The Cleft Palate–Craniofacial Journal 52(5) pp. 632–633 September 2015 Ó Copyright 2015 American Cleft Palate–Craniofacial Association
IDEAS AND INNOVATIONS Retraction of the Soft Palate During a Modified Hynes Pharyngoplasty: A Technical Note Serryth Colbert, M.B., F.R.C.S., F.F.D., Nigel Mercer, M.B. Ch.B., F.R.C.S., F.R.C.P.C.H. Surgical management of velopharyngeal insufficiency by construction of sphincter pharyngoplasty is well described in the medical literature. Hynes advocated splitting an intact soft palate when it would be helpful for better exposure of the posterior pharyngeal wall for flap inset. We describe a modification to the Hynes pharyngoplasty whereby the soft palate is retracted upward, giving the operator unrestricted surgical access to the salpingopharyngeus muscles and their overlying mucosa. This allows the surgeon to raise and inset the flaps, as described by Hynes, without the need to divide the soft palate. The retraction catheters avoid the need for splitting a soft palate, which has been optimized by either a Furlow or soft palate re-repair in the past, avoiding unnecessary compromise of the integrity and architecture of the soft palate. KEY WORDS:
Hynes pharyngoplasty, palate retraction, palate split
Surgical management of velopharyngeal insufficiency by construction of sphincter pharyngoplasty is well described in the medical literature. In 1950, Wilfred Hynes described an operation for velopharyngeal dysfunction after cleft palate repair (Hynes, 1950). Hynes advocated a two-stage approach. In the first stage, the soft palate was divided and the salpingopharyngeus muscles were transposed to the posterior pharyngeal wall in a transverse side-to-side arrangement. In the second stage the palate was repaired and, in some cases, pushed back as well. By 1953, Hynes had modified his technique (Hynes, 1953) and advocated much bulkier flaps, including salpingopharyngeus, palatopharyngeus, and part of the superior constrictor as well. He now sutured the flaps together in an end-to-end fashion, with some overlap of their tips. However, he continued to divide the soft palate, repair it, and push it back at a second operation. In 1967, Hynes made observations and recommendations based on 20 years of experience with pharyngoplasty (Hynes, 1967). He still advocated splitting an intact soft palate when it would be helpful for better exposure of the posterior pharyngeal wall for flap inset. However, by this
time, he felt it possible to repair the soft palate at the same surgical procedure. We describe a modification to Hynes pharyngoplasty whereby the soft palate is retracted upward, giving the operator unrestricted surgical access to the salpingopharyngeus muscles and their overlying mucosa. This allows the surgeon to raise and inset the flaps, as described by Hynes, without the need to divide the soft palate. A fine-bore catheter is passed into each nostril until the tips of the catheters lie just below the soft palate. The catheters are then sutured to the oral surface of the soft palate (see Fig. 1). The catheters are gently pulled 4 or 5 cm out of the nostrils. This has the effect of retracting the soft palate upward. The catheters are clamped to the surgical drapes when the soft palate has been pulled upward sufficiently to allow the surgeon to perform the pharyngoplasty without the need for division of the soft palate (see Fig. 2). The soft tissues of the nose are protected with gauze swabs. The traction on the palate tenses the posterior faucial pillars, making the dissection of the flaps easier because of countertraction. The retraction allows direct visualization of the posterior pharynx, enabling the horizontal incision of the poster pharyngeal wall, into which the flaps will be inset end to end to be made under direct vision, and hemostasis ensured. The level at which the flaps are inset is selected at multiview videofluoroscopy and nasendoscopy. These investigations demonstrate the position and pattern of attempted velopharyngeal closure. This informs the surgeon which procedure is most likely to help the patient achieve velopharyngeal
Dr. Colbert is Cleft Fellow, Cleft Unit, Frenchay Hospital, Bristol, United Kingdom. Dr. Mercer is Consultant in Plastic Surgery and Cleft Surgery, Cleft Unit, Frenchay Hospital, Bristol, United Kingdom. Submitted September 2013; Revised August 2014; Accepted August 2014. Address correspondence to: Dr. Serryth Colbert, Cleft Unit, Frenchay Hospital, Frenchay Park Road, Bristol, BS16 1LE, United Kingdom. E-mail [email protected]. DOI: 10.1597/13-241 632
Colbert and Mercer, RETRACTION OF THE SOFT PALATE DURING HYNES PHARYNGOPLASTY
FIGURE 1 Two catheters sutured to the oral surface of the soft palate.
closure and where to inset the lateral flaps in a pharyngoplasty. The retraction catheters avoid the need for splitting a soft palate, whose function has been optimized by either a Furlow or soft palate re-repair in the past, avoiding unnecessary compromise of the integrity and architecture of the soft palate. It is not necessary to obtain visual access above the adenoids, as it is practically impossible to inset the flaps above the adenoids. In any case, placing the pedicle for the lateral flap above the level of the adenoids would run the risk of devascularizing the flap.
633
FIGURE 2 Soft palate retracted sufficiently to allow a pharyngoplasty to be performed avoiding the need to divide the soft palate.
We recommend the technique of soft palate retraction during a modified Hynes (or Orticochea) pharyngoplasty. REFERENCES Hynes W. Observations on pharyngoplasty. Br J Plast Surg. 1967;20:244–256. Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg. 1950;3:128–135. Hynes W. The results of pharyngoplasty by muscle transplantation in ‘‘failed cleft palate’’ cases, with special reference to the influence of the pharynx on voice production. Ann R Coll Surg Engl. 1953;13:17–35.
IDEAS AND INNOVATIONS Retraction of the Soft Palate During a Modified Hynes Pharyngoplasty: A Technical Note Serryth Colbert, M.B., F.R.C.S., F.F.D., Nigel Mercer, M.B. Ch.B., F.R.C.S., F.R.C.P.C.H. Surgical management of velopharyngeal insufficiency by construction of sphincter pharyngoplasty is well described in the medical literature. Hynes advocated splitting an intact soft palate when it would be helpful for better exposure of the posterior pharyngeal wall for flap inset. We describe a modification to the Hynes pharyngoplasty whereby the soft palate is retracted upward, giving the operator unrestricted surgical access to the salpingopharyngeus muscles and their overlying mucosa. This allows the surgeon to raise and inset the flaps, as described by Hynes, without the need to divide the soft palate. The retraction catheters avoid the need for splitting a soft palate, which has been optimized by either a Furlow or soft palate re-repair in the past, avoiding unnecessary compromise of the integrity and architecture of the soft palate. KEY WORDS:
Hynes pharyngoplasty, palate retraction, palate split
Surgical management of velopharyngeal insufficiency by construction of sphincter pharyngoplasty is well described in the medical literature. In 1950, Wilfred Hynes described an operation for velopharyngeal dysfunction after cleft palate repair (Hynes, 1950). Hynes advocated a two-stage approach. In the first stage, the soft palate was divided and the salpingopharyngeus muscles were transposed to the posterior pharyngeal wall in a transverse side-to-side arrangement. In the second stage the palate was repaired and, in some cases, pushed back as well. By 1953, Hynes had modified his technique (Hynes, 1953) and advocated much bulkier flaps, including salpingopharyngeus, palatopharyngeus, and part of the superior constrictor as well. He now sutured the flaps together in an end-to-end fashion, with some overlap of their tips. However, he continued to divide the soft palate, repair it, and push it back at a second operation. In 1967, Hynes made observations and recommendations based on 20 years of experience with pharyngoplasty (Hynes, 1967). He still advocated splitting an intact soft palate when it would be helpful for better exposure of the posterior pharyngeal wall for flap inset. However, by this
time, he felt it possible to repair the soft palate at the same surgical procedure. We describe a modification to Hynes pharyngoplasty whereby the soft palate is retracted upward, giving the operator unrestricted surgical access to the salpingopharyngeus muscles and their overlying mucosa. This allows the surgeon to raise and inset the flaps, as described by Hynes, without the need to divide the soft palate. A fine-bore catheter is passed into each nostril until the tips of the catheters lie just below the soft palate. The catheters are then sutured to the oral surface of the soft palate (see Fig. 1). The catheters are gently pulled 4 or 5 cm out of the nostrils. This has the effect of retracting the soft palate upward. The catheters are clamped to the surgical drapes when the soft palate has been pulled upward sufficiently to allow the surgeon to perform the pharyngoplasty without the need for division of the soft palate (see Fig. 2). The soft tissues of the nose are protected with gauze swabs. The traction on the palate tenses the posterior faucial pillars, making the dissection of the flaps easier because of countertraction. The retraction allows direct visualization of the posterior pharynx, enabling the horizontal incision of the poster pharyngeal wall, into which the flaps will be inset end to end to be made under direct vision, and hemostasis ensured. The level at which the flaps are inset is selected at multiview videofluoroscopy and nasendoscopy. These investigations demonstrate the position and pattern of attempted velopharyngeal closure. This informs the surgeon which procedure is most likely to help the patient achieve velopharyngeal
Dr. Colbert is Cleft Fellow, Cleft Unit, Frenchay Hospital, Bristol, United Kingdom. Dr. Mercer is Consultant in Plastic Surgery and Cleft Surgery, Cleft Unit, Frenchay Hospital, Bristol, United Kingdom. Submitted September 2013; Revised August 2014; Accepted August 2014. Address correspondence to: Dr. Serryth Colbert, Cleft Unit, Frenchay Hospital, Frenchay Park Road, Bristol, BS16 1LE, United Kingdom. E-mail [email protected]. DOI: 10.1597/13-241 632
Colbert and Mercer, RETRACTION OF THE SOFT PALATE DURING HYNES PHARYNGOPLASTY
FIGURE 1 Two catheters sutured to the oral surface of the soft palate.
closure and where to inset the lateral flaps in a pharyngoplasty. The retraction catheters avoid the need for splitting a soft palate, whose function has been optimized by either a Furlow or soft palate re-repair in the past, avoiding unnecessary compromise of the integrity and architecture of the soft palate. It is not necessary to obtain visual access above the adenoids, as it is practically impossible to inset the flaps above the adenoids. In any case, placing the pedicle for the lateral flap above the level of the adenoids would run the risk of devascularizing the flap.
633
FIGURE 2 Soft palate retracted sufficiently to allow a pharyngoplasty to be performed avoiding the need to divide the soft palate.
We recommend the technique of soft palate retraction during a modified Hynes (or Orticochea) pharyngoplasty. REFERENCES Hynes W. Observations on pharyngoplasty. Br J Plast Surg. 1967;20:244–256. Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg. 1950;3:128–135. Hynes W. The results of pharyngoplasty by muscle transplantation in ‘‘failed cleft palate’’ cases, with special reference to the influence of the pharynx on voice production. Ann R Coll Surg Engl. 1953;13:17–35.
