Five surgical maneuvers on nasal mucosa movement in cleft palate repair: A cadaver study

Abstract

INTRODUCTION This biomechanical study aims to characterize the nasal mucosa during palatoplasty, describing the soft tissue attachments at different zones and quantifying movement following their release. METHODS Palatal nasal mucosa was exposed and divided in the midline in 10 adult cadaver heads. Five consecutive maneuvers were performed: (1) elevation of nasal mucosal off the maxilla; (2) dissection of nasal mucosa from soft palate musculature; (3) separation of nasal mucosa from palatine aponeurosis; (4) release of mucosa at the pterygopalatine junction; (5) mobilization of vomer flaps. The mucosal movements across the midline at the midpalate and posterior nasal spine following each maneuver were measured. RESULTS At the midpalate, maneuvers 1–4 cumulatively provided 3.8 mm (36.9%), 4.9 mm (47.6%), 6.1 mm (59.2%), and 10.3 mm, respectively. Vomer flap (10.5 mm) elevation led to mobility equivalent to that of maneuvers 1–4 (p=0.72). At the posterior nasal spine, cumulative measurements after maneuvers 1–4 were 1.3 mm (10%), 2.4 mm (18.6%), 5.7 mm (44.2%), and 12.9 mm. Here, vomer flaps (6.5 mm) provided less movement (p<0.001). Maneuver 4 yielded the greatest amount of movement of the lateral nasal mucosa at both the midpalate (4.2 mm, 40.8%) and posterior nasal spine (7.2 mm, 55.8%). CONCLUSION At the midpalate, complete release of the lateral nasal mucosa achieves as much movement as the vomer flap. At the hard-soft palate junction, the maneuvers progressively add to the movement of the lateral nasal mucosa. The most powerful step is release of attachments along the posterior aspect of the medial pterygoid.

Modified double-opposing Z-plasty for patients with Veau I cleft palate

“…Numerous refinements in the basic cleft palate repair principles have been described, but the optimal repair still remains scientifically unproven. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][27][28][29][30] Within the armamentarium of cleft surgical maneuvers, the lateral relaxing incisions have been systematically adopted in all patients or selectively used when further palatal flap mobilization is required based on the intraoperative judgment case by case. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]27] However, there is a debate about the potential harms of these lateral relaxing incisions as the exposed raw surface, the healing by secondary intention, and the scarring process may impair the maxillary arch development and anteroposterior maxillary growth.…”

“…Importantly, the reduction of the total number of orthognathic surgeries (a common therapeutic endpoint in cleft literature) has not been considered as a long-term endpoint in our center, because orthognathic surgery has been widely indicated and performed in our cleft patients not only to correct a Class III malocclusion but also to improve the facial appearance, symmetry, proportion, and aesthetics. [33] For the proposed MIDOZ approach, some technical principles [27][28][29][30] were compiled and formally adopted in a systematized way to achieve anatomical reconstruction with decreased disruption of normal tissues. The step-by-step process meticulously described for this approach is considered as a key element for the accurate palatal dissection.…”

“…[27] Based on the experience accumulated in last 20 years, the senior author has noticed anecdotally that the subgroup of patients with Veau I cleft palate may be repaired by a further modified small DOZ using only medial incision approach (namely, the medial incision DOZ; MIDOZ) with no lateral relaxing incisions of the hard or soft palate, no bony exposure, and consequently, less scar formation. To this end, specific principles of meticulous tissue dissection and mobilization (oral and nasal layers, greater palatine pedicle, and pyramidal process region) [28][29][30] as well as muscle reconstruction using small DOZ [27] were combined in a standardized fashion using an only medial incision to maximize vascularity and to allow adequate palatal flap mobilizations with tension-free closure. The Editor: N/A.…”