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The Double Opposing Z-Plasty +/- Buccal Flap Approach for Repair of the Cleft Palate: A review of 415 consecutive patients
Robert J. Mann, MD1, Kieth C. Neaman, MD2, Charles Sierzant, BS3, Matthew D. Martin, MD2.
1Helen Devos Children's Hospital, Grand Rapids, MI, USA, 2Grand Rapids Medical Education Partners Plastic Surgery Residency, Grand Rapids, MI, USA, 3Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
Purpose: A variety of techniques exist for repair of the palatal cleft. An ideal repair constructs a functioning velar mechanism, has minimal impact on facial growth and is applicable to all cleft shapes. Since its original description in 1985 the Double Opposing Z-Plasty +/- Buccal flap technique has evolved into seven different flap designs, making it useful in a variety of anatomical considerations. The purpose of this abstract is to review all of our patients who underwent the Double Opposing Z-Plasty +/- Buccal flap approach for cleft palate repair looking at velar function, speech outcomes and long-term impact on facial growth.
Methods: The records of all patients who underwent the Double Opposing Z-Plasty +/- Buccal flap cleft palate repair between 2/1987 and 9/2011 were reviewed. For comparison, patients were stratified based on a variety of demographic factors (e.g. cleft type, presence of a syndrome). Nasal resonance was utilized as a marker for velar function in all patients greater than five years old and graded based on the following scale: 1 - no resonance, 2 - mild, 3 - moderate, 4 - severe hypernasality. Secondary speech surgery was offered to patients with moderate or severe hypernasality. Patients greater than 15 years old at the time of our analysis were evaluated for facial growth looking at occlusion and the need for orthognathic surgery.
Results: A total of 415 patients were identified with a mean length of follow-up of 8.6 years. The distribution of cleft types was as follows: bilateral cleft lip and palate (CL&P) - 15.5%, unilateral CL&P - 57.8%, cleft palate only - 26.7%. Underlying syndromes were present in 16.8% of patients. Most patients (66.3%) required a buccal flap in addition to a Double Opposing Z-plasty at the time of CP repair. The overall fistula rate was 6.0%, with fistula rates of 5.1% and 10.0% in non-syndromic and syndromic patients, respectively (p=0.16). Velar function was evaluated in 254 patients. Eighty-seven percent (220/254) of patients exhibited grade 1 or 2 resonance with the remaining 34 patients having grade 3 or 4 resonance. Of these, 22 patients went on to have secondary speech surgery. Patients diagnosed with an underlying syndrome developed higher degrees of hypernasality (p < 0.001). Long-term growth was evaluated in 135 patients with 82.0% (110/134) exhibiting acceptable occlusion and 17.9% (24/134) for whom orthognathic surgery was recommended. Those with an underlying syndrome were more likely to require orthognathic surgery (10.0% vs. 46.7%, p = 0.001).
Conclusion: The dictum “no two clefts are created equal” has led surgeons to question the use of a single type of cleft palate repair in all patients. The Double Opposing Z-plasty +/- Buccal flap approach exhibits the versatility needed to achieve excellent outcomes in a variety of patients. Utilizing autogenous tissue it exhibited a low fistula rate with restoration of excellent velar function as evidenced by post-operative resonance and the low need for secondary speech surgery. Furthermore it exhibits minimal impact on facial growth for patients greater than 15 years of age.
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