Autologous fat grafting in the treatment of velopharyngeal insufficiency: Clinical outcomes and treatment tolerability survey in a case series of 21 patients

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.

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.

Optimizing speech outcomes for cleft palate

PURPOSE OF REVIEW

Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate.

RECENT FINDINGS

The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics.

SUMMARY

According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.

Applications of Fat Grafting in Pediatric Patients

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.

Novel treatment for mild and moderate velopharyngeal insufficiency using implantable AlloDerm for posterior pharyngeal wall augmentation and review of surgical repair techniques

PURPOSE

Mild and moderate velopharyngeal insufficiency is a relatively common structural defect of the velopharyngeal sphincter that occurs congenitally or secondarily to various medical conditions resulting in speech inadequacy. Currently, multiple surgical methods exist to treat mild and moderate velopharyngeal insufficiency; however, the revision rates are high and the outcomes are variable. This case series describes a novel technique using implantable AlloDerm to repair the posterior pharyngeal wall to treat mild and moderate velopharyngeal insufficiency.

MATERIALS AND METHODS

This paper presents four patients with mild or moderate velopharyngeal insufficiency who were treated with implantable AlloDerm in the posterior pharyngeal wall at a large, safety-net hospital in New England from 2000 to 2019. Additionally, a review of surgical repair techniques for velopharyngeal insufficiency was conducted with synthesis of a qualitative overview.

RESULTS

There were sufficient follow-up data in three of these patients. All three reported subjective improvements in symptoms after the procedure. One patient had implant extrusion one month following the procedure with subsequent removal.

CONCLUSION

Ultimately, implantable AlloDerm for posterior pharyngeal wall augmentation is a useful, low risk method for treating mild to moderate velopharyngeal insufficiency.

Autologous Fat Injection Pharyngoplasty in Adults with Velopharyngeal Insufficiency

Objectives:

Understand the utility and technique of injection pharyngoplasty with autologous fat for the treatment of mild to moderate velopharyngeal insufficiency in adults without a history of cleft palate.

Methods:

Consecutive case series of 11 patients (mean [SD] 41 ± 21 years of age) who underwent injection pharyngoplasty with autologous fat from 2012 to 2018 at a tertiary care center. Patients were followed for a mean of 8.6 ± 8 months with pre versus postoperative evaluations of improvement in rhinophonia, dysphagia, and velopharyngeal closure by nasopharyngoscopy (scored: 0, none; 1, mild; 2, moderate; 3, near-complete; 4, complete).

Results:

Patient selection and surgical techniques are described. Mean improvements were 2.3 ± 0.86 for rhinophonia, 2.0 ± 0.89 for dysphagia, and 3.0 ± 0.95 for velopharyngeal closure by nasopharyngoscopy. Five (45%) patients underwent subsequent intervention, including four repeat fat injections and three sphincter pharyngoplasties. There were two transient complications–donor site hematoma and subjective nasal obstruction.

Conclusions:

Although objective assessments are lacking to date, this is among the first reports to demonstrate the effectiveness and safety of injection pharyngoplasty with autologous fat for velopharyngeal insufficiency in a population of adults without a history of cleft. We found, on average, moderate improvement in rhinophonia and dysphagia, and near-complete improvement in velopharyngeal closure by nasopharyngoscopy; however, a portion of patients required subsequent intervention.