Reinforcing the Modified Double-Opposing Z-Plasty Approach Using the Pedicled Buccal Fat Flap as an Interpositional Layer for Cleft Palate Repair

Abstract

Pedicled buccal fat flaps have been adopted in primary Furlow double-opposing Z-plasty palatoplasty to reduce oronasal fistula formation or to attenuate maxillary growth disturbance. We combined both goals in a single intervention. This study describes a series of 33 modified Furlow small double-opposing Z-plasty palatoplasties reinforced with a middle layer of pedicled buccal fat flaps between the oral and nasal layers for full coverage of the dissected palatal surfaces, with rapid mucosalization of lateral relaxing incisions and no dehiscence or fistula formation.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

“…The presence of a fistula has been considered as an early indicator of the negative results following primary palatoplasty. 1,[8][9][10]12,13,[22][23][24]26 Different surgical tactics (eg, in-fracture of the hamulus, greater palatine medializing foraminal osteotomy, vascular pedicle skeletonization, raising the mucosa off of the alveolar region, releasing the attached gingiva from the maxillary tuberosity, the elevation of the nasal mucosa off of the medial pterygoid plate in direction to the cranial base and adenoid tissue, degloving of the inferior turbinate, and different types of lateral relaxing incision) have been proposed to release the tension during Z-plasty transposition and midline closure, aiming to reduce fistula formation. [27][28][29][30][31][32] The use of lateral relaxing incision, in particular, has been criticized for the extensive undermining and exposure of raw bone, which potentially increases scarring and impairs transverse maxillary arch development and midfacial growth.…”

“…Future investigation should also characterize the effect of controlling the size of Z-plasty (caliper-guided raising of small DOZ) as well as the absence of lateral relaxing incision on intraoperative palatal lengthening. A growing body of literature 9–12,20,22–24,67,68 has shown the adoption of the buccal fat flap in primary palatoplasty to mitigate bone denudation-related scar contracture and subsequent midfacial growth disturbance, but further research is needed to measure the impact of adding buccal fat flap on long-term outcome of small DOZ palatoplasty using medial incision approach. Prospective investigations could consider auxiliary cohort compositions, incorporating other surgical approaches 28,29,69,70 with and without the use of lateral relaxing incisions and other maneuvers to release tension.…”

“…In this setting, while surgeons adopting a new or modified surgical technique strive for the best possible outcome, the continuous monitoring and measurement of key elements of each adopted surgical procedure are indispensable to optimize the provision of care. 17–19 Existing literature supports the use of small DOZ approach 9–11 by other surgeons for treating Veau types II-IV cleft palate, 20–24 but they do not provide data on the effectiveness of this newly proposed medial incision small DOZ palatoplasty 12 performed by different surgeons to treat a Veau class I in diverse situations of care.…”