return to: Cleft Lip and Palate Protocols

Note: below is of historical perspective; last updated before 2015

GENERAL CONSIDERATIONS

1. A transposition-advancement flap

   1. Two flaps myomucosal are rotated posteriorly and the two mucosa-only flaps are transposed anteriorly

   2. Short limb of the Z is placed on the midline, and the long axis across the cleft

   3. Palate is lengthened in AP direction at the expense of increased tension in closure of the lateral mucosa

   4. Degree of lengthening is dependent on the angle of the soft palate lateral limbs from the central midline limb - usually between 45º-60º (50-75% elongation achieved)

2. Indications:

   1. Primary cleft palate closure

      1. Most appropriate for narrow soft palate clefts

      2. Can be used in combination with hard palate cleft techniques (eg. von Langenbeck)

   2. Secondary soft palate lengthening or in submucous clefts for velopharyngeal insufficiency

   3. Functions to elongate the soft palate and reconstruct/realign the muscular levator sling

   4. Assists in correction of velopharyngeal insufficiency

3. Disadvantage: Soft palate scarring, increased risk of fistula at junction of the hard and soft palates

   1. Avoiding exposed raw nasal mucosa will help prevent contraction

DICTATION TEMPLATE FOR Z-Palatoplasty

Informed consent was reviewed with the patient. The patient was then transferred and encountered in the operating suite. After a pre-induction checklist, induction and intubation by anesthesia staff was performed with a 5.0 oral RAE secured in midline. All pressure points were appropriately padded. An exam of the ears was performed with the microscope revealing bilaterally patent T-tubes in good position. The bed was turned 90 degrees from anesthesia. The child was on a Phillipine board and this was shifted down on the bed such that the head was extended off of the board. The oral cavity was cleaned with peridex and suctioned. The patient was prepped and draped in sterile fashion. A time-out was performed. The Dingman retractor was then placed and the palate was injected with 4 cc of 1:200,000 epinephrine. Once adequate time had passed, the palate was then marked for incisions. The uvular tips were trimmed to create fresh raw edges. The proposed incisions were marked on the palate. The palate was then split through the midline in sagittal plane to roughly 3 mm behind the bony palate. A posteriorly based myomucosal flap was then incised and elevated on the left-hand side. An anterior-based mucosal flap was then elevated on the right-hand side. These were retracted laterally with vicryl stay suture.  The nasal midline was then split and the nasal flaps were then developed on the left and right. There was a nasal muscle mucosal flap based posteriorly on the right, and a nasal mucosal flap based anteriorly on the left. Once these flaps were developed they were rotated and the wound was closed. The nasal side was closed first by rotating the left-sided anteriorly based nasal mucosal flap anterior and the posteriorly based left sided oral myomucosal flap posteriorly. Using 4-0 Vicryl on a TF needle, the nasal mucosa was closed first at the apices of the flaps, then in the horizontal midline, posterior and anterior flap edges, ensuring that the nasal mucosa was included within the closure. Next, a "circular" stitch of 4-0 PDS on TF needle was placed to secure the 2 myomucosal flaps together and advance the oral flap across midline. Lastly, the oral flaps were transposed and secured in a similar fashion - using 4-0 monocryl on RB needle. At this point, the edges of the bifid uvula were freshened and the uvula was closed with a horizontal mattress suture. The oral cavity was then rinsed. The stomach was suctioned. The patient was turned over to Anesthesia for emergence. The patient tolerated the procedure well. There were no complications. This concluded our procedure. The patient was then turned over to anesthesia for emergence and extubation. The patient tolerated the procedure well.