Anatomic basis of cleft palate and velopharyngeal surgery: Implications from a fresh cadaveric study
Anatomic basis of cleft palate and velopharyngeal surgery: Implications from a fresh cadaveric study
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DOI：
10.1097/00006534-199803000-00007
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发表时间：
1998-03-01
影响因子：
3.6
通讯作者：
Rajendran, K
中科院分区：
文献类型：
--
作者：
Huang, MHS;Lee, ST;Rajendran, K
本研究的目的是应用18例新鲜成人尸体标本的腭帆提肌、腭咽肌和上级缩肌的解剖学研究结果，分析目前在腭咽功能和腭裂手术中存在的争议。观察到腭帆提肌形成肌肉吊索，将腭帆从颅底悬吊。其纤维占据了软腭的中间50%，横向排列，在中线上没有明显的重叠。它在腭咽闭合的软腭组件中很好地发挥了原动机的作用。腭咽肌的软腭部分由两个头组成，它们紧紧抓住提肌，并在中线附近插入提肌。其咽部插入咽侧壁和咽后壁的上级缩肌。这两块肌肉共同在咽口周围形成了一个括约肌，表明这两块肌肉都参与了咽口闭合的咽部部分。基于腭成形术的目标是恢复正常解剖结构的前提下，行腭腭成形术具有良好的基础，并且理论上改善了软腭和咽壁的功能，因为它纠正了提肌和腭咽肌的畸形。虽然Furlow腭成形术也使这些软腭肌在横向位置正确地重新定向，但由此产生的提肌和腭咽肌在中线上的重叠在形态上是异常的。此外，在宽裂中使用大Z成形术皮瓣可能会导致过度的侧向张力，增加瘘形成的风险，并导致软腭拉伸能力受损。垂直咽瓣的抬高会分开上级缩肌的纤维，并有可能损害咽壁功能。咽括约肌成形术对咽壁解剖结构的干扰较小。阻塞性结局的可能性似乎与病灶、长皮瓣和紧密重叠型皮瓣插入的使用有关。此外，瓣内移的水平也很重要：悬雍垂水平的内移导致阻塞的风险最大，而试图关闭下咽的水平的更高内移似乎提供了实现下咽功能的最佳机会，同时避免了鼻音减退和阻塞。
The purpose of this investigation was to apply the findings of an anatomic study of the levator veli palatini, palatopharyngeus, and superior constrictor muscles in 18 fresh cadaveric specimens of normal adults to analyze current controversies in velopharyngeal function and cleft palate surgery. The levator veli palatini was observed to form a muscular sling, suspending the velum from the cranial base. Its fibers occupied the middle 50 percent of the velum, lying in transverse orientation and without significant overlap across the midline. It is well placed to function as the prime mover in the velar component of velopharyngeal closure. The velar component of the palatopharyngeus consisted of two heads clasping the levator and inserting into the latter just short of the midline. Its pharyngeal component inserted into the superior constrictor in the lateral and posterior pharyngeal walls. Together, these two muscles formed a sphincter around the velopharyngeal port, suggesting that both muscles are involved in the pharyngeal component of velopharyngeal closure. Based on the premise that the goal of palatoplasty is to restore normal anatomy, the intravelar veloplasty has a sound basis, and theoretically improves both velar and pharyngeal wall function because it corrects the dysmorphology of both the levator and palatopharyngeus. Although the Furlow palatoplasty also reorients these velar muscles correctly in the transverse position, the resulting overlap of the levator and palatopharyngeus across the midline is morphologically abnormal. In addition, the use of large Z-plasty flaps in wide clefts may cause excessive lateral tension, increasing the risk of fistula formation and causing an impairment of velar stretch capacity. The raising of a vertical pharyngeal flap divides the fibers of the superior constrictor and has the potential to impair pharyngeal wall function. The sphincter pharyngoplasty interferes less with pharyngeal wall anatomy. The potential for an obstructive outcome seems to be related to the use of nide, long flaps and a tight, overlapping type of flap inset. In addition, the level of flap inset is important: an inset at the level of the uvula has the greatest risk of causing obstruction, whereas a higher inset at the level of attempted velopharyngeal closure seems to provide the best opportunity for achieving velopharyngeal competence while avoiding hyponasality and obstruction.