Int. J. Oral Maxillofac. Surg.

2013; 42: 551–558

http://dx.doi.org/10.1016/j.ijom.2012.12.003, available online at http://www.sciencedirect.com

Clinical Paper
Cleft Lip and Palate

Two-stage palatoplasty using a N. Nadjmi1,, R. Van Erum2,

M. De Bodt3, E. M. Bronkhorst4
1
OMFS, University Hospital Antwerp (UA),
Belgium; 2Cleft & Craniofacial Team, Antwerp,
modified Furlow procedure Belgium; 3Department of Communication
Disorders, University Hospital Antwerp,
Belgium; 4Cariology Endodontology
Pedodontology and Social Dentistry, Radboud
University Nijmegen Medical Centre,
N. Nadjmi, R. Van Erum, M. De Bodt, E.M. Bronkhorst: Two-stage palatoplasty using Nijmegen, The Netherlands
a modified Furlow procedure. Int. J. Oral Maxillofac. Surg. 2013; 42: 551–558.
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Abstract. A two-stage palatal repair using a modification of Furlow palatoplasty is

presented. The authors investigate the speech outcome, fistula formation and
maxillary growth. In a prospective, successive cohort study, 40 nonsyndromic
patients with wide cleft palate were operated on between March 2001 and June 2006
by a single surgeon. 10 patients in the first cohort underwent a Furlow palatoplasty
(control group). In 30 patients in the second cohort a unilateral myomucosal cheek
flap was used in combination with a modified Furlow palatoplasty (study group).
The hard palate was closed in both groups 9–12 months later. The Bzoch speech
quality score was superior in the study group, and the hypernasality was
significantly reduced in the study group. Overall fistula formation was 0%. At the
time of hard palate reconstruction palatal cleft width was significantly reduced.
Relative short-term follow up of maxillary growth was excellent. There were no
postoperative haematomas, infections, or episodes of airway obstruction. This
Key words: palatal cleft; staged palatoplasty;
technique is particularly encouraging, because of better speech outcome, absence of Furlow technique; buccal flap.
raw surfaces on the soft palate, no fistula formation, and good maxillary growth.
Further follow-up is necessary to determine the long-term effects on facial Accepted for publication 5 December 2012
development. Available online 19 February 2013

In 1986 Furlow presented a new technique1 mucoperiosteal flaps and extensive dissec- relaxing incisions and back cuts at the base
for closure of the soft palate which has tion that caused secondary fibrosis with of the anteriorly based oral layer in order
gained an increasing number of supporters decreased soft palate mobility,2 and high- to close the palatal layer in wide palatal
due to its ability to recreate an effective rate fistula formation.7 clefts. The BMF is a dependable local
muscular sling, together with adequate The authors have modified Furlow’s sensate flap with a well-defined neurovas-
lengthening of the soft palate with better technique in two ways. The first modifica- cular pedicle8 that was originally
speech outcomes.1–3 Disadvantages of Fur- tion which they use in all their palatal described by Maeda et al.9 and Bozola
low palatoplasty (FP) in reconstructing repairs, is reuniting the levator muscle et al.10 and is currently used by other
wide palatal clefts where tension-free clo- with minimal overlap, instead of complete surgeons,2,11,12 in different ways.
sure could not be achieved, has inspired overlap of the myomucosal flaps. The The authors present the modified FP
surgeons to modify this technique.4–6 The second modification is using a buccal (MFP) with the use of a BMF for the
downside of these modifications were the myomucosal flap (BMF) to achieve a ten- repair of wide palatal clefts in a two stage
insufficient maxillary growth due to expo- sion-free oral layer closure, and avoid operation. They compared a group of
sure of raw surfaces that were created exposition of raw surfaces in wider palatal patients treated with FP and a group trea-
by medial mobilization of the palatal clefts. In these cases one needs to make ted with the MFP and a BMF. Evaluation

0901-5027/050551 + 08 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
552 Nadjmi et al.

was performed on speech outcome and

nasality, fistula formation, and short term
maxillary growth.

Materials and methods

40 patients with nonsyndromic cleft palate
(11 female and 29 male) were operated on
between March 2001 and June 2006 by a
single surgeon. Table 1 shows the type of
cleft and number of patients. Palatal clefts
were reconstructed in two stages in all
patients. Only patients with a palatal cleft
of 9 mm or more, measured at the junction
between hard and soft palate were
Fig. 1. The margins of the cleft and the Z-plasty on the oral side are outlined, as described by
included in this study.
Furlow.
In the first cohort of 10 patients an FP
was used to repair the soft palate (control
group). In the second cohort of 30 patients (i.e. cleft width data) the analyses were of the nasal surface of the uvula towards
a unilateral BMF was used to achieve a done using the t test. For all analyses SPSS the Eustachian orifice (Figs 3 and 4).
tension-free closure of the oral layer of the 16.0 was used. On the right side of the cleft, the ante-
soft palate in combination with the MFP riorly based mucosal flap is elevated from
(study group). The authors reconstructed the muscle beneath (Fig. 5). The levator
Soft palate reconstruction
the cleft palate in two stages, using FP in muscle is then identified and separated
the control group, and using MFP in com- In Fig. 1 the margins of the cleft and the Z- alongside its length from the nasal
bination with BMF in the study group. plasty on the oral side are outlined, as mucosa. The lateral limb of the right
The width of the cleft at the junction of described by Furlow.3 A dilute solution posteriorly based myomucosal flap is cut
the soft and hard palate varied from 9 to of adrenaline (1/200,000) is infiltrated into a few millimetres from the hard palate,
15 mm in both groups, 12.2  1.8 mm the palate. The cleft margin is incised along the levator muscle, and towards the
(mean  SD) for the study group and along the visible junction line between lip of the Eustachian orifice, leaving suffi-
10.8  2.0 mm for the control group. The oral and nasal mucosa in the soft palate cient nasal mucosa edge for suture place-
soft palate was closed between 9 and 12 using a Colorado-tip cautery (Ctc) (Stry- ment. This incision frees the flap with its
months (10.2  1.2 months) in the study ker Leibinger GmbH, Freiburg, Ger- muscle to swing across the cleft and just
group and between 9 and 15 months many). This makes the incision fairly over the mid-line (Fig. 6). Subsequently
(10.8  2.0 months) in the control group. easy and under complete haemostasis. the nasal layer is closed. A suture unites
The hard palate was closed in two layers On the left side the lateral limb incision the tip of the uvular tags, and while ele-
between 18 and 36 months (23.9  6.7 is made, the tip of the flap is elevated, and vated the nasal side of the uvula is closed
months) in the study group and between the palatal muscle detached from the mar- using a Vicryl 6/0 S-14 (Johnson & John-
18 and 48 months (37.2  12.8 months) in gin of the hard palate. The levator veli son Ethicon, Neuilly, France). The closure
the control group. palatini muscle is separated from the nasal of the nasal layer is completed with a
For all nominal variables, the x2 test mucosa along the cleft margin. The mus- Vicryl 5/0 RB1 (Johnson & Johnson Ethi-
with the Fisher exact test was used to cle is then elevated from the nasal mucosa con, Neuilly, France) (Fig. 7). This trans-
analyse difference between the experi- (Fig. 2). The anteriorly based flap is poses the right levator veli palatini muscle
mental groups. For the scale variables incised in the nasal mucosa, from the base towards the mid-line. Subsequently the

Table 1. Profile of the study and the control

groups: type of the cleft, and number of
patients.
Control Study
group group Total
BCLP 1 6 7
CLP 0 1 1
CP 0 1 1
UCLA + BCP 0 1 1
UCLP 9 20 29
UCLr + BCP 0 1 1
Total 10 30 40
BCLP, bilateral cleft lip and palate; CLP, cleft
lip and palate, without alveolar cleft; CP, cleft
hard and soft palate; UCLA + BCP, unilateral
cleft lip and alveolus + bilateral cleft palate;
UCLP, unilateral cleft lip and palate;
UCLr + BCP, unilateral cleft lip (right) + bi- Fig. 2. Oral posteriorly based myomucosal flap on the left side is dissected and medially
lateral cleft palate. mobilized.
 Modified Furlow palatoplasty 553

often too small to cover the nasal layer. In

order to avoid a raw area and to achieve a
tension free closure, a posteriorly based
BMF is elevated to cover the remaining
open area (Figs 8 and 9).
The remaining opening posterior to the
hard palate on the right side, and medial to
the medial limb of the right anteriorly
based mucosal flap, has a parallelogram
shape. This is closed with a left BMF. The
length of the buccal flap is determined by
the length of the long axis of the paralle-
logram. The width is usually about 1 cm.
The incision and the dissection are carried
Fig. 3. Preparation of the anteriorly based nasal mucosal flap. out by Ctc. Dissection starts posterior to
the oral commissure, through the mucosa.
The cut into the buccinators is bevelled, so
that just a small strip of the muscle is
included in the flap which is elevated in
a submuscular plane. The incision of the
anterior limb of the flap is connected to the
incision posterior to the hard palate,
whereas the posterior limb stops in the
retromolar trigone.
The buccal flap, once elevated is turned
into the parallelogram-shaped defect, and
sutured in place with Vicryl 5/0 (Fig. 10).
The donor site is closed in two layers. The
edges of the muscle are approximated by
interrupted Vicryl 5/0 sutures. The
mucosa is approximated with a Vicryl 5/
0 suture in a running fashion. Usually a
Fig. 4. Incision of the anteriorly based nasal mucosal flap. triangular defect at the base of the flap
remains open, which is filled with buccal
fat (Fig. 11).
At the end of the procedure, a naso-
palatal muscle on the left side is dissected Furlow’s method, where he sutures the gastric tube is placed for the purpose of
from the upper-lying oral mucosa over a tip of one muscle flap to the base of the feeding during the first 24 h postopera-
distance of a few mm. The tip of the left other one. tively. As soon as adequate oral feeding
muscle flap is sutured with a minimal The nasal Z-plasty flaps can usually be is resumed the patient is discharged with-
overlap to the right muscle flap with approximated completely, but on the oral out examination of the palate and is seen
PDS 4/0 II FS-2S. This contrasts with side the anteriorly based mucosal flap is two weeks later at the clinic. No special
care is required between the first and the
second stage of palatal repair. The
patients are seen at the clinic every
3 months to evaluate the changes in the
size of the cleft.

Hard palate reconstruction

A two layer hard palate closure was per-
formed in the second stage. No push-back
method was used. Unilateral or bilateral
incisions 3 mm cranial to the palatal cer-
vical edge of the teeth were performed
from canines, not extending beyond the
tuberosity. In three patients, the authors
performed a unilateral incision of about
15 mm medial to the palatal artery, with
mucoperiostal mobilization medial to the
neurovascular bundle to ease the closure
of the posterior part of the hard palate. No
palatal raw surfaces were left for second-
Fig. 5. The anteriorly based oral mucosal flap is elevated from the muscle beneath. ary healing (Figs 12 and 13).
554 Nadjmi et al.

considered to have normal speech for

their age and sex. When 65–84% of
consonants were correct a score of II
was given. A score of III was given when
only 50–64% of consonants were correct.
Patients with score II, and score III were
considered to have mild and moderate
intelligibility impairment, respectively.
Nasometric evaluation was performed
by means of the Nasometer TM Model
6200-3 (KayElemetrics Corp.) following
the standard procedures. For children
younger than 5 years the vowels/I/, /u/
and /a./ were used for calculation of the
nasalance values. For subjects older than
5 years, anphonetically balanced text
was implemented.

Fig. 6. The lateral limb of the right posteriorly based nasal myomucosal flap is cut along the Palatal measurements and clinical
hard palate towards the lip of the Eustachian orifice, leaving sufficient nasal mucosa edge for evaluations
suture placement.
The width of the cleft at the junction of
soft and hard palate was measured at the
time of soft palate reconstruction, and hard
palate closure, with a surgical calliper
(Aleamed, Lier, Belgium).
The presence of palatal fistula, anterior
and posterior cross-bites and cross-bite in
the canine region were assessed at the last
follow-up consultation.

Results
Timing of palatal closure
The mean age at the time of soft palate
reconstruction was 10.8 m (SD = 2.1) in
the control group, and 10.2 m (SD = 1.2)
in the study group. The difference
Fig. 7. Closure of the nasal layer, just before the muscle reunion. between the two groups was not signifi-
cant (p = 0.41). The mean age at the time
of hard palate closure was 37.2 m
Speech assessment first assessed at the age of 36 months. (SD = 12.8) in the control group, and
The intelligibility scores were those pro- 23.9 m (SD = 6.7) in the study group.
All subjects were evaluated by an experi- posed by Bzoch. A score of I was given The difference between the two groups
enced speech and language pathologist, when 85% of the consonants were pro- was statistically significant (p = 0.01).
who was blinded to the surgical proce- duced correctly in a short conversational The mean time between two stages of
dure chosen. The quality of speech was sample. This group of patients was palatal reconstruction was 26.4
(SD = 12.2) in the control group and
13.8 m (SD = 7.03) in the study group.
The difference between the two groups
was statistically significant (p = 0.01).

Speech quality and nasality

Based on the Bzoch test, nasometry and
hypernasality, the speech quality score
was significantly better in the study group
(p = 0.04, 0.002 and 0.015, respectively).
For cleft related articulation problems the
difference was not statistically significant
(p = 0.052) (Tables 2–4). A severe intel-
ligibility impairment was not seen in
Fig. 8. The anteriorly based oral mucosal flap is too small to cover the nasal layer. either the study or control group.
 Modified Furlow palatoplasty 555

reduction between both groups was not

significant (p = 0.28) (Fig. 14 and Table 5).

Maxillary growth
The follow-up period was 5.9  1 years in
the study group and 8.9  1.7 years in the
control group. Anterior cross-bite was
seen in one patient in the study group.
An edge-to-edge frontal bite was observed
three times, twice in the control group and
once in the study group. In the canine
region a cross-bite was observed in one
patient in each group. No posterior cross-
bite was observed.

Fistula formation
Fig. 9. Outline of a left posteriorly based buccal myomucosal flap.
The authors found one postoperative
wound dehiscence at the level of the buc-
cal flap on the third postoperative day.
This was immediately repaired and sub-
sequent wound healing was uneventful.
No fistula formation was observed, after
the closure of the hard palate, in this series
of patients. There were no postoperative
haematomas, infections, or episodes of
airway obstruction.

Discussion
The goals for treatment of the cleft palate
patient are normal speech, maxillofacial
growth, and avoiding fistulas. The timing
Fig. 10. BMF sutured in place.
of hard palate closure has been the subject
of controversy in the literature. The debate
Reduction of the width of palatal cleft The width of palatal cleft at the time of concerning one-stage cleft repair versus
hard palate closure had a mean of 3.45 mm two-stage palatoplasty has traditionally
Overall there was a significant reduction (SD = 1.42) in the control group and a been an argument about the relative value
of the palatal cleft (p < 0.001). The width mean of 4.38 mm (SD = 1.9) in the study of speech development versus acceptable
of the cleft at the junction of soft and hard group. The difference between the two maxillofacial growth.13 Fistula rates for
palate at the time of soft palate closure had groups was not significant (p = 0.164). primary palatoplasty reported in the litera-
a mean of 10.75 mm (SD = 2.02) in the The reduction of the size of the palatal ture also vary widely, between 3% and
control group, and 12.15 mm (SD = 1.83) cleft was 7.3 mm (SD = 1.34) in the 45% of cases.14,15
in the study group. The difference between control group, and 7.8 mm (SD = 1.1) in The repair of the soft palate with
the two groups was significant (p = 0.048). the study group. The difference in cleft techniques such as intravelar veloplasty
and double-opposing Z-plasty have
emerged as some of the most popular
and widely discussed repair techniques,
and the literature shows no significant
difference in fistula rates between these
two techniques.16
The purpose of this study was to eval-
uate the speech outcome, the reduction of
cleft width, the maxillary growth, and the
occurrence of oronasal fistula formation
after an early two stage palatal repair with
MFP in wide palatal clefts. The authors
evaluated the efficiency of BMF by a
comparison between patients treated with
MFP and patients treated with MFP in
combination with BMF.
Fig. 11. The donor side is closed in two layers, and a triangular defect at the base of the flap The FP is a well-established procedure
remains open, which is filled with buccal fat. that provides anatomical reestablishment
556 Nadjmi et al.

Table 4. Hypernasality score by group.

Control Study
Hypernasality group Group Total
+ 5 3 8
– 5 27 32
Total 10 30 40

of the original technique but also demon-

strated its limits in the treatment of wider
clefts where tension-free closure could
not be achieved.
Some solutions have been proposed to
Fig. 12. The remaining cleft of the hard palate. avoid this complication.1,4–6,21,24
Although these showed positive results,
exposure of raw surfaces and extensive
dissection led to insufficient maxillary
growth and to secondary fibrosis with
decreased soft palate mobility2 and an
excess of dead space with high-rate fistula
formation.7 The use of bilateral BMF in a
one-stage closure of the palate has been
published.12 In this technique the non
keratinized buccal mucosa was brought
into the hard palate. The mean age at
the time of palatal repair was 6.4 years,
with relatively short follow up. All
patients had a remaining velopharyngeal
gap (83% less than 5 mm and 17%
between 5 and 10 mm).
The authors have modified Furlow’s
technique in two ways. The first modifica-
Fig. 13. Closure of the hard palate with the help of a paramedian relaxing incision on the non tion (MFP), which they use in all their
cleft side.
palatal repairs, is reuniting the levator
muscle with minimal overlap, instead of
complete overlap of the myomucosal
of the palatal muscle sling, adequate clo- studies have revealed that FP yielded out- flaps. The second modification is using a
sure and palatal lengthening. In addition, standing speech results.7,21 BMF to achieve a tension-free oral layer
the Z-plasty prevents longitudinal scar Disadvantages of FP include a rela- closure, and avoiding exposure of raw
contracture and subsequent velar shorten- tively difficult dissection and increased surfaces in wider palatal clefts.
ing.1–3 The FP is reported to be the best operating time.22 The common problem For larger clefts, the authors have used
procedure for small or submucous clefts in FP is the closure of the areas of the unilateral BMF in combination with MFP.
compared to other techniques such as the anteriorly based oral and nasal mucosal The soft palate was reconstructed mostly
push-back method or the Von Langen- flap and the oral side of the hard palate.22 at 9–12 months. A two-layered closure of
beck. In fact it provides better maxillary The length gained by Z-plasty must, how- the hard palate was usually performed
growth and volume with less total cross- ever, be paid for by a reduction in width. 9–12 months later, when scars were sta-
bites,17 and better results in case of velo- To deal with this, smaller rather than bilized and the maxillary and soft palate
pharyngeal insufficiency.7,17–20 Different larger flaps can be used, reducing the growth had brought the remaining gap to
potential gain in length.23 Furthermore, its least extension.
the need for extensive lateral dissection, The BMF has already been used by
as far as the Eustachian tube in wide some authors, although most of them only
Table 2. Bzoch score by group.
clefts, can cause secondary fibrosis, rely on it to gain palatal length.9–11,17,25
Control Study which may reduce the mobility of soft Only Mann and Fisher22 have combined it
Bzoch group group Total palate.2 This led to some modifications with a modified Furlow Z-plasty. In the
I 4 24 28 authors’ experience, the nasal layer of the
II 3 3 6 soft palate could always be closed without
III 3 3 6 Table 3. Nasometry score by group. tension following the Furlow technique. In
Total 10 30 40 Control Study larger clefts, the anteriorly based oral
I, normal speech quality for age and sex; II, Nasometry group group Total mucosal flap seemed always to be too
mild difficulty in understanding, repetition not Subnl 5 2 7 small for reconstruction of the supposed
required, mild intelligibility impairment; III, Nl 5 28 33 area on the oral layer of the soft palate.
moderate difficulty, repetition required infre- The buccal flap on the contralateral side of
quently, moderate intelligibility. Total 10 30 40 the anteriorly based oral mucosal flap was
 Modified Furlow palatoplasty 557

Fig. 14. Dental casts with corresponding ages in months, from left to right: before lip closure, at the time of soft palate reconstruction, and at the
time of hard palate closure.

used to close the remaining raw area. The primary lip repair and posterior palato- authors think that there are two reasons for
additional extra tissue makes a tension plasty.26 They showed a significant this promising result. One is the fact that
free closure possible, and maintains the decrease in the cleft width at the junction by staging the palatal repair, the width of
achieved lengthening of the soft palate. of hard and soft palates in the group with the cleft at the junction of hard and soft
The comparison between the study the palatoplasty only. Their findings cor- palate reduces significantly. This makes a
group and the control group showed sig- respond with the present ones. The present tensionless close much easier, and without
nificantly better speech results in the first authors also found a significant reduction the need for extensive mobilization of
group, which the authors strongly think is of the palatal cleft (p < 0.001) in all their palatal flaps. Second, the utilization of
the result of the sufficient lengthening, patients. the BMF brings adequate tissue for the
and the tension-free closure of the soft Owing to the age of the patients in both palatal reconstruction at the junction of
palate. In the control group, although a groups, an inter-maxillary assessment of hard and soft palate where fistula forma-
good palatal movement was observed, cross-bite was chosen to evaluate the max- tion usually occurs.
the lengthening that was achieved by illary growth. The short-term maxillary Except for a partial wound dehiscence
double Z-plasty, was partially compro- growth was excellent in both groups. in one case at the time of soft palate
mised when attempting to close the gap One patient in the study group showed closure, there were no postoperative hae-
only with the available palatal tissue, anterior cross-bite. In the canine region matomas, infections, or episodes of airway
whereas in the study group additional a cross-bite was observed in two patients, obstruction.
sensate tissue was added into the soft one in each group. There were no wound In conclusion, the authors’ modification
palate by using the BMF. This resulted contractions at the donor side in this series of the Furlow early two-stage palatal
in sufficient lengthening and an adequate of patients. There was no cross-bite repair with the use of a unilateral buccal
movement of the soft palate, which are observed in the posterior region. flap greatly benefited patients with wide
two important factors for achieving opti- Fistula rates after palatoplasty have cleft palates. A tension free closure of the
mal velar function. been reported to range from 3% to soft palate, and maintaining the length
Lo et al. evaluated the change in the 76%.27 In the present series of patients gained by the Z-plasty has resulted in a
palatoalveolar morphology that followed the overall fistula formation was 0%. The better speech outcome. Together with the

Table 5. Comparisons of cleft width between groups. Preoperative and postoperative reduction. Results of t test.
Control group Study group Control group – study group
Mean SD Mean SD Mean 95% CI for mean p
Cleft preoperative 10.75 2.02 12.15 1.82 1.40 [ 2.78. . . 0.02] 0.048
Cleft postoperative 3.45 1.42 4.38 1.90 0.93 [ 2.26. . .0.40] 0.164
Reduction of cleft 7.30 1.34 7.77 1.11 0.47 [ 1.33. . .0.40] 0.281
558 Nadjmi et al.

absence of raw surfaces on the soft palate, Z-plasty for cleft palate repair. Plast Reconstr 19. Chen PK, Wu J, Hung KF, Chen YR,
no fistula formation and a very low post- Surg 1986;77:569–76. Noordhoff MS. Surgical correction of sub-
operative complication rate, this technique 8. Lacameli GR, Dolan R. Buccinator muscu- mucous cleft palate with Furlow palato-
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