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Teaching the pharyngeal flap and sphincter pharyngoplasty: The sticky note method
International Journal of Pediatric Otorhinolaryngology 79 (2015) 1905–1908
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Teaching the pharyngeal flap and sphincter pharyngoplasty: The sticky note method Jake J. Lee a, Noel Jabbour a,b,* a b
University of Pittsburgh School of Medicine, Department of Otolaryngology, 3550 Terrace St., Pittsburgh, PA 15261, United States Division of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 August 2015 Received in revised form 28 August 2015 Accepted 29 August 2015 Available online 3 September 2015
Objective: To demonstrate a cost-effective, quick, and easily reproducible three-dimensional sticky note model to enhance the understanding and conceptualization of the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty. Methods: The method involves making specified incisions and rearrangements of readily available components, including disposable clear plastic cups, yellow and pink sticky notes, and white paper. Once assembly is complete, further incisions and remodeling are performed to simulate a pharyngeal flap or sphincter pharyngoplasty. Results: The cost of the materials to make one model was $0.94. Average construction time was less than 10 min. Conclusion: This three-dimensional model is an efficient, interactive, and simple visual aid to teach surgical trainees the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Velopharyngeal dysfunction Velopharyngeal insufficiency Pharyngeal flap Sphincter pharyngoplasty Simulation Surgical education
1. Introduction Velopharyngeal dysfunction (VPD) refers to the inability to completely close the space between the velum and posterior pharyngeal wall during speech, resulting in nasal emission, hypernasality, and poorly intelligible speech. The pharyngeal flap and sphincter pharyngoplasty are two alternative surgical treatments for VPD first described in 1875 and 1950, respectively [1,2]. These surgical techniques are designed to create a functional seal between the nasopharynx and oropharynx during speech without creating nasal airway obstruction [3]. The pharyngeal flap procedure involves suturing a central myomucosal flap from the posterior pharyngeal wall to the posterior velum. This flap corrects central gaps and leaves smaller lateral ports on each side. While some advocate calibrating the size of the lateral ports, others endorse that successful occlusion of the pharyngeal port is more dependent on the dynamic medial movement of the lateral pharyngeal walls [4,5]. This procedure is thus ideal for patients with adequate lateral pharyngeal wall
* Corresponding author at: 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States. Tel.: +1 412 692 5466; fax: +1 412 692 6074. E-mail address: [email protected] (N. Jabbour). http://dx.doi.org/10.1016/j.ijporl.2015.08.042 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
motion visualized on video nasoendoscopy or multiview speech videofluoroscopy in the anteroposterior dimension [6]. On the other hand, the sphincter pharyngoplasty procedure involves the elevation and medialization of bilateral palatopharyngeal myomucosal flaps from the posterior tonsillar pillars. The flaps are then sutured to each other end-to-end and into a transverse incision in the posterior pharyngeal wall, thereby creating a transverse mound of tissue that resolves lateral defects and creates a smaller central port [7]. A major drawback of these two procedures is the technical challenge of teaching surgical trainees. Inherent difficulties with pharyngeal flaps and sphincter pharyngoplasty include the need to work in a small cavity, poor visualization, poor depth perception, awkward angles, and limited access by both the surgeon and assistant [8]. These procedures were conventionally taught using twodimensional (2D) drawings or photographs in textbooks. Recently, three-dimensional (3D) teaching models have been designed for better visualization and conceptualization of the Furlow doubleopposing Z-plasty, the first of which utilized styrofoam, cardboard, and latex [9]. Another model utilized sticky notes for 3D visualization of the same procedure, which greatly reduced construction time [10]. 3D cleft palate simulator models have also been created to facilitate real-time surgical training; however, these either required materials that were expensive and difficult to procure or required dental laboratory facilities for assembly [8,11].
J.J. Lee, N. Jabbour / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1905–1908
1906
Fig. 1. Steps 1–4 of the plastic cup assembly. (A and B) Anterior view. (C and D) Posterior view. (E) Completed plastic cup model, anterolateral view.
Despite the recent development of 3D models for Furlow palatoplasty, there are no 3D models for teaching pharyngeal flaps or sphincter pharyngoplasty. We propose a very affordable and swiftly reproducible 3D teaching model utilizing sticky notes, a clear plastic cup, and readily available office supplies designed to improve trainees’ understanding and conceptualization of the pharyngeal flap and sphincter pharyngoplasty. 2. Materials and methods Materials that were used to construct this model included a 9fluid ounce (roughly 0.25 L) clear plastic cup, 800 600 yellow and pink sticky notes, 1100 8.500 sheets of white paper, scissors, knife/ scalpel, clear tape, and a metric ruler. The first portion of assembly involved construction of the plastic cup (Fig. 1). (1) Two vertical straight 7.5-cm incisions were made from the rim of the cup with scissors to create a strip measuring 2.0-cm in width at the top and 1.25-cm in width at the bottom, which represented the nasal septum. (2) Two more identical incisions 2.0-cm lateral to the first two incisions were created to generate two new strips measuring 2.0-cm in width at the top and 1.25-cm in width at the bottom. These two new strips were then cut 5.0-cm from the rim to form shorter strips, which represented the palatal shelves. These two steps resulted in a 7.5cm long central strip and two 3.0-cm long lateral strips. (3) A knife was then used to create a 2.0-cm transverse slit that was 5.5-cm from the rim on the posterior surface of the cup. (4) The central strip was then retracted back through the slit and pulled 2.5-cm above the slit so that there was tension on the strip in order to resemble the posterior border of the vomer.
The second portion of assembly involved construction of the posterior pharyngeal wall using 800 600 yellow and pink sticky notes (Fig. 2). We designed a printable PDF template of the posterior pharyngeal wall model for easy tracing that is available online (Supp. material). If printed in color, the template can also be used to visualize the palatine tonsils, which are marked as darker patches on the lateral aspects of the posterior pharyngeal wall model. (1) One 800 600 pink sticky note was attached to an 800 600 yellow sticky note, which then attached to an 1100 8.500 sheet of white paper. The pink represented pharyngeal mucosa, yellow represented pharyngeal muscle and submucosal tissue, and white represented prevertebral fascia. We found it most useful to have the sticky portion of the yellow note attached upside-down toward the bottom of the sheet of white paper and then to have the sticky portion of the pink note attached 4.5-cm below the superior edge of the yellow note. (2) Next, the superior border of the posterior pharyngeal wall template was approximated to the superior edge of the pink sticky note and traced. (3) The sticky notes were then cut to create the posterior pharyngeal wall model. Similarly, the third portion involved construction of the palate using 800 600 yellow and pink sticky notes as described previously [10]. We also designed a printable PDF template of the palate model for easy tracing (Supp. material). (1) A pink sticky note was attached to a yellow sticky note, which then attached to another pink sticky note. The superficial pink represented oral mucosa, yellow represented palatal muscle and submucosal tissue, and deep pink represented nasal mucosa. We found it most useful to stagger the pink and yellow sticky notes so that there was an overlapping middle region of 7.5-cm. (3) The sticky notes were then cut with scissors using the palate template as a guide.
Fig. 2. Assembly of the pharyngeal wall model and palate model. (A) Posterior pharyngeal wall model with pink sticky note, yellow sticky note, and white paper attached in an accordion fashion. Pink = pharyngeal mucosa, yellow = pharyngeal muscle and submucosal tissue, white = prevertebral fascia. (B and C) Attachment of the posterior pharyngeal wall model and palate model to the cup, anterior and superior views.
J.J. Lee, N. Jabbour / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1905–1908
1907
Fig. 3. Assembly of the cup model using the pharyngeal wall and palate models with overlying template serving as mucosa. (A) Cutting out the pharyngeal wall and palate models from the supplemental template. (B) Cup model with the pharyngeal wall model inserted and palate model to the side, anterior view. (C) Completed model, anterior view. (D) Completed model, superior view.
The fourth portion involved adding the posterior pharyngeal wall and palate models to the plastic cup design (Figs. 2 and 3). (1) The posterior pharyngeal wall model was gently folded to fit snugly inside the cup. (2) The palate model was then taped to both lateral strips. Once assembly is complete, the trainee can utilize the 3D model to visualize the steps for either a pharyngeal flap or sphincter pharyngoplasty procedure. A pharyngeal flap is performed by (1) making an incision along the posterior pharyngeal wall to form a triangular-tipped flap, (2) elevating the pink and yellow strip off the white paper to mimic elevating the myomucosal flap off the prevertebral fascia, (3) making a 2.0cm midline incision on the soft palate model to split the palate, though other palate insertion techniques can also be modeled, (4) elevating the superficial pink and yellow sticky notes off the deep pink sticky note to simulate creation of a nasomucosal flap, and (5) insertion of the pharyngeal flap into the palate (Fig. 4). The trainee may then complete the model using clear tape in place of sutures to attach the pharyngeal flap to the two halves of the nasomucosal flap. Alternatively, a sphincter pharyngoplasty is performed by (1) making an incision along the posterior pharyngeal wall in a half‘‘H’’ configuration, (2) elevating the bilateral pink and yellow strips off the white paper to simulate elevation of the palatopharyngeal myomucosal flaps off the posterior tonsillar pillars (or by elevating
Fig. 4. Pharyngeal flap model. Elevation of the pharyngeal myomucosal flap, midline splitting of the velum, and insertion of the pharyngeal flap into the palate.
strips medial to the marked bilateral tonsils on the posterior pharyngeal wall template), and (3) transposing the bilateral flaps horizontally to be inset into the transverse incision on the posterior pharyngeal wall (Fig. 5). The trainee may once again complete the model using clear tape in place of sutures to attach the flaps in an end-to-end fashion. 3. Results The total cost of a set of assorted colored 800 600 sticky note pads and set of 80 9-fluid ounce disposable plastic cups was $20.58. The other supplies were readily available throughout the office. This supply was enough to make 22 total models, costing $0.94 per model. Construction time for each model was less than 10 min on average. Existing cup models can also be reloaded with new posterior pharyngeal wall and palate templates to save time for subsequent use. 4. Discussion The pharyngeal flap and sphincter pharyngoplasty are complex, technically challenging procedures due to the small anatomic space, poor visualization, and poor depth perception. Twodimensional images are unable to capture the 3D nature of each
Fig. 5. Sphincter pharyngoplasty model. Elevation of the palatopharyngeal myomucosal flaps off the posterior tonsillar pillars and horizontal transposition of the flaps along the transverse incision on the posterior pharyngeal wall.
1908
J.J. Lee, N. Jabbour / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1905–1908
procedure. The method as outlined above is a low cost, quick, and easily reproducible hands-on 3D model to enhance surgical trainees’ understanding of the intraoral situation of a patient with VPD and conceptualization of the steps of each procedure. It serves as an effective teaching modality of surgical technique for junior surgical trainees, especially those who are not usually afforded the opportunity to perform these complex yet valuable procedures. This model is particularly useful for demonstrating the placement of incisions and the anatomic changes seen with pharyngeal flaps and sphincter pharyngoplasty. It offers real-time visualization of both the obturation of the central port with a pharyngeal flap procedure and the lateral reduction in size of the central port with sphincter pharyngoplasty. It also allows for conceptualization of alternative techniques for pharyngeal flaps, including transverse splitting of the velum and Hogan’s lateral port control, and for sphincter pharyngoplasty, including Orticochea’s modification [4,12,13]. This model has some limitations. The sticky note paper is rigid and curls during elevation and reconstruction. Dampening or gently crumpling the paper helps relieve this problem but still does not accurately simulate the consistency of mucosa and muscle. In addition, the model is not life-sized, and its simplified modeling does not exactly represent the relationship between the soft palate and the palatoglossus and palatopharyngeus muscles. Thus, this anatomical relationship does not demonstrate sphincter pharyngoplasty with complete accuracy yet should still give the trainee a grasp of the geometry of the flaps. While these shortcomings do not make our model ideal for practicing surgical skills such as suturing in space, this model is affordable and rapidly reproducible using material easily obtained in most office settings and serves as a real-time instructional tool for teaching surgical trainees the 3D
geometry and conceptualization of each step of the pharyngeal flap and sphincter pharyngoplasty. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ijporl.2015.08.042. References [1] K. Schoenborn, Ueber eine neue methode der staphylorrhaphie, Verh. Dtsch. Ges. Chir. 4 (1875) 235–239. [2] W. Hynes, Pharyngoplasty by muscle transplantation, Br. J. Plast. Surg. 3 (1950) 128–135. [3] A.S. Woo, Velopharyngeal dysfunction, Semin. Plast. Surg. 26 (2012) 170–177. [4] V.M. Hogan, A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control (l.p.c.) pharyngeal flap, Cleft Palate J. 10 (1973) 331–345. [5] J. Karling, G. Henningsson, O. Larson, A. Isberg, Adaptation of pharyngeal wall adduction after pharyngeal flap surgery, Cleft Palate Craniofac. J. 36 (1999) 166–172. [6] R.V. Argamaso, R.J. Shprintzen, B. Strauch, M.L. Lewin, A.I. Daniller, A.G. Ship, et al., The role of lateral pharyngeal wall movement in pharyngeal flap surgery, Plast. Reconstr. Surg. 66 (1980) 214–219. [7] G.M. Sloan, Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art, Cleft Palate. Craniofac. J. 37 (2000) 112–122. [8] S. Vadodaria, N. Watkin, F. Thiessen, A. Ponniah, The first cleft palate simulator, Plast. Reconstr. Surg. 120 (2007) 259–261. [9] M.S. Matthews, A teaching device for Furlow palatoplasty, Cleft Palate Craniofac. J. 36 (1999) 64–66. [10] M.M. Liu, J. Kim, N. Jabbour, Teaching Furlow palatoplasty: the sticky note method, Int. J. Pediatr. Otorhinolaryngol. 78 (2014) 1849–1851. [11] K. Nagy, M.Y. Mommaerts, Advanced s(t)imulator for cleft palate repair techniques, Cleft Palate Craniofac. J. 46 (2009) 1–5. [12] J. Karling, G. Henningsson, O. Larson, A. Isberg, Comparison between two types of pharyngeal flap with regard to configuration at rest and function and speech outcome, Cleft Palate-Craniofac. J. 36 (1999) 154–165. [13] M. Orticochea, Construction of a dynamic muscle sphincter in cleft palates, Plast. Reconstr. Surg. 41 (1968) 323–327.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Teaching the pharyngeal flap and sphincter pharyngoplasty: The sticky note method Jake J. Lee a, Noel Jabbour a,b,* a b
University of Pittsburgh School of Medicine, Department of Otolaryngology, 3550 Terrace St., Pittsburgh, PA 15261, United States Division of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 August 2015 Received in revised form 28 August 2015 Accepted 29 August 2015 Available online 3 September 2015
Objective: To demonstrate a cost-effective, quick, and easily reproducible three-dimensional sticky note model to enhance the understanding and conceptualization of the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty. Methods: The method involves making specified incisions and rearrangements of readily available components, including disposable clear plastic cups, yellow and pink sticky notes, and white paper. Once assembly is complete, further incisions and remodeling are performed to simulate a pharyngeal flap or sphincter pharyngoplasty. Results: The cost of the materials to make one model was $0.94. Average construction time was less than 10 min. Conclusion: This three-dimensional model is an efficient, interactive, and simple visual aid to teach surgical trainees the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Velopharyngeal dysfunction Velopharyngeal insufficiency Pharyngeal flap Sphincter pharyngoplasty Simulation Surgical education
1. Introduction Velopharyngeal dysfunction (VPD) refers to the inability to completely close the space between the velum and posterior pharyngeal wall during speech, resulting in nasal emission, hypernasality, and poorly intelligible speech. The pharyngeal flap and sphincter pharyngoplasty are two alternative surgical treatments for VPD first described in 1875 and 1950, respectively [1,2]. These surgical techniques are designed to create a functional seal between the nasopharynx and oropharynx during speech without creating nasal airway obstruction [3]. The pharyngeal flap procedure involves suturing a central myomucosal flap from the posterior pharyngeal wall to the posterior velum. This flap corrects central gaps and leaves smaller lateral ports on each side. While some advocate calibrating the size of the lateral ports, others endorse that successful occlusion of the pharyngeal port is more dependent on the dynamic medial movement of the lateral pharyngeal walls [4,5]. This procedure is thus ideal for patients with adequate lateral pharyngeal wall
* Corresponding author at: 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States. Tel.: +1 412 692 5466; fax: +1 412 692 6074. E-mail address: [email protected] (N. Jabbour). http://dx.doi.org/10.1016/j.ijporl.2015.08.042 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
motion visualized on video nasoendoscopy or multiview speech videofluoroscopy in the anteroposterior dimension [6]. On the other hand, the sphincter pharyngoplasty procedure involves the elevation and medialization of bilateral palatopharyngeal myomucosal flaps from the posterior tonsillar pillars. The flaps are then sutured to each other end-to-end and into a transverse incision in the posterior pharyngeal wall, thereby creating a transverse mound of tissue that resolves lateral defects and creates a smaller central port [7]. A major drawback of these two procedures is the technical challenge of teaching surgical trainees. Inherent difficulties with pharyngeal flaps and sphincter pharyngoplasty include the need to work in a small cavity, poor visualization, poor depth perception, awkward angles, and limited access by both the surgeon and assistant [8]. These procedures were conventionally taught using twodimensional (2D) drawings or photographs in textbooks. Recently, three-dimensional (3D) teaching models have been designed for better visualization and conceptualization of the Furlow doubleopposing Z-plasty, the first of which utilized styrofoam, cardboard, and latex [9]. Another model utilized sticky notes for 3D visualization of the same procedure, which greatly reduced construction time [10]. 3D cleft palate simulator models have also been created to facilitate real-time surgical training; however, these either required materials that were expensive and difficult to procure or required dental laboratory facilities for assembly [8,11].
J.J. Lee, N. Jabbour / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1905–1908
1906
Fig. 1. Steps 1–4 of the plastic cup assembly. (A and B) Anterior view. (C and D) Posterior view. (E) Completed plastic cup model, anterolateral view.
Despite the recent development of 3D models for Furlow palatoplasty, there are no 3D models for teaching pharyngeal flaps or sphincter pharyngoplasty. We propose a very affordable and swiftly reproducible 3D teaching model utilizing sticky notes, a clear plastic cup, and readily available office supplies designed to improve trainees’ understanding and conceptualization of the pharyngeal flap and sphincter pharyngoplasty. 2. Materials and methods Materials that were used to construct this model included a 9fluid ounce (roughly 0.25 L) clear plastic cup, 800 600 yellow and pink sticky notes, 1100 8.500 sheets of white paper, scissors, knife/ scalpel, clear tape, and a metric ruler. The first portion of assembly involved construction of the plastic cup (Fig. 1). (1) Two vertical straight 7.5-cm incisions were made from the rim of the cup with scissors to create a strip measuring 2.0-cm in width at the top and 1.25-cm in width at the bottom, which represented the nasal septum. (2) Two more identical incisions 2.0-cm lateral to the first two incisions were created to generate two new strips measuring 2.0-cm in width at the top and 1.25-cm in width at the bottom. These two new strips were then cut 5.0-cm from the rim to form shorter strips, which represented the palatal shelves. These two steps resulted in a 7.5cm long central strip and two 3.0-cm long lateral strips. (3) A knife was then used to create a 2.0-cm transverse slit that was 5.5-cm from the rim on the posterior surface of the cup. (4) The central strip was then retracted back through the slit and pulled 2.5-cm above the slit so that there was tension on the strip in order to resemble the posterior border of the vomer.
The second portion of assembly involved construction of the posterior pharyngeal wall using 800 600 yellow and pink sticky notes (Fig. 2). We designed a printable PDF template of the posterior pharyngeal wall model for easy tracing that is available online (Supp. material). If printed in color, the template can also be used to visualize the palatine tonsils, which are marked as darker patches on the lateral aspects of the posterior pharyngeal wall model. (1) One 800 600 pink sticky note was attached to an 800 600 yellow sticky note, which then attached to an 1100 8.500 sheet of white paper. The pink represented pharyngeal mucosa, yellow represented pharyngeal muscle and submucosal tissue, and white represented prevertebral fascia. We found it most useful to have the sticky portion of the yellow note attached upside-down toward the bottom of the sheet of white paper and then to have the sticky portion of the pink note attached 4.5-cm below the superior edge of the yellow note. (2) Next, the superior border of the posterior pharyngeal wall template was approximated to the superior edge of the pink sticky note and traced. (3) The sticky notes were then cut to create the posterior pharyngeal wall model. Similarly, the third portion involved construction of the palate using 800 600 yellow and pink sticky notes as described previously [10]. We also designed a printable PDF template of the palate model for easy tracing (Supp. material). (1) A pink sticky note was attached to a yellow sticky note, which then attached to another pink sticky note. The superficial pink represented oral mucosa, yellow represented palatal muscle and submucosal tissue, and deep pink represented nasal mucosa. We found it most useful to stagger the pink and yellow sticky notes so that there was an overlapping middle region of 7.5-cm. (3) The sticky notes were then cut with scissors using the palate template as a guide.
Fig. 2. Assembly of the pharyngeal wall model and palate model. (A) Posterior pharyngeal wall model with pink sticky note, yellow sticky note, and white paper attached in an accordion fashion. Pink = pharyngeal mucosa, yellow = pharyngeal muscle and submucosal tissue, white = prevertebral fascia. (B and C) Attachment of the posterior pharyngeal wall model and palate model to the cup, anterior and superior views.
J.J. Lee, N. Jabbour / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1905–1908
1907
Fig. 3. Assembly of the cup model using the pharyngeal wall and palate models with overlying template serving as mucosa. (A) Cutting out the pharyngeal wall and palate models from the supplemental template. (B) Cup model with the pharyngeal wall model inserted and palate model to the side, anterior view. (C) Completed model, anterior view. (D) Completed model, superior view.
The fourth portion involved adding the posterior pharyngeal wall and palate models to the plastic cup design (Figs. 2 and 3). (1) The posterior pharyngeal wall model was gently folded to fit snugly inside the cup. (2) The palate model was then taped to both lateral strips. Once assembly is complete, the trainee can utilize the 3D model to visualize the steps for either a pharyngeal flap or sphincter pharyngoplasty procedure. A pharyngeal flap is performed by (1) making an incision along the posterior pharyngeal wall to form a triangular-tipped flap, (2) elevating the pink and yellow strip off the white paper to mimic elevating the myomucosal flap off the prevertebral fascia, (3) making a 2.0cm midline incision on the soft palate model to split the palate, though other palate insertion techniques can also be modeled, (4) elevating the superficial pink and yellow sticky notes off the deep pink sticky note to simulate creation of a nasomucosal flap, and (5) insertion of the pharyngeal flap into the palate (Fig. 4). The trainee may then complete the model using clear tape in place of sutures to attach the pharyngeal flap to the two halves of the nasomucosal flap. Alternatively, a sphincter pharyngoplasty is performed by (1) making an incision along the posterior pharyngeal wall in a half‘‘H’’ configuration, (2) elevating the bilateral pink and yellow strips off the white paper to simulate elevation of the palatopharyngeal myomucosal flaps off the posterior tonsillar pillars (or by elevating
Fig. 4. Pharyngeal flap model. Elevation of the pharyngeal myomucosal flap, midline splitting of the velum, and insertion of the pharyngeal flap into the palate.
strips medial to the marked bilateral tonsils on the posterior pharyngeal wall template), and (3) transposing the bilateral flaps horizontally to be inset into the transverse incision on the posterior pharyngeal wall (Fig. 5). The trainee may once again complete the model using clear tape in place of sutures to attach the flaps in an end-to-end fashion. 3. Results The total cost of a set of assorted colored 800 600 sticky note pads and set of 80 9-fluid ounce disposable plastic cups was $20.58. The other supplies were readily available throughout the office. This supply was enough to make 22 total models, costing $0.94 per model. Construction time for each model was less than 10 min on average. Existing cup models can also be reloaded with new posterior pharyngeal wall and palate templates to save time for subsequent use. 4. Discussion The pharyngeal flap and sphincter pharyngoplasty are complex, technically challenging procedures due to the small anatomic space, poor visualization, and poor depth perception. Twodimensional images are unable to capture the 3D nature of each
Fig. 5. Sphincter pharyngoplasty model. Elevation of the palatopharyngeal myomucosal flaps off the posterior tonsillar pillars and horizontal transposition of the flaps along the transverse incision on the posterior pharyngeal wall.
1908
J.J. Lee, N. Jabbour / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1905–1908
procedure. The method as outlined above is a low cost, quick, and easily reproducible hands-on 3D model to enhance surgical trainees’ understanding of the intraoral situation of a patient with VPD and conceptualization of the steps of each procedure. It serves as an effective teaching modality of surgical technique for junior surgical trainees, especially those who are not usually afforded the opportunity to perform these complex yet valuable procedures. This model is particularly useful for demonstrating the placement of incisions and the anatomic changes seen with pharyngeal flaps and sphincter pharyngoplasty. It offers real-time visualization of both the obturation of the central port with a pharyngeal flap procedure and the lateral reduction in size of the central port with sphincter pharyngoplasty. It also allows for conceptualization of alternative techniques for pharyngeal flaps, including transverse splitting of the velum and Hogan’s lateral port control, and for sphincter pharyngoplasty, including Orticochea’s modification [4,12,13]. This model has some limitations. The sticky note paper is rigid and curls during elevation and reconstruction. Dampening or gently crumpling the paper helps relieve this problem but still does not accurately simulate the consistency of mucosa and muscle. In addition, the model is not life-sized, and its simplified modeling does not exactly represent the relationship between the soft palate and the palatoglossus and palatopharyngeus muscles. Thus, this anatomical relationship does not demonstrate sphincter pharyngoplasty with complete accuracy yet should still give the trainee a grasp of the geometry of the flaps. While these shortcomings do not make our model ideal for practicing surgical skills such as suturing in space, this model is affordable and rapidly reproducible using material easily obtained in most office settings and serves as a real-time instructional tool for teaching surgical trainees the 3D
geometry and conceptualization of each step of the pharyngeal flap and sphincter pharyngoplasty. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ijporl.2015.08.042. References [1] K. Schoenborn, Ueber eine neue methode der staphylorrhaphie, Verh. Dtsch. Ges. Chir. 4 (1875) 235–239. [2] W. Hynes, Pharyngoplasty by muscle transplantation, Br. J. Plast. Surg. 3 (1950) 128–135. [3] A.S. Woo, Velopharyngeal dysfunction, Semin. Plast. Surg. 26 (2012) 170–177. [4] V.M. Hogan, A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control (l.p.c.) pharyngeal flap, Cleft Palate J. 10 (1973) 331–345. [5] J. Karling, G. Henningsson, O. Larson, A. Isberg, Adaptation of pharyngeal wall adduction after pharyngeal flap surgery, Cleft Palate Craniofac. J. 36 (1999) 166–172. [6] R.V. Argamaso, R.J. Shprintzen, B. Strauch, M.L. Lewin, A.I. Daniller, A.G. Ship, et al., The role of lateral pharyngeal wall movement in pharyngeal flap surgery, Plast. Reconstr. Surg. 66 (1980) 214–219. [7] G.M. Sloan, Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art, Cleft Palate. Craniofac. J. 37 (2000) 112–122. [8] S. Vadodaria, N. Watkin, F. Thiessen, A. Ponniah, The first cleft palate simulator, Plast. Reconstr. Surg. 120 (2007) 259–261. [9] M.S. Matthews, A teaching device for Furlow palatoplasty, Cleft Palate Craniofac. J. 36 (1999) 64–66. [10] M.M. Liu, J. Kim, N. Jabbour, Teaching Furlow palatoplasty: the sticky note method, Int. J. Pediatr. Otorhinolaryngol. 78 (2014) 1849–1851. [11] K. Nagy, M.Y. Mommaerts, Advanced s(t)imulator for cleft palate repair techniques, Cleft Palate Craniofac. J. 46 (2009) 1–5. [12] J. Karling, G. Henningsson, O. Larson, A. Isberg, Comparison between two types of pharyngeal flap with regard to configuration at rest and function and speech outcome, Cleft Palate-Craniofac. J. 36 (1999) 154–165. [13] M. Orticochea, Construction of a dynamic muscle sphincter in cleft palates, Plast. Reconstr. Surg. 41 (1968) 323–327.