PMC7241469_01
Illustration of the state of the LVPM. The LVPM continues from side to side, and the anterior portion is attached to the posterior border of the hard palate.
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As for intraoperative findings, her LVPM continued from side to side completely, as in the normal anatomy, and the anterior portion was attached to the posterior border of the hard palate (Figure 1).
The first operation. (A) Intraoral findings. There are no features of SMCP. (B) Separation of the abnormal attachment of the LVPM from the PNS and soft palate elongation on the nasal side. A space occurs after posterior elongation (white arrow). The pedicle of the BMMF is denuded (white dotted arrow). (C) The space is filled by the right BMMF (white arrow). (D) After the first operation.
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Therefore, Furlow's palatoplasty and intravelar veloplasty, which separate the LVPM from the nasal mucosa, were not performed to maintain the continuity of the LVPM, and for the first operation, a right BMMF (35 mm x 12 mm), of which the pedicle was denuded, was performed for soft palate elongation on the nasal side, along with Z-plasty without LVPM separation on the oral side (Figures 2 and 3). There was also no space between the posterior pharynx and the soft palate during phonation on LPG (Figure 6, Supplementary Video 2).
Illustration of Figure 2(A-D). A: The pedicle of the right BMMF is denuded (red area).
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Therefore, Furlow's palatoplasty and intravelar veloplasty, which separate the LVPM from the nasal mucosa, were not performed to maintain the continuity of the LVPM, and for the first operation, a right BMMF (35 mm x 12 mm), of which the pedicle was denuded, was performed for soft palate elongation on the nasal side, along with Z-plasty without LVPM separation on the oral side (Figures 2 and 3).
The second operation. (A) Design of the second operation. A left BMMF for soft palate elongation on the nasal side and a skin graft (SG) for soft palate elongation of the oral side were designed. (B) Soft palate elongation on the nasal side. A space occurs after posterior elongation (white arrow). (C) The space is filled by the left BMMF (white arrow). (D) One year after the second operation. Engrafted SGs (white arrow).
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Therefore, a left BMMF (35 mm x 12 mm) for soft palate elongation on the nasal side was performed again, and a skin graft, taken from her groin on the oral side, was performed for the defect of the hard palate (Figures 4 and 5).
Illustration of Figure 4(A-D). A: The basal portion of the left BMMF is denuded (red area).
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Therefore, a left BMMF (35 mm x 12 mm) for soft palate elongation on the nasal side was performed again, and a skin graft, taken from her groin on the oral side, was performed for the defect of the hard palate (Figures 4 and 5).
Findings of NPS and LPG. (A) LPG during phonation before the first operation. No contact between the posterior pharynx and soft palate (black arrow). (B) NPS midline view of the velopharyngeal valve during phonation before the first operation. A large defect is seen. (C) LPG during phonation after the second operation. The space between the posterior pharynx and the soft palate is completely closed (black arrow). (D) NPS midline view of the velopharyngeal valve during phonation after the second operation. The space between the posterior pharynx and the soft palate is completely closed.
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There was also no space between the posterior pharynx and the soft palate during phonation on LPG (Figure 6, Supplementary Video 2).