# Furlow Palatoplasty: A Comprehensive Surgical Guide ## 1.0 Introduction to the Furlow Palatoplasty The Furlow Palatoplasty is a widely utilized and highly effective surgical technique for the repair of both overt cleft palate (CP) and submucous cleft palate (SMCP), as well as for revision palate procedures. The fundamental principle of the operation is the strategic lengthening of the soft palate through the use of "double-opposing Z-plasties." This elegant approach involves creating mirror-image Z-plasties on the oral and nasal surfaces of the velum, which not only lengthens the palate but also functionally reconstructs the underlying anatomy. The primary goals of the Furlow technique are threefold and are critical to restoring normal function. First, the procedure aims to lengthen the soft palate, which is essential for achieving contact with the posterior pharyngeal wall. Second, it reorients and reconstructs the levator veli palatini muscles, transforming them from their abnormal cleft configuration into a functional muscular "levator sling" that can effectively elevate the palate. Finally, by achieving a tension-free, multilayered closure, the technique separates the oral and nasal cavities. The successful integration of these goals leads to improved velopharyngeal function, which is the cornerstone of intelligible speech. A successful repair is therefore contingent on a deep appreciation for the underlying anatomical structures and their pathologic arrangement in the cleft state. ## 2.0 Foundational Anatomy and Pathophysiology of the Cleft Palate A successful Furlow repair is predicated on a deep understanding of both normal and cleft palate anatomy. The procedure is not merely a closure of a physical gap but an intricate anatomical reconstruction designed to restore dynamic function. To correct the anomaly, one must first fully appreciate the structures involved and the precise nature of their malformation. ### Key Anatomical Structures The soft palate, or velum, is a dynamic muscular structure critical for speech and swallowing. Its primary function is controlled by a coordinated group of muscles, most notably: - **Levator veli palatini (LVP):** This is the principal muscle responsible for elevating the soft palate. In a normal palate, the paired LVP muscles originate from the petrous portion of the temporal bone, course downward and forward, and interdigitate in the midline to form a muscular sling within the intermediate 40% of the velum. When this sling contracts, it elevates the velum superiorly and posteriorly to make contact with the pharyngeal wall, closing off the nasal cavity. Its motor innervation is from the pharyngeal plexus (CN X). - **Tensor veli palatini (TVP):** Originating from the sphenoid bone, this muscle travels around the pterygoid hamulus and forms the palatal aponeurosis—a fibrous sheet in the anterior soft palate. Its primary function is to open the eustachian tube. As a derivative of the first branchial arch, it is uniquely innervated by the trigeminal nerve (CN V). ### The Cleft Palate Anomaly The key functional issue in both cleft palate and submucous cleft palate is the profound disruption of the levator muscle anatomy. Instead of forming a continuous transverse sling, the LVP muscle on each side is cleft. The muscle fibers are not in continuity across the midline; instead, they become tethered to the posterior border of the hard palate. This anomalous insertion prevents the muscle from contracting in the correct vector. Consequently, the levator sling cannot form, and the velum cannot be elevated sufficiently to achieve velopharyngeal closure. A successful functional palate repair, therefore, requires not only the closure of the mucosal defect but, more importantly, the precise dissection, release, and anatomical reconstruction of this critical levator sling. Understanding this core anatomical problem is essential for appreciating the indications for surgical correction and the logic behind the Furlow technique. ## 3.0 Indications, Contraindications, and Patient Assessment Proper patient selection and a comprehensive preoperative assessment are fundamental to achieving optimal outcomes with the Furlow palatoplasty. A thorough evaluation ensures that the patient is a suitable candidate for surgery and is in the best possible condition to tolerate the procedure and heal successfully. ### Primary Indications The Furlow palatoplasty is a versatile technique indicated for several conditions affecting the palate: - **Cleft Palate (CP):** It is a primary technique for repairing overt clefts of the soft and hard palate. - **Submucous Cleft Palate (SMCP):** The procedure is particularly well-suited for correcting the muscular diastasis and functional deficits associated with SMCP. - **Revision Palate Repair:** It can be used as a secondary procedure to address velopharyngeal insufficiency (VPI) or fistula following a previous palate repair. ### Contraindications for Cleft Repair While nearly all patients with a cleft palate are candidates for repair, surgery may be contraindicated in individuals with certain severe underlying conditions. These include: - Significant cardiopulmonary conditions that would make general anesthesia unsafe. - Permanent neurologic impairments so severe that the patient will never achieve oral feeding or speech, thus precluding any functional benefit from the repair. ### Initial Patient Assessment The initial assessment of a newborn with a cleft palate is a collaborative effort, typically involving the surgeon and a pediatrician. The evaluation is comprehensive and structured to identify the full scope of the patient's condition. 1. **Pregnancy and Birth History:** This includes details from any antenatal testing, the gestational age at birth, birth weight, and Apgar scores. 2. **Cleft Assessment:** An initial evaluation of the cleft type (e.g., unilateral, bilateral, isolated) and any related anomalies is performed. It is crucial to check for airway concerns suggestive of Pierre Robin sequence. 3. **Medical and Allergy History:** A standard review of the infant's overall health, medications, and any known allergies. 4. **Family History:** Documentation of any family history of clefts, other major health issues, or known anesthetic problems provides important context. 5. **Feeding History:** A detailed account of feeding is critical to assess the infant's ability to thrive. This includes the type of bottle used (e.g., squeezy bottle, Haberman), current weight, time taken to regain birth weight, and the volume, duration, and frequency of feeds. 6. **Physical Examination:** A focused examination assesses the cleft type, width, and any deficiency of surrounding tissues. The surgeon and pediatrician also look for any dysmorphic features or related health issues, particularly cardiac, respiratory, renal, or neurological signs. This detailed assessment provides the foundation for determining the patient's fitness for surgery and informs the subsequent operative planning. ## 4.0 Surgical Management: The Operative Workflow The success of the Furlow palatoplasty relies heavily on meticulous operative execution, which begins long before the first incision is made. Careful preoperative planning, precise patient positioning, and accurate surgical markings are critical prerequisites that create the optimal environment for a successful procedure. ### 4.1 Preoperative Planning and Optimization **Surgical Timing** is a key consideration. While protocols vary, our team prefers to perform palate repair when the infant is between **8 and 12 months of age**, corrected for any prematurity. However, the guiding principle is that a thriving, healthy baby is more important than a specific chronological age. Surgery should be postponed if the child is not growing along their expected percentile curves or has a current upper respiratory tract infection. This patient-centric approach helps reduce complications such as fistula formation and improves functional outcomes. ### 4.2 Patient Positioning and Preparation A standardized and systematic approach to patient positioning ensures safety and optimal surgical access. 1. **Anesthesia and Airway:** A south-facing RAE endotracheal tube (uncuffed or microcuffed) is secured in a V-shape along the mandible to prevent displacement when the mouth gag is opened. As this is a "shared airway" surgery, clear communication between the surgeon and anesthetist, often facilitated by a WHO checklist and team brief, is paramount. 2. **Positioning:** The child is placed supine on a **warming blanket**, with the head at the very end of the operating table. A large horseshoe-shaped gel head ring is placed under the shoulders and around the head to provide stable support without overextending the neck. The table is tilted to a **slight head-up position**. 3. **Draping:** A head drape is applied. A clear plastic drape over the trunk is useful as it allows the anesthetist to monitor the endotracheal tube without disturbing the surgical field. 4. **Preparation:** The nose and mouth are rinsed with **aqueous chlorhexidine solution**. An **operating microscope** is brought into position, as it is essential for magnification and illumination throughout the procedure. 5. **Gag Placement:** A modified Dingman mouth gag is carefully placed to provide exposure of the palate. To protect the corners of the mouth from abrasion, Steri-Strips may be applied like "cat's whiskers." 6. **Throat Pack:** A throat pack is placed in the oropharynx to prevent aspiration of blood. A highly visible marker sticker is placed across the drapes as a prominent reminder to ensure its removal at the end of the case. The pack is also included in the official nursing count as an additional safety measure. ### 4.3 Operative Markings and Approach Accurate marking of the Z-plasties is the blueprint for the entire repair. - The limbs of the oral Z-plasty are typically marked to be **8 to 10 mm** in length. - The angles of the flaps are designed to accommodate tissue elasticity. The oral layer is more elastic than the nasal layer, particularly towards the uvula. Therefore, the oral flaps are designed with wider angles, typically from **80 to 90 degrees**. Clinical experience demonstrates that the posterior part of the palate is even more elastic, so the posterior limb is best designed slightly wider (around 90 degrees) as it will narrow after incision. The nasal layer flaps are designed with angles around **60 degrees**. - For a right-handed surgeon, the posteriorly based myomucosal flap on the oral surface is typically designed on the patient's left side to provide the most ergonomic access for the most challenging part of the dissection. With these preparatory steps completed, the surgeon is positioned to execute the technical phases of the repair with precision and safety. ## 5.0 The Furlow Technique: A Step-by-Step Guide The Furlow palatoplasty is executed in a series of precise stages, each building upon the last to achieve a complete anatomical and functional reconstruction. The procedure demands meticulous dissection to separate, mobilize, and transpose the oral and nasal layers while preserving the critical muscular components. ### 5.1 Hard Palate Management The procedure begins with careful management of the hard palate tissues. - **Infiltration:** A long-acting local anesthetic with adrenaline (e.g., levobupivacaine 1:100,000) is infiltrated along the planned incision lines. This serves two purposes: providing vasoconstriction for hemostasis and hydrodissecting the subperiosteal plane on the hard palate, which facilitates flap elevation. - **Flap Elevation:** An incision is made along the cleft margin on the hard palate down to the bone. Using a **raspatory or Warwick-James elevator**, subperiosteal flaps are raised from the bony palatal shelves. This maneuver releases the mucoperiosteum from the arched palate, allowing the flaps to descend into a more horizontal position to facilitate a tension-free midline closure. ### 5.2 Dissection of the Oral Layer Z-Plasty With the hard palate addressed, attention turns to creating the first of the two opposing Z-plasties on the oral surface. 1. On the patient's left side, an incision is made through the oral mucosa and the underlying levator muscle, down to but not through the nasal mucosal layer. This creates the **posteriorly based myomucosal flap**. 2. The muscle is then carefully freed from the underlying nasal layer and dissected laterally toward the hamulus, completely releasing its abnormal attachment to the posterior edge of the hard palate. 3. On the patient's right side, a mirror-image incision is made. Here, however, the dissection plane is more superficial, elevating a **mucosal-only anteriorly based flap** while leaving the levator muscle attached to the underlying nasal layer. ### 5.3 Dissection of the Nasal Layer Z-Plasty Once the oral flaps are elevated and retracted, the nasal surface is exposed for the creation of the opposing Z-plasty. 1. On the right side (contralateral to the oral myomucosal flap), the **posteriorly based nasal myomucosal flap** is created. The muscle, which was left attached to the nasal layer during the oral dissection, is now incised along with the nasal mucosa. 2. The muscle is freed laterally, releasing it from the tensor aponeurosis. A useful tip is to leave a small rim of the tensor aponeurosis intact on the hard palate margin, as this tougher tissue provides a secure anchor for suturing later. 3. On the left side, the **anteriorly based nasal flap (mucosa-only)** is incised and elevated. ### 5.4 Flap Inset and Closure The closure sequence is logical and methodical, beginning with the deeper nasal layer and concluding with the oral layer. 1. **Nasal Layer Closure:** The nasal flaps are transposed and inset first. The posteriorly based nasal myomucosal flap from the right is rotated posteriorly and across the midline, while the anteriorly based mucosal flap from the left is moved anteriorly. 2. **Oral Layer Closure:** The oral flaps are then transposed. The posteriorly based oral myomucosal flap from the left is moved posteriorly and across the midline. This maneuver places the two levator muscle bundles in an overlapping, transverse orientation, functionally reconstructing the levator sling in a more anatomic, retropositioned location. 3. **Optional Muscle Suture:** Although the flap transposition provides excellent muscle overlap, some surgeons choose to place sutures directly between the two levator muscles to ensure a robust connection. 4. **Suture and Final Closure:** Our preference is to use **5-0 Monocryl plus on the nasal layer and 4-0 Monocryl on the oral layer**. The oral mucosal flaps are inset to complete the Z-plasty closure, creating a lengthened, multilayered, and functionally reconstructed soft palate. This step-by-step process systematically addresses the anatomical deficits of the cleft palate, setting the stage for alternative approaches and postoperative management. ## 6.0 Procedural Variations and Considerations While the core principles of the Furlow double-opposing Z-plasty are standardized, experienced surgeons have developed variations and hybrid techniques to address specific anatomical challenges, such as particularly wide clefts, or to combine the advantages of different surgical philosophies. ### Randall Variation for Wider Clefts For patients with very wide clefts of the hard and soft palate, achieving a tension-free closure with a standard Furlow technique can be challenging. The variation described by Randall incorporates **Langenbeck-type lateral releasing incisions** along the alveolar ridge. These incisions allow for the creation of bipedicled mucoperiosteal flaps on the hard palate, which can be mobilized more effectively toward the midline. This modification helps to relieve tension on the oral Z-plasty closure at the junction of the hard and soft palate, a common site for fistula formation. ### Hybrid Approach: Z-Plasty with Intravelar Veloplasty Another modification is a hybrid technique that combines a Sommerlad-style muscle dissection (radical intravelar veloplasty) with a Furlow Z-plasty closure. This approach can be particularly useful in cases of submucous cleft palate. The procedure is performed as follows: 1. **Marking and Incision:** The oral layer incisions are marked in a Z-plasty pattern, as for a standard Furlow repair. 2. **Muscle Dissection:** A complete dissection of the levator muscles off the nasal layer is performed on **both sides**, identical to the dissection in a radical intravelar veloplasty. 3. **Muscle Repair:** The two fully mobilized levator muscle halves are sutured directly together in the midline to reconstruct the sling anatomically. 4. **Z-Plasty Closure:** A mirror-image Z-plasty is created in the posterior nasal layer. The nasal and oral layers are then closed with the Z-plasty flaps to achieve palatal lengthening. This hybrid approach aims to achieve both a robust, anatomically precise muscle repair and the palatal lengthening afforded by the Z-plasty design. These variations highlight the adaptability of palatoplasty, allowing the surgeon to tailor the procedure to the patient's unique anatomy before proceeding to the crucial phase of postoperative care. ## 7.0 Postoperative Care and Management The postoperative period is focused on three primary goals: ensuring patient comfort, maintaining a patent airway, and facilitating a swift and safe return to feeding. Meticulous care in the hours and days following surgery is essential for a smooth recovery. Key elements of the postoperative management plan include: - **Positioning:** The baby should be nursed with the head elevated to reduce postoperative swelling. Cuddling the baby over a parent's shoulder provides an ideal position. - **Airway Monitoring:** The patient's airway and oxygen saturation levels must be monitored closely, especially during the first night after surgery. This is particularly critical for infants with Pierre Robin sequence, who are at higher risk for airway compromise. - **Feeding:** Infants can be offered feeds as soon as they are fully awake postoperatively. A swift return to their normal feeding routine is encouraged to ensure adequate hydration and nutrition. - **Analgesia:** Providing a top-up of long-acting local anesthetic at the end of the procedure contributes significantly to postoperative comfort and facilitates an earlier return to feeding. Careful adherence to this protocol helps to minimize immediate postoperative risks and sets the foundation for evaluating long-term surgical outcomes. ## 8.0 Outcomes and Potential Complications The success of a palatoplasty is measured by a combination of anatomical and functional outcomes. While the Furlow technique has demonstrated excellent results, like any major surgical procedure, it carries inherent risks of complications that must be carefully managed. ### Measuring Surgical Outcomes The primary metrics for assessing the success of cleft palate repair include: - **Fistula Rate:** The incidence of an oronasal fistula (a persistent hole between the oral and nasal cavities). Systematic reviews show that fistula rates after Furlow palatoplasty can range from **2.6% to 11.6%**, varying according to the type and severity of the cleft. - **Speech Outcomes:** The rate of structural speech problems, primarily hypernasality, which indicates persistent velopharyngeal insufficiency. Reported hypernasality rates range from **8.9% to 18.5%**. - **Need for Secondary Surgery:** The percentage of patients requiring a subsequent operation for speech improvement, such as a pharyngoplasty. Reported rates for **secondary surgery for speech range from 0% to 11.4%**. - **Maxillary Growth:** The long-term impact of the surgery on the growth of the midface. While this was an original focus for the technique, long-term data remains limited. ### Potential Complications Surgeons and care teams must be vigilant for potential postoperative complications, which include: - **Airway Compromise:** This is a significant risk, especially in younger, smaller babies and those with Pierre Robin sequence, due to postoperative swelling of the tongue and palate. - **Fistula Formation:** Despite meticulous technique, a fistula can develop, most commonly at the junction of the hard and soft palate. The risk is influenced by cleft width and surgical tension. - **Speech Problems:** Persistent velopharyngeal incompetence or the development of compensatory articulation errors can occur. - **Infection and Bleeding:** While rare after palate surgery, infection and significant bleeding are potential risks. A clear understanding of these outcomes and risks is essential for patient counseling and guides the clinical wisdom applied to every case. ## 9.0 Key Clinical Pearls and Pitfalls Distilled from extensive clinical experience, the following practical tips and points of caution can help enhance surgical safety, improve efficiency, and optimize the outcomes of the Furlow palatoplasty. - **Prioritize a Thriving Patient:** A well-nourished baby growing along their percentile lines is a better candidate for surgery than one who meets a specific age criterion but is not thriving. - **Communicate in a Shared Airway:** Palate surgery involves a "shared airway" between the surgeon and anesthetist. Clear, continuous communication, facilitated by tools like the WHO checklist and a team brief, is essential for safety. - **Utilize an Operating Microscope:** The routine use of an operating microscope provides excellent lighting and magnification, enhancing visualization of delicate tissue planes and improving the precision of the dissection and repair. - **Elevate Postoperatively:** Nursing the baby in a "head-up" position after surgery is a simple but effective measure to reduce postoperative swelling and improve comfort. - **Respect Tissue Elasticity:** The oral layer of the soft palate is more elastic than the nasal layer. Design the oral Z-plasty flaps with wider angles (80-90 degrees), particularly the posterior limb, to account for this difference and ensure a better inset. - **Leverage Topical Adrenaline:** Applying topical 1:1000 adrenaline on neurosurgical patties after initial incisions provides excellent vasoconstriction, creating a drier field and facilitating a more precise dissection of subsequent tissue layers. - **Preserve a Tensor Aponeurosis Rim:** When incising the nasal layer, intentionally leave a small rim of the tougher tensor aponeurosis tissue along the hard palate. This provides a strong, reliable edge for placing sutures during the nasal flap inset. - **Protect the Oral Commissures:** Placing Steri-Strips at the corners of the mouth before inserting the gag can prevent abrasions and trauma from instruments during the procedure.