Presentation: Oct. 10, 2004, 2:10 PM, Craniomaxillofacial Papers

Clinical Outcomes of the Furlow Z-plasty for Primary Cleft Palate Repair

Rohit K. Khosla, MD; Ziv M. Peled; MD, Charles L. Castiglione, MD; Kelly Mabry, PhD; CCC/SLP

Speech outcomes after cleft palate repair have significantly improved with the evolution of palatoplasty techniques. The most effective technique for the surgical repair of palatal clefts continues to provoke significant controversy. Many previous studies have suggested superior speech results with the Furlow Z-plasty.

We were interested to evaluate the speech quality of our patient population after the Furlow repair. We wanted to determine if the presence of a genetic syndrome, Robin sequence in non-syndromic patients, age at palate repair, cleft type, or surgeon experience had an influence on clinical outcomes. We also assessed the number of patients that required a secondary surgery to manage velopharyngeal insufficiency (VPI) as well as the incidence of an oro-nasal fistula in our patient population.

Method: We retrospectively reviewed the clinical outcomes in 140 patients after primary Furlow palatoplasties performed by a single surgeon. Cleft palate repair was performed on all patients using a modification of the Furlow technique described by Randall et al.1

Standardized speech evaluations were performed on all patients by a single licensed speech pathologist experienced in the management of speech disorders associated with a cleft palate. After surgical repair, hypernasality, nasal escape and misarticulation were evaluated and scored on a scale of none, mild, moderate, and severe. The primary symptoms of VPI are hypernasality, nasal escape and misarticulation.1-3 VPI was ranked on a scale of none, mild, moderate, and severe by assessing these primary symptoms on each post-operative evaluation.

Results: The overall speech outcomes for our entire patient population are shown in Figure 1.

The presence of Robin sequence in non-syndromic patients, or the diagnosis of a genetic syndrome did not have a significant effect on speech outcomes with the majority of patients without VPI. (Table 1)

Patients that had their palate repaired between 6-12 months of age did just as well as patients with repairs after age 12, with the majority without VPI. (Table 2)

There was no significant difference in the distribution of speech outcomes based on cleft type, with the majority of patients without VPI. (Table 3)

There was no significant difference in the distribution of speech outcomes based on surgeon experience, with the majority of patients without VPI. (Table 4)

Secondary posterior pharyngeal flap to correct VPI was required in only 2.14% of patients. The formation of an oro-nasal fistula occurred in only 2.17% of patients.

Conclusion: The Furlow Z-plasty yielded excellent speech results in our patient population, with minimal and acceptable rates of velopharyngeal dysfunction, fistula formation and the need for additional corrective surgery. Stratification of our patient population by diagnosis of Robin Sequence, genetic syndrome, age at palatoplasty, cleft type, and surgeon experience did not yield statistically significant differences in clinical outcomes for velopharyngeal insufficiency.

Fig. 1 Speech outcomes in the entire patient population in terms of VPI, hypernasality, nasal escape, and misarticulation after Furlow repair. Percentage of patients demonstrating none, mild, moderate and severe symptoms.

none / mild / mod / sev
VPI / 84.28 / 13.57 / 0 / 2.14
Hypernasality / 82.85 / 14.28 / 0.71 / 2.14
Nasal Escape / 90.71 / 7.85 / 0 / 1.42
Misarticulation / 69.28 / 24.28 / 4.28 / 2.14

Table 1. Incidence of VPI in the study population by diagnosis. p=0.3521 for comparison across all groups by Kruskal-Wallis exact test.

none / mild / mod / sev
Non-syndromic (n=88) / 80.68 / 18.18 / 0 / 1.14
Robin Sequence (n=34) / 91.18 / 5.88 / 0 / 2.94
Syndromic (n=18) / 88.89 / 5.56 / 0 / 5.56

Table 2. Incidence of VPI in study population by age at palatoplasty. p=0.4404 for comparison across both groups by Wilcoxon-Mann-Whitney exact test.

none / mild / mod / sev
6-12 mo. (n=90) / 85.56 / 14.44 / 0 / 0
>12 mo. (n=50) / 82 / 12 / 0 / 6

Table 3. Incidence of VPI in study population by cleft type. p=0.3990 for comparison across all groups by Kruskal-Wallis exact test.

none / mild / mod / sev
Submucous Cleft (n=7) / 85.71 / 14.29 / 0 / 0
Veau Class I (n=24) / 87.5 / 8.33 / 0 / 4.17
Veau Class II (n=46) / 78.26 / 19.57 / 0 / 2.17
Veau Class III (n=47) / 91.49 / 6.38 / 0 / 2.13
Veau Class IV (n=16) / 75 / 25 / 0 / 0

Table 4. Incidence of VPI in study population by surgeon experience. p=0.1290 for comparison across all groups by Jonckheere-Terpstra exact test.

none / mild / mod / sev
First 35 pts. / 82.86 / 14.29 / 0 / 2.86
Second 35 pts. / 77.14 / 17.14 / 0 / 5.71
Third 35 pts. / 82.86 / 17.14 / 0 / 0
Fourth 35 pts. / 94.29 / 5.71 / 0 / 0

References

1. Randall P, LaRossa D, Solomon M, et al. Experience with the furlow double reversing z-plasty for cleft palate repair. Plast Reconstr Surg. 77:569-576, 1986

2. Hobar PC, Donnell FJ, Flood J. Cleft palate repair and velopharyngeal insufficiency. In: Aston SJ, Beasley RW, Thorne CHM. (Eds.), Plastic Surgery. 5th Ed. Philadelphia: Lippincott-Raven, 1997

3. Huang MHS, Riski JE, Cohen SR, et al. An anatomic evaluation of the furlow double opposing z-plasty technique of the cleft palate repair. Ann Acad Med Singapore. 28:672-676, 1999