An Evaluation of Autologous Fat Injection as a Treatment for Velopharyngeal Insufficiency: A Review and Integrated Data Analysis

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.

Surgical Treatment of Acquired Velopharyngeal Insufficiency in Adults With Dysphagia and Dysphonia

OBJECTIVES

Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions.

METHODS

A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort.

RESULTS

VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision.

CONCLUSION

This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions.

Autologous Fat Grafting in Velopharyngeal Insufficiency Gives Complete and Stable Speech Recovery in Patient Under 7 years

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.

Metanalysis of alloplastic materials versus autologous fat for injection augmentation pharyngoplasty treatment of velopharyngeal insufficiency

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.

Regenerative medicine approaches for the management of respiratory tract fistulas

Respiratory tract fistulas (or fistulae) are abnormal communications between the respiratory system and the digestive tract or the adjacent organs. The origin can be congenital or, more frequently, iatrogenic and the clinical presentation is heterogeneous. Respiratory tract fistulas can lead to severely reduced health-related quality of life and short survival. Therapy mainly relies on endoscopic surgical interventions but patients often require prolonged hospitalization and may develop complications. Therefore, more conservative regenerative medicine approaches, mainly based on lipotransfer, have also been investigated. Adipose tissue can be delivered either as unprocessed tissue, or after enzymatic treatment to derive the cellular stromal vascular fraction. In the current narrative review, we provide an overview of the main tissue/cell-based clinical studies for the management of various types of respiratory tract fistulas or injuries. Clinical experience is limited, as most of the studies were performed on a small number of patients. Albeit a conclusive proof of efficacy cannot be drawn, the reviewed studies suggest that grafting of adipose tissue-derived material may represent a minimally invasive and conservative treatment option, alternative to more aggressive surgical procedures. Knowledge on safety and tolerability acquired in prior studies can lead to the design of future, larger trials that may exploit innovative procedures for tissue processing to further improve the clinical outcome.