|IDEA AND INNOVATION
|Year : 2017 | Volume
| Issue : 3 | Page : 189-191
Our unified pharyngeal flap operation
Mikihiko Kogo, Takayoshi Sakai, Takeshi Harada, Kanji Nohara, Emiko Tanaka Isomura, Tetsuya Seikai, Koichi Otsuki, Chihiro Sugiyama, Kiyoko Nakagawa, Susumu Tanaka
The Cleft Center, Osaka University Dental Hospital, Suita, Japan
|Date of Web Publication||21-Nov-2017|
The Cleft Center, Osaka University, Graduate School of Dentistry, Osaka University, 1-8, Yamadaoka, Suita City, Osaka 565-0871
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kogo M, Sakai T, Harada T, Nohara K, Isomura ET, Seikai T, Otsuki K, Sugiyama C, Nakagawa K, Tanaka S. Our unified pharyngeal flap operation. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:189-91
|How to cite this URL:|
Kogo M, Sakai T, Harada T, Nohara K, Isomura ET, Seikai T, Otsuki K, Sugiyama C, Nakagawa K, Tanaka S. Our unified pharyngeal flap operation. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:189-91. Available from: https://www.jclpca.org/text.asp?2017/4/3/189/218896
| Pharyngeal Flap Operation|| |
A pharyngeal flap operation has been employed for cleft palate treatments for more than a century and was originally reported in 1875 by Schoenborn. It is the basic concept underlying the present velopharyngoplasty, with variations in methods utilized for pharyngeal flap formation and use.
A pharyngeal flap has also been used to treat the velum near the posterior pharyngeal wall, even before the establishment of a pushback operation during Schoenborn's era. Rosental reported the use of a lower pharyngeal flap so that the velum did not return to the front. To stop flap contraction after surgery, Fruend proposed flap folding, whereas Sanvenero and Rosselli used a pharyngeal valve to sufficiently move the velum with a side cut on the nasal cavity side mucous membrane and covering the raw surface. At present, a pharyngeal flap operation uses the flap in a different manner to join the velopharyngeal closure at the closing plane.
| Pharyngeal Flap Choice|| |
A pharyngeal flap is usually formed from the posterior pharyngeal wall and classified as superior or lower based on whether the base is at the top or bottom. Hynes reported elevating the flap from the lateral pharyngeal wall, whereas Kapetansky reported the use of a horizontal flap. An inferiorly located flap is unsuitable for velopharyngeal closure because of the pharynx level difference. Because the level of the velopharyngeal closure plane is usually on the prolongation of the hard palate, it is not possible to establish an inferior located flap with adequate length for pronunciation. Thus, it is important to assure that the pharyngeal flap unites with the levator veli palatini to join the velopharyngeal closure. When soft palate mobility is low and the length short, the uvula membrane is used because of its high location ahead of the velopharynx.
| Orifice Size and Flap Width|| |
Deciding orifice size for a pharyngeal flap operation is important, as it must be sufficient. Air resistance in the orifice does not exceed nasal cavity resistance. A patient requiring a secondary operation has low motility of the soft palate; thus, orifice size should be small. In our study of respiratory tract resistance, it was higher at the velopharynx than nasal cavity, when the diameter is <9 mm. When converted into two bilateral wall orifices, the diameter is calculated to be 6.3 mm. On the other hand, when the diameter is >5 mm, the patient does not sense an obstacle in the nasal airway. Warren reported that a velopharyngeal orifice size of 0.20 cm2 (diameter 5.05 mm) is needed. For velopharynx closing to produce affricate and fricative consonants, it is necessary to have a diameter <3.6 mm and for that to be within 2.1 mm from the nasal passage. Such parameters lead to good function.
| Flap Shrinkage|| |
A transplanted pharyngeal flap shows a tendency to shrink. When the flap shrinks after the operation, it is not possible to maintain the established velopharyngeal form. In response, Fara et al. attempted to reduce the raw surface. Kapetansky reported prevention of scar shrinkage by folding the pharyngeal flap. Thus, shrinkage after a pharyngeal flap operation cannot be avoided.
| Unified Velopharyngoplasty|| |
The superior constrictor and levator veli palatini muscles are the main participants in velopharynx closing. The levator is larger at the point of momentum, whereas the velum shows valve-like movements in lateral X-ray cine findings. However, the velopharynx closes in a constricting fashion. Following a cleft palate operation, the movements of the bilateral pharyngeal walls rather than the velum become important because of reduced motility and levator muscle movement on the lateral pharyngeal wall are noticeable. The primary objective of our unified velopharyngoplasty procedure is to use this movement; thus, we reorganize the bilateral levator muscles in the soft palate to produce movement toward the back and upward in relation to the velum [Figure 1] and [Figure 2].
- A midline cut of the velum is performed
- Using Furlow's method, a slanting rear cut of the left soft palate is added; then the left side levator veli palatini muscle is separated from the mucous membrane on the nasal cavity side. Furthermore, based on Furlow's method for the right side, after producing a mucous membrane flap for a Z-plasty, the right side levator veli palatini muscle is exposed, then separated from the mucous membrane on the nasal cavity side, and the right side levator muscle is freed.
- A transverse cut is added to the nasal cavity mucous membrane on both sides, and a space for the entrance of the pharyngeal valve is made. Next, the velum mucous membrane on the nasal cavity side is moved in a posterior direction to the pharyngeal wall.
- While suturing the pharyngeal flap in the mucous membrane of the nasal cavity side, the velum is moved to the rear and orifice size is adjusted.
- The oral side mucous membrane is reorganized and closed while reconfiguring the levator muscles on the left and right sides.
| Conclusion|| |
It is possible to reorganize the velum levator muscle for an appropriate orifice size with our method, without a raw surface on the pharyngeal flap [Figure 3]. [Figure 4] shows the effects of a representative operation, in which good results were obtained. The nasalance score before and after surgery was 43.8 and 18.2, respectively [Figure 5].
|Figure 4: Result of operation velopharyngeal movement (fiberscopic view)|
Click here to view
We made the oral presentation about this procedure in Cleft 2017 Congress at Chennai, India at 2017.
| References|| |
Schoenborn K. On a New Method of Staphylorrhaphy. Verh Dtsch Ges Chir 1875;4:235-9.
Rosental W. On the Question of Palatoplasty. Ztb Chir 1924;51:1621-7.
Fruend H, Cleft Palate Operation according to Schoenborn-Rosental. Ztb Chir 1927;54:3206-10.
Sanvenero-Rosselli G. Division of Palatal Surgery. Alu Congr Int Stomat Milian 1935;1:391-2.
Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg 1950;3:128-35.
Kapetansky DI. Bilateral transverse pharyngeal flaps for repair of cleft palate. Plast Reconstr Surg 1973;52:52-4.
Warren DW. Velopharyngeal orifice size and upper pharyngeal pressure-flow patterns in normal speech. Plast Reconstr Surg 1964;34:15-20.
Fára M, Sedlácková E, Klásková O, Hrivnáková J, Chmelová A, Supácek I, et al.
Primary pharyngofixation in cleft palate repair. A survey of 46 years' experience with an evaluation of 2,073 cases. Plast Reconstr Surg 1970;45:449-58.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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