Search

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.

Background: Velopharyngeal insufficiency is frequently managed surgically via the superiorly based pharyngeal flap procedure. The flap used in this procedure traditionally consists of both mucosa and muscle. Although muscle is included to potentially increase survival and tissue bulk, its inclusion may result in postoperative dysfunction of pharyngeal sidewall motion. Although the benefits of pharyngeal flap surgery are established, the denervated muscular portion of the flap appears to atrophy. The purpose of this study was to evaluate whether a flap consisting entirely of mucosa provides the same tissue bulk as a conventional pharyngeal flap 12 weeks postoperatively., Methods: Ten laboratory-grade cats served as direct patient surrogates. Cats were randomized to undergo a superiorly based pharyngeal flap procedure with flaps composed of either both muscle and mucosa (n = 5) or mucosa only (n = 5). Blinded volumetric analysis was performed by three board-certified neuroradiologists using magnetic resonance imaging of the pharynx immediately after surgery and at 4, 8, and 12 weeks., Results: At 12 weeks postoperatively, pharyngeal flaps composed of both mucosa and muscle atrophied to reach volumetric equivalence with mucosa-only flaps. Evaluation of final pharyngeal flap volume demonstrated no statistical differences between the two groups., Conclusions: This study demonstrates equivalent final superiorly based pharyngeal flap tissue bulk for flaps composed of only mucosa when compared with conventional pharyngeal flaps. Thus, the mucosa-only pharyngeal flap may yield similar outcomes while potentially providing for an earlier return of normal pharyngeal function.

Background: Pharyngeal flaps are used to treat velopharyngeal insufficiency. Occasionally the flap exceeds its intended function and results in an obstructive airway. In this article, the results of management of these cases are analysed., Methods: This is a 39-year retrospective review of patients who had revision of pharyngeal flaps causing obstructive airway symptoms. Three methods of relieving the airway obstruction were used, and the patients were thus separated into three groups, namely group 1 (release and Z-plasty of the lateral ports), group 2 (division of the pharyngeal flap) and group 3 (division of the pharyngeal flap combined with Furlow palatoplasty). The results obtained were based on four parameters: symptomatic improvement, velopharyngeal sufficiency, the presence of re-attachment of the pharyngeal flap and the necessity for re-operation. These results were then pooled into two groups: 'good result' and 'bad result'. The respiratory disturbance index (RDI) was also obtained and analysed separately. Statistical analysis was performed with the Fisher's exact test and the paired t-test in SPSS v.11., Results: A total of 44 patients were included in the study. There were 20, 11 and 13 patients in groups 1, 2 and 3, respectively. The Pearson's chi-square test indicated that group 3 patients had a statistically significant proportion of 'good results' when compared to groups 1 (p=0.019) and 2 (p=0.004). There was a statistically significant reduction in RDI in group 3 (p=0.003). There was no statistically significant difference between the groups 1 and 2., Conclusions: Division of a pharyngeal flap for obstructive airway complications should be accompanied by a Furlow palatoplasty to reduce the myriad complications that arise from either a release+Z-plasty or a simple division of the pharyngeal flap., (Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Velopharyngeal insufficiency remains a sequel of labial-alveolar-velopalatine clefts. It may occur despite a good quality primary repair. A surgical management must be considered as soon as speech therapy is no longer efficient or before any irreversible compensatory speech pattern appears. Thus, surgery should be decided on after consultation between the surgeon and the speech pathologist or speech therapist, when considering that speech therapy has failed. Several surgical techniques are discussed: intravelar veloplasty, Furlow double-opposing Z-plasty, pharyngoplasty using an inferior or superior pedicle flap. Superior pedicle flap surgery is currently the most commonly used technique. For the past twenty years we have used this technique as described by Petit and modified by Malek, because of the excellent speech results. The drawbacks are known and can be contained by a preventive management.

Introduction: The term insuffisance velopalatine was first used by Larmoyez in 1892 r. Nowadays the term is used to denote the failure of the palate to produce velopharyngeal closure that would completely block the nasopharynx from the lower pharynx during physiological processes of swallowing, blowing, speaking, breathing and ventilation of the internal auditory canal. Numerous surgical techniques used in the treatment of VPI were described in the past 100 years. Several techniques have been used to decrease the velopharyngeal space, like operations aiming at bulging of the posterior pharyngeal wall and alternating "Z-plasty" of the soft palate aiming at prolongation and improvement of the mobile function of the palate., Material and Method: The prospective studies were carried on from May 2003 to October 2004. Patients with severe forms of VPI were qualified for surgical treatment by a phoniatrist, speech therapist and plastic surgeon. All the surgical procedures were performed by the same surgeon. Bulging of the posterior pharyngeal wall by means of corionic graft was performed in 8 patients as the first stage treatment followed by prolongation of the palate by means of Furlow's technique 6 months later. The anatomical conditions as well as speech quality prior to, after the first and the second procedure were evaluated on the basis of direct examination, speech assessment, nasofibroscopic examinations and nasometric measurements., Results: Examinations performed 6 months after termination of surgical treatment revealed improvement or significant improvement in speech quality, especially concerning reduced nasality, speech intelligibility and decreased nasal airflow (on an average from 48% to 33%). Five patients rated in questionnaires the outcome of treatment as "significant improvement"., Conclusion: Complex staged management consisting in bulging of the posterior pharyngeal wall and Furlow's operation appeared to be a successful modality of treatment in patients with severe forms of velo-pharyngeal insufficiency in about 75% of cases.

This investigation compares the patterns of velopharyngeal growth in cleft lip and/or palate patients. Those who had velopharyngeal competence and acceptable speech are compared with those who presented with velopharyngeal incompetence requiring pharyngeal flap surgery or prosthesis later. Lateral cephalograms of 30 cleft palate only (CPO), 35 unilateral cleft lip and palate (UCLP), and 20 bilateral cleft lip and palate (BCLP) children of the Lancaster Cleft Palate Clinic were studied. These records were taken at 6 month intervals during the first 2 postnatal years and annually thereafter up to 6 years of age. Soft tissue landmark points in the velopharyngeal region were digitized. Length and thickness of the soft palate and height and depth of the nasopharynx were measured. Evaluation of the growth curves of these four cephalometric variables indicated only two significant differences between children who later required pharyngeal flap surgery and those who did not. These differences were found in the growth in length of the soft palate of the CPO group and in the growth in depth of the nasopharynx of the BCLP group. Based on the present cephalometric data, it is impossible to predict at an early age those cleft lip and/or palate patients who will later require pharyngeal flaps.

Twenty-two patients, with hypernasal speech and asymmetric velopharyngeal insufficiency (VPI) identified preoperatively by multi-view video-fluoroscopy and nasopharyngoscopy, were managed with superiorly based pharyngeal flaps skewed to the side with reduced lateral pharyngeal wall movement. Patient age ranged from 5 to 58 years. The etiology of the VPI included cleft palate with or without cleft lip, neurogenic VPI, velocardiofacial syndrome, tumor resection or iatrogenic causes, submucous cleft palate, neurofibromatosis, and hemifacial microsomia. Follow-up, at 1 year and thereafter, showed resolution of VPI in all but two patients. An auxiliary flap to augment the primary flap was added on the side of diminished lateral pharyngeal wall motion which corrected the residual VPI. Three patients developed hyponasality. One was a child whose symptoms improved with time and growth. Two were adults, but the hyponasal resonance was mild and required no further intervention. The advantage of skewing flaps is that at least one port functions adequately for ease in respiration and for drainage of secretions, thus reducing the risk of nasal obstruction. One open port also allows access for nasoendotracheal intubation should anesthetic be required for future operations.

Twenty-one consecutive patients who had earlier superiorly based pharyngeal flap surgery and persistent velopharyngeal insufficiency were seen between 1976 and 1991. Patients were divided into two treatment groups, depending on the results of videofluoroscopic and nasopharyngoscopic assessment. The first group consisted of 18 patients who had bilateral port insufficiency and required a complete reconstruction of a new superiorly based pharyngeal flap that was elevated from a scarred posterior pharyngeal wall. After an average follow-up of 6.2 years, 15 patients had normal resonance, 2 patients had improvement but continued hypernasality, and 1 patient was hyponasal. The second group consisted of 3 patients who had "patch" flaps to a unilateral port insufficiency. Postoperatively, all 3 of those patients had normal resonance. Indications for the decision to "redo" or patch flaps are described.

The anatomical basis for the application of neurovascular pedicled muscle transfers of the digastric and stylohyoid muscles in the treatment of velopharynx incompetence is described. The fact that the neurovascular pedicle is located in the cranial third of the muscle bellies provides the safety of the operative procedure. The muscles have to be dissected with respect to that. The direction in which the transferred muscles pull is described. The muscle transposition is combined with the classic Wardill-Kilner operation to lengthen the soft palate. The transferred muscles have to avoid scar contraction and shortening of the soft palate and to gain a muscular function of the soft palate. The clinical use is justified in rare cases as demonstrated in one case.

Position of the tongue was studied in lateral cineradiographic pictures of 15 patients with cleft palate and velopharyngeal incompetence, and from ten unaffected reference subjects. The patients were examined before and after pharyngoplasty. Before operation there was no difference in the degree of tongue/velum contact between the patients and the reference subjects, but after the operation, contact was lost in 13 of the 15 patients because the tongue was lowered and the velum raised by the pharyngeal flap. This contradicts the previous theory that the position of the tongue should be expected to be higher to maintain the posterior oral seal. The tongue was in a more posterior position in the patients than in the reference subjects both before and after operation. After operation the tip of the tongue retracted into the anterior oral cavity. The posterior and downward change in position of the tongue may account for part of the posterior and downward growth pattern of the lower third of the face which occurs in children after pharyngoplasty. A loss of tongue-lip balance around the premaxilla may be one of the factors that causes the maxillary retrusion that has been reported after pharyngoplasty in patients with cleft palates.

Accurate mapping of the defect of velopharyngeal closure in patients with velopharyngeal incompetence is paramount to the planning of an operative procedure that will have a successful outcome. Nasoendoscopy and videonasoendoscopy are valuable tools for examination of the abnormal pattern of velopharyngeal movement in patients with velopharyngeal incompetence. On the basis of the knowledge of the observed defect in velopharyngeal closure for the particular patient, a pharyngeal flap operation is planned. The flap width, level of placement of the flap base, and control of the lateral port size vary to suit each individual velopharyngeal closure defect. Postoperative speech results in 86 patients are reported.