The Furlow Double-opposing Z-Plasty: History, Technique, Modifications, and Outcomes

Primary palatoplasty represents an important procedure in pediatric plastic surgery, with long-term implications for speech, feeding, and craniofacial development. Historical techniques often struggled to balance anatomic closure with functional restoration, resulting in high rates of velopharyngeal insufficiency. The Furlow double-opposing Z-plasty (DOZ) simultaneously lengthens the soft palate and reconstructs the levator muscular sling to address these challenges. This review examines the historical evolution of cleft palate repair and analyzes the Furlow DOZ in terms of its design, surgical technique, clinical outcomes, and contemporary modifications. Comparisons are made with established techniques, including von Langenbeck, Wardill-Kilner V-Y pushback, and Bardach 2-flap palatoplasty, which use a straight-line repair. Across multiple studies, the Furlow palatoplasty demonstrates favorable speech outcomes, with high rates of velopharyngeal competence and reduced need for secondary speech surgery. Several modifications, including the Children's Hospital of Philadelphia modification and the use of buccal myomucosal or buccal fat flaps, have expanded the applicability of the technique to a wide spectrum of cleft morphologies.