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Smetona JT, Naran S, Ford M, Losee JE. What's New in Cleft Palate and Velopharyngeal Dysfunction Management: An Update. Plast Reconstr Surg 2024; 154:378e-390e. [PMID: 39046844 DOI: 10.1097/prs.0000000000011312] [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: 07/27/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Describe the pathology of velopharyngeal dysfunction (VPD) as it relates to patients with a cleft palate. (2) Use the perceptual speech assessment and objective diagnostic tools to determine the presence or absence of VPD. (3) Describe the surgical options available for the treatment of patients with VPD. (4) Develop an evidence-based, customized treatment plan for VPD founded on objective considerations. SUMMARY To treat patients with cleft palate effectively, the surgeon must understand the diagnosis and surgical management of cleft-associated velopharyngeal dysfunction. The authors review diagnostic modalities including perceptual speech assessment, video nasendoscopy, fluoroscopy, magnetic resonance imaging, and nasometry. Surgical treatments including palatal lengthening with buccal myomucosal flaps, conversion Furlow palatoplasty, sphincter pharyngoplasty, and pharyngeal flap are discussed. Selection of an optimal surgical treatment is addressed.
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Affiliation(s)
- John T Smetona
- From the Division of Pediatric Plastic Surgery, Advocate Children's Hospital
| | - Sanjay Naran
- From the Division of Pediatric Plastic Surgery, Advocate Children's Hospital
- Department of Plastic Surgery, Division of Pediatric Plastic Surgery, University of Pittsburgh
- Section of Plastic and Reconstructive Surgery, University of Chicago Medicine & Biological Sciences
| | - Matthew Ford
- Department of Plastic Surgery, Division of Pediatric Plastic Surgery, University of Pittsburgh
| | - Joseph E Losee
- Department of Plastic Surgery, Division of Pediatric Plastic Surgery, University of Pittsburgh
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Pavlovich VA, Chkadua TZ, Anelikov AI. [The choice of method of surgical treatment of velopharyngeal insufficiency]. STOMATOLOGIIA 2024; 103:37-43. [PMID: 39171342 DOI: 10.17116/stomat202410304137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
OBJECTIVE To establish the criteria for selecting surgical treatments for velopharyngeal disfunction and to evaluate their effectiveness. Materials and Methods. 34 patients with velopharyngeal insufficiency underwent surgery at the National Medical Research Center for Surgery and Maxillofacial Surgery. Five common surgical methods for treating velopharyngeal disfunction were employed. RESULTS The choice of surgery was primarily based on the anatomical and functional state of the muscle lifting the soft palate, specifically its position, which was determined visually or by MRI. Repositioning of the muscle helped to improve or restore speech in patients with velopharyngeal disfunction through surgeries such as secondary cleft revision, Furlow's palatoplasty, and triangular miomucosal flaps. In cases of soft palate palsy or correct positioning of the m. levator veli palatini, the focus of surgical treatment shifted to the pharynx, where surgeries like pharyngoplasty with a posterior pharyngeal flap and Hynes pharyngoplasties were performed. These also improved or restored speech in patients, though more towards improvement than complete restoration. If the muscle's position was optimal, the choice of treatment method subsequently depended on the results of additional nasopharyngoscopy: determining the size of the opening and the type of velopharyngeal closure. Besides the common methods used for speech management, various surgical procedures were combined based on the clinical situation. CONCLUSION The position of the levator muscle is very important for its function. The optimal treatment for velopharyngeal disfunction, especially in patients with large openings, involved using a buccal flap alone or in combination with triangular mucosal-muscle flaps, where the highest percentage of normal speech rate was achieved.
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Affiliation(s)
- V A Pavlovich
- Central Research Institute of Dentistry and Maxillofacial Surgery, Moscow, Russia
| | - T Z Chkadua
- Central Research Institute of Dentistry and Maxillofacial Surgery, Moscow, Russia
| | - A I Anelikov
- Central Research Institute of Dentistry and Maxillofacial Surgery, Moscow, Russia
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Morrison KA, Park J, Rochlin D, Lico M, Flores RL. Anatomical Study of Domain Rescue of Palatal Length in Patients With a Wide Cleft Palate: Buccal Flap Reconstruction in Primary Palatoplasty. Cleft Palate Craniofac J 2024; 61:103-109. [PMID: 35918811 DOI: 10.1177/10556656221117930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty. METHODS A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap. RESULTS Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6 ± 2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5 ± 2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications. CONCLUSIONS Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion.
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Affiliation(s)
| | - Jenn Park
- NYU Langone Health, New York, NY, USA
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Aycart MA, Caterson EJ. Advances in Cleft Lip and Palate Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1932. [PMID: 38003981 PMCID: PMC10672985 DOI: 10.3390/medicina59111932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/21/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.
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Affiliation(s)
- Mario A. Aycart
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Nemours Children’s Health-Delaware, 1600 Rockland Road, Wilmington, DE 19803, USA;
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Chiang SN, Fotouhi AR, Grames LM, Skolnick GB, Snyder-Warwick AK, Patel KB. Buccal Myomucosal Flap Repair for Velopharyngeal Dysfunction. Plast Reconstr Surg 2023; 152:842-850. [PMID: 37768860 DOI: 10.1097/prs.0000000000010443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND Velopharyngeal dysfunction (VPD) is the incomplete separation of the nasal and oral cavities during speech sound production that can persist following primary palatoplasty. Surgical technique used in management of VPD (palatal re-repair versus pharyngeal flap or sphincter pharyngoplasty) is often dictated by the preoperative velar closing ratio and closure pattern. Recently, buccal flaps have increased in popularity in management of VPD. Here, the authors investigate the effectiveness of buccal myomucosal flaps in the treatment of VPD. METHODS A retrospective review was performed of all patients undergoing secondary palatoplasty with buccal flaps at a single center between 2016 and 2021. Preoperative and postoperative speech outcomes were compared. Speech assessments included perceptual examinations, graded on a four-point scale of hypernasality, and speech videofluoroscopy, from which the velar closing ratio was obtained. RESULTS A total of 25 patients underwent buccal myomucosal flap procedures for VPD at a median of 7.1 years after primary palatoplasty. Patients had significantly increased velar closing postoperatively (95% versus 50%; P < 0.001) and improved speech scores ( P < 0.001). Three patients (12%) had continued hypernasality postoperatively. There were no occurrences of obstructive sleep apnea. CONCLUSIONS Treatment of VPD with buccal myomucosal flaps leads to improved speech outcomes without the risk of obstructive sleep apnea. Traditionally, palatal re-repair techniques have been used for smaller preoperative velopharyngeal gaps; however, the addition of buccal flaps allows for anatomical velar muscle correction for patients with a larger preoperative velopharyngeal gap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Sarah N Chiang
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Annahita R Fotouhi
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Lynn M Grames
- Cleft Palate and Craniofacial Institute, St. Louis Children's Hospital
| | - Gary B Skolnick
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Alison K Snyder-Warwick
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Kamlesh B Patel
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
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Tse RW, Sie KC, Tollefson TT, Jackson OA, Kirshner R, Fisher DM, Bly R, Arneja JS, Dahl JP, Soldanska M, Sitzman TJ. Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations. Cleft Palate Craniofac J 2023:10556656231181359. [PMID: 37441787 PMCID: PMC10787042 DOI: 10.1177/10556656231181359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique. RESULTS Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation. CONCLUSIONS A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.
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Affiliation(s)
- Raymond W Tse
- Craniofacial and Pediatric Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Plastic Surgery, University of Washington, Seattle, WA, USA
| | - Kathleen C Sie
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Travis T Tollefson
- Otolaryngology Head and Neck Surgery, University of California, Davis, Sacramento, CA, USA
| | - Oksana A Jackson
- Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard Kirshner
- Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
- Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David M Fisher
- Plastic Surgery, The Hospital for Sick Children, Toronto, ON, USA
- Plastic Surgery, University of Toronto, Toronto, ON, USA
| | - Randall Bly
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Jugpal S Arneja
- Plastic Surgery, BC Children's Hospital, Vancouver, BC, USA
- Plastic Surgery, University of British Columbia, Vancouver, BC, USA
| | - John P Dahl
- Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA
- Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | | | - Thomas J Sitzman
- Plastic Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Plastic Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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