 17, 17–24
postoperative stage of, 24, 27
preoperative stage of, 18–20, 26
quality assurance guidelines, 24–25
site selection for, 18, 20, 26
site visit for, 18, 19, 26
team members
selection of, 18–20, 21, 27
standardization of roles for, 29–30, 36–37
Surgical safety checklist, 63, 87
Suspending sutures, in unilateral complete cleft lip
repair, 70, 71
T
Tennison, C.W., 57
Tensor veli palatini, 7, 277
Tessier hooks, 188
3D photography, 53
Tibial bone graft, alveolar cleft repair with, 185–186,
186–189
Tip projection
deformity of, 202, 204
graft of, 168
Tip rhinoplasty, 223–224
Toddlers, 250
Tongue flaps
anteriorly based, 155, 237, 239, 239
posteriorly based, 241
Transfixion sutures
bilateral complete cleft lip repair, 94, 94
unilateral complete cleft lip repair, 70, 70–71
Transverse crural sutures, 219
2D photography, 53
U
Unilateral cleft lip
classification of, 58
complete
description of, 5, 58
repair of, 62–78
description of, 4
difficult laryngoscopy in, 10
illustration of, 5
incomplete, 5, 58
nasal deformities associated with, 165
nasolabial anthropometric measurements, 54–55
pathophysiology of, 3
surgical repair of. See Unilateral cleft lip repair
Unilateral cleft lip repair
in adult awake patient, 77, 77–78
age of patient, 60
anesthesia for
description of, 61–62, 62
local. See Unilateral cleft lip repair, local
anesthesia for
complete, 62–74
complications of, 79
contraindications for, 58
dehiscence after, 79
endotracheal tube placement before, 62
equipment and tools for, 61
goals of, 57, 60, 60
history of, 57
incomplete, 74–76, 77–78
indications for, 58
Le Fort osteotomy modifications, 185–186, 186–189
local anesthesia for
description of, 61
external nasal nerve block, 76, 76
infraorbital nerve block, 76, 76
injection technique, 76, 76–77
nerve blocks, 61, 62
nasoalveolar molding before, 43, 44, 46, 60
outcomes of, 74–75, 78
patient positioning for, 62
pearls and pitfalls of, 79–80
postoperative considerations, 79
presurgical orthopedics, 60
residual cleft lip deformities after, 199–202, 199–202
revision surgery
Type II, 207–209, 208–209
Index
313
Type III, 210, 211
Type IV, 216, 217–222
secondary rhinoplasty after, 168, 170, 171–172, 172
surgical procedure
in adult awake patient, 77, 77–78
alar base flap suspending suture, 67, 69, 69–70
flap design for, 63, 64, 65, 74–75
Hamdan sliding V-cheiloplasty technique, 58,
67–69, 68–69, 75, 218
interdigitating muscle sutures, 73, 73
interdomal sutures, 69, 70
lip dissection, 64, 64–66, 67
mucosal flaps, 64, 64, 74–75
mucosal-muscle dissection, 65, 66
outcomes of, 74–75, 78
preparations for, 62–64
rhinoplasty, 66, 66, 69–76, 70–74
rotation advancement flap, 57, 64, 74
surgical markings, 62–64, 63
suspending sutures, 70, 71
transfixion sutures, 70, 70–71
vermilion flap, 72, 72–73
surgical safety checklist for, 63
timing of, 46, 60–61
Unilateral complete cleft palate
anatomy of, 113, 114
description of, 113
repair of
anesthesia for, 115
complications of, 120
equipment and tools for, 114–115
goals for, 113
greater palatine artery injury during, 120
indications for, 113–114
pearls and pitfalls of, 120–121
postoperative considerations, 120
surgical procedure for, 115–120, 115–120
timing of, 114
V
Velocardiofacial syndrome, 132, 269, 285–286, 294
Velopharyngeal dysfunction, after orthognathic
surgery, 194
Velopharyngeal function, 277
Velopharyngeal gap, 282
Velopharyngeal insufficiency
causes of, 263, 265
definition of, 269, 277
magnetic resonance imaging of, 249, 265
nasal valve for, 256–257
nasopharyngoscopy evaluations, 269, 275
noninstrumental assessment of, 248
nonsurgical management of, 263, 265
obstructive sleep apnea and, 265
phoneme-specific, 269
prostheses for
construction of, 260–261
fabrication of, 260–261
meatal obturator, 256, 256, 261
obturator/speech aid, 255–256, 256, 259, 259
palatal lifting, 256, 257, 261, 261
palatal pharyngeal landmarks, 259–260
palatopharyngeal obturator, 265
resonant speech therapy for, 265
submucous cleft palate and, 132
surgical management of
effectiveness of, 295
Furlow palatoplasty. See Furlow palatoplasty
nasopharyngoscopy before, 269, 275
options for, 266, 266
overview of, 265–266, 295
posterior pharyngeal wall augmentation, 266,
266, 291–294, 292–294, 297
sphincter pharyngoplasty. See Sphincter
pharyngoplasty
superiorly based pharyngeal flap, 266, 269–275,
270–274
terminology associated with, 255, 263
workup for, 265
Velopharyngeal port
airway obstruction caused by, 300
size increases in, 300–301, 300–301
size reductions in, 298–300, 299
Velopharyngeal sphincter
anatomy of, 263, 264
nasoendoscopy of, 265
videofluoroscopy evaluation of, 265
Velopharynx
anatomy of, 263, 264
closure of, 265
functions of, 263, 277
Vermilion border asymmetries
V–Y flap for, 206–207, 207
Z-plasty for, 206, 206
Vermilion flap
bilateral cleft lip repair, 94, 213
unilateral complete cleft lip repair, 72, 72–73
Vermilion-mucosal height, 55
Vertical dimension, 257–258
Videofluoroscopy
speech and resonance disorders evaluation, 249, 252
velopharyngeal insufficiency evaluations, 265
Vocal loudness, 248
314
Video Atlas of Cleft Lip and Palate Surgery
Vomer, 124, 124
Vomer flap, 127–129, 128
Von Langenbeck straight-line closure technique
for incomplete cleft palate, 107–110, 108–110
for submucous cleft palate, 131, 133, 139, 139
VPI. See Velopharyngeal insufficiency
V–Y flap
columellar stretching using, 82
Type I revision cleft lip repair, 206–207, 207
W
“Whistle lip deformity,” 55
X
Xenografts, for nasoalveolar cleft repair, 147
Z
Z-plasty
incisions for, 287, 287
lateral sliding flap, 156, 158
preoperative markings for, 206, 206
Type I revision cleft lip repair, 206, 206