THE TRIANGULAR FLAP PROCEDURE FOR LENGTHENING THE SHORT REPAIRED PALATE

By THOMAS GIBSON, M.B., F.R.C.S.E., F.R.F.P.S.G.

Plastic Surgery Unit, Royal Infirmary, Glasgow

INADEQUATE length of the soft palate after cleft palate repairs may be due to various factors and is the most common cause of the persistence of speech defects. I f speech therapy fails to correct these, there is a clear indication for secondary operations designed to lengthen the soft palate, modify the pharynx, or both.

Palate lengthening procedures are of two types: the soft tissues covering the bony palate may be used to give added length to the soft palate as in the operation of Dorrance (1933) or the V-Y advancement of Kilner (1937); alternatively the soft palate may be detached completely from the hard palate and held in a more posterior position by means of an obturator (Gillies and Fry, 1921) or a tube pedicle (Gillies and Millard, 1957).

Neither the Dorrance nor the Kilner operation correct the contracture of the midline scar, and in my experience show a tendency for the soft palate to drift forwards as healing occurs. The Gillies-Fry operation has been criticised because of the difficulty of fitting a rigid prosthesis against the mobile soft palate; an obturator may be avoided by insetting a tube pedicle, but this is a time-consuming and hazardous technique.

The operation to be described combines the advantages and avoids most of the drawbacks of these procedures. The soft palate is completely detached from the bony palate and into the defect is rotated a triangular flap from the mucosa of half of the hard palate. This flap is unlined but is thickened by scar tissue from the previous repair and contraction does not occur. Experience has shown that the backward displacement obtained at operation is permanent with no tendency to forward " drift." An anterior bony defect may be exposed when the flap is raised, but an obturator will fit accurately since it abuts on immobile tissue.

The technique was first devised in an attempt to apply the principles of the Z-plasty to the central palatal scar. There is little doubt, however, that it owes much to a subconscious recollection of one of the flaps which Cuthbert (1951) described for closure of clefts confined to the soft palate.

OPERATIVE DETAILS

The technique is shown diagrammatically in Fig. I. In cases of complete unilateral clefts the flap should be raised from the normal side in order to avoid the underlying bony defect. The triangular flap is elevated as far back as the junction between the hard and soft palates and the posterior palatine vessels are ligated if this has not been done at the previous operation. The transverse incision lies just anterior to the junction between hard and soft palates and is deepened until the palatal muscles can be separated from the bony palate. The nasal mucosa is then divided in the same line so that the full thickness of the soft palate is detached. When this is completed it falls backwards into position (it does not need to be

223

224 BRITISH JOURNAL 0F PLASTIC SURGERY

" pushed ") and the triangular flap is rotated into the defect and stitched in position with black silk (Figs. 2 to 4).

A

Bleeding from small vessels divided in the transverse

t i

~ - ~

B C

F I G . I

Diagrammatic representation of the operation.

A, The triangular flap is marked out on the side opposite the original deft. B, The flap is raised and the soft palate separated completely from the

hard palate. C, The flap is sutured in position and any defects in the soft palate repaired.

FIG. 2 FIG. 3 Fig. 2 . - -A very short contracted soft palate immediately prior to the triangular flap repair. Fig. 3 . - -The flap has been raised and the soft palate freed. Note how the palate falls back

into better position.

incision is occasionally troublesome, but can be checked with carefully placed sutures. A small piece of Oxycel is packed into the defect to control oozing.

TRIANGULAR FLAP PROCEDURE FOR LENGTHENING SHORT REPAIRED PALATE 225

It is essential that the flap should not be under tension and should have a good blood supply at the end of the operation. I f too tight, it may be freed by prolonging the lateral incision backwards and, i f need be, by infracturing the hamular process.

In many instances complete closure can be obtained, but when there is a wide defect in the bony palate it is difficult to avoid a persistent oro-nasal fistula which

FIG. 5

Fig. 4 . - -The flap sutured. Every effort was made to take the photographs in Figs. 2, 3, and 4 from the same angle to show the exact amount of retro-

positioning achieved.

Fig. 5 . - -When a bony palatal defect is exposed this may sometimes be closed

by a secondary anteriorly based flap.

FIG. 4

must be closed with an obturator. In some cases a second flap (Fig. 5) based anteriorly may be swung across the defect, particularly where a sufficiently broad anterior base is available.

RESULTS

The triangular flap operation has been performed in thirty-five patients with a short repaired palate and a speech defect. Complete necrosis of the flap occurred in one case, partial necrosis in another ; in each instance excessive tension on the flap appeared to be the cause. These patients were treated as if they had had a Gillies-Fry operation and an obturator was fitted into the defect. In a few cases post-operative bleeding from vessels divided in the transverse incision has been troublesome. This may be largely prevented, however, by carefully placed sutures taking a deep bite of the soft tissues.

The retrodisplacement obtained is just less than one-half of the distance between the maxillary tuberosities and is permanent. It may be forecast accurately before operation, and in no case has there been any contracture of the flap (Figs. 6 and 7).

In almost all cases the triangular flap operation was combined with a pharyngoplasty of the Hynes type (Hynes, 195o) or with a pharyngeal flap. It is thus not possible to discuss the effect of retropositioning alone on speech. All

226 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. 6 FIG. 7 Fig. 6.--A short contracted soft palate in an i8-year-old girl with marked nasal escape. Fig. 7 . - -Two years after operation the triangular flap is clearly seen and has not contracted in any way. A Hynes' pharyngoplasty was also carried out and almost

perfect speech was obtained.

FIG. 8 FIG. 9 Fig. 8 .~An unrepaired cleft palate in a I6-year-old girl. Fig. 9.--Closure of the cleft was combined with a triangular flap and is seen here one

week post-operatively.

TRIANGULAR FLAP PROCEDURE FOR LENGTHENING SHORT REPAIRED PALATE 227

the patients showed improvement and many achieved perfect speech, but these results may be due in part to the other procedures.

In three patients a triangular flap was used during the initial closure of clefts. Although it was much thinner than in previously repaired cases, surprisingly

FIG. IO The healed condition three months after operation to illustrate the added length of the palate obtained. No contraction of the flap has occurred after

two years.

little contracture occurred (Figs. 8 to IO). It would seem to be particularly valuable in clefts confined to the soft palate in older patients.

In conclusion the advantages of the operation may be summarised :-- I. It is technically simple. 2. It may be completed in one stage. 3. The posterior displacement obtained varies from I "5 to 3 cm. 4. There is no tendency towards forward drifting post-operatively. 5. Any defects remaining may be easily blocked with an obturator.

I am greatly indebted to Mrs J. B. Griffith for the diagrams, to Mr T. Meikle for the photographs, and to Mr ft. S. Tough for permission to publish cases admitted under his care.

REFERENCES

CUTHBERT, J. (I95I). Brit. ft. plast. Surg., 4, I85- DORRANCE, G. M. (I933). " The Operative Stor~ of Cleft Palate." London:

W. B. Saunders Co. GILLIES, H. D., and FRY, W. K. (I9zI). Brit. reed. J. , I , 335- GILLIES, H. D., and MILLARO, R. D. (I957)-" " The Principles and Art of

Plastic Surgery." London : Butterworth & Co. HYNES, W. (I95o). Brit. J. plast. Surg., 3, Iz8. KILNER, T. P. (I937). St. Thorn. Hosp. Rep., 2, rz 7.