To achieve maximum transposition of the flaps, particularly at the hard-soft palate junction, we need to elevate the flaps from the mucoperiosteum of the hard palate. I find that a right-angled beaver blade is helpful here because we can skim at the base of the oral mucosal only flap, hit the back of the hard palate, and come to a submucoperiosteal plane. Similarly, on the contralateral side, we are going to elevate the remaining oral mucosa in a submucoperiosteal plane such that there's enough mobility that the contralateral oral mucosal only flap can transpose and not cause too much tension at the flap closure. Having mobilized the nasomuscular flap on the right side, the muscle is going to be swept off of the posterior hard palate and swept posteriorly to be part of the flap, the goal being not to sacrifice any muscle that could be part of the levator mechanism and allow that to stay with the nasomuscular flap. We can then start incising the mucosa, preserving as much muscle as possible with that mucosa in creation of the nasomuscular flap. Now that the nasomuscular flap has been elevated, we are going to put a stitch to transpose the nasomuscular flap posteriorly and to the left side. We start with a stitch coming through the nasal mucosa on the left side, far posteriorly such that the muscle can be transposed posteriorly. The stitch is then going to come and catch the muscle of the nasomuscular flap and end on the mucosal surface of the nasomuscular flap. This will keep the knot on the nasal side and is considered to be the keystone stitch of the furlopalatoplasty as it pulls the nasomuscular flap posteriorly and to the left and it narrows the posterior pharynx. Upon transposition and closure of the nasal mucosal only flaps, we then work up to the tip of the uvula from the nasal side and bring this together to re-approximate this in anatomic fashion. Once the buccal fat flaps have been secured, we now are ready to transpose the oral flaps. The first oral flap to be transposed is the left-sided oromuscular flap which is going to be transposed posteriorly and to the right. Note that we are going to take a three-point suture through the oromuscular flap to preserve the tip and we're going to take it as far back as possible, recalling that this incision was made further posterior than the conventional 60-degree z-plasty so as to transpose the muscle as close to the anterior tonsillar pillars as possible to give a posterior muscular transposition. We are now ready to take the right-sided oral mucosal only flap and transpose it anteriorly and to the left, coming again through the flap and coming into the left-sided defect. Recall that we have released the mucoperiosteum anteriorly so as to decrease tension on this inset. During the inset, we have the added advantage of having vascularized buccal fat beneath the oral mucosal only flap. The oral mucosal only flap is the most tenuous of the flap transpositions and should this break down, this tends to cause significant scarring. Having a vascularized layer beneath this gives added protection and assurance of increased vascularity should there be breakdown. Once the two z-flaps have been transposed, the remaining mucosal incisions are meticulously closed, taking care to avert all edges. I prefer not to use mattress sutures as this eats up more of the mucosa and well-placed simple sutures, catching more of the raw surface and less of the mucosal surface, provides adequate aversion. Pictured here is the final furlough transposition showing all flaps have been transposed, remain viable and all oral mucosal surfaces have been closed.

flap transposition

mucoperiosteum

nasomuscular flap

buccal fat pads

mucosal incisions