The goal of cleft palate repair is to create a palate that is both anatomically and functionally normal (Fisher and Sommerlad, 2011). However, approximately 20–40% of cleft palate patients require surgical intervention for velopharyngeal insufficiency (VPI) after primary cleft palate repair (Naran et al., 2017; Prabhu et al., 2020). The most frequently mentioned operative procedures for VPI correction include intravelar veloplasty, Furlow double-opposing Z-plasty (DOZ), posterior pharyngeal flap (PPF), sphincter pharyngoplasty, and posterior pharyngeal augmentation (Pet et al., 2015; Naran et al., 2017; de Blacam et al., 2018; Chauhan et al., 2020). Among these procedures, PPF is the most frequently described technique and is reportedly utilized under various velopharyngeal conditions (Belcher et al., 2016; de Blacam et al., 2018). Nevertheless, it is associated with a higher risk of obstructive sleep apnea (OSA) due to nasopharyngeal port obturation (de Blacam et al., 2018; Prabhu et al., 2020). In contrast, DOZ is reportedly efficacious and offers a lower risk of nasal airway obstruction (Hsu et al., 2015; Yamaguchi et al., 2016; Kurnik et al., 2020). DOZ offers a less invasive approach to improving velopharyngeal function by velar muscle reorientation and velar lengthening (Muzaffar et al., 2014; Pet et al., 2015; Cheng et al., 2020; Kara et al., 2021).

Despite the obvious benefits of Furlow DOZ, it has not been widely utilized because of the uncertainty of surgical indications (Kurnik et al., 2020). VPI severity is the most important factor when choosing between DOZ and PPF (Cheng et al., 2020; Wu et al., 2021). Furlow palatoplasty is selected when patients have marginal-to-moderate VPI or a small velopharyngeal gap size (Woo et al., 2014; Yamaguchi et al., 2016; Cheng et al., 2020; Kurnik et al., 2020). Chim et al. reported that patients with velopharyngeal gaps <7 mm were more likely to achieve adequate velopharyngeal function (Chim et al., 2015). Wu et al. identified that the preoperative velopharyngeal closure ratio (VCR), which emphasizes the dynamics of the velopharyngeal gap, correlates with postoperative velopharyngeal function (Wu et al., 2021). In addition, Cheng’s recent study of 83 patients with a preoperative VCR >80%, who underwent DOZ for palatal re-repair, found that age was another significant predictor of surgical success (Cheng et al., 2020).

Considering these wide discrepancies, our study aimed to improve the treatment precision and exploit the advantages of Furlow palatoplasty and PPF in the treatment of secondary VPI, since both techniques were routinely performed in our department.