Bilateral buccinator myomucosal flap outcomes in nonsyndromic patients with repaired cleft palate and velopharyngeal insufficiency

Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions

PURPOSE OF REVIEW

This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction.

RECENT FINDINGS

Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea.

SUMMARY

Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.

Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients

OBJECTIVE

Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients.

SETTING

An academic tertiary pediatric care center.

METHODS

Retrospective cohort study.

PATIENTS

Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL).

OUTCOME MEASURES

The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS).

RESULTS

97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05).

CONCLUSION

Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.

Posterior Positioning of Levator Veli Palatini with Intact Nasal Layer and Side-by-Side Bilateral Buccinator Flaps: Modified Approach for Palatal Lengthening

OBJECTIVE

To introduce a modified surgical method using bilateral buccinator flaps with posterior positioning of levator veli palatini muscles to treat velopharyngeal insufficiency.

DESIGN

Cross-sectional clinical study.

PATIENTS

Non-syndromic patients with velopharyngeal insufficiency.

INTERVENTION

We performed a modified surgical method using posterior positioning of levator veli palatini muscles and side-by-side bilateral buccinator flaps.

MAIN OUTCOME MEASURES

Patients' characteristics, severity of hypernasality, palatal lengthening size, and operative complications were recorded and described. The severity of hypernasality was determined by a speech therapist before and after the operation.

RESULTS

A total of 26 non-syndromic patients, with a median age of 8.5 years, were enrolled. All patients presented with severe hypernasality. Following the operation and during the follow-up period, 12 patients showed a complete resolution of hypernasality, while 9, 3, and 2 patients exhibited mild, moderate, and severe hypernasality, respectively. In addition, the mean palatal lengthening was measured to be 25.3 ± 3.5 mm. Overall, three patients experienced partial flap loss in one flap, which was successfully repaired with a secondary intention without the development of a fistula. In five cases, complete closure of the donor sites couldn't be achieved and thus were treated with secondary intention. Additionally, postoperative food restrictions were observed in seven cases but were resolved within one month. No other complications were noted in the remaining patients.

CONCLUSION

This modified palatal lengthening technique results in a significant lengthening of the palate while maintaining favorable speech outcomes. Future randomized clinical trials are warranted to validate our findings.

Speech Outcomes After Palatal Lengthening Via Double Opposing Buccinator Myomucosal Flaps

BACKGROUND

Palatal lengthening is becoming a first-line treatment choice for cleft patients with velopharyngeal insufficiency (VPI). As cleft palate-related surgical outcomes are age dependent, speech outcomes may be similarly affected by patient age at the time of treatment. The primary goal of this study is to determine whether there are age-related speech outcome differences when double opposing buccinator myomucosal flaps are used as part of a palatal lengthening protocol and whether these outcome differences preclude utilization of this technique for specific patient age groups.

METHODS

A retrospective study was performed on consecutive nonsyndromic patients with VPI who underwent treatment using double opposing buccinator myomucosal flaps at our hospital between 2014 and 2021. Patients who completed the 15-month follow-up were stratified by age. Group A aged between 2 and 7 years (n = 14), group B aged 8 and 18 years (n = 23), and group C aged older than 18 years (n = 25) were included. Standardized perceptual speech evaluations and nasopharyngoscopy were performed. Hypernasality, soft palate mobility, and lateral palatal wall mobility were assessed both preoperatively and at a 15-month postoperative interval. Complications were also recorded. The χ2 test was used for statistical comparison.

RESULTS

All of the age-stratified patient groups in this study showed significant improvement in hypernasality, soft palate mobility, and lateral wall mobility (P < 0.01), with no statistically significant differences between the different patient age groups. Overall speech success was achieved in 69.4% of patients. Patients in group A achieved 78.6% speech success, patients in group B achieved 78.3% speech success, and patients in group C achieved 56% speech success, with no statistically significant differences being shown regarding speech success between the different patient age groups (P > 0.05).

CONCLUSIONS

Regardless of age, palatal lengthening via double opposing buccinator myomucosal flaps similarly improves speech outcomes.

Treatment of Velopharyngeal Insufficiency Using Bilateral Myomucosal Buccinator Flaps

SUMMARY

The buccinator myomucosal flap, also referred to as a buccal myomucosal flap, is an effective technique to address velopharyngeal insufficiency after cleft palate repair. Challenges related to flap harvesting may deter plastic surgeons from incorporating this strategy as a first-line treatment. The primary objective of this study and accompanying video is to provide support regarding indications, planning, and surgical steps of the buccinator myomucosal flap technique, including important technical details for soft-palate dissection and flap harvesting.

Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-Analysis

OBJECTIVE

Buccal myomucosal flaps (BMF) anatomically lengthen the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing literature on speech outcome of BMF palatal lengthening.

DESIGN

Three databases were used to identify studies of interest published in English. Studies that did not use standardized speech assessments were excluded. PRISMA checklist was followed, and the risk of bias in the included studies was assessed.

SETTING

Long-term follow up of patients.

PATIENTS

With history of cleft palate presenting with VPI.

INTERVENTION

BMF palatal lengthening.

MAIN OUTCOME MEASURE

Random-effects model meta-analyses were performed for hypernasality, intelligibility, and nasal air emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment.

RESULTS

From the initial 7115 articles, 13 were included in this review. Two of these had a significant patient overlap and a study with a smaller patient population was excluded. All 12 included articles met the National Institutes of Health Quality Assessment Tool criteria. Six retrospective studies evaluated 230 patients and six prospective studies evaluated 181 patients. The most common indications for BMF were large size of the velopharyngeal gap and prior surgery for VPI. Meta-analyses demonstrated effect sizes below zero, confirming the improvement of standardized assessment scores in patients with VPI after BMF palatal lengthening. Egger regressions revealed low risk of publication bias.

CONCLUSIONS

BMF palatal lengthening provides adequate treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.

Buccal Myomucosal Flap Repair for Velopharyngeal Dysfunction

BACKGROUND

Velopharyngeal dysfunction (VPD) is the incomplete separation of the nasal and oral cavities during speech sound production that can persist following primary palatoplasty. Surgical technique used in management of VPD (palatal re-repair versus pharyngeal flap or sphincter pharyngoplasty) is often dictated by the preoperative velar closing ratio and closure pattern. Recently, buccal flaps have increased in popularity in management of VPD. Here, the authors investigate the effectiveness of buccal myomucosal flaps in the treatment of VPD.

METHODS

A retrospective review was performed of all patients undergoing secondary palatoplasty with buccal flaps at a single center between 2016 and 2021. Preoperative and postoperative speech outcomes were compared. Speech assessments included perceptual examinations, graded on a four-point scale of hypernasality, and speech videofluoroscopy, from which the velar closing ratio was obtained.

RESULTS

A total of 25 patients underwent buccal myomucosal flap procedures for VPD at a median of 7.1 years after primary palatoplasty. Patients had significantly increased velar closing postoperatively (95% versus 50%; P < 0.001) and improved speech scores ( P < 0.001). Three patients (12%) had continued hypernasality postoperatively. There were no occurrences of obstructive sleep apnea.

CONCLUSIONS

Treatment of VPD with buccal myomucosal flaps leads to improved speech outcomes without the risk of obstructive sleep apnea. Traditionally, palatal re-repair techniques have been used for smaller preoperative velopharyngeal gaps; however, the addition of buccal flaps allows for anatomical velar muscle correction for patients with a larger preoperative velopharyngeal gap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

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.

Treatment algorithm for velopharyngeal dysfunction in patients with cleft palate: a systematic review

The aim of this study was to review current literature regarding the speech outcome of different techniques of surgical treatment of VPD in cleft patients, in an attempt to reach a treatment algorithm. A systematic review was done, by searching Pubmed, Scopus, and Web of Science electronic databases, following the PRISMA guidelines. Articles reporting speech assessment results of secondary VPI surgeries on non-syndromic patients with CP. Surgical techniques were categorised into two groups; palatal and pharyngeal surgeries. Raw data were extracted to compare speech outcome and complication of each technique, with special emphasis on the factors affecting, the patients' selection for each technique. Our results showed comparable success and complication rates among these techniques. However, the factors governing selection of each technique were identified and taken into consideration to reach a preliminary algorithm. A preliminary treatment algorithm is described based on the results of our review; the most important factors affecting the technique choice are: VP gap size, LVP position, palatal mobility, palatal scarring, VP closure pattern and age of the patient.

Buccal Myomucosal Flap for Reconstruction of Red Lip Defects Close to Mouth Angle

BACKGROUND

Owing to the special esthetic and functional role in the face, red lip reconstruction presents a challenge to plastic surgeons. Various reconstructive techniques can be employed to fix the red lip defects close to the mouth angle. The purpose of this study was to demonstrate that the buccal myomucosal flap could be an available option to repair red lip defects with preservation of its esthetics and function.

METHODS

A single-center, retrospective study of 7 patients with red lip defects who were treated with buccal myomucosal flap was conducted between June 2017 and March 2022. All patients were followed up for at least 6 months including questionnaires and photography.

RESULTS

Of these 7 patients, 2 were women, and 5 were men. The average age was 14.3 years (range, 1-32 y). All the buccal myomucosal flaps survived well. All the donor sites were closed directly without complications. The average follow-up time was 33.4 months (range, 6-57 mo). All patients were satisfied with the aesthetic and functional results.

CONCLUSION

The buccal myomucosal flap is versatile and reliable, with the advantages of rich vascularity, flexible design, and easy access. This study was presented to highlight that the flap could be a good candidate to treat red lip defects close to the mouth angle.

Design of a Novel Orthodontic Appliance to Prevent Pedicle Trauma in Patients Undergoing Double-Opposing Buccal Flaps for Palatal Lengthening

OBJECTIVE

To describe a novel orthodontic appliance to prevent pedicle trauma in patients undergoing double-opposing buccal flap surgery for secondary palatal lengthening.

DESIGN

Case series.

SETTING

Cleft and craniofacial clinic, Johns Hopkins Children's Center.

PATIENTS, PARTICIPANTS

Four patients undergoing double-opposing buccal flap surgery for repair of velopharyngeal insufficiency.

INTERVENTIONS

Patients were fitted with the device, which consists of a lower lingual holding arch with acrylic bite blocks.

MAIN OUTCOME MEASURE

Presence of pedicle trauma postsurgery and tolerability of the device.

RESULTS

The appliance was well tolerated in all 4 patients and no biting trauma to the pedicles was observed.

CONCLUSIONS

A reliable appliance has been developed to prevent biting trauma to the pedicles in patients undergoing double-opposing buccal flap surgery in the permanent dentition stage.

Tissue Augmenting Palatoplasty for the Treatment of Velopharyngeal Insufficiency

PURPOSE

Persistent velopharyngeal insufficiency (VPI) following primary palatoplasty remains a difficult problem to treat. This study evaluates speech outcomes following revision palatoplasty with tissue augmentation using buccal myomucosal flaps (BMF) as an alternative to pharyngoplasty for patients with VPI.

METHODS

A retrospective single-center review of revision palatoplasty with tissue augmentation at a tertiary pediatric hospital Cleft-Craniofacial Center between January 2017 and March 2021 was conducted. Patients with a history of previous palatoplasty, a diagnosis of persistent or recurrent VPI, and comprehensive pre- and postoperative speech evaluations who underwent revision palatoplasty with BMF were included.

RESULTS

Twenty patients met inclusion criteria (35% female, 20% syndromic). Mean age at the time of revision palatoplasty with BMF was 9.7 years. Preoperatively, all patients had stigmatizing speech and received the recommendation for speech surgery; the mean Pittsburgh Weighted Speech Score (PWSS) was 14.3 ± 4.9. The mean postoperative PWSS at the most recent assessment was 4.2 ± 2.3, representing a statistically significant improvement from preoperative scores (P < .001). Mean follow-up time was 8.9 months. Following revision palatoplasty with BMF, only one patient has received the recommendation for further speech surgery. No complications were noted.

CONCLUSION

In patients with VPI following primary palatoplasty, revision palatoplasty with tissue augmentation offers an alternative to pharyngoplasty. This approach preserves dynamic velopharyngeal function, improves speech outcomes, and should be considered an option when treating patients with post-primary palatoplasty VPI.

Speech Outcomes Following Orticochea Pharyngoplasty in Patients With History of Cleft Palate and Noncleft Velopharyngeal Dysfunction

OBJECTIVE

To report speech outcomes following Orticochea pharyngoplasty in 43 patients with cleft palate and noncleft velopharyngeal dysfunction.

DESIGN

A retrospective surgical audit of patients undergoing Orticochea pharyngoplasty between 2004 and 2012, with speech as a primary outcome measure.

SETTING

Patients known to a regional UK cleft center.

METHODS

Forty-three patients underwent Orticochea pharyngoplasty by a single surgeon in a UK regional cleft center. Twenty-one patients had undergone a prior procedure for velopharyngeal dysfunction. Pre- and postoperative speech samples were assessed blindly using the Cleft Audit Protocol for Speech-Augmented by a specialist cleft speech and language therapist, external to the team. Speech samples were rated on the following parameters: hypernasality, hyponasality, audible nasal emission, nasal, turbulence, and passive cleft speech characteristics. Statistical differences in pre- and postoperative speech scores were tested using the Wilcoxon matched-pairs signed-ranks test. Inter- and intrareliability scores were calculated using weighted Cohen κ.

RESULTS

Whole group: A statistically significant difference in pre- and postoperative scores for hypernasality (P < .001), hyponasality (P < .05), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported. Patients with cleft diagnoses: A statistically significant difference in scores for hypernasality (P < .001), nasal emission (P < .01), and passive cleft speech characteristics (P < .01) were reported for this group of patients. Patients with noncleft diagnoses: The only parameter to demonstrate a statistically significant difference was hypernasality (P < .01) in this group.

CONCLUSIONS

Orticochea pharyngoplasty is a successful surgical procedure in treating velopharyngeal dysfunction in both the cleft and noncleft populations.

Buccinator Re-Repair (Bs + Re: IVVP): A Combined Procedure to Maximize the Palate Form and Function in Difficult VPI Cases

Objectives:

To assess the outcome of a modified buccinator flaps’ palatal lengthening combined with radical intravelar veloplasty (Bs + Re: IVVP) for the management of postpalatoplasty velopharyngeal incompetence and report the functional and structural changes occurring in the palate.

Design:

Prospective cohort study of consecutive cleft patients presenting with velopharyngeal incompetence and managed by buccinator re-repair procedure. Blind assessment of randomized recordings of speech and evaluation of velar form and function with nasoendoscopy and lateral videofluoroscopy were done. Patients’ demographic data were also collected.

Patients:

Among 30 consecutive cases who had Bs + Re: IVVP, 24 had adequate pre- and postoperative records of speech outcome data.

Setting:

Multidisciplinary cleft team in a tertiary referral center.

Results:

There were significant improvements in hypernasality, nasal emission, facial grimace and weak consonants, and overall intelligibility of speech. Endoscopy and lateral videofluoroscopy showed significant improvement in total and functional velar length, closure ratio, velopharyngeal gap at closure, palatal thickness, palatal convexity, and mobility. Regarding the procedure complications, no flap ischemia, fistula, or obstructive sleep apnea reported, but there were one cheek hematoma and two minor oral mucosal dehiscence which healed spontaneously.

Conclusions:

Buccinator re-repair (Bs + Re: IVVP) has been shown to be an effective and safe procedure in treating difficult postpalatoplasty velopharyngeal incompetence. It was also shown that it is still a physiological nonobstructive procedure with low morbidity.

Brazilian-Portuguese Linguistic Validation of the Velopharyngeal Insufficiency Effects on Life Outcome Instrument

BACKGROUND

The purpose of this study was to conduct a linguistic validation of the velopharyngeal insufficiency (VPI) Effects on Life Outcome (VELO) instrument for use in Brazilian-Portuguese patients with VPI.

METHODS

The original English version of the VELO instrument was translated into Brazilian-Portuguese, back-translated, and adapted among the Brazilian patients (n = 21) with VPI and their parents, based on the standardized guidelines for the cross-culture adaption process. Discrepancies in the forward and backward translation steps were computed. Comprehension rates were captured for each debriefing interview. The content validity index (CVI) per item (I-CVI) and of the scale (S-CVI universal agreement [S-CVI/UA] and averaging [S-CVI/Ave]) were calculated.

RESULTS

Reconciliation of the 2 forward translations and the comparison between the back translation and the original VELO version resulted in some item wordings with discrepancies which were reviewed by the research team (translators, expert committee, and original developers of instrument). Three rounds of cognitive interviews also led to some revisions of wording. Comprehension rates of patients and their parents were 60% to 100%, 80% to 100%, and 100% in the first, second, and third rounds of cognitive interviews, respectively. The I-CVI, S-CVI/AU, and SCI/Ave for the Brazilian-Portuguese VELO version were 0.83 (or higher), 0.83 (or higher), and 0.97, respectively.

CONCLUSIONS

The linguistic validation process of the VELO instrument created a cross-culturally equivalent Brazilian-Portuguese version for use in Brazilian-Portuguese speaking patients with VPI.

Measuring Patient-Reported Health-Related Quality of Life in Velopharyngeal Insufficiency: Reliability and Validity of the Brazilian Portuguese Version of the VELO Instrument

OBJECTIVE

To test the Brazilian Portuguese velopharyngeal insufficiency (VPI) Effects on Life Outcome (VELO) instrument for reliability and validity.

DESIGN

Cross-sectional methodological study.

SETTING

Tertiary craniofacial medical center.

PARTICIPANTS

Participants with VPI (VPI group, n = 60), with cleft and without VPI (no VPI/cleft group, n = 60), and with no cleft nor VPI (no VPI/no cleft group, n = 60) and their parents (n = 180).

INTERVENTIONS

All patients with VPI 8+ years old and their parents completed the Brazilian-Portuguese VELO instrument and other questionnaires (Pediatric Quality of Life Inventory4.0, PedsQL4.0; Pediatric Voice-Related Quality of Life, PVRQOL; and Intelligibility in Context Scale, ICS) at baseline; patients with VPI and their parents completed the VELO instrument again 2 weeks later.

MAIN OUTCOME MEASURES

The VELO instrument was tested for internal consistency, test-retest reliability, discriminant validity (participants with VPI against participants with no VPI), concurrent validity against other questionnaires, criterion validity against hypernasality severity, and construct validity against nasal air emission and overall velopharyngeal competence (speech construct) and velopharyngeal gap (anatomic construct).

RESULTS

The VELO had excellent internal consistency (Cronbach α 0.99 for parents and 0.98 for participants with VPI) and test-retest reliability (all intraclass correlation coefficient > 0.87). The VELO discriminated well between VPI group and unaffected groups (all P < .05). The VELO was significantly correlated with the PedsQL^4.0, PVRQOL, and ICS (-r > 0.75; P < .001). The VELO met criterion validity, speech construct validity, and anatomic construct validity (r > 0.7; P < .001).

CONCLUSIONS

The Brazilian-Portuguese VELO instrument demonstrated reliability (internal consistency and test-retest) and validity (discriminant, concurrent, criterion, and construct).