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Furlow Double Opposing Z-Palatoplasty

last modified on: Tue, 12/19/2023 - 08:42

return to: Cleft Lip and Palate Protocols

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


  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


  1. Positioning, prep, drape and placement of Dingman retractor as for other palate surgeries (see Cleft palate (general considerations))

  2. Injection of the palate with 1:200,000 epinephrine

  3. For submucous cleft - split soft palate in midline in sagittal plane to ~3mm posterior to hard palate junction

    1. May incise full-thickness vs incise oral and nasal layer separately as proceed through procedure

  4. For incomplete soft palate clefts - incise first along the free margin of the soft palate in an axial plane

    1. Depending on width, may require release of the lateral hard palate mucosa from the alveolus to minimize tension on flaps (as in von Langenbeck palatoplasty)

  5. Trim tips and medial edges of uvula

  6. Design and marking of flaps - lateral limbs general designed ~60º from central midline limb (stay posterior to the alveolus)

    1. Posteriorly-based left-sided oral myomucosal flap with corresponding anteriorly based nasal mucosal flap

    2. Anteriorly-based right-sided oral mucosal flap with corresponding posteriorly based nasal myomucosal flap

  7. Oral flaps are incised

    1. On left - raise muscle with the oral mucosa off of the nasal mucosa - may need to separate the muscle from posterior hard palate

    2. On right - raise mucosa and submucosa only, leaving the muscle layer on the nasal side - often carry this dissection up onto the posterior hard palate

      1. May increase mobility by creating a backcut following the medial edge of the alveolus

  8. Nasal flaps are then incised with incision oriented parallel to the base of the corresponding oral flap (mirror image of oral flaps)

  9. Flaps are rotated with left and right myomucosal flaps rotated posteriorly and mucosal flaps anteriorly

    1. Ideally, the tips of each myomucosal flap reach laterally to the opposite superior constrictor

  10. Nasal side is closed first - 4-0 absorbable suture (eg. Vicryl)

    1. Start at apices of flaps, proceed to horizontal midline

    2. Ensure nasal mucosa is included in closure for integrity

  11. Oral side is transposed, advanced across midline and closed - 4-0 absorbable suture (eg. Monocryl or undyed Vicryl)

    1. Useful to use a stronger stitch such as 4-0 PDS near midline to secure the oral flaps together in a submucosal plane

  12. Uvula edges are freshened and closed with horizontal mattress suture


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.   


Furlow LT Jr: Cleft palate repair by double opposing z-plasty. Plast Reconstr Surg 1986; 78: 724–736

Raol, N. and C Hartnick. Furlow Double-Opposing Z-plasty. Surgery for Pediatric Velopharyngeal Insufficiency. Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 67–73

Salyer, K. Salyer and Bardach's Atlas of Craniofacial & Cleft Surgery. 1999. pp 764-767