The endoscopically assisted pharyngeal flap

OBJECTIVE

To describe a modification of the Hogan lateral port control technique for pharyngeal-flap surgery.

RESULTS AND CONCLUSIONS

Use of a 70-degree nasal endoscope to assist in the determination of lateral port diameter allows for better control of flap and port construction.

[Long-term results after velopharyngoplasty]

BACKGROUND

Children with cleft palate frequently demonstrate speech and resonance disorders following primary cleft repair. In some patients no improvement can be achieved with conservative therapy and a velopharyngoplasty (VPP) may be indicated. This study was performed to evaluate the long-term results after VPP.

MATERIAL AND METHODS

Twenty-six patients were followed up on an average 9 years after VPP (mean age: 16+/-5 years). Apart from the phoniatric-pedaudiologic findings, the speech intelligibility and nasality were judged by speech pathologists and by laymen. The extent of the speech handicaps was evaluated with a questionnaire. The nasalance was measured with NasalView. The vowels, two test sentences, and three reading texts (LT(1-3)) were used as test materials.

RESULTS

The phoniatric-pedaudiologic examination revealed a clear improvement of hearing, language, and speech function. Compared to the previous results, decreased nasality and improved ability in articulation were detected. The judgment of laymen was also positive. The speech intelligibility was mostly evaluated as favorable. A speech handicap was present in only a few patients. The evaluation using NasalView showed significantly increased nasalance values for the LT(2) ( p=0.030). Moreover there were lower nasalance values for all the reading texts compared to the control group (LT(1) p=0.257, LT(2) p=0.408, LT(3) p=0.187).

CONCLUSION

A clear improvement can be achieved with VPP in patients with a high degree of therapy-resistant nasality. In many cases even normal colloquial language is possible. The evaluation of nasalance has proved to be successful for rating surgical outcome.

[Surgical treatment of severe velopharyngeal insufficiency following uvulopalatopharyngoplasty (UPPP)]

BACKGROUND

For the implementation of an uvulopalatopharyngoplasty (UPPP) it is nowadays common practice to operate in a manner which is gentle on the tissue and which retains as much muscle as possible. However, even when the greatest possible care is taken during the operation, serious complications such as persistent velopharyngeal insufficiency can arise.

PATIENT AND METHOD

Based on a case report of a 55 year old man with a persistent severe velopharyngeal insufficiency after UPPP performed at another institution and serious OSA, we suggest a so-called push back technique, adapted from the cleft-palate surgery, for the extension of the soft-palate. With regard to the operative technique, it is thus possible to produce an effective extension of the soft-palate by means of a dorsocaudal displacement of a wide and on the palatal vascular fascicle pedicled mucoperiosteum flap of the mucous membrane of the hard palate, as well as similar mobilisation of the soft-palate from the os-palatinum.

RESULT

Only 3 weeks after the operation, our patient showed a clinically sufficient velopharyngeal functioning. After 3 months, a complete restoration of the nasal CPAP-acceptance was evident. As a result, a complete social rehabilitation was possible for our patient.

CONCLUSION

The modified push back technique of the palate retrodisplacement which is described above offers an efficient possibility of anatomically and functionally correcting the persistent and serious velopharyngeal insufficiency after UPPP.

Aerodynamic and cephalometric analyses of velopharyngeal structure and function following re-pushback surgery for secondary correction in cleft palate

OBJECTIVE

The goal of this study was to clarify the efficacy of and indication for re-pushback surgery as secondary treatment for cleft palate.

PARTICIPANTS

Fifteen patients treated by re-pushback surgery involving intravelar veloplasty (IVV) with buccal mucosal grafting on the nasal surface and followed up more than 6 months were enrolled in this study.

MAIN OUTCOME MEASURES

Pre- and postoperative velopharyngeal functions were analyzed by perceptual voice analysis, blowing ratio, and nasalance scores during phonation of /i/ and /tsu/. Cephalometric analysis was used to evaluate the relationship between velopharyngeal structure and the outcome of re-pushback surgery. Control data were obtained from the longitudinal files of normal 10-year-old children in Kyushu University Dental Hospital.

RESULTS

Eight of 15 patients obtained complete velopharyngeal closure (complete group), five patients improved remarkably (improved group), and no effective result was seen in two patients (ineffective group). Nasality disappeared or remarkably improved after the operation in 13 patients. Effective surgical results were found in 86.7% of the patients. Partial flap necrosis was seen in two patients in whom re-pushback surgery was performed using mucosal palatal flaps instead of mucoperiosteal flaps. Preoperative velar length and the length/depth ratio of the re-pushback group were significantly smaller than the controls, but there was no difference after the operation. Furthermore, the preoperative length/depth ratio of the complete group (ranged more than 100%) was significantly greater than those of the other two groups (ranged less than 100%).

CONCLUSION

Re-pushback surgery by IVV with free mucous grafting on the nasal surface was effective in managing velopharyngeal incompetence secondarily, improving velopharyngeal structure and function.

Short-term and long-term results of speech improvement after surgery for velopharyngeal insufficiency with pharyngeal flaps in patients younger and older than 6 years old: 10-year experience

Velopharyngeal insufficiency (VPI) is a well-known cause for hypernasality. To overcome this problem, the authors use a static surgical technique: a cranially or caudally based flap. In 93 patients, the results of this technique on speech (hypernasality, nasal air escape, articulation) and velopharyngeal function were evaluated over a period of at least 1 year. In 53 patients, pharyngoplasty flaps were based caudally. In 40 patients, pharyngoplasty flaps were based cranially. The patients were age 2.5 to 24.5 years, with a mean of 5.5 years (SD: 4 years and 2 months). Improvement was found in almost all patients. The patients who underwent surgery when they were younger than age 6 significantly improved better then the patients who were treated when they were older than age 6. There were no differences in outcome between cranially based and caudally based flaps. There were also no differences between patients with plain VPI and patients with VPI (e.g., Pierre Robin sequence and Shprintzen).

A survey of cleft lip and palate management taught in training programs in Korea

OBJECTIVE

A national survey was conducted to obtain an overall view of the status, assess changes in trends of cleft management, and study new categories of interest.

METHOD

Questionnaires were sent to 90 chief residents of all Korean institutes with plastic surgery training programs.

RESULTS

Forty-eight respondents returned completed questionnaires. The results were: (1) the most common unilateral cleft lip repair method used is the rotation-advancement technique (100%); (2) 73% of respondents correct cleft lip nasal deformity at preschool age; (3) the Millard technique is the most common management in bilateral cleft lip repair (65%); (4) in the management of protruding premaxilla, 44% of the respondents choose presurgical orthopedics; (5) the usual cleft palate repairs are the pushback (64%) and double-opposing Z-plasty (43%) in complete cleft palates and the double-opposing Z-plasty (75%) and pushback (36%) comprised the common techniques in incomplete cases; (6) 86% of responding programs perform alveolar cleft repairs during the period of mixed dentition; the most common treatment of velopharyngeal incompetence is pharyngeal flap (71%); and (8) the interdisciplinary team approach is practiced by 64% of respondents.

CONCLUSIONS

Many changes were noted since a previous 1995 survey. We hope that this study provides the necessary information needed for the eventual establishment of standard cleft management in Korea.

Frequency of pharyngoplasty after primary repair of cleft palate

BACKGROUND

The frequency of pharyngoplasty after initial repair of cleft palate is a direct measure of the success or failure of the primary palatal repair with respect to velopharyngeal function. The optimal timing and surgical technique for the repair of cleft palate remain subjects of debate.

PURPOSE

To assess the outcome of various techniques for primary palatal repair, specifically the frequency of secondary pharyngoplasty, and to determine the significance, if any, of certain variables to this outcome.

METHODS

A pool of 114 patients with cleft lip and palate was compiled from a retrospective analysis of medical records for more than 300 consecutive patients treated over a 15-year period (1980-1995). The review included only patients who had been treated by the same surgeon or by his resident. A 1-stage palatal repair was performed on all patients, in which the hard and the soft palate were closed simultaneously. The following data were collected: patient's sex, patient's date of birth, type of cleft, technique used for initial repair, age at initial repair and date of secondary pharyngoplasty surgery, if performed.

RESULTS

The overall frequency of subsequent pharyngoplasty was 25% (28 patients). The rate of secondary surgery was significantly higher for boys (21/63 or 33%) than for girls (7/51 or 14%). There were also significant differences in the rate of secondary pharyngoplasty according to type of cleft: 50% (6/12) for patients with bilateral cleft lip and palate, 44% (7/16) for those with hard and soft cleft palate, 21% (8/38) for those with unilateral cleft lip and palate, 20% (3/15) for those with submucous cleft palate and 12% (4/33) for those with soft cleft palate. Surgical technique for the primary repair (V-Y pushback or von Langenbeck procedure) was not a significant factor in determining the rate of subsequent pharyngoplasty, nor was age at primary repair, although those who underwent primary repair at age 12-14 months were least likely to require pharyngoplasty.

CONCLUSION

In this study the frequency of velopharyngeal insufficiency after 1-stage palatoplasty was consistent with previously reported results. Of interest would be a comparison of 1-stage and 2-stage approaches to primary palate repair in young patients.

A 10-year review of perioperative complications in pharyngeal flap surgery

A 10-year retrospective study was undertaken to investigate perioperative complications in pharyngeal flap surgery in one institution using inferiorly and superiorly based flaps. In this fashion the current practice of surgical technique based on local findings and perioperative care, through regular monitoring by experienced nurses on the ward, was evaluated for adequacy. The charts of 275 patients who had 287 pharyngeal flap procedures were studied. Demographics, type and duration of operation, associated procedures, surgeon, anesthetist, duration of hospital stay, associated medical conditions, and perioperative complications such as bleeding, respiratory insufficiency, or flap dehiscence were evaluated. In this series a total complication rate of 6 percent was found, with 2.4 percent early (<6 weeks) and 3.8 percent late (>6 weeks) complications. Only two patients (0.7 percent) had postoperative bleeding requiring reoperation, and one patient (0.3 percent) needed reintubation. The most frequent complication was flap dehiscence in nine patients (3.1 percent), which occurred early in three and late in six. Pharyngeal flap surgery can be performed safely with very few complications provided the correct experience and infrastructure are present. Careful surgery, in conjunction with adequate anesthesia and postoperative monitoring, makes these procedures safe and rewarding.

[Surgical reconstruction of velopharyngeal incompetence in postoperative cleft palate patients]

OBJECTIVE

To explore the clinical result of velopharyngeal cerclage in repairing velopharyngeal incompetence of postoperative cleft palate patients.

METHODS

From 1987 to 2000, 25 cases of velopharyngeal incompetence due to postoperative cleft palate were given the velopharyngeal cerclage. The mucosa flap of palate was pushed back, the autogenous free grafts of denervated skeletal muscle were selectively used for velopharyngeal cerclage. All the patients were followed up for 2 and a half years on average.

RESULTS

All the patients achieved good results with velopharyngeal competence and good articulation. The patients' sound of voices was clear.

CONCLUSION

This method can be used to repair velopharyngeal incompetence of postoperative cleft palate patients; the operation is simple and the results are satisfactory.

Velopharyngeal surgery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties

Residual velopharyngeal insufficiency after palatal repair varies from 10 to 20 percent in most centers. Secondary velopharyngeal surgery to correct residual velopharyngeal insufficiency in patients with cleft palate is a topic frequently discussed in the medical literature. Several authors have reported that varying the operative approach according to the findings of videonasopharyngoscopy and multiview videofluoroscopy significantly improved the success of velopharyngeal surgery. This article compares two surgical techniques for correcting residual velopharyngeal insufficiency, namely pharyngeal flap and sphincter pharyngoplasty. Both techniques were carefully planned according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. Fifty patients with cleft palate and residual velopharyngeal insufficiency were randomly divided into two groups: 25 in group 1 and 25 in group 2. Patients in group 1 were operated on by using a customized pharyngeal flap according to the findings of videonasopharyngoscopy and multiview videofluoroscopy in each case. Those in group 2 received a sphincter pharyngoplasty also customized according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. The median age of the patients in both groups was not significantly different (p > 0.5). The frequency of residual velopharyngeal insufficiency after the individualized velopharyngeal surgery was not significantly different between the patient groups (12 percent versus 16 percent; p > 0.05). It seems that customized pharyngeal flaps and sphincter pharyngoplasties performed according to the findings of videonasopharyngoscopy and multiview videofluoroscopy are safe and reliable procedures for treating residual velopharyngeal insufficiency in cleft palate patients.

Impact of malocclusion and orthognathic reconstruction surgery on resonance and articulatory function: an examination of variability in five cases

Articulatory patterns and nasal resonance were assessed before and 6 months after orthognathic reconstruction surgery in five patients with dentofacial deformities. Perceptual and physiological assessments showed disorders of nasality and articulatory function preoperatively, two patients being hyponasal, and one hypernasal. Four patients had mild articulatory deficits, and four had reduced maximal lip or tongue pressures. Operation resulted in different patterns of change. Nasality deteriorated in three patients and articulatory precision and intelligibility improved in only one patient and showed no change in the other four. Operation improved interlabial pressures in three patients, while its impact on tongue pressures varied, being improved in one case, deteriorating in one, and remaining unchanged in the other three. The variability in the results highlights the need for routine assessment of speech and resonance before and after orthognathic reconstruction.

[Furlow palatoplasty--experiences with 114 consecutive cases]

After introducing the Furlow's double opposing palatoplasty [4] in our clinic in 1991 114 patients were operated on and registered prospectively. Using this procedure for closure of small clefts and/or with moderate velopharyngeal incompetence only at the beginning it became the method of choice not only for primary palatoplasty at the age of 18-24 months but also for corrective measures now. An increase of length of the soft palate of 10 +/- 3 mm at the average was gained immediately after surgery. There were no specific side effects of the method, especially no fistulas occurred. Good speech results were obtained in 61% at the age of 8 years using profound phoniatric tests. Mixed velopharyngeal closure investigated by means of nasal videoscopy was the dominating form in 55%. The results underwent a positive change comparing results in patients after longitudinal investigation at the age of 5 and 8 years bzw. They corresponded with or exceeded the results found in a control group operated on with other methods of palatoplasty at another centre.

Palatal adhesion: the treatment of unilateral palatal paralysis after high vagus nerve injury

BACKGROUND

Resection of skull base tumors commonly necessitates intraoperative sacrifice of lower cranial nerves at the level of the jugular foramen. Sequelae of unilateral vagus nerve loss include ipsilateral laryngeal paralysis, ipsilateral palatal and pharyngeal paralysis, and velopharyngeal incompetence (VPI) marked by hypernasal speech and nasopharyngeal reflux of liquids during swallowing.

METHODS

Palatal adhesion (PA), a procedure whereby the unilaterally paralyzed palate is attached to the posterior pharyngeal wall, decreases the size of the velopharyngeal port and minimizes the symptoms. This study assessed the outcome of PA in 31 patients with VPI secondary to proximal vagus nerve injury.

RESULTS

PA decreased postoperative nasality in 96% of patients. Nasopharyngeal reflux was significantly improved in 83%. Three patients (11%) had minor wound breakdown postoperatively, all of which healed completely with conservative management.

CONCLUSION

PA offers a favorable result with minimal concomitant morbidity and is recommended for patients with VPI secondary to unilateral proximal vagus nerve paralysis.

Cephalometric pharyngeal changes after Le Fort I osteotomy in patients with unilateral cleft lip and palate

Pharyngeal changes after Le Fort I osteotomy were evaluated cephalometrically in 37 patients (27 M, 10 F; mean age 23.8 years) with unilateral cleft lip and palate (UCLP). Seven patients had previously undergone velopharyngeal (VPP) flap surgery to improve speech. One year postoperatively the patients without previous VPP showed a significant change (55%-85% of the surgical change) in the upper and lower sagittal depth of the nasopharyngeal airway, but not in the depth of oropharyngeal airway, length of soft palate, or position of hyoid bone. No significant changes were observed between 6 months and 1 year postoperatively. Mean surgical horizontal advancement was 4.7 mm and the mean vertical lengthening 4.7 mm anteriorly and 1 mm posteriorly. There was a correlation between the amount of horizontal advancement and the amount of change in the nasopharyngeal airway. The patients with previous VPP showed significant postoperative change (85% of the surgical change) only in the lower nasopharyngeal airway, although their surgical advancement was similar to that without previous VPP. Patients with previous VPP showed significantly smaller depths of upper nasopharyngeal airway postoperatively than the patients without previous VPP. Five patients (13%) needed VPP after the osteotomy. There was no difference in the nasopharyngeal airway in the patients with VPP after the osteotomy when compared to those without, but they seemed to have shortest maxillary lengths and largest mean surgical changes vertically both anteriorly (5.5 mm) and posteriorly (2.3 mm). Moderate maxillary advancement in UCLP patients results in significant changes in the nasopharyngeal airway.

Evaluation and treatment of velopharyngeal insufficiency: the University of Florida experience

This retrospective study spans the years 1988 to 2000 and looks specifically at the treatment procedures and outcomes for the correction of velopharyngeal insufficiency (VPI). Ninety-eight patients underwent preoperative assessment by speech pathologists that included perceptual speech evaluation, videofluoroscopy, and, for some, nasendoscopy. Based on this evaluation protocol, a specific surgical procedure was chosen to serve the patients' needs. The four procedures of choice were the palatal pushback with a pharyngeal flap lining, sphincter pharyngoplasty, a superiorly based obturating pharyngeal flap, and Furlow palatoplasty. The criteria for selecting these procedures are reviewed. The results revealed VPI resolution and the establishment of normal nonnasal speech in more than 95% of the 75 patients for whom outcomes were determined. This study reiterates the importance of thorough preoperative evaluation and the individualization of the secondary corrective procedure.

Incidence and severity of obstructive sleep apnea following pharyngeal flap surgery in patients with cleft palate

OBJECTIVE

To investigate the incidence and severity of obstructive sleep apnea (OSA) associated with pharyngeal flap surgery in patients with cleft palate at least 6 months postoperatively and to determine whether age or the flap width had an effect on them. The hypothesis tested in this study was that the severity of OSA associated with pharyngeal flap surgery is greater in children than in adults.

SUBJECTS

Ten adults, six men and four women, with a mean age of 28.0 years at pharyngeal flap (adult group). Twenty-eight children, 13 boys and 15 girls, with a mean age of 6.3 years at pharyngeal flap (child group).

DESIGN

A prospective analysis.

MAIN OUTCOME MEASURES

An overnight polysomnographic study was used to determine the incidence and severity of OSA 6 months after pharyngeal flap.

RESULTS

The incidence of OSA following pharyngeal flap was high but not significantly different between these two groups (90% in adults and 93% in children, p = 1.000). When OSA was stratified into different levels of severity according to the values of respiratory disturbance index, there were noticeable differences between these two groups (p =.022). In the adult group, eight patients (89%) had mild OSA and 1 patient (11%) had moderate to severe OSA. In the child group, 11 patients (42%) were found to have mild OSA, and 15 patients (58%) had moderate to severe OSA. No relation was found between the flap width and the incidence (p =.435 in adults and.640 in children) or the severity (p =.325 in adults and.310 in children) of OSA in each group.

CONCLUSIONS

Six months following pharyngeal flap surgery, more than 90% of the patients with cleft palate still had OSA. The severity of OSA associated with pharyngeal flap surgery tended to be greater in children than in adults. The flap width was unrelated to the incidence and severity of OSA, no matter in adults or in children.

Palate re-repair revisited

OBJECTIVE

To analyze the results of a consecutive series of palate re-repairs performed using the operating microscope and identify predictive factors for outcome.

DESIGN

Prospective data collection, with blind assessment of randomized recordings of speech and velar function on lateral videofluoroscopy and nasendoscopy.

PATIENTS

One hundred twenty-nine consecutive patients with previously repaired cleft palates and symptomatic velopharyngeal incompetence (VPI) and evidence of anterior insertion of the levator veli palatini underwent palate re-repairs by a single surgeon from 1992 to 1998. Syndromic patients, those who had significant additional surgical procedures at the time of re-repair (23 patients), and all patients with inadequate pre- or postoperative speech recordings were excluded, leaving a total of 85 patients in the study.

INTERVENTIONS

Palate re-repairs, with radical dissection and retropositioning of the velar muscles, were performed using the operating microscope with intraoperative grading of anatomical and surgical findings.

MAIN OUTCOME MEASURES

Pre- and postoperative perceptual speech assessments using the Cleft Audit Protocol for Speech (CAPS) score, measurement of velar function on lateral videofluoroscopy, and assessment of nasendoscopy recordings.

RESULTS

There were significant improvements in hypernasality, nasal emission, and nasal turbulence and measures of velar function on lateral videofluoroscopy, with improvement in the closure ratio, velopharyngeal gap at closure, velar excursion, velar movement angle, and velar velocity.

CONCLUSIONS

Palate re-repair has been shown to be effective in treating VPI following cleft palate repair, both in patients who have not had an intravelar veloplasty and those who have had a previous attempt at muscle dissection and retropositioning. Palate re-repair has a lower morbidity and is more physiological than a pharyngoplasty or pharyngeal flap.

Pharyngeal flap and the internal carotid in velocardiofacial syndrome

Internal carotid artery anomalies have been documented as a common clinical feature in velocardiofacial syndrome. There has been some controversy over the need for preoperative imaging procedures, such as magnetic resonance angiography, when planning pharyngeal surgery for correcting velopharyngeal insufficiency. The purpose of this article is to describe 20 patients with velocardiofacial syndrome who received comprehensive evaluation and underwent pharyngeal flap surgery within a 2-year period and to report the technique used for dissecting the flap and the surgical outcomes. Anomalies of the major neck vessels were present in all cases, but 5 of these 20 cases had particularly severe anomalies of the internal carotid arteries that placed the vessels directly deep within the donor site for the pharyngeal flap. Surgery was carried out successfully in all 20 cases using a modified approach after radiographic imaging was performed to locate the arteries. In the 5 cases with severe malpositioning of the internal carotid arteries, it was clear that the vessels could have been injured had their location not been identified and the surgical approach modified to avoid them.

Craniofacial characteristics and velopharyngeal function in cleft lip/palate children with and without adenoidectomy

The association between velopharyngeal function, craniofacial morphology and adenoidectomy was investigated using 27 craniofacial and nasopharyngeal variables taken from lateral cephalograms. The sample consisted of 96 boys with cleft palates with or without cleft lips. They were examined at 6 years of age when cephalograms were obtained and perceptual speech assessments were performed. The subjects were divided into three groups: (1) velopharyngeal competence (VPC, n = 45); (2) mild incompetence not requiring velopharyngoplasty (VPI, n = 36); and (3) previous incompetence operated on with velopharyngoplasty ad modum Hoenig (VPP, n = 15) before the 6-year examination. The groups were further divided into two subgroups according to previous adenoidectomy (Ad+, Ad-). The cranial base, size and interrelationship of the maxilla and mandible and their relationship to the cranial base or the bony nasopharynx did not differ among the VPC, VPI and VPP groups. The sagittal depth of the nasopharyngeal airway (Pm-ad1, Pm-ad2, Pm-ad3) was significantly wider in the VPP group than in the the VPC and VPI groups. The previous adenoidectomy decreased the thickness of the posterior pharyngeal wall (ad1-Ba, ad2-so) and thus increased airway size. The length of the velum did not differ between the three groups or their subgroups with and without adenoidectomy. The results showed that adenoidectomy is a risk to velopharyngeal function by widening the nasal airway, but velopharyngeal incompetence cannot definitely be attributed to adenoidectomy.

An analysis of the strengths and weaknesses of endoscopic and radiological investigations of velopharyngeal incompetence based on a 20 year experience of simultaneous recording

The simultaneous recording of nasopharyngoscopy and video fluoroscopy allows a comparison to be made of their reliability under various circumstances. While the monocular view and the number of optical fallacies make measurement from endoscopy impossible, radiological views can also be shown to be fallacious, and all measurements should be treated with caution. However, through clinical observation the variability of the final dimensions of tissues raised to treat velopharyngeal incompetence can be roughly gauged. Indeed, the need for more accurate measurement awaits the arrival of a predictable procedure to allow fine tuning of surgery. Simultaneous recording has permitted improved clarity of interpretation and accuracy of measurement in some cases. The chief gain from investigations over the past 30 years has been in the considerably increased understanding of the range of normal and pathological morphology that must be taken into account in surgical treatment.

[Development of speech and facial skull growth after primary velopharyngoplasty in lip-jaw-palate clefts]

BACKGROUND

A two-armed, prospective, randomized study was performed to evaluate the influence of primary velopharyngoplasty on speech and facial growth in patients with cleft lip and palate.

PATIENTS AND METHODS

Forty-two patients born between 1978 and 1982 were included. All patients were treated with an intravelar veloplasty, and 21 patients simultaneously with a velopharyngoplasty according to Sanvenero-Rosselli. The patients were examined at the age of 5, 10, 15, and 18 years according to the recommendations of the research group of the German Association of Craniomaxillofacial Surgery for minimal documentation.

RESULTS

Patients treated with primary velopharyngoplasty showed a higher deficit in transversal growth of the maxilla of 0.6 mm in the molar region in adolescence in comparison to the control group. The sagittal growth of the maxilla was reduced at 2.6 degrees in the SNA angle. A statistically significant decrease in growth of the maxilla caused by primary velopharyngoplasty was not detectable (p > 0.05). The incidence of rhinophonia and dyslalia did not differ significantly. Primary velopharyngoplasty did not lead to speech improvement either in childhood or in adolescence.

CONCLUSION

With regard to a potential decrease in growth of the maxilla and the disadvantages of a hindered nasal respiration, a primary velopharyngoplasty therefore does not seem to be indicated.

Lipoinjection augmentation of the soft palate for velopharyngeal stress incompetence

OBJECTIVES/HYPOTHESIS

Velopharyngeal stress incompetence in professional musicians is an uncommon but potentially career-ending problem. Pharyngeal flaps, V-Y palatal pushback procedures, Teflon or collagen injection of the posterior pharyngeal wall, and speech therapy have all been used to address this problem. The ideal procedure for this subset of patients with velopharyngeal incompetence (VPI) with high-pressure, mild VPI would be one that combines low morbidity and an expedient recovery for the busy musician. We describe an approach of endoscopically assisted autologous lipoinjection of the soft palate.

STUDY DESIGN

A retrospective review of our experience treating high-pressure stress VPI in two professional musicians.

METHODS

Literature review and retrospective chart review.

RESULTS

Two musicians underwent autologous lipoinjection of the soft palate for stress VPI. Patients resumed full play within 2 weeks of the operation with no serious complications. There has been no recurrence of the VPI after 18 and 12 months of follow-up, respectively.

CONCLUSIONS

Velopharyngeal stress incompetence in musicians is an uncommon disorder. Velopharyngeal incompetence in these patients may not present as in a typical manner with hypernasality but may go undiagnosed for years mistakenly rationalized as a declining performance ability rather than a curable structural problem. The performance demands of professional musicians necessitate a timely solution to their VPI. More precise and limited contouring of palatal bulk can be achieved through the lipoinjection technique than compared with traditional palatal V-Y pushback or a standard pharyngeal flap. Lipoinjection of the palate can be performed as an outpatient procedure with only minor discomfort and an expedient recovery for the career musician.

Reconstruction of palatal defect using mucoperiosteal hinge flap and pushback palatoplasty

This article describes a simple, new surgical technique to provide a complete two-layer closure of palatal defect resulting from a surgical complication of trans palatal resection of skull base chordoma. The nasal layer was reconstructed with triangular shape oral mucoperiosteal turn over hinge flap based on anterior margin of palatal defect and rectangular shaped lateral nasal mucosal hinge flaps. The oral layer was reconstructed with conventional pushback V-Y advancement 2-flaps palatoplasty. Each layer of the flaps were secured with two key mattress suture for flap coaptation. This technique has some advantages: simple, short operation time, one-stage procedure, no need of osteotomy. It can close small- to medium-sized palatal defect of palate or wide cleft palate and can prevent common complication of oronasal fistula, which could be caused by tension.