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Brachycephalic Syndrome: Innovative Surgical Techniques

Laurent Findji, DMV, MS, MRCVS, DECVS VRCC Veterinary Referrals Essex, United Kingdom

Gilles Dupré, DMV, DECVS University of Veterinary Medicine, Vienna Vienna, Austria

Surgery, Soft Tissue

|June 2013|Peer Reviewed

Brachycephalic Syndrome: Innovative Surgical Techniques

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This article is part of the WSAVA Global Edition of Clinician's Brief.

Canine brachycephalic syndrome (BS) consists of anatomic abnormalities (eg, stenotic nares, tortuous nasal cavities, aberrant conchae, elongated soft palate [ESP], everted laryngeal saccules, laryngeal collapse, tracheal hypoplasia) of brachycephalic dogs, which can lead to obstructive dyspnea and digestive disorders. In one study, 97% of brachycephalic dogs presented for BS had concurrent GI diseases.¹ Upper obstructions (eg, nares, conchae, soft palate) may aggravate and sometimes cause deeper obstructions (eg, laryngeal, tracheal, bronchial collapses) and digestive disorders.

Early surgical correction of these abnormalities is often recommended and commonly includes treatment for stenotic nares and ESP. Other abnormalities (eg, laryngeal collapse²) occasionally require surgical attention but rarely in first intention. ESP, the most consistent anatomic abnormality encountered in dogs with BS, has been reported in up to 100% of cases.^3,4 Initially, ESP was primarily described as excessive soft palate length, which can cause obstruction of the rima glottidis on inspiration (laryngeal obstruction). However, in many brachycephalic dogs, it has long been observed^5-11 and recently demonstrated^12,13 that the soft palate is also excessively thick, adding nasopharyngeal and oropharyngeal components to airway obstruction.

Related Article: Surgeon’s Corner: Soft Palate & Stenotic Nares Resection for Brachycephalic Dogs

Folded flap palatoplasty (FFP) was developed to address the three components of obstruction caused by the soft palate by making it both thinner and shorter.^8,9-11 Stenotic nares, when present, should be corrected following FFP. Various techniques have been described, but the authors prefer vertical wedge alaplasty, which consists of excising a vertical wedge from the ala nasi.

Comparing Traditional & Innovative

Conventional surgical techniques for ESP correction often consist of a simple resection of the redundant portion of the soft palate using different devices and various resection landmarks; although these techniques address the laryngeal component of obstruction, they may fail to fully address nasopharyngeal and oropharyngeal obstructions.^14-26 FFP can address all components of the obstruction by reducing the soft palate’s length and thickness. The use of bipolar cautery in FFP increases intraoperative comfort. Compared with conventional staphylectomies, the suture material is more rostral and therefore farther from the pharynx, which should result in less postoperative pharyngeal inflammation and edema. Also, the rostroventral traction exerted on the remainder of the soft palate tends to further widen the nasopharyngeal opening. FFP tends to be longer and more technically demanding than conventional staphylectomy.

Before surgery, the patient should be premedicated (see Premedications to Consider) and stress avoided. Before anesthesia induction, oxygen can be supplied by mask or flow-by. Induction must be swift to allow prompt control of the airway via tracheal intubation. The pharynx should be examined and the larynx assessed for signs of laryngeal collapse.

Premedications to Consider

Acepromazine (0.01–0.05 mg/kg IM, SC)
Dexamethasone (0.1–0.2 mg/kg IM, SC)
Opioid analgesic (eg, morphine or methadone, 0.2–0.5 mg/kg IM)
Glycopyrrolate (2–10 µg/kg IM)
Antiemetics & antacids (SC or IM, depending on drugs)

What You Will Need:

Basic surgical kit

Long instruments to facilitate the procedure in small dogs with narrow pharynges (eg, pugs)

Electrocautery

Precise monopolar cautery used in cutting mode for the initial palatoplasty incision
Bipolar electrocautery to facilitate hemostasis during the dissection of the soft palate

Absorbable monofilament sutures on swaged round or tapercut needles, size 3-0–5-0

1 of 17

Step 1.

Place the dog in sternal recumbency. Restrain the head with the mouth open and the tongue gently pulled and fixed rostrally (Figures A, B, C).

2 of 17

Step 1B.

Place the dog in sternal recumbency. Restrain the head with the mouth open and the tongue gently pulled and fixed rostrally (Figures A, B, C).

3 of 17

Step 1C.

Restrain the head with the mouth open and the tongue gently pulled and fixed rostrally (Figures A, B, C).

4 of 17

Step 2A.

To prepare the oral cavity for surgery, pack the deep portion of the pharynx with swabs to prevent blood from reaching the glottis (Figure A).

5 of 17

Step 2B.

Place stay sutures on each side of the caudalmost part of the soft palate (Figure B).

6 of 17

Step 3A.

Rotate the caudal border of the soft palate rostrally until the caudal opening of the nasopharynx is directly visible (Figure A).

Author Insight: Laterally, the sides of the trapezoid pass just medially to the tonsils.

7 of 17

Step 3B.

Apply the retracted caudal edge on the ventral mucosa of the soft palate and mark the point to which the free border of the palate can be brought rostrally with a point of electrocautery. Incise the ventral mucosa of the soft palate in a trapezoidal shape from this mark rostrally to the free edge of the soft palate caudally (Figure B).

8 of 17

Step 4A.

Using fine scissors for blunt dissection, resect most of the soft tissues between the nasopharyngeal and oropharyngeal mucosae of the soft palate: ventral mucosa, connective tissue, part of the palatinus, and levator veli palatini muscles (Figures A, B, C, D, E).

9 of 17

Step 4B.

Author Insight: Bleeding of the palatine vessels can be anticipated on the rostrolateral corners of the resection area. Hemostasis can be achieved with electrocautery, preferably using bipolar forceps. With experience, these vessels can be identified and cauterized before being sectioned, thereby avoiding any substantial bleeding.

10 of 17

Step 4C.

11 of 17

Step 4D.

12 of 17

Step 4E.

13 of 17

Step 5A.

Trim the border of the palate’s free end, consisting of the mucosa reflection. To keep the holding effect of the stay sutures, trim progressively in sequences alternating cutting and suturing (Figures A, B, C).

14 of 17

Step 5B.

15 of 17

Step 5C.

16 of 17

Step 5D.

Fold the soft palate on itself and suture with monofilament absorbable sutures in an interrupted pattern (Figures D and E).

17 of 17

Step 5E.

Fold the soft palate on itself and suture with monofilament absorbable sutures in an interrupted pattern (Figures D and E).

Step 1.

Place the dog in sternal recumbency. Restrain the head with the mouth open and the tongue gently pulled and fixed rostrally (Figures A, B, C).

Step 1B.

Place the dog in sternal recumbency. Restrain the head with the mouth open and the tongue gently pulled and fixed rostrally (Figures A, B, C).

Step 1C.

Restrain the head with the mouth open and the tongue gently pulled and fixed rostrally (Figures A, B, C).

Step 2A.

To prepare the oral cavity for surgery, pack the deep portion of the pharynx with swabs to prevent blood from reaching the glottis (Figure A).

Step 2B.

Place stay sutures on each side of the caudalmost part of the soft palate (Figure B).

Step 3A.

Rotate the caudal border of the soft palate rostrally until the caudal opening of the nasopharynx is directly visible (Figure A).

Author Insight: Laterally, the sides of the trapezoid pass just medially to the tonsils.

Step 3B.

Step 4A.

Step 4B.

Step 4C.

Step 4D.

Step 4E.

Step 5A.

Step 5B.

Step 5C.

Step 5D.

Fold the soft palate on itself and suture with monofilament absorbable sutures in an interrupted pattern (Figures D and E).

Step 5E.

Fold the soft palate on itself and suture with monofilament absorbable sutures in an interrupted pattern (Figures D and E).

1 of 10

Step 1A.

Start incising with a #11 scalpel blade at the apex of the wedge, which is positioned slightly dorsolaterally to the dorsal limit of the slit-like opening of the stenotic naris (Figure A).

Author Insight: The degree of postoperative opening of the naris will be grossly proportional to the angle chosen.

2 of 10

Step 1B.

Make incisions deep to include a portion of the alar fold to fully relieve the obstruction without limiting the opening to the rostral part of the nostril (Figure B).

3 of 10

Step 1C.

The medial border of the wedge is parallel to the medial wall of the ala nasi. Make the lateral border of the wedge at a 40°–70° angle from its medial border (Figure C and D).

4 of 10

Step 1D.

The medial border of the wedge is parallel to the medial wall of the ala nasi. Make the lateral border of the wedge at a 40°–70° angle from its medial border (Figure C and D).

Author Insight: Hemorrhage is usually brisk on incision and may somewhat impair visibility, but it resolves quickly when the wound is sutured.

5 of 10

Step 2A.

Place 3 or 4 absorbable monofilament sutures in a simple interrupted pattern. Place the first suture at the ventrolateral corner of the naris (Figure A and B) to obtain good alignment of the ventral border of the wound edges and a satisfactory cosmetic result.

6 of 10

Step 2B.

Place the first suture at the ventrolateral corner of the naris (Figure A and B) to obtain good alignment of the ventral border of the wound edges and a satisfactory cosmetic result.

7 of 10

Step 3A.

Place another in-depth suture from medial to lateral, exiting through the skin just laterally to the caudal end of the alar notch (Figures A and B).

8 of 10

Step 3B.

Place another in-depth suture from medial to lateral, exiting through the skin just laterally to the caudal end of the alar notch (Figures A and B).

9 of 10

Step 3C.

When gently tied, this suture should keep the deep portion of the naris wide during healing (Figure C). Change scalpel blades and repeat the procedure on the other side.

10 of 10

Step 3D.

Take care to obtain symmetry on both sides (Figure D); starting at the side of the surgeon’s dominant hand (eg, right nostril for a right-handed surgeon) may help control symmetry.

Author Insight: When necessary, a nasotracheal tube for postoperative oxygen supplementation can be placed before the patient is allowed to recover from anesthesia.

Step 1A.

Start incising with a #11 scalpel blade at the apex of the wedge, which is positioned slightly dorsolaterally to the dorsal limit of the slit-like opening of the stenotic naris (Figure A).

Author Insight: The degree of postoperative opening of the naris will be grossly proportional to the angle chosen.

Step 1B.

Make incisions deep to include a portion of the alar fold to fully relieve the obstruction without limiting the opening to the rostral part of the nostril (Figure B).

Step 1C.

The medial border of the wedge is parallel to the medial wall of the ala nasi. Make the lateral border of the wedge at a 40°–70° angle from its medial border (Figure C and D).

Step 1D.

The medial border of the wedge is parallel to the medial wall of the ala nasi. Make the lateral border of the wedge at a 40°–70° angle from its medial border (Figure C and D).

Author Insight: Hemorrhage is usually brisk on incision and may somewhat impair visibility, but it resolves quickly when the wound is sutured.

Step 2A.

Step 2B.

Place the first suture at the ventrolateral corner of the naris (Figure A and B) to obtain good alignment of the ventral border of the wound edges and a satisfactory cosmetic result.

Step 3A.

Place another in-depth suture from medial to lateral, exiting through the skin just laterally to the caudal end of the alar notch (Figures A and B).

Step 3B.

Place another in-depth suture from medial to lateral, exiting through the skin just laterally to the caudal end of the alar notch (Figures A and B).

Step 3C.

When gently tied, this suture should keep the deep portion of the naris wide during healing (Figure C). Change scalpel blades and repeat the procedure on the other side.

Step 3D.

Take care to obtain symmetry on both sides (Figure D); starting at the side of the surgeon’s dominant hand (eg, right nostril for a right-handed surgeon) may help control symmetry.

Author Insight: When necessary, a nasotracheal tube for postoperative oxygen supplementation can be placed before the patient is allowed to recover from anesthesia.

BS = brachycephalic syndrome, ESP = elongated soft palate, FFP = folded flap palatoplasty

LAURENT FINDJI, DMV, MS, MRCVS, DECVS, is soft-tissue surgeon and director at VRCC Veterinary Referrals near London. His primary interests include oncologic, reconstructive, and general soft tissue surgeries. Before spending 3 years in private practice and 4 years as a consultant surgeon, Dr. Findji was a teaching assistant and completed a 2-year surgical internship at the Alfort Veterinary School in Paris, where he also earned his doctorate in veterinary medicine; he earned a master’s of science in biology and physiology of circulation and respiration at La Pitié-Salpˆeterière Hospital in Paris and a degree in experimental surgery and microsurgery at the Lariboisère/St. Louis Hospital in Paris.

GILLES DUPRÉ, DMV, DECVS, is professor of small animal surgery and clinic head for small animal surgery, ophthalmology, dentistry, and rehabilitation at University of Veterinary Medicine Vienna in Austria. After practicing as a surgical assistant and resident in both France and the United States, he earned a degree in human surgical pneumology and thoracoscopic surgery; Dr. Dupré then spent 17 years in referral practice. His primary interests include oncologic, upper airway, and mini-invasive surgeries. Dr. Dupré has published more than 120 articles in peer-reviewed journals and book chapters and lectured at the NAVC Conference. He earned his doctorate in veterinary medicine from the Alfort Veterinary School.

References

Prevalence of gastrointestinal tract lesions in 73 brachycephalic dogs with upper respiratory syndrome. Poncet CM, Dupré GP, Freiche VG, et al. J Small Anim Pract 46:273-279, 2005.
Surgical management of laryngeal collapse associated with brachycephalic airway obstruction syndrome in dogs. White RN. J Small Anim Pract 53:44-50, 2012.
Long-term results of upper respiratory syndrome surgery and gastrointestinal tract medical treatment in 51 brachycephalic dogs. Poncet CM, Dupré GP, Freiche VG, Bouvy BM. J Small Anim Pract 47:137-142, 2006.
Brachycephalic airway obstructive syndrome. Wykes PM. Probl Vet Med 3:188-197, 1991.
Folded flap palatoplasty for treatment of elongated soft palates in 55 dogs. Findji L, Dupré G. Wiener Tierärztliche Monatsschrift 95:56-63, 2008.
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Pattern of breathing in brachycephalic dogs. Amis TC, Kurpershoek C. Am J Vet Res 47:2200-2204, 1986.
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The folded flap palatoplasty: A new technique for treatment of elongated soft palate in dogs. Dupré G, Findji L, Poncet C. ECVS Annual Scientific Meeting, 2005, pp 265-267.
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