Revisional surgery following the superiorly based posterior pharyngeal wall flap. Historical perspectives and current considerations

Pharyngeal flap in velopharyngeal insufficiency: Proposal of an algorithm in a series of 31 patients

This study evaluated the results of a reproductible protocol indicating the need for a pharyngeal flap in children with cleft palate and velopharyngeal insufficiency (VPI). A retrospective review of all patients operated for a pharyngeal flap between 2010 and 2019 in our center was conducted. After exclusion of patients with primary VPI or residual fistulas, 31 patients' data were analyzed. Our main outcome measure was the improvement of the Borel Maisonny Classification (BMC) by at least 1 rank. Further analysis was made to evaluate the impact of age, type of cleft, and BMC before surgery on the gain in the velopharyngeal function. Of the 31 patients, success was achieved in 29 (93.5%, p<0.005). There was no significant correlation between age and gain in the velopharyngeal function (p = 0.137). There was no significant correlation between type of cleft and gain in the velopharyngeal function (p = 0.148). There was a significant correlation observed between the starting classification and gain in velopharyngeal function. The gain observed was greater as the initial velopharyngeal function was worse (p = 0.035). The use of an algorithm combining clinical assessment with a standardized classification of the velopharyngeal function proved to be a reliable tool for the indication of surgery in patients with VPI. A close follow up is essential in a multidisciplinary team.

Inspiration After Posterior Pharyngeal Flap Palatoplasty: A Preliminary Study Using Computational Fluid Dynamic Analysis

Posterior pharyngeal flap palatoplasty (PPF) is one of the most commonly used surgical procedures to correct speech, especially for patients suffering from velopharyngeal insufficiency (VPI). During PPF, surgeons use the catheter to control the lateral velopharyngeal port on each side. Airway obstruction and sleep apnea are common after PPF. To understand the air dynamics of the upper airway after PPF, we used computational fluid dynamics (CFD) to demonstrate the airflow. In our previous study, we have revealed the expiration process of the upper airway after PPF and shown the features of how PPF successfully restores the oral pressure for speech. In this study, we focus on examining the inspiration process. Normal airway structures were included. For the normal velopharyngeal structure, one cylinder was applied to each model. For recapitulating the velopharyngeal structure after PPF, two cylinders were used in each model. The ports for borderline/inadequate closure, which can help the oral cavity get the required pressure, were chosen for this study. A real-time CFD simulation was used to capture the airflow through the ports. We found that the airflow dynamics of the upper airway's inspiration were dependent on the velopharyngeal structure. Although the airflow patterns were similar, the velocities between one-port and two-port structures were different, which explained why patients after PPF breathed harder than before and suggested that the one-port structure might be a better choice for secondary VPI reconstruction based on the CFD analyses.

Reconstruction of Large Acquired Palatal Defects Using Facial-Submental Artery Island Flap

OBJECTIVE

To evaluate the feasibility and clinical effect of facial-submental artery island flap (FSAIF) in the repair of palatal defects, and to provide reference for the clinical application of submental artery island flap.

METHODS

Nine patients with palatal defects, the range of nasal palatal perforation defects were 3 cm × 4cm to 3 cm × 6 cm (median 3 cm × 5.4 cm), were repaired by FSAIF, and the sizes of FSAIF were 4 cm × 9cm to 4 cm × 12 cm (median 4 cm × 10.4 cm,). Postoperative clinical efficacy was evaluated, including infection and necrosis of mucosal flap and postoperative palatal fistula perforation. Patients were followed up to evaluate their chewing, swallowing, speech function, and satisfaction of appearance.

RESULTS

All patients were successfully repaired with FSAIF. Followed up 13∼35 months, there was no palatal fistula perforation in all patients. The speech, agitation, and swallowing function were not affected and the patients were satisfied with the appearance.

CONCLUSION

FSAIF is a safe and reliable method for palatal defect repair.

Airflow of the Two-Port Velopharyngeal Closure: Study Using Computational Fluid Dynamics

Posterior pharyngeal flap palatoplasty is used to restore the function of velopharyngeal (VP) closure, after which 2 ports remain between the nasal and oral cavity. The authors hypothesized that the airflow dynamics of the upper airway is different in PPF patients compared to health subjects, who only has 1 movable port. Twenty adults who have multislice spiral computed tomography scan were included in this study. Two cylinders (radius, 2.00 mm; height, 4.5 mm) were used to recapitulate the 2-port VP structure after PPF palatoplasty. The areas of ports were modified by changing the radius of 2 cylinders. Real-time computational fluid dynamics simulation was used to capture the airflow velocity and pressures through the 2 ports. The airflow velocity and pressure of upper airway were recorded as the total areas of 2 VP ports increased. The total orifice areas of the 2-port VP closure for 4 VP conditions, including adequate closure, adequate/borderline closure, borderline/inadequate closure, and inadequate closure, were demonstrated. Significant differences between the 2-port VP function for demonstrating PPF reconstruction and the 1-port VP function were found. Airflow dynamics is dependent on the VP structure. The 2-port airflow model for mimicking VP closure after PPF palatoplasty demonstrated airflow characteristics that were significantly different from the 1-port model in normal VP closure.

Palatal Mucoperiosteal Island Flaps for Palate Reconstruction

Background

Many options are available to cover a palatal defect, including local or free flaps. The objective of this study was to evaluate the usefulness of palatal mucoperiosteal island flap in covering a palatal defect after tumor excision.

Methods

Between October 2006 and July 2013, we identified 19 patients who underwent palatal reconstruction using a palatal mucoperiosteal island flap after tumor excision. All cases were retrospectively analyzed by defect location, size, tumor pathology, type of reconstruction, and functional outcomes. Speech and swallowing functions were evaluated using a 7-point visual analog scale (VAS) score.

Results

Among the 19 patients, there were 7 men and 12 women with an age range of 25 to 74 years (mean, 52.5±14.3 years). The size of flaps was 2-16 cm² (mean, 9.4±4.2 cm²). Either unilateral or bilateral palatal island flaps were used depending on the size of defect. During the follow-up period (mean, 32.7±21.4 months), four patients developed a temporary oronasal fistula, which healed without subsequent operative. The donor sites were well re-epithelized. Speech and swallowing function scores were 6.63±0.5 and 6.58±0.69 on the 7-point VAS, indicating the ability to eat solid foods and communicate verbally without significant disability.

Conclusion

The palatal mucoperiosteal island flap is a good reconstruction modality for palatal defects if used under appropriate indications. The complication rates and donor site morbidity are low, with good functional outcomes.

Palate Lengthening by Buccinator Myomucosal Flaps for Velopharyngeal Insufficiency

Objective

To assess the outcome of palate lengthening by myomucosal buccinator flaps for velopharyngeal insufficiency both in terms of speech and changes in palate length.

Design

Thirty-two consecutive patients who underwent the buccinator flap procedure were reviewed retrospectively. Palate length and the presence or absence of a velopharyngeal gap were assessed on pre- and postoperative videofluoroscopic recordings using a calibrated image analysis system. Hypernasality, nasal emission, nasal turbulence, and passive cleft type articulation errors were evaluated blindly by a speech-language pathologist external to the team using pre- and postoperative speech recordings.

Setting

Multidisciplinary cleft team based in a tertiary referral center.

Results

In 81% of patients, speech outcome was such that no further velopharyngeal surgery was considered necessary at the time of follow-up. The buccinator flap procedure resulted in a mean palate lengthening of 7.5 mm (±5.5 SD). After the operation, there was a complete elimination of the velopharyngeal gap on lateral videofluoroscopy in 77% of patients. There were significant decreases in hypernasality ratings and passive cleft type articulation errors postoperatively.

Conclusion

Palatal lengthening with myomucosal buccinator flaps in patients with velopharyngeal insufficiency is effective and safe. It has become one of our routinely practiced procedures for velopharyngeal insufficiency.

Results and complications of 1104 surgeries for velopharyngeal insufficiency

Velopharyngeal insufficiency (VPI) means that the velopharyngeal closure is inadequate or disturbed. VPI may be organic or functional, congenital or acquired and is caused by structural alterations or paresis. The symptoms are primarily to be found in speech (hypernasality), more rarely in swallowing and hearing. The management types are as follows: speech therapy, surgery, speech bulb, and others. Surgery is indicated if the symptoms of VPI cannot be improved by speech therapy. Among the operative methods, velopharyngoplasty constitutes the basis of the surgery. The pharyngeal flap was incorporated and survived in 98.1% of the cases, hyperrhinophony disappeared or became minimal in 90% after surgery in our material (1104 cases). The speech results seemed to be the same with superiorly or inferiorly based pharyngeal flap. The Furlow technique, push-back procedure, the sphincteroplasty, and the augmentation were indicated by us if the VP gap was less than 7 mm; these methods may also be used as secondary operation. We observed among 1104 various surgeries severe hemorrhage in 5 cases, aspiration in 2 cases, significant nasal obstruction in 68 patients, OSAS in 5 cases; tracheotomy was necessary in 2 cases. Although the complication rate is rare, it must always be considered that this is not a life-saving but a speech-correcting operation. A tailor-made superiorly based pharyngeal flap is suggested today, possibly in the age of 5 years.

In search of the optimal surgical treatment for velopharyngeal dysfunction in 22q11.2 deletion syndrome: a systematic review

BACKGROUND

Patients with the 22q11.2 deletion syndrome (22qDS) and velopharyngeal dysfunction (VPD) tend to have residual VPD following surgery. This systematic review seeks to determine whether a particular surgical procedure results in superior speech outcome or less morbidity.

METHODOLOGY/ PRINCIPAL FINDINGS

A combined computerized and hand-search yielded 70 studies, of which 27 were deemed relevant for this review, reporting on a total of 525 patients with 22qDS and VPD undergoing surgery for VPD. All studies were levels 2c or 4 evidence. The methodological quality of these studies was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. Heterogeneous groups of patients were reported on in the studies. The surgical procedure was often tailored to findings on preoperative imaging. Overall, 50% of patients attained normal resonance, 48% attained normal nasal emissions scores, and 83% had understandable speech postoperatively. However, 5% became hyponasal, 1% had obstructive sleep apnea (OSA), and 17% required further surgery. There were no significant differences in speech outcome between patients who underwent a fat injection, Furlow or intravelar veloplasty, pharyngeal flap pharyngoplasty, Honig pharyngoplasty, or sphincter pharyngoplasty or Hynes procedures. There was a trend that a lower percentage of patients attained normal resonance after a fat injection or palatoplasty than after the more obstructive pharyngoplasties (11-18% versus 44-62%, p = 0.08). Only patients who underwent pharyngeal flaps or sphincter pharyngoplasties incurred OSA, yet this was not statistically significantly more often than after other procedures (p = 0.25). More patients who underwent a palatoplasty needed further surgery than those who underwent a pharyngoplasty (50% versus 7-13%, p = 0.03).

CONCLUSIONS/ SIGNIFICANCE

In the heterogeneous group of patients with 22qDS and VPD, a grade C recommendation can be made to minimize the morbidity of further surgery by choosing to perform a pharyngoplasty directly instead of only a palatoplasty.