INTRODUCTION
Surgical options for cleft palate closure have historically ranged from simple apposition to the use of buccal flaps, aiming to achieve both optimal structural integrity and functional outcomes. To meet these goals, two well-established surgical procedures are widely performed: Furlow’s double opposing Z-plasty and von Langenbeck’s palatoplasty with intravelar veloplasty. Numerous studies have compared speech outcomes and complication rates between these methods. While Furlow’s procedure is generally believed to produce superior speech results, it has been suggested that wider clefts require additional relaxing incisions, potentially compromising long-term palatal length. Conversely, it has been hypothesized that a meticulously performed intravelar veloplasty may yield comparable speech outcomes.
In this study, we compared the two surgical techniques performed by the same surgeon under uniform clinical conditions, with the specific goal of assessing intraoperative palatal lengthening. Although previous research has compared the procedures in terms of speech outcomes, few studies have directly examined differences in achieved lengthening. This study represents the first phase of a planned longitudinal cohort, in which speech outcomes will later be evaluated when the patients reach 5 years of age. We hypothesize that if the intraoperative lengthening achieved by the two procedures is comparable, their long-term speech outcomes will also be similar.
Various techniques for cleft palate repair have been described, yet none is universally accepted as ideal. This lack of consensus has sustained debate over the optimal approach for different cleft configurations [1,2]. The von Langenbeck technique, which uses lateral relaxing incisions, accounts for approximately 60% of palatoplasty cases [1,3,4]. Bardach’s two-flap technique provides tension-free closure, particularly in unilateral clefts [5]. Furlow’s double opposing Z-plasty, introduced in 1976, enhances velar length and muscle alignment [6]. The von Langenbeck method is straightforward and suitable for narrow defects but may cause scar-related shortening (Fig. 1) [7].
Victor Veau was the first to advocate midline levator reapproximation, later refined by Braithwaite through extensive dissection and retropositioning [8,9]. Kriens [10] subsequently introduced the term intravelar veloplasty, describing a procedure involving muscle freeing, separation, retropositioning, and sling formation. Trier and Dreyer [11] reported an 89% rate of velopharyngeal closure using the von Langenbeck method. Furlow’s double Z-plasty achieved a midline muscle sling and approximately 90% closure success (Fig. 2) [6]. Velopharyngeal insufficiency may result from either a short velum or inadequate muscle realignment following palatoplasty [12]. This study aimed to compare the perioperative and postoperative outcomes of Furlow’s double opposing Z-plasty and von Langenbeck palatoplasty with intravelar veloplasty, and to examine the relationship between initial cleft width and the degree of palatal lengthening achieved.
The primary objective was to compare Furlow’s double opposing Z-plasty and von Langenbeck palatoplasty with intravelar veloplasty in terms of curved and straight palatal lengthening, as well as the incidence of wound dehiscence, infection, bleeding, and airway compromise. The secondary objective was to evaluate the correlation between the initial cleft width and the final palatal lengthening achieved postoperatively.
Several key studies have explored related topics. Randall et al. [13] emphasized the importance of assessing velar length preoperatively to predict postoperative speech outcomes, highlighting that post-surgical palatal lengthening is a critical goal. Spauwen et al. [14] demonstrated that Furlow’s Z-plasty was superior to the von Langenbeck technique in speech outcomes but noted greater technical difficulty for clefts wider than 1 cm. Bae et al. [15] quantitatively measured palatal lengthening and found that the double opposing Z-plasty and two-flap palatoplasty were superior to the pushback technique. Ravishanker [16] reported that Furlow’s method yielded greater increases in palatal length than the Veau-Kilner-Wardill procedure. Guneren and Uysal [17] also demonstrated that Furlow’s technique produced a substantial and long-lasting increase in velar length. Williams et al. [1] conducted a prospective study revealing better speech outcomes in Furlow’s Z-plasty patients, though fistula rates were lower in the von Langenbeck group. Dong et al. [3] found improved velar competence after Furlow’s procedure, as confirmed by speech analysis and cephalometry, attributing this to greater palatal lengthening. Dubey et al. [18] compared Furlow’s Z-plasty with intravelar veloplasty and observed similar speech scores between groups, although the Furlow technique required longer operative time. Chang et al. [19] reported an average palatal lengthening of 7.48% after Furlow’s repair and found no correlation between cleft width and lengthening.
Stein et al. [20], in a meta-analysis of 227 studies comparing different techniques, concluded that Furlow’s method offered better velar competence and lower fistula rates than von Langenbeck palatoplasty. Sakran et al. [21] compared Furlow’s, von Langenbeck’s, and Bardach’s two-flap techniques for velopharyngeal function and determined that the double opposing Z-plasty yielded superior speech outcomes. Kara et al. [22] compared intravelar veloplasty and Furlow’s double opposing Z-plasty, emphasizing that surgical expertise and preference are key determinants of successful soft-palate closure. While palatal lengthening is widely regarded as a central goal of palatoplasty, standardized quantitative methods for measuring palatal length and objectively comparing lengthening outcomes have not yet been fully established [15].
METHODS
Study design
An open-label randomized controlled trial meeting the criteria for evidence-based medicine level 1 and conducted in accordance with internationally accepted ethical standards and the Declaration of Helsinki was performed [23]. The study protocol was developed in the Department of Burns and Plastic Surgery, All India Institute of Medical Sciences (AIIMS), Rishikesh, and approved by the Institutional Ethics Committee (Reg. No.: ECR/736/Inst/UK/2015/RR-18; Letter No.: AIIMS/IEC/20/ 367). The sequence of the study is depicted in Fig. 3.
Patient enrollment
Over a 2-year period (2019–2021), 22 patients with cleft palate were randomly assigned to two groups. Eleven participants underwent von Langenbeck palatoplasty with intravelar veloplasty, while the other eleven were treated with Furlow’s double Z-plasty. The aim was to demonstrate the differences between the two techniques and their influence on perioperative and postoperative outcomes, particularly the relationship between cleft width and palatal lengthening achieved after palatoplasty.
Clinical appraisal
Patient information and clinical details are presented in Scheme 1 (CONSORT flow diagram) and Table 1. All participants were selected based on similar cleft deformities to ensure two homogeneous groups. Cleft measurements were recorded preoperatively and postoperatively. The inclusion and exclusion criteria are provided in Table 2.
Participant randomization
Allocation of participants into Groups 1 and 2, based on the defined inclusion and exclusion criteria, was performed by an independent individual not involved in the trial, using an online randomization generator (https://www.randomizer.org). All individuals involved in the study—including participants, clinical staff, and outcome assessors—were aware of treatment allocation.
Surgical technique
The preoperative measurements were as follows: (1) straight palatal length: distance from the central mid-alveolar ridge to the tip of the uvula, measured with a hard ruler (Fig. 4: AA’); (2) soft palate length: distance from the tangent at the posterior border of the alveolus to the tip of the uvula (Fig. 4: BB’); (3) hard palate length: distance from the central mid-alveolar ridge to the tangent at the posterior border of the alveolus (Fig. 4: CC’); (4) cleft length: distance from the anterior border of the cleft to the tip of the uvula (Fig. 4: DD’); (5) cleft width: width of the cleft palate at the junction of the hard and soft palate (Fig. 5: aa’); (6) widest cleft width: maximum cleft width and its location from the hard–soft palate junction, which sometimes coincided with the previously measured cleft width (Fig. 5: bb”); and (7) curved palatal length: distance from the central mid-alveolar ridge to the tip of the uvula along the palatal contour (Fig. 6).
Group 1: Von Langenbeck’s palatoplasty with intravelar veloplasty
This procedure involves simple approximation of the cleft margins with relaxing incisions beginning posterior to the maxillary tuberosity and extending to the tonsillar pillars. It employs medial movement of two bipedicle mucoperiosteal flaps to close the cleft, leaving lateral raw areas to heal by secondary intention. Extensive muscle dissection is performed to allow posterior repositioning and tension-free approximation of the levator palatini. Although fistula rates may be higher, this technique is considered safe once the learning curve is achieved and also improves aesthetic outcomes [24].
Group 2: Furlow’s double Z-plasty
This technique consists of two mirror-image Z-plasties involving the nasal and oral layers of the soft palate. After transposition in the midline, a palatal muscle sling is created, resulting in lengthening of the palate along the central Z-axis. In cases of wide clefts, the limb length was not reduced. Lateral releasing incisions were added as needed to mobilize tissue and achieve tension-free closure.
Postoperative measurements
At the conclusion of surgery, while the child was still under anesthesia, the following parameters were measured: (1) straight palatal length from the central mid-alveolar ridge to the tip of the uvula using a hard ruler (Fig. 4: AA’); (2) soft palate length from the tangent at the posterior border of the alveolus to the tip of the uvula (Fig. 4: BB’); (3) hard palate length from the central mid-alveolar ridge to the tangent at the posterior alveolar border (Fig. 4: CC’); and (4) surface palate length from the central mid-alveolar ridge to the tip of the uvula (Fig. 6). After the completion of measurements, the child was extubated and transferred to the recovery room.
Complicating factors
All palatoplasty procedures carry a risk of postoperative complications, as outlined below. Early complications include immediate or delayed palatal bleeding, which may necessitate urgent return to the operating room for hemostasis; thus, meticulous control of bleeding is essential. Infections, although uncommon, can delay healing and lead to surgical failure. Perioperative antibiotics and antiseptic mouthwashes are recommended to minimize infection risk. Wound dehiscence may result from infection, closure under tension, excessive crying that stresses the suture line, inadequate release of abnormal muscle attachments, or poor nutritional status. Dehiscence can lead to oronasal fistula formation. Airway compromise may occur due to postoperative narrowing from mucosal edema and inflammation. Gentle tissue handling, smooth intubation, and cautious steroid use help prevent this complication, and some centers employ a tongue stitch to prevent posterior tongue displacement and obstruction.
Delayed complications include oronasal fistulae caused by closure under tension, wound breakdown, or infection, typically occurring at the hard–soft palate junction and requiring secondary surgery. Velopharyngeal incompetence is the most common indication for revision, as most procedures may fail to achieve adequate velar length or muscular bulk to enable complete palatal contact with the pharyngeal wall during phonation. This results in hypernasality and nasal emission, prompting secondary corrective procedures.
Statistical analysis
All data were entered into an Excel spreadsheet according to a standardized proforma and analyzed using appropriate statistical tests based on data distribution. Quantitative variables were expressed as mean±standard deviation. The unpaired t-test was used to evaluate differences between the two groups at a 5% level of significance (p<0.05). Pearson correlation coefficient was calculated to assess the relationship between cleft width and palatal lengthening, with corresponding p-values. Statistical analyses were performed using SPSS software (version 23.0).
RESULTS
In this study, we measured the straight, curved, soft, and hard palatal lengths both preoperatively and postoperatively. The mean preoperative straight palate length was 43.2 mm (95% confidence interval [CI], 39.2–47.2) in the von Langenbeck group and 46.5 mm (95% CI, 42.6–50.4) in the Furlow group. Similarly, the mean preoperative curved palate length was 49.0 mm (95% CI, 45.3–52.7) in the von Langenbeck group and 51.7 mm (95% CI, 47.5–55.9) in the Furlow group, with a p-value greater than 0.05, indicating no significant difference.
Regarding straight palate length and percentage gain in curved palate length, the mean palatal lengthening was greater in the Furlow group than in the von Langenbeck group by 4.7%. However, this difference was not statistically significant, with p-values of 0.19 and 0.16, respectively (Figs. 7,–10). Chang et al. [19] reported that Furlow’s technique was associated with a mean palatal lengthening of 15.8%, which is comparable to the 16.5% lengthening observed in our study.
Preoperative measurements
Preoperative measurements were expressed as mean distances (with 95% CIs) and standard deviations in millimeters. The p-values were calculated using the unpaired t-test (Table 3).
Correlation of preoperative width and palatal lengthening
The correlation between preoperative cleft width and palatal lengthening achieved was analyzed using Pearson correlation coefficient, and the results were represented graphically using scatter plots. The corresponding p-values were calculated to assess significance (Table 4). The relationship between cleft width at the junction and percentage curved palatal lengthening in the von Langenbeck group is shown in Fig. 7. The association between maximum cleft width and percentage curved palatal lengthening in the same group is illustrated in Fig. 8. Similarly, Fig. 9 depicts the relationship between cleft width at the junction and percentage curved palatal lengthening in the Furlow group, while Fig. 10 shows the relationship between maximum cleft width and percentage curved palatal lengthening in the same group. Immediate preoperative and postoperative status (Fig. 11), corresponding measurements (Fig. 12), and the final postoperative appearance at the junction of the hard and soft palate (Fig. 13) are also presented.
Complicating factors
None of the patients (0%) in either group experienced any immediate postoperative complications. However, one patient in each group (9.09%) developed a palatal fistula. The patient in the von Langenbeck group required reoperation for fistula closure at the junction of the hard and soft palate, whereas the patient in the Furlow group was managed conservatively and healed without further intervention. All observed complications are summarized in Table 6.
DISCUSSION
Furlow’s technique has long been recognized as highly effective, particularly in cases of narrow cleft palates (<1 cm in width) [14]. However, our findings demonstrate that in the Furlow group, the mean cleft width at the junction of the hard and soft palate was 10.9 mm, ranging from 8 to 18 mm, and we were able to achieve a mean palatal lengthening of 16.7% without difficulty in closure. The absence of complications such as wound dehiscence and bleeding, with only a 9.1% incidence of oronasal fistula (1 of 11 cases), indicates the tension-free nature of the repair. Lateral relaxing incisions were required in 72.7% of patients (8 of 11 cases). The gain in palatal length also depends on local tissue laxity; in the absence of relaxing incisions, the ease of oral layer closure is primarily determined by cleft width. When relaxing incisions are used, wider clefts can be managed by mobilizing greater quantities of lateral tissue, leaving broad raw areas laterally that heal by secondary intention [21]. This observation explains our ability to successfully manage wider clefts in this study using the Furlow Z-plasty technique. The advantages of the Furlow double opposing Z-plasty, including sustained palatal lengthening, have been consistently described in prior studies [19,25–28].
Several studies have suggested that it is intravelar veloplasty that reestablishes the velopharyngeal sphincter and improves speech [29]. Furlow’s palatoplasty generally provides excellent speech results and velopharyngeal competence, though some patients may still require an additional pharyngeal flap [26]. Better speech outcomes after Furlow’s procedure than after von Langenbeck palatoplasty were reported by Yu et al. [30], although their study included only patients with incomplete clefts.
It is often assumed that wider clefts are more difficult to close and result in less palatal lengthening. In our study, we observed a weak correlation between cleft width and palatal lengthening in both the Furlow and von Langenbeck groups (Figs. 7,–10). However, in both groups, the correlation was statistically insignificant. This finding aligns with previous literature [31]. Chang et al. [19] also attempted to correlate initial cleft width with final palatal lengthening but found no significant association.
Whether the amount of palatal lengthening translates into improved speech outcomes requires a longer follow-up, ideally until at least 5 years of age, when formal speech evaluation can be performed. Another limitation of our study is that we measured true cleft width rather than relative cleft width, as recommended by Rossell-Perry et al. [32] in their 2014 study, which concluded that greater relative cleft width is associated with a higher incidence of oronasal fistulae. Additionally, we did not consider the CHOP modification [33] or other described modifications [34] of the Furlow palatoplasty that may facilitate tension-free closure and promote palatal lengthening.
In conclusion, our study found no significant difference between von Langenbeck palatoplasty with intravelar veloplasty and Furlow’s double opposing Z-plasty regarding palatal lengthening, complication rates, operative time, or hospital stay. Cleft width did not influence surgical outcomes, and both techniques effectively achieved tension-free closure. Intravelar veloplasty may restore sphincteric function, while Furlow’s Z-plasty minimizes the risk of scar contracture and shortening. Intraoperative palatal lengthening occurs with the modified small double opposing Z-plasty, though variability exists across the spectrum of cleft palate deformities [35]. Determining which of the two techniques yields more sustainable palatal length and improved speech will require longer follow-up. Nevertheless, both procedures remain valuable tools for cleft surgeons, offering affected children the potential for near-normal speech and function when performed by experienced surgeons.
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