Redo double-opposing Z-plasty is effective for correction of marginal velopharyngeal insufficiency

Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations

OBJECTIVE

Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique.

RESULTS

Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation.

CONCLUSIONS

A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.

Velopharyngeal Function Change after 2-Jaw Orthognathic Surgery in Patients with Cleft: A Study of 162 Consecutive Cases

BACKGROUND

Orthognathic surgery (OGS) is a common intervention used to correct midfacial hypoplasia in patients with cleft. Previous studies have reported that Le Fort I maxillary advancement may affect velopharyngeal function, but similar investigations focusing on 2-jaw OGS have not been conducted.

METHODS

A total of 162 consecutive patients with cleft lip and palate who underwent 2-jaw OGS between 2015 and 2020 were enrolled. Clinical data were collected, and preoperative and postoperative skeletal measurements were obtained from cephalometric images. Velopharyngeal function was evaluated using perceptual analysis and nasopharyngoscopy. A logistic regression model was used for risk factors associated with changes in velopharyngeal function.

RESULTS

After 2-jaw OGS, 82.1% of patients showed no change in velopharyngeal function, 3.7% experienced improvement, and 14.2% exhibited worsening of function. Changes in velopharyngeal function were statistically significant compared with velopharyngeal status before OGS. Multivariable logistic regression revealed that the amount of maxillary advancement independently predicted the deterioration of velopharyngeal function after OGS (odds ratio, 1.74; 95% CI, 1.20 - 2.52; P = 0.004). The receiver operating characteristic curve based on maxillary advancement demonstrated good discrimination, with an area under the curve of 0.727 (95% CI, 0.62 - 0.83; P = 0.001). The Youden index was 4.27 mm.

CONCLUSIONS

Despite the risk of velopharyngeal function deterioration in patients with cleft palate undergoing OGS, some individuals experienced improved function after 2-jaw OGS. The extent of maxillary advancement has a negative effect on velopharyngeal function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Medial incision approach in modified small double-opposing Z-plasty for Veau II cleft repair

An encouraging outcome was described for the use of modified Furlow small double-opposing Z-plasty (sDOZ) using the medial incision (MIsDOZ) approach in repair of Veau type I cleft palate. This retrospective study assessed early results of using extended indication criterion of MIsDOZ for the management of consecutive non-syndromic patients with Veau II cleft palate treated by a single surgeon. Bardach two-flap plus sDOZ (two-flap approach) or medial incision approach with a tension-driven stepwise application of lateral palatal incisions (soft palate only, von Langenbeck type, or two-flap type) were applied. Surgical (age, cleft width, operative time, hospital stay, and complication)- and auditory-perceptual assessment-related data were collected. Two-flap approach (n = 21) demonstrated a significantly (p < 0.001) increased operative time (132.8 ± 12.2 versus 114.8 ± 19.9 min, respectively) and higher use of lateral incisions (100% versus 44.4%) than medial incision approach (n = 27), with no significant (p > 0.05) difference for age at surgery (13.0 ± 6.1 versus 13.6 ± 5.8 months), cleft width (8.5 ± 4.1 versus 8.7 ± 3.8 mm), hospital stay (1.0 ± 0 versus 1.0 ± 0 day), and complication (0% versus 0%) and hypernasality (9.5% versus 7.4%) rates. In conclusion, the medial incision approach for Veau II cleft repair resulted in reduced need for lateral palatal incision with no increase of complication or hypernasality rates.

Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study

BACKGROUND

The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center.

METHODS

A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included.

RESULTS

A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0.

CONCLUSION

Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula.

Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series

BACKGROUND

Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG).

METHODS

A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated.

RESULTS

Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases.

CONCLUSION

The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

Surgical Management of Velopharyngeal Dysfunction

Velopharyngeal dysfunction (VPD) is caused by inadequate closure of the velopharyngeal port. VPD can hinder a child's ability to communicate and can impact his/her quality of life. Evaluation of children with VPD is often completed in a multidisciplinary setting and often involves studies that allow for the visualization of the velopharyngeal closure during voluntary speech (ie, nasopharyngoscopy). Multiple surgical options exist for the treatment of VPD including pharyngeal flap, sphincter pharyngoplasty, buccal myomucosal flaps, Furlow palatoplasty, palate re-repair, intravelar veloplasty, and injection pharyngoplasty. Each speech surgery has its unique benefits and drawbacks and the decision on which surgery to recommend should be tailored to each patient's specific needs and weighing the risk/benefit profile for their specific surgeries.

Pearls and pitfalls in contemporary management of marginal velopharyngeal inadequacy among children with cleft palate

Marginal velopharyngeal inadequacy (MVPI) is a particular status of velopharyngeal closure after cleft palate repair. The physiological and phonological characteristics of patients with MVPI are significantly different from those with typical velopharyngeal insufficiency. The pathological mechanisms and diagnostic criteria of MVPI are still controversial, and there is limited evidence to guide the selection of surgical and non- surgical management options and a lack of recognized standards for treatment protocols. Based on a systematic study of the relevant literatures, this review identifies specific problems that are currently under-recognized in the diagnosis and treatment of MVPI and provides guidelines for further exploration of standardized and reasonable intervention protocols for MVPI.

Long-term treatment outcome of patients with complete bilateral cleft lip and palate: a retrospective cohort study

BACKGROUND

Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature.

PATIENTS AND METHODS

A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis.

RESULTS

A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient.

CONCLUSION

Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

Double-opposing Z-Plasty Extended with a Pedicled Buccal Fat Pad Flap for Correcting Velopharyngeal Insufficiency after Primary Palatoplasty

INTRODUCTION

Furlow double-opposing Z-plasty (DOZ) lengthens the soft palate; however, this lengthening is achieved at the expense of increased mucosal flap tension. Thus, its use is limited in patients with severe tension applied on mucosal flap after DOZ. In this study, DOZ was combined with a buccal fat pad (BFP) flap to maximize palatal lengthening and muscle repositioning.

METHODS

This study included patients who underwent surgical correction for velopharyngeal insufficiency between December 2016 and February 2019. Patients with more than moderate degree hypernasality following primary palatoplasty were included in the study. Patients younger than 4 years of age, those with a submucous cleft palate, or syndromic patients were excluded. Speech outcomes were investigated for those who underwent DOZ only (DOZ group, n = 17) and those in whom a BFP was used (BFP group, n = 15) pre- and postoperatively. The velopharyngeal gaps between the uvula and pharyngeal wall were measured before and immediately after surgery to estimate the palatal length.

RESULTS

Most patients who received a BFP showed improvement in hypernasality. However, the hypernasality of the DOZ group was more severe than that of the BFP group (p = 0.023). The extent of palatal lengthening was 4.4 ± 1.7 mm and 7.5 ± 2.1 mm in the DOZ and BFP groups, respectively (p = 0.001).

CONCLUSIONS

BFPs reduced the tension of the DOZ mucosal flap and maximized palatal lengthening and muscle repositioning. They promoted velopharyngeal closure in patients with moderate and moderate-to-severe velopharyngeal insufficiency. Hence, our method improves the surgical outcomes of patients with velopharyngeal insufficiency after primary palatoplasty.

Evaluation of Velopharyngeal Closure Ratio by a New Semi-Automatic Detection Method Based on Nasopharyngoscopy With Image Processing Method

ABSTRACT

The goal of this study is to develop and validate a novel semi-automatic detection method (SADM) under nasopharyngoscopy based on the image processing technique, which can assist the evaluation of the velar closure ratio (VCR). After the development of the SADM, 72 patients were enrolled. The reliability of SADM was evaluated by repeated measurements. Velar closure ratio are given by conventional nasopharyngoscopy method and SADM were compared. Velar closure ratios given by SADM were further translated into a trichotomous classification for velopharyngeal function diagnosis, that is, velopharyngeal closure (VPC), marginal VPC (MVPC), and velopharyngeal incomplete. The 2 VCR-thresholds used for the translation were explored and validated. As results shown, SADM was proved to be reliable with an intraclass correlation coefficient of 0.996 (95% confidence interval: 0.993-0.997, P < 0.001). Intraclass correlation coefficient between conventional nasopharyngoscopy method and SADM was 0.954 (95% confidence interval: 0.927- 0.971, P < 0.001). Velar closure ratio-thresholds were set at 0.82 and 0.92 according to the ROC curve. Diagnostic sensitivity and specificity for velopharyngeal incomplete were 1.00 and 1.00. MVPC had 0.58 sensitivity and 0.96 specificities while VPC had 0.92 and 0.79, respectively. No statistically significant difference was found between the diagnosis of SADM and speech pathologists (P > 0.1). In conclusion, this study successfully developed an accurate and reliable semi-automatic method to evaluate VCR, which could help improve the efficacy of VCR evaluation and velopharyngeal function diagnosis.

Videofluoroscopic Findings as Predictors of Velopharyngeal Insufficiency After Orthognathic Surgery in Patients With Cleft Lip and Palate

BACKGROUND

Midface retrusion is a common problem in patients with cleft lip and palate owing to the lack of adequate growth of the maxilla. Midface advancement surgery is a definite treatment for midface retrusion; however, the subsequent oropharyngeal airway changes might result in velopharyngeal insufficiency (VPI) in affected patients. Determining the predictors of VPI beforehand and modifying the surgical procedure would be beneficial.

MATERIALS AND METHODS

A retrospective review of 42 patients with cleft lip and palate who underwent orthognathic surgery from 2013 to 2014 was performed. A total of 25 patients met the inclusion criteria and had undergone complete pre- and postsurgery videofluoroscopy, nasopharyngoscopy (NPS), and speech assessment. We compared 2 groups of patients, those who showed NPS finding changes of more than 0.1 (8 patients) and those without changes (17 patients), by measuring the distances of the contact point to the tip of the velum, gap size at maximum closure (MC) and rest, contact area length, lateral wall closure rate, closure velocity, and 2 angles (from the velum to the hard palate and genu) at MC and rest. The amount of maxillary advancement was also recorded.

RESULTS

Among the 8 patients with NPS finding changes, 3 underwent Furlow palatoplasty for VPI. No significant difference was found in the amount of maxillary advancement between the groups (5.8 vs 5.7 mm). Significant differences were found in the preoperative gap size at MC and angle at the genu at MC (P = 0.035 and .012). These could be considered as the predictors before surgery. After surgery, a significant difference was found in the contact area, lateral wall closure rate, and gap size at MC (P = 0.005, 0.018, and 0.01).

CONCLUSION

Videofluoroscopy is a relatively applicable method of determining dynamic changes in the velum function. By performing videofluoroscopy before midface advancement surgery in patients with cleft lip and palate, we may predict the risk of VPI and consider alternative surgical strategies.

A Comparative Study Evaluating Speech Outcomes in Classic versus Occult Submucous Cleft Palate Using a Primary Furlow Palatoplasty Technique

BACKGROUND

No consensus exists on the selection of procedures for the treatment of submucous cleft palate, with scarce reports on long-term outcomes from single-surgeon experience. This study assessed the outcomes of using extended indication criteria of Furlow palatoplasty as the first-line procedure for the management of submucous cleft palate-associated velopharyngeal insufficiency.

METHODS

Consecutive nonsyndromic patients with submucous cleft palate (n = 216) treated by a single surgeon between 1998 and 2018 were reviewed. Furlow palatoplasty was performed in all patients diagnosed with submucous cleft palate-associated velopharyngeal insufficiency, regardless of the age cutoff, number of Calnan triad features, or velopharyngeal gap size and pattern. Postoperative velopharyngeal function outcome (adequate, marginal, or inadequate) and the need for secondary surgery were investigated. Age at surgery, sex, submucous cleft palate type (classic and occult), and presence of complication were evaluated for potential associations with this outcome.

RESULTS

Forty-seven patients aged 8.3 ± 4.6 years with occult submucous cleft palate were significantly (p < 0.001) older than those with the classic type (n = 169; 5.6 ± 3.1 years). Most (p < 0.001) of the included patients [n = 181 (83.8 percent)] achieved adequate postoperative velopharyngeal function outcome. Three patients (1.4 percent) presented surgery-related complications, including bleeding and partial wound disruption. Secondary speech surgery was recommended in 24 patients (11.1 percent). In the bivariate and multivariate analyses, none of the tested variables was found to be associated (all p > 0.05) with the postoperative velopharyngeal function outcome.

CONCLUSION

The extended indication criteria of Furlow palatoplasty provided adequate velopharyngeal insufficiency management with a low complication rate and satisfactory speech outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Modified double-opposing Z-plasty for patients with Veau I cleft palate: Are lateral relaxing incisions necessary?

Low fistula rate and a satisfactory speech outcome were previously reported by adopting a modified Furlow palatoplasty using small double-opposing Z-plasty (DOZ). The purposes of this study were to (1) describe the technical standardization of further modification of this small DOZ using the medial incision (MIDOZ) approach for Veau I cleft repair; (2) assess the early postoperative outcomes of a single surgeon's experience using this technique; and (3) evaluate the temporal association of this standardization with the necessity of lateral relaxing incisions.A prospective study (n = 24) was performed consecutively to non-syndromic patients with Veau I cleft palate who underwent MIDOZ approach. Patients with similar characteristics who underwent small DOZ were included as a retrospective group (n = 25) to control for the potential effect of the standardization of surgical maneuvers (including the hamulus fracture) on the rate of lateral relaxing incisions. Six-month complication rate was collected.No postoperative complications, such as bleeding, flap necrosis, dehiscence or fistula were observed. The prospective group had a significantly (all P < .05) higher rate of hamulus fractures (n = 48, 100%) and a lower rate of lateral relaxing incisions (n = 1, 2%) than the retrospective group (n = 16, 32%; n = 26, 52%).This technical standardization for performing palatoplasty using MIDOZ approach provided adequate Veau I cleft palate closure, without fistula formation, and with a low need of lateral relaxing incisions.

Age and Preoperative Velar Closure Ratio Are Significantly Associated With Surgical Outcome of Furlow Double-Opposing Z-Plasty in Palatal Re-Repair

PURPOSE

The patient selection criteria for Furlow double-opposing Z-plasty in palatal re-repair remain obscure. This study investigated whether patients' preoperative characteristics significantly affected the surgical outcome of Furlow double-opposing Z-plasty in palatal re-repair.

MATERIALS AND METHODS

We designed and implemented a case-control study nested in a cohort, which could be divided into 2 stages. In the first stage, a retrospective cohort study was performed to collect basic information and the preoperative status of the patients who would undergo Furlow double-opposing Z-plasty to correct velopharyngeal insufficiency after primary cleft palate repair. Eight predictor variables were included: age, gender, primary surgical technique, velopharyngeal closure pattern, velar movement, lateral pharyngeal wall movement, levator muscle orientation, and preoperative velar closure ratio. The outcome variable was postoperative velopharyngeal function described as velopharyngeal competence or velopharyngeal insufficiency. In the second stage, a case-control analysis was performed to explore the potential factors affecting the surgical outcome. Univariate and multivariate analyses were applied to examine the relationship between the predictor variables and surgical outcome.

RESULTS

The sample was composed of 83 patients and resulted in 54 velopharyngeal competence outcomes and 29 velopharyngeal insufficiency outcomes after surgery. Two predictors showed statistical significance: age and preoperative velar closure ratio. The possibility of postoperative velopharyngeal insufficiency in patients older than 14.5 years was 6 times higher than that in patients younger than 14.5 years. The possibility of postoperative velopharyngeal insufficiency in patients with preoperative velar closure ratios of 0.9 or greater was one fifth that in patients with preoperative velar closure ratios between 0.8 and less than 0.9.

CONCLUSIONS

The results of this study suggest that age and preoperative velar closure ratio are significantly associated with postoperative velopharyngeal insufficiency. Age was a risk factor in achieving good surgical outcomes, and the preoperative velar closure ratio remained a protective factor.

Craniofacial Interventions in Children

Craniofacial interventions are common and the surgical options continue to grow. The issues encountered include micrognathia, macroglossia, midface hypoplasia, hearing loss, facial nerve palsy, hemifacial microsomia, and microtia. In addition, a unifying theme is complex upper airway obstruction. Throughout a child's life the focus of interventions may change from airway management to speech, hearing, and language optimization, and finally to decannulation and procedures aimed at social integration and self-esteem. Otolaryngologists play an important role is this arena and provide high-quality care while continuing to expand what can be done for our patients.

[Effectiveness of Furlow palatoplasty in velopharyngeal insufficiency after cleft palate surgery]

OBJECTIVE

To explore the application value of Furlow palatoplasty in reconstruction of velopharyngeal insufficiency (VPI) after cleft palate surgery.

METHODS

Between August 2015 and January 2017, 48 patients with VPI after cleft palate surgery were treated with Furlow palatoplasty. There were 29 males and 19 females, aged from 4 to 17 years (mean, 6.1 years). There were 16 cases of incomplete cleft palate and 32 cases of complete cleft palate; and 16 cases of soft cleft palate and 32 cases of soft and hard cleft palate. The interval between first cleft palate surgery and Furlow palatoplasty was 3 to 13 years (mean, 5.9 years). The patients were accompanied by significant open rhinolalia and nasal leakage. The degree of velopharyngeal closure assessed by electronic nasopharyngeal fiberoptic endoscopy was grade Ⅲ. The operation time and intraoperative blood loss were recorded. The total length of palate, the length of soft palate, the depth of pharyngeal cavity, and the width of pharynx and palate arch were measured before operation and at immediate after operation, and the change of the above indexes before and after operation was calculated. According to the results of clinical assessment, the patients were allocated into three groups: velopharyngeal competence (VPC) group, marginal velopharyngeal inadequacy (MVPI) group, and VPI group. The relationship between the soft palate and the posterior pharyngeal wall was evaluated by lateral cephalometric radiographs at 3 months after operation, and the patients were allocated into complete contact group, point contact group, and non-contact group. The velopharyngeal closure was evaluated by electronic nasopharyngeal fiberoptic endoscopy (grade Ⅰ, Ⅱ, Ⅲ). Spearman analysis was used to analyze the correlation between the changes of the total length of palate, the length of soft palate, the depth of pharyngeal cavity, and the width of pharynx and palate arch before and after operation. The contact degree of soft palate and posterior pharyngeal wall and the closure degree of pharynx and palate were grouped separately, and the above indexes were analyzed statistically.

RESULTS

The operation time was 35-64 minutes (mean, 41 minutes); the intraoperative blood loss was 3-10 mL (mean, 6 mL). All patients were followed up 3 months. After 3 months of operation, the clinical evaluation results were 34 cases of VPC, 7 cases of MVPI, and 7 cases of VPI. Lateral cephalometric radiographs showed that 30 cases had complete contact with the posterior pharyngeal wall, 11 cases had point contact, and 7 cases had no contact. Electronic nasopharyngeal fiberoptic endoscopy showed that the pharyngeal closure function was improved to varying degrees, 29 cases of grade Ⅰ, 12 cases of grade Ⅱ, and 7 cases of grade Ⅲ. There were significant differences in the total length of palate, the length of soft palate, the depth of pharyngeal cavity, and the width of pharynx and palate arch between pre- and post-operation ( P<0.05). Spearman correlation analysis showed a correlation between the change in the total length of palate before and after operation and the change in the length of soft palate ( r=0.448, P=0.001). There were significant differences in the changes of total length of palate, the length soft palate, and the depth of pharyngeal cavity before and after operation between VPC, MVPI, and VPI groups ( P<0.05); and there was no significant difference in the change of the width of pharynx and palate arch before and after operation between groups ( P>0.05). There were significant differences in the changes of total length of palate and the length soft palate before and after operation between complete contact, point contact, and non-contact groups ( P<0.05); and there was no significant difference in the change of the depth of pharyngeal cavity and the width of pharynx and palate arch before and after operation between groups ( P>0.05).

CONCLUSION

Furlow palatoplasty can restore the VPI after cleft palate surgery, which can effectively prolong the soft palate and reduce the depth of the pharynx. It can cover the physiological and anatomical morphology of velopharyngeal closure significantly and improve the velopharyngeal function.

Palatal Protective Stents Prevent Oro-Nasal Fistulas after Surgery for Velopharyngeal Insufficiency: A Preliminary Report

Background: One of the potential complications of surgery for velopharyngeal insufficiency (VPI) is postoperative oral-nasal fistula (ONF). Reported rates vary from 0 to 60%. Several factors are on account of these disproportionate rates. Objective: The purpose of this study was to describe the use of a palatal protective stent (PPS) to preserve the VPI repair surgical site and to study its effectiveness for decreasing the incidence of postoperative ONF. Materials and Methods: A retrospective study was carried out. All patients undergoing surgery for VPI with complete preoperative and postoperative evaluations including at least one year follow up after surgery from 2012 to 2016 were studied. Some of the patients were operated on using a pre-molded palatal protective stent (PPS). Twenty-seven patients were included in the study group. Most of the patients underwent a customized pharyngeal flap according to findings of imaging procedures. The remaining cases underwent a Furlow palatoplasty. Twelve patients were operated on using PPS. Results: There were no surgical complications during the procedures. ONF was detected in four of the patients operated on without PPS. None of the patients undergoing surgery using PPS demonstrated ONF. All fistulas were located at the soft/hard palate junction. VPI was corrected in 92% of the cases. Conclusion: Although only a reduced number of cases were studied, these preliminary results suggest that using PPS during surgical procedures for correcting VPI is a safe and reliable tool for preventing ONF.

A Treatment Protocol for Velopharyngeal Insufficiency and the Outcome

BACKGROUND

A simple algorithm is applied to treat velopharyngeal insufficiency. The purpose of this study was to assess its success rate and complications.

METHODS

The diagnosis includes speech perceptual assessment and nasopharyngoscopy, focusing on velopharyngeal closure ratio. The treatment is composed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A retrospective chart review was conducted for 84 consecutive nonsyndromic postpalatoplasty patients undergoing velopharyngeal insufficiency surgery from August of 2007 to December of 2014. The demographic, perioperative, and follow-up data were collected. Statistical analyses were performed.

RESULTS

Mean age at velopharyngeal insufficiency surgery was 7.0 years. The overall improvement rate for patients was 86.9 percent. Nine patients in the double-opposing Z-plasty group and two patients in the pharyngeal flap group were refractory to velopharyngeal insufficiency surgery. The improvement rates for each surgical group were 80.4 percent for the double-opposing Z-plasty group and 94.7 percent for the pharyngeal flap group. There were no significant differences in postoperative velopharyngeal function between the coronal and noncoronal groups. Airway-associated complications were observed in nine patients (10.7 percent). The complications in the double-opposing Z-plasty group were observed in two patients (4.3 percent), and none of the patients presented obstructive sleep apnea. Seven patients (18.4 percent) in the pharyngeal flap group showed postoperative snoring, and one (2.6 percent) of them presented with obstructive sleep apnea.

CONCLUSION

The authors' algorithm is a simple patient- and surgeon-friendly strategy to obtain satisfactory improvement of velopharyngeal function for velopharyngeal insufficiency patients, with a low risk of airway complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.