What are the different types of palatoplasty procedures?

Different Types of Palatoplasty Procedures

Palatoplasty procedures vary in technique and application, with the most common types being uvulopalatal flap, Furlow double-reversing Z-plasty, von Langenbeck repair, Wardill-Kilner V-Y repair, and two-flap palatoplasty, each with specific indications and outcomes for treating conditions like cleft palate and obstructive sleep apnea. 1, 2

Uvulopalatal Flap Technique

• Created as a modification of classic uvulopalatopharyngoplasty (UPPP), involving removal of oral mucosa and salivatory glands with bilateral incisions into the posterior pillar 1
• The flap is rotated upwards and sutured into the defect, preserving all muscles but leaving no visible uvula 1
• Can be performed under local or general anesthesia with complications similar to gentle UPPP 1
• Transient nasal regurgitation occurs in approximately 4% of cases, but permanent velopharyngeal incompetence or nasopharyngeal stenoses have not been reported 1
• Studies show significant improvement in obstructive sleep apnea (OSA) with AHI decreasing from 45 to 14 within 6-12 months after surgery 1
• Surgical success (defined as 50% reduction in AHI and reduction below 20) was calculated at 81.5% 1
• Can be combined with other surgeries of the nose and tongue base with acceptable perioperative risk 1

Furlow Palatoplasty (Double-Reversing Z-Plasty)

• First described by Dr. Leonard Furlow in 1978 for cleft soft palate repair 3
• Allows repair of overt or submucous cleft palate while providing additional length to the palate and realigning palatal musculature 3, 4
• Particularly effective for treating velopharyngeal insufficiency 3, 4
• Studies show 81.5% of patients had postoperative improvements in lateral video-fluoroscopic parameters, 63% improved nasality scores, and 65.2% had improved speech intelligibility 4
• Preoperative closure ratio, hypernasality (moderate and severe), and audible nasal air emission are predictors for postoperative outcomes 4

Von Langenbeck Repair

• One of the oldest and most basic palatoplasty techniques 2
• Involves creation of bipedicled mucoperiosteal flaps that are mobilized and joined in the midline 5, 2
• Associated with lower in-hospital morbidity compared to Wardill-Kilner repair 5
• Only 6% of patients experience postoperative airway obstruction 5
• Does not require blood transfusion, unlike some other techniques 5

Wardill-Kilner V-Y Repair

• Involves V-Y pushback technique to lengthen the palate 5, 2
• Higher transfusion requirements compared to von Langenbeck repair 5
• No reported cases of postoperative airway obstruction in comparative studies 5
• Designed to achieve greater palatal length but may have more significant impact on maxillofacial growth 2

Two-Flap Palatoplasty

• Commonly used for cleft palate defects with good outcomes 6, 2
• Incorporates modified intravelar veloplasty with near-total muscle retropositioning 6
• Studies show low rates of complications requiring revision surgery: symptomatic fistula (5.4%) and velopharyngeal insufficiency (5.3%) 6
• Speech outcomes are satisfactory in 70-86% of patients regarding intelligibility, hypernasality, and nasal emissions 6
• Dental arch relationships were judged good or excellent in 62% of evaluated patients 6
• 45% of patients with otitis media experienced spontaneous resolution 2-8 months post-operation 6

Pillar Implant Method

• Involves placing three cylindrical, non-resorbable polyethylenterephthalate implants into the soft palate 1
• Implants and surrounding fibrosis reduce three-dimensional flutter of the soft palate and decrease inspiratory airway resistance 1
• Case series show reduction of AHI >50% and postoperative AHI <10 in 15-50% of cases within 3-15 months 1
• Minor complications include sore throat or foreign body sensation within first 4 days post-procedure 1
• Infections, mucosal irritations, or ulcerations at implant sites reported in <1% of patients 1

Considerations for Procedure Selection

• For cleft palate repair, timing is crucial with soft palate repair generally recommended between 6-12 months of age 2
• For OSA treatment, uvulopalatal flaps can be recommended for patients with palatal obstruction (Grade C recommendation) 1
• Radiofrequency surgery for OSA cannot be broadly recommended except in carefully selected patients (Grade C) 1
• The European Respiratory Society explicitly recommends against uvuloplasty for OSA treatment due to lack of demonstrated efficacy (negative recommendation B) 7
• Surgical success rates for isolated soft palate procedures for OSA are generally poor (approximately 50%) and even lower in patients with multi-level obstruction 7
• Serious complications of UPPP include intubation difficulties, bleeding, and acute upper airway obstruction (1.5% incidence) with a mortality rate of 0.2% 7
• Long-term side effects persist after UPPP in 58% of patients, including swallowing difficulties, globus sensation, voice changes, and nasopharyngeal stenosis 7

Special Considerations for Petiole Supraglottopexy

• Used for intractable aspiration in selected patients 1
• Involves plicating the petiole of the epiglottis to the false vocal folds and interarytenoid mucosa 1
• Four of five adult patients in one study returned to partial oral nutrition with supplemental tube feeds 1
• Patients with intractable aspiration may be considered for this surgical intervention (Grade B recommendation) 1