Int. J. Oral Maxillofac. Surg.

2015; 44: 738–744

http://dx.doi.org/10.1016/j.ijom.2015.01.005, available online at http://www.sciencedirect.com

Clinical Paper
Cleft Lip and Palate

Comparison of the effect of the D. Isik 1,, A. Bora2, S. Yuce3,

R. Davran4, O. F. Kocak3, Y. Canbaz3,
S. Avcu2, B. Atik5

rotation palatoplasty and V–Y

1
Department of Plastic, Reconstructive and
Aesthetic Surgery and Department of Oral
and Maxillofacial Surgery, Faculty of
Medicine, Izmir Katip Celebi University, Izmir,

pushback palatoplasty Turkey; 2Department of Radiology, Faculty of

Medicine, Yüzüncü Yıl University, Van, Turkey;
3
Department of Plastic, Reconstructive and

techniques on palate elongation

Aesthetic Surgery, Faculty of Medicine,
Yüzüncü Yıl University, Van, Turkey;
4
Department of Radiology, Faculty of
Medicine, Mustafa Kemal University, Hatay,

with magnetic resonance Turkey; 5Department of Plastic,

Reconstructive and Aesthetic Surgery,
Faculty of Medicine, Medeniyet University,
Istanbul, Turkey

imaging
D. Isik A. Bora, S. Yuce, R. Davran, O.F. Kocak, Y. Canbaz, S. Avcu, B. Atik:
Comparison of the effect of the rotation palatoplasty and V–Y pushback palatoplasty
techniques on palate elongation with magnetic resonance imaging. Int. J. Oral
Maxillofac. Surg. 2015; 44: 738–744. # 2015 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Most surgical techniques used in cleft palate repair require the extension of
the palate to the pharynx. However, no adequate information exists regarding the
extent to which this elongation obtained during operation continues in late
postoperative period. In this study, we compared and measured palate elongation in
patients with a cleft palate who underwent a V–Y pushback or rotation palatoplasty,
by means of magnetic resonance images obtained before and 1 year after surgery.
The hard palate, soft palate, and total palate lengths were measured for all of the
patients, and the velopharyngeal opening area width was calculated. In patients who
underwent the V–Y pushback technique (n = 13), the total palate and soft palate
lengths were shortened by an average of 0.10 and 0.14 cm after surgery,
respectively. However, the hard palate length was elongated by an average of
0.13 cm. In the rotation palatoplasty group (n = 13), the total palate, hard palate, and
soft palate lengths were elongated by 0.57, 0.10, and 0.49 cm, respectively. The
Keywords: cleft palate; palatoplasty; V–Y push-
velopharyngeal opening was narrowed by 0.06 cm2 using the V–Y pushback back; rotation palatoplasty.
technique and by 0.29 cm2 using the rotational palatoplasty. This study
demonstrated that the palate does not elongate during the V–Y pushback technique, Accepted for publication 8 January 2015
as expected. However, rotational palatoplasty elongates the soft palate. Available online 1 March 2015

0901-5027/060738 + 07 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

To normalize the physiological functions of
patients with a cleft palate, including
speech and sucking, the anatomical disor-
der must be repaired appropriately. Within
the historical development of cleft palate
repair, each surgical technique has separat-
ed the nasal and oral cavities from one
another.1–14 In addition to this basic surgi-
cal goal, several techniques have focused
on improving the anatomical repair of the
palate muscles.1–3 Some techniques have
been directed towards increasing the palate
length,4–8 whereas others have focused on
both anatomical repair of the muscles and
increasing the palate length.9
The V–Y pushback technique is an ef-
fective surgical technique for cleft palate
repair and is the first choice in many clinics
interested in the treatment of patients with a
cleft palate. The rotation palatoplasty is a
new cleft palate repair technique developed
by the senior author of this article (DI).9
This surgical technique depends on the
principle that the entire soft palate is sepa-
rated from the hard palate and then the soft
palate is turned into a rotation flap that
includes the oral mucosa and tensor veli
palatini and levator veli palatini muscles.
The flap is then extended through the pos-
terior pharynx.
In this study, we compared the palatal
elongation and radiological data by means
of magnetic resonance images obtained
before and 1 year after surgery from
patients who had undergone both techni-
ques. We also examined healthy children
who had undergone nasopharyngeal mag-
netic resonance imaging (MRI) for other
reasons, to determine the extent of palate
elongation due to each of these techniques.
Materials and methods
This study was approved by the local
ethics committee. The records of the Plas-
tic, Reconstructive and Aesthetic Surgery
Clinic of the Medical Faculty Hospital of
Yüzüncü Yıl University were reviewed
retrospectively. One hundred and sixty-
seven cases of cleft palate repair per-
formed between 2002 and 2012 were re-
trieved. Between 2002 and 2008, 100
patients were treated with the V–Y push-
back and Furlow palatoplasty techniques.
Table 1. Study inclusion and exclusion criteria.
Inclusion criteria
Age between 4 and 12 years
Veau class 2 cleft
V–Y pushback and rotation
palatoplasty surgery
High quality MRI available
MRI obtained before surgery
and 1 year after surgery
Palatoplasty techniques and palate elongation
Between 2008 and 2012, 67 patients were
treated with the rotation palatoplasty tech-
nique. If the patients were older than 4
years of age and had undergone cleft
palate repair at the same clinic, their
palate length and velopharyngeal sphere
measurements were recorded using preop-
erative and postoperative dynamic and
static MRI.
An MRI study was performed retro-
spectively including patients aged 4 to
12 years who had undergone a cleft palate
repair with the V–Y pushback technique
(Wardill–Kilner) or the rotation palato-
plasty technique due to a Veau class 2
cleft palate. The patients had all had an
MRI scan before surgery and another at 1
year after surgery. The exclusion criteria
were age >12 years, Veau class 1, 3, and 4
cleft palates, lack of a high-quality MRI
from which measurements could be per-
formed, and no MRI obtained at 1 year
after surgery. The inclusion and exclusion
criteria are listed in Table 1.
Among the patients included in this
study, 13 had undergone the V–Y pushback
technique (group VY) and 13 the rotation
palatoplasty technique (group R). To com-
pare the MRI measurements of these
patients with those of healthy children,
we also examined the imaging findings of
patients aged 4 to 12 years who had under-
gone a nasopharyngeal MRI for other rea-
sons, but who were not diagnosed with any
pathology. These patients were included in
the study as a control group (group C).
Although the patients in group R and group
VY each had two MRI of the nasopharynx,
one done before surgery and the other at the
1-year follow-up, these measurements
were compared to a single nasopharynx
MRI from the children in group C. To
decrease the analysis errors, each measure-
ment was performed by two radiologists
who had no knowledge of the patient group
assignments. The results from the radiolo-
gists were averaged for each patient, and
the data were then analyzed.
Surgical details for the V–Y pushback
palatoplasty technique (group VY)
In this surgical technique, a hard palate
mucoperiosteal flap is retroposed in the
Exclusion criteria
Age <4 years or >12 years
Veau class 1, 3, and 4 clefts
Surgery by Furlow or other techniques
No high quality MRI available
No MRI obtained 1 year after surgery
739
V–Y style, and the cleft palate repair is
performed by increasing the anteroposter-
ior length. The palatal muscles (levator
veli palatini and aponeurosis of the tensor
veli palatini) are dissected from the nasal
and oral mucosa and then sutured along
the middle, in accordance with the intra-
velar palatoplasty technique. After V–Y
pushback, the raw membranous bone areas
remain in the mucoperiosteal flap area.
These areas close spontaneously by muco-
salization.
Surgical details for the rotation
palatoplasty technique (group R)
This approach uses incisions from the
tooth margins and cleft margins, which
is similar to the von Langenbeck tech-
nique. The mucoperiosteal flaps are ele-
vated from the hard palate. A blunt
dissection is made to turn behind the
greater palatine artery. The nasal mucosa
is then scraped from the back of the pala-
tine bone. The initial surgery performed is
the same as for the von Langenbeck tech-
nique. After this phase, a periosteal scrap-
er is placed behind the greater palatine
artery and a horizontal incision is made to
separate the soft palate and hard palate.
While making this incision, the surgeon
should be careful not to injure the greater
palatine artery. The soft palate and the
hard palate are then separated from each
other. The soft palate flaps are formed, as
in the incomplete cleft palate mentioned
above, after repairing the nasal mucosa.
The oral musculomucosal flaps that were
prepared as rotator flaps are rotated and
sutured to each other. The soft palate is
then sutured to the hard palate.9,13,14
MRI
The MRI examinations were performed
using a Siemens Magnetom Symphony
system (Siemens, Erlangen, Germany) with
the following features: a magnet with
1.6 M, a field power of 1.5 Tesla (T), a
high magnetic field power, a gradient of
30 mT/m, and a field of view (FOV) greater
than 50 cm. To evaluate the anatomical
structures and identify additional airway
pathologies, measurements were recorded
during the resting period, especially those
associated with T1-weighted sequences.
The following parameters were used: a
T1-Weigted Fast Spin Eko (FSE) sequence
in the sagittal and axial plane, repetition
time (TR)/ echo time (TE):582/10 ms, Flip
angle 150 degrees, FOV 300, matrix size
200  256, NEX(number of excitations) 2,
section thickness 3.5 mm, scan time 20
seconds within the sagittal and axial planes.
740 Isik et al.

The images from each patient were ar-

chived on a CD for examination after im-
aging.
A cephalometric examination was per-
formed on the archived images using a
workstation (Leonardo; Siemens, Erlanger,
Germany), by evaluating the lengths of the
total palate, soft palate, and hard palate in
centimetres. The velopharyngeal opening
was measured in square centimetres. The
total palate length (TPL), hard palate length
(HPL), and soft palate length (SPL) were
measured in the sagittal plane within the
section in which all the structures of the
corpus callosum were clearly visible. The
velopharyngeal opening (VPO) was mea-
sured in the axial plane within the section in
which the cerebellar inferior structures and
dens axis odontoid arch were visible.
Fig. 1. Sagittal section reference points used for the cephalometric analysis: MRI and schematic
drawing. Ba: basion; N: nasion; ANS: anterior nasal spine; PNS: posterior nasal spine; PW:
posterior pharyngeal wall; U: distal end of the uvula.
Cephalometric analysis
The cephalometric analysis was performed
using midsagittal T1 A images taken in the
supine position. The reference points are
indicated in Fig. 1. The axial figures were
examined at the level where the dens axis
odontoid arch and cerebellum inferior
structures are visible (Fig. 2). In the MRIs
of the patients, the anterior nasal spine
(ANS), posterior nasal spine (PNS), and
distal end of the uvula (U) were identified
in the sagittal plane. The TPL was calcu-
lated as the distance between ANS and U,
the HPL was calculated as the distance
between ANS and PNS, and the SPL was
calculated as the distance between PNS and
U. The VPO was measured in square centi-
metres in the axial sections obtained pre-
operatively and postoperatively using a
semi-automated calculation program in
both patient groups; the VPO was also
measured in the control group.

Fig. 2. MRI T1. A axial section showing measurement of the velopharyngeal opening (labelled Statistical analysis
VFA).
The means and standard deviations of all
measurements were calculated. All data
were analyzed using SPSS v. 16 software

Table 2. Average values of palate measurements performed in all groups (the data are provided as the mean  standard deviation). The difference
was calculated by subtracting the postoperative value from the preoperative value.
TPL (cm) HPL (cm) SPL (cm) VPO (cm2)
Group R
Preoperative 5.20  0.69 2.72  0.50 2.48  0.84 1.86  1.65
Postoperative 5.77  0.60 2.82  0.52 2.97  0.69 1.57  1.18
Difference +0.57 +0.10 +0.49 0.29
Group VY
Preoperative 5.26  0.93 2.80  0.47 2.40  0.74 1.93  0.37
Postoperative 5.16  0.80 2.93  0.53 2.26  0.43 1.87  0.54
Difference 0.10 +0.13 0.14 0.06
Group C 7.33  0.84 4.03  0.45 3.30  0.50 1.51  0.34
TPL, total palate length; HPL, hard palate length; SPL, soft palate length; VPO, velopharyngeal opening.
 Palatoplasty techniques and palate elongation 741

Postop vs.

VY vs.

TPL, total palate length; HPL, hard palate length; SPL, soft palate length; VPO, velopharyngeal opening; Preop, preoperative; Postop, postoperative; R, group R; VY, group VY. Significant at
control
<0.01
0.05
(SPSS Inc., Chicago, IL, USA). To deter-

control
mine the significance of the dependent vari-

0.39
0.05
ables, the preoperative and postoperative
measurements within each group were
calculated and the Wilcoxon test (two re-

control
Preop vs.
lated samples) was used. To compare the

R vs.

0.05
0.39
control
0.73
<0.01
independent variables between groups, the
Mann–Whitney U-test (two independent
samples) was used. A P-value of 0.05

VPO (cm2)
was considered to be statistically significant.

VPO (cm2)

R vs. VY
Preop vs.
Postop

0.58
0.45
0.03
0.03
Results
Each group included 13 patients. The av-
erage age of the patients in group R at

Postop vs.

VY vs.
control
surgery was 7.73 years; nine were male

0.02
<0.01
control
and four were female. The average age of

0.08
<0.01
the patients in group VY at surgery was
9.92 years; six were male and seven were
female. In group C, the average age of the

control
Preop vs.
children at MRI was 9.02 years and seven

R vs.

0.01
0.08
control
were male and six female. The average

0.01
0.02
values of the palate measurements from
the static MRIs of these patients and the P-
values calculated for the comparisons be-

SPL (cm)

R vs. VY
SPL (cm)
Preop vs.
tween and within groups are given in

0.73
<0.01
Postop
Tables 2 and 3. The comparisons between

0.01
0.3
groups are illustrated in Figs. 3 and 4. The
comparisons of the palate measurements
in each group before and after surgery are
Postop vs.

shown in Figs. 5 and 6.

VY vs.
control
<0.01
<0.01
control

In group R patients, the values of TPL,

<0.01
<0.01

HPL, and SPL increased significantly after

surgery compared to those obtained in the
preoperative period, and VPO decreased control
significantly. The TPL and HPL values of
Preop vs.

<0.01
<0.01
R vs.
control

the patients in group R before and after

<0.01
<0.01
Table 3. P-values for the comparisons between the groups and within the groups.

surgery and the preoperative SPL values

were significantly lower than those of the
HPL (cm)

controls. Although the postoperative SPL

R vs.
HPL (cm)

of group R was lower than that of the

0.59
Preop vs.

VY
1.0
Postop

control group, this difference was not

0.04

statistically significant (P = 0.08). A com-

0.1

parison of group R and the control group

VY vs.
control

with respect to VPO values showed a

<0.01
<0.01
Postop vs.

significant difference. However, there

was no difference after surgery.
control
<0.01
<0.01

There was no statistically significant

difference between the R and VY groups
control

for any of the variables measured before

<0.01
<0.01
R vs.

surgery (TPL, HPL, SPL, and VPO). In the

Preop vs.

postoperative period, there was no differ-

control
<0.01
<0.01

ence observed in TPL, HPL, or VPO.

However, the SPL values were significant-
TPL (cm)

R vs. VY

ly higher in group R than in group VY.

There were significant differences
TPL (cm)
Preop vs.

0.70
0.26

detected between group VY and the con-

Postop
0.01

trol group for all of the variables measured

0.3

preoperatively and postoperatively. The

patients in group VY have shorter palate
Postoperative
Preoperative

lengths and larger VPO values in the

Group VY

P  0.05.
Group R

period before and after surgery compared

to the control group. When we compared
the postoperative values of group VY with
742 Isik et al.
Fig. 3. Comparisons of preoperative average palate measurements between group R and group
VY, and between these groups and the control group (g indicates P > 0.05; b indicates
P  0.05).
Fig. 4. Comparisons of the first-year postoperative average palate measurements between group
R and group VY, and between these groups and the control group (g indicates P > 0.05; b
indicates P  0.05).
their preoperative values, no significant
differences were observed. The TPL and
SPL values were lower and the HPL
values had increased. Additionally, in
group VY, the VPO values were signifi-
cantly lower after surgery.
Fig. 5. Comparisons of the preoperative average palate measurements of patients in group R
with the measurements taken 1 year after surgery (g indicates P > 0.05; b indicates P  0.05).
Discussion
During the first month of embryonic de-
velopment, both halves of the palate are
within a structure that extends vertically
on both sides of the tongue. During weeks
11 and 12, the palates fuse by passing each
other on a horizontal plane. During the
development of patients with a cleft pal-
ate, the tensor veli palatini muscles cannot
unite in the midline and adhere to the
posterior margin of the hard palate. As a
result, the levator veli palatini muscles
adhere to both the posterior margin of
the hard palate and the two mucosal layers
within the margin of the cleft. The dis-
orientation of these muscles on the soft
cleft palate means that the mucosa that
moves with the muscles during the em-
bryonic period cannot unite in the midline.
The result is that the palate muscles and
mucosa are not found in their normal
anatomical positions and there is a short
soft palate.
In 1962, Edgerton reported that through
dissection of the greater palatine artery
and neurovascular bundle, the flaps could
elongate the oral mucosa of the palate.7 In
1970, Millard published the results of 10
years of experience using these flaps in an
individual palate repair technique that
elongated the nasal mucosa of the soft
palate.6 In 1986, Furlow used double op-
posing z-plasty flaps that were removed
from the soft palate to increase palate
elongation.4 Guneren and Uysal10 showed
the postoperative lateral roentgenographic
palate length to be elongated by 12.47 mm
in patients who had undergone the Furlow
palatoplasty. Wardill suggested pushing
back the mucoperiosteal flaps to ensure
palate elongation.8 Using measurements
obtained from dynamic MRI, Atik
et al.11 reported that palate elongation
was not ensured after V–Y pushback pala-
toplasty. Bae et al.12 reported that the
intraoperative two-flap palatoplasty elon-
gated the palate to a greater extent than the
V–Y pushback in the incomplete cleft
palate. In patients with a complete cleft
palate, the Furlow palatoplasty elongated
the palate to a greater extent than the V–Y
pushback technique. Rotation palatoplasty
is believed to ensure palate elongation by
turning all of the soft palate into rotation
flaps during surgery in patients with a cleft
palate. It has been shown that the soft
palate can be elongated by an average
9.5 mm (range 6–14 mm) intraopera-
tively.9 All of these studies were focused
on elongating the palate length. A short-
ened palate length is observed in patients
with a cleft palate, and this shortened
length may increase the velopharyngeal
opening, which causes velopharyngeal
failure. Palate elongation is required to
prevent velopharyngeal failure.
The surgical elongation of the palate
length is not guaranteed to remain after
surgery. It is logical to assume that a

Fig. 6. Comparisons of the preoperative average palate measurements of patients in group VY
with the measurements taken 1 year after surgery (g indicates P > 0.05; b indicates P  0.05).
straight line scar on a repaired cleft palate
will gradually shorten due to contracture
of the scar. However, there is inadequate
information in the literature regarding to
what extent the elongation obtained during
surgery is maintained after cleft palate
repair.
In the present study, a comparison was
made to determine the extent of palate
elongation using the rotation palatoplasty,
which is a recently developed surgical
technique, and the V–Y pushback tech-
nique. The V–Y technique is a frequently
used surgical technique. It was found that
the hard palate continues to elongate after
surgery using both techniques, and that the
soft palate remains significantly longer
after rotation palatoplasty. In group VY
patients, the average soft palate length was
shorter at 1 year after surgery. If the
surgical technique does not result in elon-
gation, which occurs in the rotation ma-
noeuvre during surgery in straight line
repairs, then the soft palate may shorten
due to scar contracture. The V–Y push-
back technique (Wardill–Kilner opera-
tion) is a surgical technique in which
the oral mucosa is classically pushed back.
With this surgical technique, an elonga-
tion or pushback manoeuvre is not applied
to the nasal mucosa. However, if any
actual elongation is observed in the oral
mucosa, then the nasal mucosa would be
required to elongate. We did not find this
requirement for the V–Y pushback pala-
toplasty. With other techniques, such as
the Furlow palatoplasty, rotation palato-
plasty, Millard palatoplasty, and the indi-
vidual technique of Moore in which the
palate is pushed back, and also in patients
with velopharyngeal failure, nasal mucosa
elongation is required because actual elon-
gation is observed in the oral mucosa. This
situation indicates that an actual elongation
Palatoplasty techniques and palate elongation
is not ensured during surgery using the V–Y
pushback technique.
In this study, we observed that while the
TPL was elongated in group R patients
after surgery, there was no statistically
significant difference for the group VY
patients. However, the TPL was short-
ened. The elongation of the TPL in group
R patients was dependent on the elonga-
tion of the soft palate (Fig. 5). In group VY
patients, the shortened TPL resulted from
the shortening of the soft palate (Fig. 6).
For both surgery groups, we found that the
TPL, HPL, and SPL values were signifi-
cantly lower than those of the controls
before the surgeries. At 1 year after sur-
gery the TPL and HPL values of both
groups were still significantly lower than
those of the controls. Furthermore, there
was no statistical difference in SPL be-
tween group R and control group patients.
However, the group VY patients had sig-
nificantly lower SPL values than patients
in the control group. This result shows that
patients with a cleft palate repaired by
rotation palatoplasty have an elongated
soft palate similar to that of healthy chil-
dren. However, after cleft palate repair
with V–Y pushback and intravelar velo-
plasty, the patients still have a significant-
ly shorter soft palate than healthy children.
The VPO in each group narrowed sig-
nificantly. However, the VPO of group R
patients was narrower than that of group
VY patients after surgery. There was no
difference between the postoperative av-
erage VPO values for the group R patients
and the control group. In group VY
patients, there was a larger VPO after
surgery compared to the control group.
Although promising results were
achieved for the rotation palatoplasty in
the current study, palatal elongation deter-
mined by radiological data does not
743
represent functional outcomes. In 2011,
the senior author (DI) described the rota-
tion palatoplasty and compared the results
of speech analysis of these patients with
those of healthy children. The amounts of
intraoperative elongation of the soft palate
were also recorded, and a postoperative
audiometric assessment was also done.
According to that study, although the pre-
operative speech analysis results were
significantly worse in the patients than
in healthy children, no significant differ-
ence was found between the healthy chil-
dren and patients with cleft palate after
repair with the rotation palatoplasty.9
Several researchers have attempted to
elongate the soft palate in cleft palate
repair. However, there is limited informa-
tion in the literature regarding the extent to
which this elongation persists in the long
term. In this study, we found that in V–Y
pushback palatoplasty, the soft palate
shortens after surgery and this is depen-
dent on scar contracture. In contrast, in
rotation palatoplasty, significant elonga-
tion was observed in the soft palate at 1
year after surgery.
Funding
None.
Competing interests
None.
Ethical approval
This study was approved by the local
ethics committee of Yüzüncü Yıl Univer-
sity, Medical Faculty Hospital (reference
number 28052014-01).
Patient consent
Not required.
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