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Mirsky NA, Slavin BV, Sheinberg DS, Stauber ZM, Parra M, Vivekanand Nayak V, Witek L, Coelho PG, Thaller SR. An Evaluation of Autologous Fat Injection as a Treatment for Velopharyngeal Insufficiency: A Review and Integrated Data Analysis. Ann Plast Surg 2024; 93:115-123. [PMID: 38775371 DOI: 10.1097/sap.0000000000003971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
BACKGROUND Velopharyngeal insufficiency (VPI) is a condition characterized by incomplete separation of the oral and nasal cavities during speech production, thereby leading to speech abnormalities and audible nasal emissions. Subsequently, this adversely impacts communication and potentially interpersonal social interactions. Autologous fat grafting (AFG) to the velopharynx, a minimally invasive technique, aims to improve oronasal separation by providing bulk and advancing the posterior pharyngeal wall toward the soft palate. Despite its potential, the relative novelty of AFG in treating VPI has resulted in reporting of inconsistent indications, varied surgical techniques, and mixed outcomes across existing literature. METHODS This systemic review examined the evidence of AFG for VPI treatment over the past decade (2013-2023). A thorough search across five electronic databases yielded 233 studies, with 20 meeting the inclusion criteria (e.g., utilized fat injection as their selected VPI treatment, conducted study in human subjects, did not perform additional surgical procedure at time of fat injection). Selected studies encompassed patient and surgical intervention characteristics, perceptual speech assessment (PSA) scores, gap sizes, nasalance measurements, and complications. RESULTS The majority of patients had a prior cleft palate diagnosis (78.2%), in which nasoendoscopy was the prevalent method for visualizing the velopharyngeal port defect. Fat harvesting predominantly occurred from the abdomen (64.3%), with an average injection volume of 6.3 mL across studies. PSA and subjective gap size scores were consistently higher preoperatively than postoperatively. PSA score analysis from seven studies revealed significant and sustained improvements postoperatively. Gap size score analysis from four studies demonstrated similar preoperative and postoperative differences. Complications were reported in 17 studies, yielding a 2.7% summative complication rate among 594 cases. CONCLUSIONS Autologous fat grafting has emerged as a minimally invasive, safe, and effective treatment for mild to moderate VPI. However, challenges remain because of variability in patient selection criteria, diagnostic modalities, and outcome measurements. This review underscores the need for randomized control trials to directly compare AFG with standard-of-care surgical interventions, providing more conclusive evidence of its clinical efficacy.
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Affiliation(s)
| | - Blaire V Slavin
- From the University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | - Vasudev Vivekanand Nayak
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, FL
| | | | | | - Seth R Thaller
- DeWitt Daughtry Family Department of Surgery, Division of Plastic & Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL
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Posterior pharyngeal wall augmentation in post-adenoidectomy velopharyngeal insufficiency. Eur Arch Otorhinolaryngol 2022; 279:4605-4615. [PMID: 35527305 PMCID: PMC9363290 DOI: 10.1007/s00405-022-07406-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/15/2022] [Indexed: 11/03/2022]
Abstract
Purpose To assess the efficacy of posterior pharyngeal wall augmentation using septal or conchal cartilages with other bulks—according to the persistent gap and the individual anatomy of each patient—in improving velopharyngeal function in patients who acquired persistent velopharyngeal insufficiency (VPI) post-adenoidectomy. Methods Observational descriptive prospective case series of 24 patients (their ages ranged between 3 and 26 years) who developed persistent VPI post-adenoidectomy (more than 3 months) although they had normal speech resonance before adenoidectomy. Results The present study demonstrated that statistically significant improvement in auditory perceptual assessment (APA) was found regarding all obligatory speech disorders and unintelligibility of speech. Significant improvement was observed in the degree of velar mobility, size of the persistent gap, and the gap distance between velum and posterior pharyngeal wall at rest and during phonation in post-operative evaluation versus pre-operative. A significant change was observed in the closure pattern of the velopharyngeal port (VPP) as all patients turned to coronal closure. Conclusions Posterior pharyngeal wall augmentation could be used in VPI post-adenoidectomy up to 7 mm and lead to better speech outcomes. Also, it revealed that using conchal and/or septal cartilage as a graft regardless of the patient’s age is a safe procedure.
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Autologous Fat Grafting in Velopharyngeal Insufficiency Gives Complete and Stable Speech Recovery in Patient Under 7 years. J Craniofac Surg 2021; 33:e8-e14. [PMID: 34510057 DOI: 10.1097/scs.0000000000007845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT The authorspresent a retrospective observational cohort study of 47 French speaking consecutive patients treated with retropharyngeal wall filling with autologous fat graft from 2006 to 2019 in a single tertiary center, to assess with a long-term follow-up, the best tailored treatment to recovery speech for velopharyngeal insufficiency, and to stress the importance of early treatment with minimally invasive procedure with retropharyngeal wall fat grafting. In preoperative setting, a clinical and instrumental evaluation with aerophonoscope is completed by a palatal closure assessment with nasal endoscopy. All patients were classified according with Borel Maisonny score pre- and post-operatively. Sixty three fat injections were performed. In 4 cases a pharyngeal flap was performed after fat graft for an insufficient speech result. The authors had no complications. Patients with less than 7 years of age obtained a complete recovery of their velopharyngeal incompetence (P = 0.03) compared to older patients. In conclusion, the authors can state that this tailored surgical technique needs a multidisciplinary approach. Many variables can affect postoperative results: fat reabsorption, concurrently performed surgery, pattern of pharyngeal closure, hearing impairment. None of these factors affected our result. Early treatment plays a crucial role to achieve better results. Patients with less of 7 years showed a better result in this functional treatment.
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Metanalysis of alloplastic materials versus autologous fat for injection augmentation pharyngoplasty treatment of velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2021; 146:110738. [PMID: 33957548 DOI: 10.1016/j.ijporl.2021.110738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/05/2021] [Accepted: 04/24/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Velopharyngeal insufficiency (VPI) can cause resonance, speech and feeding problems. While reconstructive palatoplasty and surgical pharyngoplasty techniques are the mainstay of treatment for severe VPI, injection augmentation pharyngoplasty offers a minimally invasive approach in patients with mild-to-moderate VPI. METHODS We conducted a systematic review of the literature available on PubMed and Embase from 1990 to 2019 including studies that addressed VPI, incompetence, or dysfunction managed with injection augmentation. Patient demographics, etiology of VPI, injection material, volume of injection, number of injections, complications and both subjective and objective outcomes were recorded. RESULTS Twenty-nine studies met our inclusion criteria encompassing 587 patients, ages 3-75 years (mean = 16) who underwent injection pharyngoplasty. Injection materials included glutaraldehyde cross-linked (GAX) collagen (n = 5), calcium hydroxyapatite (n = 36), dextranomer and hyaluronic acid (n = 72) and autologous fat (n = 471). Follow-up averaged 15.4 months (range = 2-60 months). Functional improvements in nasality were recorded in a large proportion of patients (0.79, 95% CI 0.75 to 0.82). However, a greater proportion of patients in the synthetic materials group demonstrated either reduced or resolved hypernasality compared with those receiving autologous fat injections (χ2 = 7.035, n = 91/103 vs. 255/338, p = 0.008). Complete velopharyngeal gap closure post-injection was achieved at a higher frequency with injection of synthetic materials compared with autologous fat (χ2 = 11.270, n = 61/69 vs. 58/91 p = 0.001).r CONCLUSION: Injection pharyngoplasty offers a minimally invasive alternative intervention for treatment of VPI secondary to small velopharyngeal gaps. Patients treated with synthetic materials experienced a greater improvement in velopharyngeal closure and a corresponding improvement in resonance balance.
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Secondary Treatment of Cleft Lip Correction Sequelae With Percutaneous Needleotomy, Autologous Fat Grafting, and Local Flaps: An Integrated Approach. J Craniofac Surg 2021; 32:642-646. [PMID: 33705000 DOI: 10.1097/scs.0000000000007028] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Cleft lip and/or palate (CL/P) is the most common congenital craniofacial malformation. The severity of the anatomic deformity is highly variable and different techniques can be employed depending on whether the defect is unilateral or bilateral, complete or incomplete. Patients usually undergo multiple steps of reconstruction throughout childhood and adolescence and, for this reason, secondary deformities of the nasolabial region of the midface may ensue. Considering our experience in the treatment of scars, we opted to correct the cleft lip surgery sequelae not only with local flaps/scar revisions, but we decided to add the use of the autologous fat grafting (AFG) to induce a regenerative effect in these young patients. MATERIALS AND METHODS In this study we present the results obtained from a series of 12 consecutive Caucasian patients aged from 23 to 44 years with widened paramedian lip scars secondary to cleft lip reconstruction surgery, treated with a combination of needle-induced lysis of the scar tissue and AFG from January 2013 to December 2018. RESULTS After the procedure we observed an overall improvement in the quality of the scar tissue, in the function of mimic features, in the symmetry and cosmetics of the lower third of the nose. Patients' satisfaction was excellent. Results were long lasting and remained virtually unchanged after 1 year of follow-up. CONCLUSIONS Scar release by needle, AFG and local flaps are excellent tools for the treatment of cleft lip correction sequelae, but the combination of these surgical techniques can lead to even better results.Level of Evidence: Level V.
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Isomura ET, Matsukawa M, Nakagawa K, Mitsui R, Kogo M. Endoscopic soft palate augmentation using injectable materials in dogs to ameliorate velopharyngeal insufficiency. PLoS One 2020; 15:e0238646. [PMID: 32886712 PMCID: PMC7473532 DOI: 10.1371/journal.pone.0238646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Velopharyngeal structure augmentation methods are used as alternatives to pharyngeal flap operations. Recently, we investigated the sites of velopharyngeal structure augmentation in dogs and reported that the most effective injection location is the soft palate. However, there have been no reports regarding the optimal materials for implantation or injection. In this study, we aimed to investigate the injectable materials used in soft palate augmentation in dogs to ameliorate velopharyngeal insufficiency (VPI). Methods Endoscopic soft palate augmentation (ESPA) was performed in dogs using purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. ESPA is an original technique developed by our group, and this is the first report of its performance. Moreover, we assessed the amount of nasal air leakage during inspiration at rest and during expiration under the rebreathing system at 1, 2, 3, 4, 5, and 6 months after injection of these materials. Results The amount of nasal air leakage during expiration under the rebreathing system was significantly decreased in all dogs injected with the ESPA materials, but neither apnea nor hypopnea was observed. Conclusions We investigated the optimal materials for use in ESPA, such as purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. We found that all of them reduced nasal air leakage and only autogenic fat tissue showed significant histologic differences in dogs at 6 months. This technique may also be useful for the treatment of patients with VPI.
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Affiliation(s)
- Emiko Tanaka Isomura
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
- * E-mail:
| | - Makoto Matsukawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Kiyoko Nakagawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Ryo Mitsui
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Mikihiko Kogo
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
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Shih L, Abu-Ghname A, Davis MJ, Xue AS, Dempsey RF, Buchanan EP. Applications of Fat Grafting in Pediatric Patients. Semin Plast Surg 2020; 34:53-58. [PMID: 32071580 DOI: 10.1055/s-0039-3402517] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Autologous fat grafting has become a widely utilized technique for a variety of cosmetic and reconstructive procedures. Its potential for volume restoration and tissue regeneration has made it a popular method for treating soft tissue defects in both adult and pediatric populations. While autologous fat grafting in the pediatric setting is not as well characterized as it is in the adult setting, various reports have demonstrated the safety and utility of its applications in nonadult patient populations. In this article, we present the first comprehensive review of the current applications of autologous fat grafting in pediatric patients. Specific challenges to fat grafting in the pediatric setting and future applications will also be discussed.
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Affiliation(s)
- Linden Shih
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amy S Xue
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Robert F Dempsey
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Edward P Buchanan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
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Autologous Fat Grafting for the Treatment of Mild to Moderate Velopharyngeal Insufficiency. J Craniofac Surg 2019; 30:2441-2444. [DOI: 10.1097/scs.0000000000005337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Tailored Posterior Pharyngeal Fat Grafting Outcomes in Velopharyngeal Insufficiency Managed According to a Simplified Algorithm. Ann Plast Surg 2019; 83:172-179. [PMID: 31295169 DOI: 10.1097/sap.0000000000001930] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Impieri D, Tønseth K, Hide Ø, Feragen K, Høgevold H, Filip C. Autologous fat transplantation to the velopharynx for treating mild velopharyngeal insufficiency: A 10-year experience. J Plast Reconstr Aesthet Surg 2019; 72:1403-1410. [DOI: 10.1016/j.bjps.2019.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/17/2018] [Accepted: 03/30/2019] [Indexed: 02/07/2023]
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Panizza R, Ghiglione M, Zingarelli EM, Massa M, Carlini C, Arnoldi R, Prato AP, Scarrone S, Vaccarella F. Autologous fat grafting in the treatment of velopharyngeal insufficiency: Clinical outcomes and treatment tolerability survey in a case series of 21 patients. Indian J Plast Surg 2019; 51:145-154. [PMID: 30505084 PMCID: PMC6219368 DOI: 10.4103/ijps.ijps_183_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Velopharyngeal insufficiency (VPI) is the inability to close the velopharyngeal sphincter during phonation and/or feeding. VPI is clinically characterised by hypernasal speech and nasal regurgitation. In cases of severe VPI, pharyngoplasty is recommended. Cases of mild-to-moderate VPI can be treated with fat grafting of the posterior pharyngeal wall in addition to speech therapy. The lipofilling can also be useful after pharyngoplasty to improve the outcomes. Materials and Methods: Twenty-one patients (14 males and 7 females), ages 4–23 affected by mild-to-moderate VPI and treated with lipofilling were included in this retrospective study. The mean injected fat volume was 7.95 cc (median 6 cc, min 4 cc, max 20 cc and range 16 cc). The follow-up ranged from 6 to 60 months. The pre- and post-operative Borel–Maisonny scores were compared using Wilcoxon test. Moreover, we performed a telephone survey with the aim to assess the parental perception on child's speech and quality of life after the surgical treatment. Results: Despite the small sample size, in this case series, we observed a statistically significant Borel–Maisonny score improvement and a parental satisfaction rate of about 85%. Conclusions: The augmentation of the posterior pharyngeal wall in addition to speech therapy improved the Borel–Maisonny score and the intelligibility of this case series of patients affected by mild-to-moderate VPI. In these patients, evaluated in a multidisciplinary approach, this technique allowed us to avoid major surgical procedures that would modify the anatomy of the velopharyngeal port. However, prospective comparative studies or randomised controlled trials could be useful to compare fat grafting with velopharyngoplasty techniques, with the aim to clarify indications and to define a specific treatment protocol.
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Affiliation(s)
- Renzo Panizza
- Department of Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Marco Ghiglione
- Department of Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Enrico Maria Zingarelli
- Department of Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Michela Massa
- Department of Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Claudio Carlini
- Department of Pediatric Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Rossella Arnoldi
- Department of Pediatric Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Alessio Pini Prato
- Department of Pediatric Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Silvia Scarrone
- Department of Operating Theatre Management, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Francesco Vaccarella
- Department of Pediatric Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
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Karampour LS, Saki N, Lalvand F, Nikakhlagh S. Analysis of the effects of pharyngeal flap surgery on reducing hypernasality in patients with velopharyngeal insufficiency. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2019. [DOI: 10.29333/ejgm/94223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Zaer S, Felix I, Amstutz Montadert I, Vivier PH, Bon-Mardion N, Marie JP. Retropharyngeal lipostructure in the treatment of velopharyngeal insufficiency: A prospective study and update. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:173-177. [PMID: 30902555 DOI: 10.1016/j.anorl.2019.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Retropharyngeal lipostructure is a recent procedure in velopharyngeal insufficiency (VPI), offering an effective alternative to heavier surgery. OBJECTIVES To update and assess retropharyngeal lipostructure as a treatment for VPI in the University Hospital Center of Rouen (France). TYPE OF STUDY Single-center prospective study, from May 2012 to May 2014. PATIENTS AND METHODS Six patients (4 girls, 2 boys) presenting with VPI were treated by retropharyngeal lipostructure. Age at surgery ranged between 6 and 12 years. Four of the patients bore a 22q11 microdeletion. Treatment was indicated in case of Borel-Maisonny type 2b (n=2) or 2m (n=4) despite well-conducted speech therapy and of≥50% velopharyngeal sphincter closure on nasal endoscopy. Patients were assessed preoperatively and at 3 months, by a multidisciplinary team. Borel-Maisonny type was assessed by a speech therapist. Nasality was measured on assisted vocal evaluation (EVA®). Sphincter closure was assessed on dynamic MRI. RESULTS Between 6 and 8cm3autologous fat was injected. At 3months, 4 children showed 1-grade improvement in Borel-Maisonny type. Nasality decreased systematically, from a mean 14.5% preoperatively to 10.5% postoperatively. MRI showed improvement in all cases, with complete closure in occlusive vowels in 3 children. CONCLUSION EVA® and MRI provide precise objective assessment of VPI. Retropharyngeal lipostructure is a simple, relatively non-invasive, reproducible technique, providing good results in VPI.
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Affiliation(s)
- S Zaer
- Service d'ORL et chirurgie cervico-faciale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France.
| | - I Felix
- Service d'ORL et chirurgie cervico-faciale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - I Amstutz Montadert
- Service d'ORL et chirurgie cervico-faciale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - P-H Vivier
- Service d'imagerie médicale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - N Bon-Mardion
- Service d'ORL et chirurgie cervico-faciale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - J-P Marie
- Service d'ORL et chirurgie cervico-faciale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
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Isomura ET, Nakagawa K, Matsukawa M, Mitsui R, Kogo M. Evaluation of sites of velopharyngeal structure augmentation in dogs for improvement of velopharyngeal insufficiency. PLoS One 2019; 14:e0212752. [PMID: 30802272 PMCID: PMC6388922 DOI: 10.1371/journal.pone.0212752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 02/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Velopharyngeal structure augmentation methods are used as alternatives to velopharyngeal plasty. Anatomic sites of implantation/injection vary widely due to a lack of standardized criteria. Here, we experimentally investigated optimal sites of velopharyngeal structure augmentation via saline injection in dogs as they naturally exhibit velopharyngeal insufficiency (VPI). Methods Velopharyngeal structure augmentation was performed on 10 beagles (age range: 20–24 months; weight range: 9–12 kg). Saline containing 1/80,000 epinephrine was injected intraorally in 1-mL increments into the nasal mucosa of the soft palate (n = 4), posterior pharyngeal wall (n = 3), or bilateral pharyngeal walls (n = 3) of each dog. Nasal air leakage was measured under rebreathing until velopharyngeal closure was achieved; the measurement was performed using flow meter sensors on both nasal apertures, and the oral cavity was filled with alginate impression material to prevent oral air leakage. Results Pre-injection, the dogs exhibited an average of 0.455 L/s air leakage from the nasal cavity. The dogs with saline injected into the nasal mucosa of the soft palate achieved steady augmentation, and nasal air leakage disappeared under rebreathing following 6-mL saline injection. Conversely, nasal air leakage remained in the dogs with saline injected in the posterior pharyngeal wall or bilateral pharyngeal walls. Conclusions During VPI treatment in dogs, augmentation was most effective at the nasal mucosa of the soft palate. Improvement in nasal air leakage was highly dependent on the saline injection volume. Although velopharyngeal structures vary between dogs and humans, velopharyngeal closure style is similar. Thus, our results may aid in the treatment of VPI patients.
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Affiliation(s)
- Emiko Tanaka Isomura
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
- Unit of Dentistry, Osaka University Hospital, Suita City, Osaka, Japan
- * E-mail:
| | - Kiyoko Nakagawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Makoto Matsukawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Ryou Mitsui
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Mikihiko Kogo
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
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Abdali H, Yaribakht M. Assessment of outcomes and complications of posterior pharyngeal wall augmentation with dermal fat graft in patients with Velopharyngeal Insufficiency (VPI) after primary cleft palate repair: A pilot study. JPRAS Open 2018; 19:6-18. [PMID: 32158847 PMCID: PMC7061665 DOI: 10.1016/j.jpra.2018.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/25/2018] [Accepted: 10/11/2018] [Indexed: 01/30/2023] Open
Abstract
Introduction Materials used for posterior pharyngeal wall augmentation have been associated with important complications (exogenous materials) or variable and unpredictable durability (exogenous and endogenous materials); therefore, introducing a different material for augmenting the posterior pharyngeal wall seems necessary for reviving this relatively forgotten technique. The purpose of this study was to emphasize on the use of a material associated with minimal complications and maximum recovery and durability in correcting VPI and the use of evaluative adjuncts such as nasoendoscopy and videofluoroscopy to assess surgical outcomes. Methods In a pilot study, 24 patients underwent posterior pharyngeal wall augmentation with dermal fat graft harvested from the low crease abdominal region. Early and late complications, autologous graft durability in posterior pharynx, and speech improvement were assessed. Results There was a significant improvement in hypernasality, nasal emission, and nasal grimace after posterior pharyngeal wall augmentation with dermal fat graft (p<0.0001). The authors observed no significant life-threatening complication. The most evident short-term complication was snoring, which occurred in five patients, and all relieved uneventfully. Conclusion The authors believe that augmenting the posterior pharyngeal wall with dermal fat graft is effective in improving hypernasality in patients with moderate velopharyngeal gap size and relatively adequate velar motion. This method has minimal complication profile because of autologous tissue application.
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Affiliation(s)
- Hossein Abdali
- Associate professor of plastic surgery - Craniofacial & cleft research center - Isfahan University of Medical Sciences - Isfahan- Iran
| | - Mohammad Yaribakht
- Craniofacial & cleft research center - Isfahan University of Medical Sciences- Isfahan- Iran
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Abstract
BACKGROUND Management of velopharyngeal insufficiency (VPI) has traditionally involved surgical repair to improve speech. Posterior pharyngeal augmentation using injectable synthetic materials has been advocated. However, outcomes have been equivocal. More recently, autologous fat injection (AFI) has been advocated for correction of mild to moderate VPI. However, long-term efficacy and safety of this procedure remain unsettled. METHODS A systematic review of the literature was performed. Available studies that reported outcomes of autologous fat velopharyngeal injection for treatment of documented VPI were included. Preclinical animal studies were excluded. Study characteristics, patient demographics, treatment details including fat harvest site, volume injected, and outcome measures were evaluated. RESULTS Fifteen studies met inclusion criteria, yielding 251 patients who underwent AFI. There was high variability in terms of indications for procedure and reporting of outcomes. Majority of studies required velopharyngeal gap closure of at least 50% in order to undergo AFI. Most common etiology of VPI was secondary to cleft palate. Some studies included patients with velocardiofacial syndromes. Improvements in speech and nasalance were reported in a majority of patients. Major complications were rare. Only 1 patient with graft hypertrophy resulting in obstructive sleep apnea was reported. CONCLUSION Autologous fat injection offers a minimally invasive approach to the treatment of VPI. Current literature is limited to small noncomparative studies. These appear to suggest efficacy and safety in mild to moderate patients with VPI. Future prospective studies with standardized technique and objective outcomes are required to definitively establish its safety and efficacy, as well as define patient selection criteria.
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Phua YS, Edmondson MJ, Kerr RJ, Macgill KA, Teixeira RP, Burge JA. Safety and Efficacy Concerns of Autologous Fat Grafting for Velopharyngeal Insufficiency. Cleft Palate Craniofac J 2017; 55:383-388. [DOI: 10.1177/1055665617739002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: Autologous fat grafting of the velopharynx has been well described for the treatment of velopharyngeal insufficiency (VPI), with most studies purporting it as a technique with low morbidity useful in the treatment of mild VPI. Prompted by 3 cases of obstructive sleep apnea (OSA) following fat grafting of the velopharynx, we undertook a review of the outcomes of this procedure at our unit. Design: Retrospective case series. Participants: All patients who underwent autologous fat grafting for VPI at the Royal Children’s Hospital Melbourne. Main Outcome Measures: Preoperative nasendoscopy findings, perceptual speech assessment results, and rates of revisional surgery and complications. Results: Twenty-eight patients were included in the study. Three patients (11%) developed severe OSA requiring removal of the grafted fat. In a subanalysis of cleft patients, there was a reported improvement in hypernasality in 63% though only 25% had complete resolution of their hypernasality. Patients who had an improvement in speech were more likely to have a velopharyngeal gap of less than 0.5 cm2 on preoperative nasendoscopy. All 3 patients who developed OSA had syndromes associated with hypotonia. Conclusions: This study raises serious concerns over the safety and efficacy of fat grafting for VPI. Overall, there was a relatively high complication rate with generally poor speech results in our series of patients. Stringent criteria should be used to select candidates for fat grafting, namely, a velopharyngeal gap less than 0.5 cm2 and the absence of a syndrome associated with hypotonia.
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Affiliation(s)
- Yun S. Phua
- Department of Plastic and Maxillofacial Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Mark J. Edmondson
- Department of Plastic and Maxillofacial Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Rachel J. Kerr
- Department of Speech Language Therapy, Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Kirstie A. Macgill
- Department of Plastic and Maxillofacial Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Rodrigo P. Teixeira
- Department of Plastic and Maxillofacial Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Jonathan A. Burge
- Department of Plastic and Maxillofacial Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
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Impieri D, Tønseth K, Hide Ø, Feragen K, Høgevold H, Filip C. Change in quality of life after treatment of mild velopharyngeal insufficiency with autologous fat transplantation. JPRAS Open 2017. [DOI: 10.1016/j.jpra.2017.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Dinsever Eliküçük Ç, Kulak Kayıkcı ME, Esen Aydınlı F, Çalış M, Özgür FF, Öztürk M, Günaydın RÖ. Investigation of the speech results of posterior pharyngeal wall augmentation with fat grafting for treatment of velopharyngeal insufficiency. J Craniomaxillofac Surg 2017; 45:891-896. [PMID: 28381372 DOI: 10.1016/j.jcms.2017.02.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/07/2017] [Accepted: 02/22/2017] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the speech results of posterior pharyngeal wall augmentation (PPWA) with fat grafting both in the early and late postoperative period, and to clarify the impact of the procedure concomitant with speech therapy. MATERIALS AND METHODS This is a prospective case-control study. The study involved 87 cleft palate ± cleft lip patients with velopharyngeal insufficiency (VPI) who has been treated with PPWA. Patients were separated into two groups according to age; the first group consisted of 49 pediatric participants between 6 and 12 years of age and the second group consisted of 38 adolescent participants between 13 and 18 years of age. Preoperative velopharyngeal function and articulation were compared postoperatively at the following time points: the 3rd month, 12th month, 18th month and 24th month. The velopharyngeal function was evaluated with regards to the velopharyngeal closure type and velopharyngeal closure amount, by using the pediatric flexible nasoendoscopy and the nasometer methods. In the nasometer evaluation, nasalance sores were measured by using nonsense syllables and meaningful sentences. The Ankara Articulation Test (AAT) (Ege et al., 2004) was used to detect compensatory articulation products secondary to VPI. Consonant production error types and frequencies were determined according the guidelines stated in the study of Hardin-Jones et al. (2009). These were Pharyngeal Fricatives - Posterior Nasal Fricatives/Stop Production, Glottal Stop Production, Middorsum Palatal Stop Production, Nasal Frictional Production, Posterior Nasal Frictional Production/Phoneme Specific Nasal Emission, use of Nasal Consonants for Oral Consonants, and Replacement of Trills. All the participants received concurrent speech therapy four times, twice in the post-operative period between 1 and 3 months and twice between 3 and 6 months. RESULTS PPWA improved the speech performance from the 18th month to 24th month of the postoperative period. AAT assessment of the first group after 24 months comparing the post-PPWA with the preoperative data showed a highly significant decrease with regard to compensatory production errors and hypernasality; however, in the second group, the same comparison revealed a highly significant decrease in regard to the degree of hypernasality and a significant difference in terms of glottal articulation and pharyngealization of fricatives. A circular closure pattern was observed in 17 individuals with cleft palate at a rate of 70.6%. CONCLUSION PPWA with concurrent speech therapy is an acceptable surgical method to correct VPI and to improve speech performance.
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Affiliation(s)
- Çağla Dinsever Eliküçük
- Department of Audiology and Speech Pathology, Audiologist and Speech Pathologist, Hacettepe University Health Sciences Institute, Ankara, Turkiye; Numune Education and Research Hospital, ENT Clinic, Center of Hearing, Speech and Balance, Ankara, Turkiye.
| | - Maviş Emel Kulak Kayıkcı
- Speech and Language Therapy, Hacettepe University Health Science Faculty, Hacettepe University Faculty of Health Sciences Vice Dean, Bologna Coordinator, Sıhhiye, Ankara, Turkiye.
| | - Fatma Esen Aydınlı
- Speech and Language Therapy, Hacettepe University, Health Science Faculty, Ankara, Turkiye.
| | - Mert Çalış
- Hacettepe Hospital University, Medicine Faculty Professor in Plastic Reconstructive Surgery, Sıhhiye, Ankara, Turkiye.
| | - Fatma Figen Özgür
- Department of Plastic, Reconstructive and Esthetic Surgery, Faculty of Medicine, Hacettepe University, Research and Application Center for the Treatment of Cleft Lip and Palate and Craniomaxillofacial Deformities, Ankara, Turkiye.
| | | | - Rıza Önder Günaydın
- Hacettepe Hospital University, Medicine Faculty, Ear, Nose and Throat Department, 06000, Ankara, Turkiye.
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Rhinopharyngeal autologous fat injection for treatment of velopharyngeal insufficiency in patients with cleft palate. Eur Arch Otorhinolaryngol 2014; 272:1277-85. [PMID: 25411074 DOI: 10.1007/s00405-014-3380-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 10/25/2014] [Indexed: 10/24/2022]
Abstract
Patients with cleft palate are prone to velopharyngeal insufficiency. In minor cases or when hypernasal speech does not resolve after velopharyngoplasty, an augmentation pharyngoplasty with autologous fat can be proposed. The aim of the present study is to evaluate the short-term (within 2 months) and long-term efficiency (during the 24 months following the procedure) of our procedure in the setting of velopharyngeal insufficiency related to a cleft palate. Twenty-two patients with cleft palate related velopharyngeal insufficiency were included in this retrospective study. All patients were operated following the same technique, in the same institution. The pre- and postoperative evaluations included a nasometry, a subjective evaluation using the Borel-Maisonny score, and a nasofibroscopy to assess the degree of velopharyngeal closure. Scores of Borel-Maisonny and nasometry were compared before, shortly after the procedure (within 2 months) and long term after the procedure (within 24 months). Forty-one procedures in 22 patients with a cleft palate performed in our institution between October 2004 and January 2012 were included in the study. Nine patients had a previous velopharyngoplasty with persistent rhinolalia despite intensive speech therapy. In 14 patients the procedure was repeated because of recurrent hypernasal speech after the first injection. The average number of procedures per patient was 1.8. Postoperative nasometry and Borel-Maisonny scores were statistically significantly improved and remained stable until the end of the follow-up (median 42 months postoperative) in most patients. Complications were rare and minor. Autologous fat injection is a simple procedure for treatment of minor velopharyngeal insufficiencies in patients with cleft palate, with good long-term results and few complications.
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Bishop A, Hong P, Bezuhly M. Autologous fat grafting for the treatment of velopharyngeal insufficiency: State of the art. J Plast Reconstr Aesthet Surg 2014; 67:1-8. [DOI: 10.1016/j.bjps.2013.09.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/03/2013] [Accepted: 09/03/2013] [Indexed: 10/26/2022]
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Rossleigh M, Purcell A, McGlynn M, Parkin M, Shield K. Parental perceptions of posterior pharyngeal wall augmentation using autologous fat for treating velopharyngeal dysfunction. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2013; 15:268-278. [PMID: 23570292 DOI: 10.3109/17549507.2013.777785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Posterior pharyngeal wall augmentation using autologous fat to treat velopharyngeal dysfunction (VPD) is an alternative surgical procedure to more commonly used invasive procedures such as the pharyngeal flap. However, limited research exists on this technique. The aim of this study was to qualitatively investigate parental perceptions of posterior pharyngeal wall augmentation using autologous fat when treating velopharyngeal dysfunction. Furthermore, this research aimed to examine parent's perspectives of their child's speech and quality-of-life following this procedure. A qualitative collective case study methodology was used in the form of semi-structured interviews with seven participants. These were then analysed using constant comparative analysis. Four distinct themes emerged: post-surgical outcomes; speech-language pathology, not just medicine; factors for successful post-operative speech and resonance; and long-term sustainability and worthiness of the procedure. Six out of seven participants expressed positive post-operative speech and resonance results. Five further expressed long-term satisfaction up to 6 years post-operatively. Overall the majority of participants were satisfied that this procedure provided their child with long-term successful speech outcomes. The participants also discussed the importance of receiving speech-language pathology services alongside surgery and the positive impact of the procedure on their child's quality-of-life including social interactions, confidence, friendships, as well as eating and drinking.
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Cao Y, Ma T, Wu D, Yin N, Zhao Z. Autologous Fat Injection Combined with Palatoplasty and Pharyngoplasty for Velopharyngeal Insufficiency and Cleft Palate. Otolaryngol Head Neck Surg 2013; 149:284-91. [PMID: 23702974 DOI: 10.1177/0194599813490893] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective The aim was to evaluate clinical application of autologous fat transplantation in the posterior pharynx to treat velopharyngeal incompetence and cleft palate. Study Design Case series with chart review. Setting Cleft Lip and Palate Center of Plastic Surgery Hospital, an academic medical center. Subjects and Methods We studied 11 patients (age, 5-26 years) with a cleft palate and velopharyngeal insufficiency who underwent autologous fat injection. Patients were followed for 9 to 40 months. Pronunciation evaluation, visual appearance of the palatopharyngeal area, nasopharyngeal fibroscopy (NPF), palatopharyngeal lateral radiography, and magnetic resonance imaging (MRI) were undertaken before and after the operation. Results Speech intelligibility was markedly increased in all patients. Pronunciation was good to excellent compared with the preoperative level ( P = .001). Mean velopharyngeal insufficiency rate was significantly reduced from 26.05% to 6.96% ( P = .028) by NPF and from 26.42% to 7.11% ( P = .017) by MRI (axial plane). Magnetic resonance imaging indicated significantly reduced mean minimum velopharyngeal distance, from 10.39 to 3.65 mm ( P = .012) in the sagittal plane, and markedly increased thickness of transplanted fat in the posterior pharyngeal wall (sagittal, 5.43 mm; axial, 4.74 mm). There were few complications (sleep apnea, nasopharyngeal regurgitation). Conclusion Autologous fat transplantation in the posterior pharyngeal wall was a good method for treating velopharyngeal incompetence. The safety profile was good in our sample, and we got a consistent result in the follow-up period. In addition, it also could be combined with routine surgery.
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Affiliation(s)
- Yimei Cao
- The 1st Department of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical School, Beijing, China
| | - Tingting Ma
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Di Wu
- The 1st Department of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical School, Beijing, China
| | - Ningbei Yin
- The 1st Department of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical School, Beijing, China
| | - Zhenmin Zhao
- The 1st Department of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical School, Beijing, China
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Abstract
Patients with congenital craniofacial malformations present with complex challenges for reconstruction. Successful management requires individualized treatment often involving rebuilding the facial skeleton de novo, as well as correcting the overlying soft-tissue deficiencies in the final stages. At the University of California, Los Angeles (UCLA) Craniofacial Clinic, serial autologous fat transplantation performed during staged reconstruction is the preferred method.A total of 27 patients with a diagnosis of either craniofacial microsomia/Goldenhar (CM) (n = 19) or Treacher Collins syndrome (TC) (n = 8) were treated at the UCLA Craniofacial Clinic by autologous fat transfer between July 1999 and February 2009. Two-dimensional analysis was conducted on standardized preoperative and postoperative photographs to determine facial symmetry for every patient. Results was grouped based on pathology and analyzed by comparing adipocyte donor site (abdomen vs other).The mean ages at the time of first fat transfer were 17 years for the CM group and 15 years for the TC group. The average numbers of fat transfers per patient were 2.05 (CM) and 2.12 (TC). A mean of 3.74 procedures other than fat grafting was performed in each CM patient, whereas 4.38 other procedures were performed in each TC patient. In CM patients, less than 10.5 months between procedures resulted in improved symmetry. There was an average 6.63% improvement in facial symmetry in the CM group, and a 7.67% improvement in the TC group.Based on the UCLA experience, the durability of facial asymmetry and contour correction with fat transplantation is attainable in the craniofacial patient but may also require concomitant skeletal correction in the most severe cases.
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Filip C, Matzen M, Aagenæs I, Aukner R, Kjøll L, Høgevold HE, Tønseth K. Autologous fat transplantation to the velopharynx for treating persistent velopharyngeal insufficiency of mild degree secondary to overt or submucous cleft palate. J Plast Reconstr Aesthet Surg 2012; 66:337-44. [PMID: 23254179 DOI: 10.1016/j.bjps.2012.11.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 08/25/2012] [Accepted: 11/13/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Autologous fat transplantation to the velopharynx has been described in a few smaller studies including heterogeneous groups of patients for the treatment of velopharyngeal insufficiency (VPI). The aim of this study was to evaluate speech and to measure velopharyngeal closure with magnetic resonance imaging (MRI) in patients who underwent autologous fat transplantation for the treatment of persistent VPI of mild degree secondary to overt or submucous cleft palate. METHODS A prospective study of 16 patients with persistent VPI of mild degree secondary to overt or submucous cleft palate who underwent autologous fat transplantation to the velopharynx. The patients were injected with a median of 5.6 (3.8-7.6) ml autologous fat to the velopharynx. Pre- and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists. Hypernasality, hyponasality, nasal turbulence and audible nasal emission were scored on a five-point scale. Pre- and 1-year postoperative MRIs were obtained during vocal rest and during phonation in 12 patients. Data measured were the velopharyngeal distance in the sagittal plane and the velopharyngeal gap area in the axial plane. RESULTS Hypernasality improved significantly (p=0.030), but not audible nasal emission (p=0.072) or nasal turbulence (p=0.12). The velopharyngeal distance during phonation decreased significantly (p=0.013), but not the velopharyngeal gap area (p=0.16). There was no significant correlation between speech and MRI results. CONCLUSION Autologous fat transplantation to the velopharynx improved hypernasality significantly, but not audible nasal emission or nasal turbulence in patients with persistent VPI of mild degree secondary to overt or submucous cleft palate. Given the low number of patients and the lack of a control group, the value of fat transplantation for the treatment of mild VPI is not proven for sure.
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Affiliation(s)
- Charles Filip
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Rikshospitalet, PO Box 4950, Nydalen, 0424 Oslo, Norway.
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Abstract
The aim of this article was to describe the technical details of a fat injection procedure for the treatment of mild to moderate velopharyngeal insufficiency (VPI). Before surgery, the velopharyngeal gap is assessed by means of flexible nasoendoscopy, and speech intelligibility, hypernasality, and nasal air escape are perceptually evaluated and scored by independent raters; nasal airflow during speech is objectively measured. The lipoaspirate is centrifuged at 1200g for 3 minutes to separate and remove blood, cell debris, and the oily layer. Patients are injected with 3.5 to 8 mL of fat in the posterior and lateral pharyngeal walls and soft palate under general anesthesia. The fat is placed within the superior constrictor muscle on the posterior pharyngeal wall to avoid injection behind the prevertebral fascia and possible intraoperative or postoperative fat displacement in a caudal direction. A 19-gauge malleable, blunt, single-hole cannula is used for fat grafting, and the operative field is exposed by means of a Digman mouth gag. Two Nelaton probes are inserted through the nostrils and retracted from the mouth under moderate tension to favor visualization of the nasopharynx. No donor-site or injection-site morbidity has been observed so far, and the 12 patients (aged 5-48 y) treated so far have not manifested snoring or nasal obstruction at any time after surgery. Improved voice resonance is audible soon after the operation, and no hyponasality can be detected. The patients are discharged the day after surgery. Subsequent fat grafting procedures can be performed to achieve further improvement. Correctly performed fat injections improve voice resonance and reduce nasal air escape in VPI, as demonstrated by nasoendoscopy, speech perceptual evaluation, and the objective measurement of nasal airflow and represent an alternative to velopharyngoplasty for mild to moderate VPI.
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Kummer AW, Clark SL, Redle EE, Thomsen LL, Billmire DA. Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals. Cleft Palate Craniofac J 2012; 49:146-52. [DOI: 10.1597/10-285] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. Design A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. Participants The survey was distributed through E-mail lists for the American Cleft Palate–Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. Results Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and “improved” speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). Conclusion This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.
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Affiliation(s)
- Ann W. Kummer
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati, Cincinnati, Ohio
| | - Stacey L. Clark
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin E. Redle
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leisa L. Thomsen
- Division of Speech Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David A. Billmire
- University of Cincinnati, Cincinnati, Ohio
- Division of Pediatric Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Lau D, Oppenheimer AJ, Buchman SR, Berger M, Kasten SJ. Posterior pharyngeal fat grafting for velopharyngeal insufficiency. Cleft Palate Craniofac J 2012; 50:51-8. [PMID: 22329568 DOI: 10.1597/11-038] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective : To determine if autologous fat grafting to the posterior pharynx can reduce hypernasality in patients with cleft palate and mild velopharyngeal insufficiency (VPI). Design : Retrospective case series. Setting : Tertiary care center. Patients : Eleven patients with cleft palate status after palatoplasty (with or without secondary speech surgery) with nasendoscopic evidence of VPI. Interventions : Autologous fat was harvested and injected into the posterior pharynx under general anesthesia. Main Outcome Measures : Pre- and postoperative subjective, nasometry, and nasendoscopy data. Apnea-hypopnea indices (AHIs) were also assessed. Comparisons were made using Fisher's exact test, Student's t tests, and relative risk (RR) assessments. Results : An average of 13.1 mL of fat was injected (range: 5 to 22 mL). Mean follow-up was 17.5 months (range: 12 to 25 months). Statistically significant improvements in speech resonance were identified in nasometry (Zoo passage; p = .027) and subjective hypernasality assessment (p = .035). Eight of the patients (73%) demonstrated normal speech resonance after posterior pharyngeal fat grafting (PPFG) on subjective or objective assessment (p = .001). All five patients with previous secondary speech surgeries demonstrated normal speech resonance on similar assessment (RR = 1.8; p = .13). Complete velopharyngeal closure was observed in seven patients on postoperative nasendoscopy. No changes in AHIs were observed (p = .581). Conclusion : PPFG may be best used as an adjunct to secondary speech surgery. In this series, PPFG was not accompanied by the negative sequelae of hyponasality, sleep apnea, or airway compromise.
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Leboulanger N, Blanchard M, Denoyelle F, Glynn F, Charrier JB, Roger G, Monteil JP, Garabedian EN, Charrier JB, Jean-Baptiste C, Roger G, Gilles R, Monteil JP, Jean-Paul M, Garabedian EN, Eréa-Noël G. Autologous fat transfer in velopharyngeal insufficiency: indications and results of a 25 procedures series. Int J Pediatr Otorhinolaryngol 2011; 75:1404-7. [PMID: 21872348 DOI: 10.1016/j.ijporl.2011.08.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 08/03/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the efficiency of autologous fat transfer (AFT/Coleman procedure) in the management of velopharyngeal insufficiency (VPI). SETTINGS Tertiary academic center, retrospective case series over a 4 year period. Pre- and post-speech assessment by a speech pathologist using the Borel-Maisonny scale. PATIENTS AND METHOD Twenty-five (25) procedures were performed on 22 patients during the considered period. Mean age at surgery was 12.4 ± 4.1 years-old. Main associated conditions were 22q11 deletion (n=6 including 2 with cleft palate), isolated cleft palate (n=3), and Robin sequence (n=2). Indications were VPI grade 2a (n=5), 2b (n=11) and 3 (n=6), despite prolonged speech therapy (pre-op mean duration: 4.2 years) and previous surgery (velopharyngoplasty, n=13). Four patients had a contraindication of velopharyngoplasty (aberrant internal carotid arteries). RESULTS AND CONCLUSION Fat harvesting sites were umbilicus (n=23) and buttock (n=2). Mean injected fat volume was 7.8 ml, in the posterior wall of the pharynx (n=25) the soft palate (n=15), the peritonsillar arches (n=3), and the pre-existing flap (n=3). Mean follow-up was 17 months. Two patients relapsed once and one patient twice, requiring additional injections. Final post-operative examination 1 year after the last procedure showed an improvement of speech in 90% of cases (grade 1, n=2; 1/2a, n=5; 2a n=10; 2b, n=5). AFT is a safe technique indicated in the primary and secondary management of VPI, with stable results on speech. However, if a complete return to normal is difficult to achieve, its simplicity allows multiple procedures in the same patient.
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Affiliation(s)
- Nicolas Leboulanger
- Otolaryngology, Head and Neck Surgery Department, Armand-Trousseau Children Hospital, Paris, France.
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Teixeira RP, Reid JA, Greensmith A. Fatty Hypertrophy Cause Obstructive Sleep Apnea after Fat Injection for Velopharyngeal Incompetence. Cleft Palate Craniofac J 2011; 48:473-7. [DOI: 10.1597/09-024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Intervention Soft tissue augmentation of the posterior pharyngeal wall and the soft palate is reported to reduce velopharyngeal incompetence, and fat grafting in selected patients has shown effective and lasting results for restoring normal resonance. Potential complications of soft tissue augmentation for velopharyngeal incompetence include obstructive sleep apnea. Patient An 8-year-old boy with velopharyngeal incompetence and a small velopharyngeal gap underwent a fat injection procedure and subsequently developed obstructive sleep apnea concomitant with a significant weight gain. Videofluoroscopy and nasendoscopy showed a remarkable enlargement of the grafted fat areas that required a soft palate debulking procedure, significantly improving obstructive sleep apnea. Conclusion This is an unusual case where alteration in volume of grafted fat at the recipient site is suspected of causing obstructive sleep apnea. It is also an example of long-term fat graft survival and fat graft overgrowth.
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Affiliation(s)
- Rodrigo P. Teixeira
- Department of Plastic and Maxillofacial Surgery The Royal Children's Hospital, Melbourne, Australia
| | - Julie A. Reid
- Department The Royal Children's Hospital, Melbourne, Australia
| | - Andrew Greensmith
- Department of Plastic and Maxillofacial Surgery The Royal Children's Hospital, Melbourne, Australia
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Cantarella G, Mazzola RF, Mantovani M, Baracca G, Pignataro L. Treatment of velopharyngeal insufficiency by pharyngeal and velar fat injections. Otolaryngol Head Neck Surg 2011; 145:401-3. [PMID: 21636838 DOI: 10.1177/0194599811411655] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this prospective study was to evaluate the effectiveness of fat injections in the treatment of velopharyngeal insufficiency (VPI). The study involved 10 patients (6 adults aged 19-48 years and 4 children aged 5-13 years) with mild/moderate VPI who were injected with 3.5 to 8 mL of fat in the posterior, lateral pharyngeal walls and soft palate under general anaesthesia. A second fat-grafting procedure was performed in 2 patients to achieve further improvement. Nasoendoscopy revealed a reduction in the closure gap in all patients, and the perceptual evaluation demonstrated improved speech intelligibility and resonance and reduced nasal air leakage in all cases (P < .005). The aerodynamic assessment showed a significant reduction in nasal airflow during phonation (P < .05). Follow-up was 6 to 23 months. In conclusion, fat injections improved voice resonance and reduced nasal air escape in all treated cases and can be a promising alternative to major procedures, such as velopharyngoplasties, for the treatment of mild/moderate VPI.
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Affiliation(s)
- Giovanna Cantarella
- Otolaryngology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Filip C, Matzen M, Aagenæs I, Aukner R, Kjøll L, Høgevold HE, Abyholm F, Tønseth K. Speech and magnetic resonance imaging results following autologous fat transplantation to the velopharynx in patients with velopharyngeal insufficiency. Cleft Palate Craniofac J 2011; 48:708-16. [PMID: 21463181 DOI: 10.1597/09-161] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To measure velopharyngeal closure with magnetic resonance imaging (MRI) and to evaluate speech when treating velopharyngeal insufficiency (VPI) with autologous fat transplantation to the velopharynx. PATIENTS Nine patients were recruited. Six patients had undergone cleft palate repair and subsequently developed VPI. Three were noncleft patients of which one had developed VPI after nasopharyngeal cancer treatment; another patient had developed VPI after combined adenotonsillectomy, and a third patient had VPI of unknown etiology. MAIN OUTCOME MEASURE Preoperative and 1-year postoperative MRIs were obtained during vocal rest and during phonation. Data measured were the velopharyngeal distance in the sagittal plane and the velopharyngeal gap area in the axial plane. Preoperative and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists. RESULTS When comparing preoperative and 1-year postoperative MRI during phonation we found a significant reduction of the median velopharyngeal distance from 4 to 0 mm (p = .011), and a significant reduction of the median velopharyngeal gap area from 42 to 34 mm(2) (p = .038). Nasal turbulence improved significantly (p = .011). Hypernasality/hyponasality and audible nasal emission did not change significantly. CONCLUSIONS Autologous fat transplantation to the velopharynx resulted in a significant reduction of the velopharyngeal distance and the velopharyngeal gap area during phonation, as measured by MRI. This was in accordance with a significant improvement in nasal turbulence. However, hypernasality and audible nasal emission did not change significantly and could not be correlated to the MRI findings.
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Posterior pharyngeal augmentation in the treatment of velopharyngeal insufficiency: a 40-year experience. Ann Plast Surg 2010; 65:48-51. [PMID: 20548221 DOI: 10.1097/sap.0b013e3181c1fec6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Velopharyngeal insufficiency (VPI) remains a common problem in the care of patients with cleft palate and other related conditions. It may be successfully corrected with augmentation of the posterior pharynx. The purpose of this study was to review the experience and results of posterior pharyngeal augmentation over a 40-year period at one cleft center in the United States. METHODS All patients from 1968 to 2008 who underwent posterior pharyngeal augmentation for the treatment of VPI were reviewed retrospectively. Diagnosis, age at the time of operation, type of implant used, duration of follow-up, speech performance both pre- and postoperatively, and complications were analyzed. Speech performance preoperatively was assessed by video fluoroscopy and/or nasoendoscopy. Resonance was assessed by both the surgeon and speech pathologist using a 4 point grading scale. RESULTS One hundred eleven patients underwent posterior pharyngeal augmentation. Thirteen patients required removal of the implant because of extrusion (n = 12) or postoperative sleep apnea (n = 1). Five patients with failed implants at the primary operation had successful replacement at a second operation, resulting in a retained implant success rate of 93%. Of the 103 patients who were successfully augmented, 15 were lost to follow-up, leaving 88 patients with full postoperative speech evaluations. Of the 88 patients evaluated, 64 exhibited normal or near normal speech (73%), 22 patients had mildly nasal speech (25%), and 2 patients (2%) were not improved. Highest extrusion rates were seen for smooth surface silicone and rolled gortex implants. CONCLUSION Augmentation of the posterior pharyngeal wall is a safe and effective treatment for patients with VPI. Implants are well tolerated and speech is substantially improved.
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Leuchter I, Schweizer V, Hohlfeld J, Pasche P. Treatment of velopharyngeal insufficiency by autologous fat injection. Eur Arch Otorhinolaryngol 2009; 267:977-83. [DOI: 10.1007/s00405-009-1157-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2009] [Accepted: 11/05/2009] [Indexed: 10/20/2022]
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The management of velopharyngeal insufficiency with Furlow double-opposing Z-plasty procedure. EUROPEAN JOURNAL OF PLASTIC SURGERY 2008. [DOI: 10.1007/s00238-008-0254-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bardot J, Salazard B, Casanova D, Pech C, Magalon G. Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Pharyngoplastie par Lipostructure® du pharynx. ACTA ACUST UNITED AC 2007; 108:352-6. [PMID: 17675123 DOI: 10.1016/j.stomax.2007.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Accepted: 06/15/2007] [Indexed: 10/28/2022]
Abstract
Advancing the posterior pharyngeal wall is a classic technique to treat velopharyngeal insufficiency. Injection of autologous fat behind the posterior pharyngeal mucosa according to the Coleman Lipostructure technique is a recent development. The authors report their experience in six cases using this modification. The preoperative work-up was performed by a speech therapist with a physical examination and measurement of the nasal air loss was performed using an aerophonometer. Fat was harvested either on the abdominal wall or on a buttock and then centrifuged. Fat injection was performed using a curved blunt cannula under the mucosa of the lateral and posterior pharyngeal walls. Injecting fat is an autologous graft of fat tissue: after a postoperative period of three months, the volume of fat becomes permanently stable. In five out of the six patients who presented moderate velopharyngeal insufficiency, speech improvement was significant. The single failure was a patient with bilateral cleft lip and palate sequels after previous pharyngoplasty using the Orticochea procedure. Treatment of moderate velopharyngeal insufficiency using fat injection is an efficient method. The advantages are its innocuousness and that scaring of the pharynx is avoided.
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Affiliation(s)
- J Bardot
- Service de chirurgie plastique réparatrice et esthétique, hôpital de la Conception, 147, boulevard Baille, 13005 Marseille, France.
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Goehde SC, Kuehl H, Ladd ME. Magnetic resonance imaging of autologous fat grafting. Eur Radiol 2005; 15:2423-6. [PMID: 15906038 DOI: 10.1007/s00330-005-2765-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2005] [Accepted: 03/29/2005] [Indexed: 11/27/2022]
Abstract
A 30-year-old female patient with isolated facial lipodystrophy underwent two sessions of fat injection. MR signals of injected fat at different injection ages were compared to native fat. Native T1 signal was smaller for transplant fat, probably due to a slightly lower fat content and/or fibrosis or due to higher perfusion. T2 signal of transplants was significantly higher than that of native fat. T1 post-contrast was also higher, and contrast uptake of transplanted fat increased slightly with transplant age, which could be explained by an increasing perfusion. This study demonstrates the differences and MR signal time changes of native and transplanted fat.
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Affiliation(s)
- Susanne C Goehde
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany.
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Kummer AW. Velopharyngeal dysfunction: current thinking on the cause, effect, assessment and treatment. Curr Opin Otolaryngol Head Neck Surg 2002. [DOI: 10.1097/00020840-200212000-00007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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