What Is a Cleft Palate?
A cleft palate is a congenital defect that occurs as an opening or slit in the roof of the mouth (palate), leaving a hole between the nose and mouth. It may occur alone or in association with any genetic conditions or syndromes. It is often associated with cleft lip. These can be corrected by surgeries which can help achieve a normal appearance with minimal scars and restore normal function.
What Are the Causes of Cleft Palate?
A cleft palate occurs due to improper fusion of the palatal bones. It can be caused by
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Environmental factors.
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Genetic factors.
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Family history.
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Pregnant women with habits of smoking, drinking alcohol or taking certain medications.
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Pregnant women with diabetes.
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Obese pregnant women.
What Are the Problems Associated With Cleft Palate?
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Difficulty in Breastfeeding: A cleft palate makes breastfeeding difficult by separating the oral and nasal cavities, passing the milk from the mouth to the nose, and making it difficult to obtain a good seal around the nipple.
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Hearing Loss: If the cleft palate is not treated, it may cause a middle ear infection, and in severe cases, it can lead to hearing loss.
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Speaking Difficulty: Cleft palate patient’s tone sounds nasal, and their voices are not clear, making them difficult to understand.
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Dental Problems: Cleft palate patients tend to have more dental problems like crowding, spacing, malalignment, displaced teeth, etc.
What Is the Treatment for Cleft Palate?
A cleft palate repair, usually done at 12 months, can reduce fluid accumulation in the middle ear and provide a working palate. To prevent fluid accumulation in the middle ear, special tubes can be placed in the eardrums, allowing fluid drainage and avoiding hearing problems. Many patients with cleft palates require speech therapy or surgery to enhance their speech. At the age of 4 and 5 years, movement of the palate and throat is to be evaluated by nasopharyngeal scope. Speech can be improved by some surgery performed at 5 years of age. If the cleft involves the gum line, it has to be done between 6 and 10 years of age. A bone graft can be used to fill in the upper gum line, thereby supporting permanent teeth and also stabilizing the upper jaw. The patient may need braces and a palate expander to straighten and widen the palate respectively.
What Is the Technique of Double Opposing Z-Plasty for Cleft Palate Repair?
Steps to be followed for double opposing z-Plasty including
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Initially, general anesthesia is given, and a Dingman mouth gag is used to expose the cleft palate. The cleft palate margins are infiltrated with local anesthesia (1 percent lidocaine with 1: 100000 dilution of epinephrine).
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Carefully incise the margin of the cleft palate to separate the oral and nasal mucosa by allowing the closure of both nasal and oral surfaces.
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After the incision, elevate the hard palate mucoperiosteum along the nasal and oral surfaces of the cleft palate.
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The closure of the cleft palate occurs in two layers. First, the nasal mucosal layer is closed, followed by the oral mucosal layer, with simple and horizontal mattress sutures. In case of a larger cleft, vomer flaps are used to close the hard palate.
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Incision of the lateral limbs of the z-plasty can be done along the oral mucosal layer. On the left palate, extend the incision along the posterior margin of the hard palate from the hamulus to the cleft margin.
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On the right palate, the incision extends from the base of the uvula to the hamulus.
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On the right nasal mucosal layer, elevate the soft palatal flap with the inclusion of palatal musculature by detaching it from its bony insertion and forming a posterior mucosal flap.
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The palatal muscle is separated laterally from the superior constrictor’s fascia through the division of palatine aponeurosis, thereby permitting the flap to move across the cleft.
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On the right oral mucosal layer, elevate the z-plasty flap, including minor salivary glands.
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The incision is made on the opposite side of the nasal mucosal layer, from the base of the uvula to the eustachian tube.
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The incision is made on the right nasal my mucosal flap along the posterior hard palate from the eustachian tube orifice to the cleft margin with the preservation of 1 to 2mm soft tissue on the posterior hard palate to suture it with the opposing side nasal mucosal layer.
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The transposition of the nasal z-plasty flaps is done and then sutured.
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The lateral relaxing incisions can be done to derive the adequate flap in case of larger defects. This incision can be done carefully to prevent injury to the greater palatine vessels supplying oral flaps.
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Finally, the uvula edges are sutured.
What Are the Indications for Double Opposing Z-Plasty?
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Narrow soft palate clefts.
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Submucous clefts.
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Soft palate lengthening
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Velopharyngeal insufficiency.
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Prior palatal repair.
What Are the Contraindications for Double Opposing Z-Plasty?
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Wide palatal cleft.
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Reduced palatal neuromuscular sensation.
What Are the Benefits of Double Opposing Z-Plasty?
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It can be combined with Von Langanbeck techniques for primary cleft palate closure.
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It can be used to lengthen the soft palate.
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Reduce the risk of fistula by minimizing the overlap of the oral and nasal mucosal surfaces.
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Improve the speech when comparing the speech outcomes with other techniques of cleft palate repair.
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Avoid raising a large mucoperiosteal flap from the hard palate.
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Reduce palatal muscle damage.
What Are the Risks and Limitations Associated With Double-Opposing Z-Plasty?
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Its limitations include non-anatomical cleft closure, not being used in wide palatal clefts, and avoiding musculus uvulae.
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Its risks include bleeding, infection, and damage to vital vessels near the surgical site during the surgery.
Conclusion:
Double opposing z-plasty or Furlow palatoplasty helps to close the cleft palate and produces an overlapping muscle sling in one procedure without an additional relaxing incision. The main advantage of this technique is improved speech results. But this technique requires greater dissection skills and cannot be used in the case of a wide cleft palate.
