We are now evaluating the palate, looking at the distance from the uvula to the posterior pharynx. Taking the uvula and seeing where it easily touches the posterior pharynx provides the Randall classification. If it hits the bottom of the adenoids, which is seen here, that is a Randall 2. Where to easily come below the adenoids, that would be Randall 1. Where to come to the upper half of the adenoids, Randall 3. And not to hit at all would be Randall 4. We'll now mark our flaps for the furlough palatoplasty. On the left side is the oromuscular flap. We begin with an incision close to 90 degrees and taper it off from there to approximate a 60 degree line. On the right side is the oral mucosal only flap, which is going to be anteriorly based. And this starts again with a 90 degree angle at the edge, coming posteriorly, and I keep my incision much further posterior than a 60 degree angle would take it, so that the oromuscular flap can be inset as far posterior as possible. My goal is that all flaps containing muscle, being the oromuscular flap from the left side and the nasal muscular flap from the right side, be inset as far posterior as possible to achieve the maximum posterior transposition of the respective muscle layers. Once the markings are complete, I will inject the soft palate, providing as much turgor as possible to the junction between the nasal and oral mucosa, such that we are able to incise this and allow the turgor of the injection to serve as countertension. Once we have adequate turgor, we will incise from the anterior or hard palate side to posterior or the tip of the uvula. We use the hard palate as our countertension and allow the turgor to help us as well, so we get the cleanest cut possible, dividing the oral and nasal mucosa, coming right to the tip of the uvula where the palate will be reconstructed. The first palatal incision is the left-sided oromuscular flap, coming along the preplanned incision, again making this a posteriorly based flap containing muscle but preserving the nasal mucosa beneath it. We will now raise the left-sided posteriorly-based myomucosal flap containing oral mucosa. The incision will be taken down to the nasal mucosa and the flap elevated off the nasal mucosa but preserving the mucosa. After elevating the left-sided oral muscular flap, a left-sided anteriorly-based nasal mucosal only flap will be elevated. Note that this flap is going to go to a more posterior position on the base because it will serve as the inset for the right-sided nasomuscular flap. As mentioned earlier, whenever there is muscle in the flap, I like the inset to be as far posterior as possible so that we achieve the maximum efficacy to our Velar transposition. We now turn our attention to the right-sided anteriorly-based oral mucosal only flap. Pulling the uvula away, we're going to make our incision in continuity with the midline incision. When elevating the oral mucosal only flap, we want to be deep enough such that the submucosal glands remain with the mucosal flap. We are not elevating immediately below the mucosa, but we're elevating below the submucosal glands, thereby with the deep layer being the muscle. A common mistake is to elevate too superficially and thereby put the flap at risk. As demonstrated here, we are raising a thick oral mucosal only flap, and it is thick because of the submucosal glands that are attached to the mucosa. Beneath us is the muscle layer that is going to comprise the subsequent nasomuscular flap.

furlough palatoplasty

Randall classification

uvula contact

muscle transposition

nasal mucosa preservation