CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY

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Simultaneous Double-Opposing Z-Plastyand Posterior Pharyngeal Flap

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Philipp Metzler, MD, DMD,* David W. Low, MD,y Gerhard S. Mundinger, MD,zand Derek M. Steinbacher, MD, DMDx

Purpose: Strategies to address severe anteroposterior palatal shortening with velopharyngeal insuffi-

ciency include palatal lengthening or manipulation of posterior pharyngeal tissue as a flap or sphincter.

In some cases, a single procedure alone is not sufficient to achieve dynamic velopharyngeal closure.

The objective of this study was to determine whether double-opposing Z-plasty coupled with a posteriorpharyngeal flap would achieve adequate palatal length in severe velopharyngeal dysfunction.

Materials andMethods: Six patients, 3 with previously unrepaired cleft palate and 3 children with pre-vious straight-line repairs and significant anteroposterior shortening, were included. Demographic and

perioperative information was tabulated. Subjective and objective speech data were gathered, if available.

Complications, follow-ups, and postoperative nasometric results were compiled. Statistical analysis

involved the paired t test.

Results: There were no perioperative complications. Follow-up was at least 1 year. No postoperative fis-

tulas or nasal obstruction developed. Hypernasal speech and nasal emission were subjectively improved in

all patients. Nasometric data showed a statistically significant improvement in nasal air escape with

speech.

Conclusions: Simultaneous double-opposing Z-plasty and posterior pharyngeal flap can be performed

effectively. This strategy is useful for severe velopharyngeal dysfunction secondary to anteroposterior

palatal shortening or a previously unrepaired cleft palate, and the technique optimizes palatal function

and creates a mechanical blockade to nasal air escape.

� 2014 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 72:803.e1-803.e6, 2014

Thegoals inprimary cleft palate repair are conserved in

partitioning the oral and nasal cavities, achieving

muscular unification, and optimizing velopharyngeal

(VP) competence.1 A myriad of approaches using

1- or 2-stage strategies (Furlow, Wardil-Killner, Veau,

von Langenbeck, and Widmaier-Perko) are currently

used for primary cleft palate repair.2-5 Despite these

espoused methods, the current literature shows upto 20% secondary VP dysfunction (VPD).6-8 Various

case-dependent strategies, including palatal length-

ening or reduction of the static opening between the

nasal and oral pharynges for VPD management,

exist.1,9-12 Palatal lengthening, by conversion to

facial Fellow, Department of Plastic and Reconstructive

ale University School of Medicine, New Haven, CT.

sor, Division of Plastic Surgery, Hospital of the University

vania, Philadelphia, PA.

nt, Department of Plastic and Reconstructive Surgery,

kins Hospital, Baltimore, MD.

or of Craniofacial Program, Department of Plastic and

ctive Surgery, Yale University School of Medicine, New

.

803.e

a double-opposing Z-plasty, may be most appropriate

to address a VP gap of 5 to 10 mm in secondary VPD

correction.8 However, in cases with significant lack

of VP closure, with gaps larger than 10 mm or a func-

tionally adynamic muscular pattern, a pharyngeal flap

or sphincter procedure is typically performed.3,5

Nevertheless, severe anteroposterior palatal short-

ening or previously untreated cleft palates with wideVP gaps in older children or adults bring these

techniques to their limits, leading to a persistence of

hypernasality and nasal emission. Therefore, sub-

sequent attempts to establish a competent VP valve

are needed. In severe cases, a Z-plasty lengthening

Address correspondence and reprint requests to Dr Steinbacher:

Craniofacial Center, Yale University School of Medicine, Plastic and

Craniomaxillofacial Surgery, 330 Cedar St, BB 3rd Floor, New Haven,

CT 06520; e-mail: derek.steinbacher@gmail.com

Received October 3 2013

Accepted November 26 2013

� 2014 American Association of Oral and Maxillofacial Surgeons

0278-2391/13/01438-9$36.00/0

http://dx.doi.org/10.1016/j.joms.2013.11.027

1

FIGURE 1. Composite operative photographs showing the described technique. A, Unrepaired adult cleft. B, Pharyngeal flap outline.C, Pharyngeal flap elevation. D, Double-opposing Z-plasty outline. (Fig 1 continued on next page.)

Metzler et al. Z-plasty and Posterior Pharyngeal Flap. J Oral Maxillofac Surg 2014.

803.e2 Z-PLASTY AND POSTERIOR PHARYNGEAL FLAP

alone has been shown to be insufficient to achieve

dynamic VP closure, but does optimize velar retro-

positioning and function. The posterior pharyngeal

flap has been shown to be most effective in patients

with satisfactory lateral pharyngeal wall movement

and sagittal or circular VP closure patterns. This flap

provides a static central mechanical blockade of the

nasopharyngeal space, aiming to preserve any intrinsicvelar and lateral pharyngeal wall function. However,

the anteroposterior palatal distance is not lengthened,

and a greater levator muscle unification or function

is not possible. In an attempt to simultaneously

achieve palatal lengthening, improved muscle overlap

and function, and a central pharyngeal obstruction,

the authors sought to combine the double-opposing

Z-plasty and the posterior pharyngeal flap in a single

stage. To the authors’ knowledge, the combination of

a double-opposing Z-plasty and a posterior pharyngeal

flap has not been reported in the literature. The pur-

pose of this report is to describe this technique and

the preliminary results.

Materials and Methods

This study was carried out in concordance with Yale

University (NewHaven, CT; HIC 1101007932). Patients

FIGURE1 (cont’d). E, Elevated mirror image of oral and nasal myomucosal andmucosal-only flaps. F,Closed simultaneous double-opposingZ-plasty and pharyngeal flap.

Metzler et al. Z-plasty and Posterior Pharyngeal Flap. J Oral Maxillofac Surg 2014.

METZLER ET AL 803.e3

who underwent simultaneous Z-plasty lengthening and

a posterior pharyngeal flap were included. Demo-

graphic information was tabulated, including patients’

age, gender, diagnosis, and associated conditions. Peri-

operative details, including operative time, hospital

stay, and perioperative complications, were docu-

mented. Pre- and postoperatively, all patients were eval-

uated clinically, including measurement of gap size andVP closure, examination of palatal movement, and

the dental mirror test to assess for fogging. Nasometric

readings also were compared, where possible, using

a nasometer (KayPENTAX, Montvale, NJ). Published

threshold values for nasal air escape during speech

were compared. A longitudinal follow-up (>1 year),

with special attention to complications, postoperative

variables relating to the continuity of repair, palatal func-tion including speech (hypernasality, hyponasality

mixed nasality, cul-de-sac resonance), swallowing, and

nasal emission, was documented.

Statistical analysis involved the paired t test.

SURGICAL TECHNIQUE

General anesthesia was performed using a midline

oral right angle endotracheal endotracheal tube. A

Dingman retractorwas used as amouth gag. Local anes-

thesia, 1% lidocaine with epinephrine 1:100,000, was

infiltrated into the posterior pharyngeal wall, soft pal-ate, and as greater palatine blocks. A meticulous palpa-

tion of the pharyngeal wall was performed to exclude

aberrant branches of the internal carotid artery. A supe-

riorly pedicled posterior pharyngeal flap was outlined,

with enough length for the tip to reach the junction be-

tween the hard and soft tissues of the palate. Incisions

weremade and a blunt preparation down to the prever-

tebral fascia was performed. The flap was elevated to a

point above the level of the soft palate. Further, a stan-

dard double-opposing Z-plasty2 was designed on the

oral soft palate with bipedicled anterior mucoperios-

teal flaps. The posterior pharyngeal flap was insertedalong the nasal- and oral-side Z-flaps; a 10Fr nasal cath-

eter was used to control port size and prevent VP oblit-

eration. The component far back toward the base of

the flap was not lined because it was tented flat and

served to pull the soft palate farther posteriorly. All in-

cisions were closed with resorbable suture. Lateral re-

laxing incisions were left open bilaterally along the

hard palate. The raw pharyngeal fascial donor sitewas closed as superiorly as possible without constrict-

ing the flap pedicle (Figs 1, 2). All patients were

observed for 24 hours postoperatively.

Results

Six patients met the inclusion criteria (4 male,

2 female; mean age, 7.6 yr). Three were older children

or adultswith previously unrepaired cleft palate. Three

were childrenwithprevious straight-line repairs (mean

surgical age, 7 months) and significant anteroposteriorshortening (Table 1). None of the patients with VP

incompetence after palatoplasty had undergone a Fur-

low palatoplasty or pharyngeal flap. VPD was docu-

mented at anatomic examination, perceptual and

FIGURE 2. Schematic drawing.

Metzler et al. Z-plasty and Posterior Pharyngeal Flap. J Oral Maxillofac Surg 2014.

803.e4 Z-PLASTY AND POSTERIOR PHARYNGEAL FLAP

objective speech assessments, nasoendoscopy, and

nasometric recordings (Table 2). All patients exhibited

a VP gap larger than 10 mm, but with clinically

good function of the superior pharyngeal constrictor.No peri- or postoperative complications occurred.

No postoperative fistulas or nasal or obstruction devel-

oped. Hypernasal speech and nasal emission dramati-

cally improved in all patients. Further, objective

speech assessment and nasometric data showed

a statistically significant postoperative improve-

ment (Table 2).

Discussion

VPD in patients with cleft palate results mainly

from insufficient upward and backward movement of

the velum or a poor lateral pharyngeal wall motion.

Large pre-existing VP gaps, insufficient primary closure,

or congenital neurologic disorders are mainly and

reasonably associated with VPD.6,7,13 Secondary cleft

palate surgery focuses on anatomically correctingthese functional deficits.1 The concept of differential

management, based on the sphincteric patterns of VP

competence, has become vogue.14-17 Traditionally and

currently, lengthening of the palate by repositioning

the velum (V-Y pushback, intravelar veloplasty, or

double-opposing Z-plasty) or reduction of the VP port

(pharyngeal flap, sphincter pharyngoplasty, posterior

wall augmentation) is used.18-25 For severe VP gaps,the modified Furlow repair has been shown to

produce excellent results owing to excellent palatal

lengthening, re-orientating the aberrant velar muscula-

ture, and creating an active sling for VP function.2,26

Nevertheless, it is limited to VP gaps of 5 to 10 mm.8

The cross-sectional reduction of the VP port using

the sphincter pharyngoplasty has been shown to

achieve good results in patients with poor lateral wallmotion.23,27

In contrast, pharyngeal flaps, which produce subto-

tal central static or dynamic VP obstruction, are used

preferably in patients with a satisfactory lateral

pharyngeal wall and sagittal or circular VP closure pat-

terns.23 As for severe VP gaps, previous primary and

secondary surgical techniques are limited, frankly

leading to a persistence of hypernasality or nasal emis-sion; additional procedures seem to be mandatory to

achieve a competent valve mechanism.

Gosain and Arneja13 showed excellent results in

large VP gaps and poor lateral pharyngeal wall motion

when combining the Furlow double-opposing Z-plasty

Table 1. DEMOGRAPHIC AND CLINICAL DATA

Parameter

Male:female ratio 2:1

Age (yr) 7.6 � 7.9*

Diagnosis severe VPD (gap, >10 mm)

Previous cleft surgery yes = 3 (all straight line

repair), no = 3

Operative time (minutes) 112 � 27*

Hospital stay (days) 3.2 � 1.2*

Abbreviation: VPD, velopharyngeal dysfunction.* Mean � standard deviation.

Metzler et al. Z-plasty and Posterior Pharyngeal Flap. J Oral Max-illofac Surg 2014.

METZLER ET AL 803.e5

with sphincter pharyngoplasty. All patients showed

significant improvement in postoperative speech andvoice with VP competence, respectively.

Pharyngeal flaps, a common technique for VPD

correction, pull the soft palate backward, creating a cen-

tral subtotal VPobstructionwith 2 lateral ports.28,29 The

authors hypothesized a significant benefit in patients

with severe VPD using a modified Furlow double-

opposing Z-plasty and a superior pharyngeal flaps in a

single stage.30 The double-opposing Z-plasty providesa significant anteroposterior velar enlargement and

back- and upward movement, respectively. Consecu-

tively, owing to the latter mechanism and the preserved

lateral pharyngeal wall motion, the flap width can be

reduced and still provide proper valve function.28,29

This results in larger lateral port size, minimizing the

risk of postoperative nasal obstruction and hyponasal

speech, obstructive sleep apnea, and snoring. Flapsize has to be individually tailored, based on pre- and

perioperative examination.28 To the authors’ knowl-

edge, this combination has not been described

previously.

The present study data showed no peri- or postoper-

ative complications. Postoperative healingwas unevent-

ful and total rehabilitation time showed no significant

difference compared with a single procedure. No post-

Table 2. OBJECTIVE SPEECH AND NASOMETRICOUTCOME ANALYSES

Parameter T1 T2 D T2-T1 % T2-T1

Speech (sibilant fricatives) 58 22 36* 62.1*

Nasometry (bilabial plosive) 53 28 25* 47.2*

Abbreviations: D, difference; T1, preoperative; T2, postoper-ative.* P < .05.

Metzler et al. Z-plasty and Posterior Pharyngeal Flap. J Oral Max-illofac Surg 2014.

operative fistulas, nasal obstruction, sleep apnea, or

snoring was noted clinically. Hypernasal speech and

nasal emission dramatically improved in all patients.

No hyponasality or mixed nasal speech could be de-

tected. Furthermore, objective speech assessment and

nasometric data confirmed the clinical findings in

showing a statistically significant improvement post-

operatively.All results consisted of significant functional

improvement of the VP valve after severe primary or

secondary cleft palate repair. The combination of the

2 techniques clearly showed its efficacy by establish-

ing palatal length, back- and upward motion, and

conserving intrinsic pharyngeal function. This combi-

nation allowed the establishment of a reliably func-

tional valve even for VP gaps larger than 10 to15 mm. Nevertheless, surgical experience is neces-

sary, because an oversized pharyngeal flap can result

in considerable hyponasal speech, acute airway

obstruction, and obstructive sleep apnea.

Simultaneous double-opposing Z-plasty and poste-

rior pharyngeal flap is an effective method to treat se-

vere VP insufficiency in the setting of significant

anteroposterior palatal shortening or a previously un-repaired cleft palate. This strategy optimizes palatal

function and creates a mechanical blockade to nasal

air escape.

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