Does Folded Flap Palatoplasty Really Thin the Soft Palate? New CT Evidence Says Otherwise

Evaluation of Soft Palate Thickness in Brachycephalic Dogs 3 Months After Folded Flap Palatoplasty Versus Standard Staphylectomy

Joep Timmermans, Bart Van Goethem, Emmelie Stock, Tim Bosmans, Jimmy Saunders, Hilde de Rooster

Background

Brachycephalic obstructive airway syndrome (BOAS) arises from conformational upper‐airway abnormalities that cause significant respiratory compromise in affected dogs. Traditional management includes standard staphylectomy (STS), whereas folded flap palatoplasty (FFP) was developed to both shorten and thin the soft palate by replacing thickened oropharyngeal mucosa with nasopharyngeal mucosa. Despite widespread use of FFP, objective postoperative data on soft palate thickness have been lacking. This study aimed to compare soft palate morphology before and 3 months after FFP or STS, hypothesizing that FFP would reduce thickness while STS would not.

Methods

This was a prospective, observational study enrolling 20 client-owned brachycephalic dogs undergoing multilevel BOAS surgery. Preoperative assessment included physical examination, a standardized questionnaire, a 3-minute exercise tolerance test (ETT), laryngeal evaluation, and CT imaging performed under a standardized open-mouth protocol. Dogs were randomly assigned to either FFP or STS (10 each). Soft palate length, rostral thickness, middle thickness, cross-sectional area, and volume were measured preoperatively and repeated 3 months postoperatively. All surgeries were performed by a single surgeon, and CT measurements were taken by a blinded observer.

Results

Eighteen dogs completed the 3-month follow-up. Clinical signs improved in 89% of dogs based on ETT scores, with improvement seen in 6/8 FFP dogs and 10/10 STS dogs. Both procedures produced substantial reductions in soft palate length (≈35–40%), cross-sectional area (≈25–40%), and volume (≈35–42%). However, FFP did not reduce middle soft palate thickness (median +7.9%), whereas STS produced a median 16.9% decrease. Rostral thickness increased modestly in both groups. One major postoperative complication occurred (FFP flap dehiscence requiring revision; the dog later died), and one STS dog with severe preoperative laryngeal collapse was euthanized months later. Minor complications occurred in 2/20 dogs.

Limitations

The study cohort was small, preventing robust subgroup analysis. Breed distribution differed slightly between groups, potentially influencing anatomical measurements. The absence of an immediate postoperative CT prevented assessment of early postoperative thickness changes. CT performed under anesthesia may not perfectly represent soft palate behavior in awake animals. Inclusion criteria did not specifically target dogs with markedly thickened soft palates for FFP, potentially diluting its expected effect.

Conclusions

Folded flap palatoplasty did not demonstrate a reduction in soft palate thickness 3 months postoperatively, contrary to the original hypothesis and proposed mechanism. Both FFP and STS similarly improved clinical BOAS status, and both produced meaningful reductions in soft palate length, volume, and cross-sectional area. The clinical benefits of FFP may therefore arise from shortening rather than thinning of the palate. Future studies should include immediate postoperative imaging and larger, more targeted populations to clarify the morphological impact of FFP.

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