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Armencea G, Reddy GS, Bran S, Bereanu A, Anton D, Onișor F, Dinu CM, Papuc AD, Stoia S, Tamaș T, Băciuț MF. The Use of Buccal Fat Pad Versus Buccal Mucosal Flap in Cleft Patient Palatoplasty-A Literature Review. J Clin Med 2025; 14:3114. [PMID: 40364144 PMCID: PMC12072586 DOI: 10.3390/jcm14093114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2025] [Revised: 04/26/2025] [Accepted: 04/29/2025] [Indexed: 05/15/2025] Open
Abstract
The buccal fat pad and buccal mucosa are anatomical structures closely related to palatal clefts which can provide additional tissues for defect reconstruction which is crucial for practitioners aiming to lessen the need for additional corrective surgeries in patients with cleft palates and to lower the rates of residual palatal fistulae. Objectives: Aims to explore the recent scientific data available on the applications and outcomes of two surgical techniques involving the buccal fat pad and buccal mucosal flap in primary and secondary palatoplasty. Methods: The analyzed articles published between 2020 and 2025 from PubMed, Web of Science, and Scopus. The search strategy included terms related to buccal fat pad flaps, buccal mucosal flaps, and cleft palate repair. Results: After performing the search, including eligible articles and removing duplicates, 15 articles were included in this review. Eight studies explored the effectiveness of buccal fat pad or buccal mucosal flap during primary palatoplasty and seven studies for secondary palatoplasty. The articles included in this review provide insights on the usefulness of buccal fat pad flaps and buccal mucosal flaps in primary and secondary palatoplasty. Conclusions: The buccal fat pad and buccal mucosal flaps are highly effective in secondary palatoplasty, particularly for velopharyngeal dysfunction and fistula closure. In primary palatoplasty, the buccal fat pad flap aids mucosal healing, reduces complications, and improves speech, while the buccal mucosal flap is beneficial for wide palatal defects.
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Affiliation(s)
- Gabriel Armencea
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Gosla Srinivas Reddy
- G.S.R. Hospital, Institute of Cranio-Maxillofacial and Facial Plastic Surgery, Vinay Nagar Colony, Saidabad, Hyderabad 500059, India;
| | - Simion Bran
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Alexandru Bereanu
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Damaris Anton
- Department of Periodontology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Florin Onișor
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Cristian-Mihail Dinu
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Alexandra Denisa Papuc
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Sebastian Stoia
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Tiberiu Tamaș
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
| | - Mihaela-Felicia Băciuț
- Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dental Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, TEAM Group Project, 400012 Cluj-Napoca, Romania; (G.A.); (A.B.); (F.O.); (C.-M.D.); (A.D.P.); (S.S.); (T.T.); (M.-F.B.)
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Youssef Arkoubi A. Investigating the Effectiveness of Buccal Flap for Velopharyngeal Insufficiency: A Systematic Review Article. J Clin Med 2025; 14:2593. [PMID: 40283423 PMCID: PMC12027865 DOI: 10.3390/jcm14082593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2025] [Revised: 03/24/2025] [Accepted: 04/01/2025] [Indexed: 04/29/2025] Open
Abstract
Background: Velopharyngeal insufficiency (VPI) is a failure of the sphincter mechanism, causing speech patterns like hypernasality and decreased intelligibility. Causes include structural, neurologic, and mechanical issues. Treatment options include non-surgical and surgical interventions, but complications can arise. A new approach using the buccal flap (BF) has been suggested for palatal length augmentation. This systematic review assessed speech outcomes after BF palatal lengthening. Methods: A thorough investigation was conducted by methodically reviewing numerous databases, including PubMed, Scopus, Web of Science, and Embase, until December 2024. The goal of our analysis was to find studies that assess the short- and long-term efficacy of BF on speech outcomes on patients with VPI. We used the NIH Quality Assessment Tool to assess the quality of the evidence, ensuring the dependability of the results reached during these investigations. Results: This systematic review identified 23 studies (total sample size of 995) that assessed the speech outcomes of BF on VPI. The BF significantly improves speech outcomes in patients with VPI. Hypernasality improved significantly post-surgery, with outcomes measured using different scales and methods, including both subjective and objective tools. Benefits were observed within three months postoperatively, with sustained benefits up to 15 months in several studies. Speech intelligibility also improved notably, with mean differences up to 1.09 (p < 0.001). Reductions in audible nasal air emissions were observed, though some variability was noted across studies. Secondary outcomes, including better velopharyngeal closure and decreased facial grimacing, further highlight its efficacy. However, inconsistent findings for nasal turbulence and limited long-term data suggest that benefits may plateau over time. These findings support the BF as an effective intervention, though further research is needed on extended outcomes. Conclusions: BF is an effective surgical intervention for VPI, significantly improving hypernasality, speech intelligibility, and audible nasal air emissions. While benefits are evident across diverse populations, long-term outcomes and secondary features, such as nasal turbulence, show variability, emphasizing the need for individualized approaches and continued follow-up. This technique offers a reliable option for functional and speech rehabilitation, though further research is needed to optimize its long-term efficacy and broader outcomes.
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Affiliation(s)
- Amr Youssef Arkoubi
- Department on Anesthesia and Surgery, Faculty of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh 11564, Saudi Arabia
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Lentskevich MA, Yau A, Figueroa AE, Termanini KM, Gosain AK. Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-Analysis. Cleft Palate Craniofac J 2025; 62:545-557. [PMID: 37993983 DOI: 10.1177/10556656231216834] [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: 11/24/2023] Open
Abstract
ObjectiveBuccal myomucosal flaps (BMF) anatomically lengthen the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing literature on speech outcome of BMF palatal lengthening.DesignThree databases were used to identify studies of interest published in English. Studies that did not use standardized speech assessments were excluded. PRISMA checklist was followed, and the risk of bias in the included studies was assessed.SettingLong-term follow up of patients.PatientsWith history of cleft palate presenting with VPI.InterventionBMF palatal lengthening.Main Outcome MeasureRandom-effects model meta-analyses were performed for hypernasality, intelligibility, and nasal air emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment.ResultsFrom the initial 7115 articles, 13 were included in this review. Two of these had a significant patient overlap and a study with a smaller patient population was excluded. All 12 included articles met the National Institutes of Health Quality Assessment Tool criteria. Six retrospective studies evaluated 230 patients and six prospective studies evaluated 181 patients. The most common indications for BMF were large size of the velopharyngeal gap and prior surgery for VPI. Meta-analyses demonstrated effect sizes below zero, confirming the improvement of standardized assessment scores in patients with VPI after BMF palatal lengthening. Egger regressions revealed low risk of publication bias.ConclusionsBMF palatal lengthening provides adequate treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.
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Affiliation(s)
- Marina A Lentskevich
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Alice Yau
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Ariel E Figueroa
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Kareem M Termanini
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Arun K Gosain
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
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Coull L, Bussell M, Fallico N. The Use of Fixed and Removable Bite Blocks in Bilateral Buccinator Flap Surgery for Velopharyngeal Insufficiency. Cleft Palate Craniofac J 2025:10556656251314257. [PMID: 39967048 DOI: 10.1177/10556656251314257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
Abstract
To ascertain the current practice in the United Kingdom with regard to the use of bite blocks and the division of the pedicles in buccinator flap surgery for velopharyngeal insufficiency. To compare the outcomes of fixed and removable bite blocks in buccinator flap surgery, in terms of the incidence of pedicle injury and patient experience. Survey of cleft surgeons in the United Kingdom on their use of bite blocks and division of the pedicles. Retrospective cohort review of consecutive patients that underwent buccinator flap surgery at Salisbury District Hospital between January 1, 2021, and December 31, 2022, comparing the use of fixed and removable bite blocks. Survey of patients who had bite blocks fitted to understand the patient and family experience. Cleft consultants from the United Kingdom and Ireland responded: half (11 of 22) reported using bite blocks and half reported routinely dividing the pedicles, most commonly at 4 to 6 weeks after surgery. In our cohort (19 patients), fixed bite blocks had a higher incidence of pedicle injury (33%) and difficulty eating (78%) than removable bite blocks (20% and 20%, respectively). Generally, parents/patients tolerated the presence of bite blocks and were often unaware of pedicle injury, even in cases of repeated severe biting. There is variation in the current use of bite blocks and pedicle division following buccinator flap surgery in the United Kingdom. In compliant patients, removable bite blocks may be associated with lower complication rates but neither fixed nor removable bite blocks compromise flap integrity.
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Affiliation(s)
- Lucy Coull
- Southampton Medical School, University of Southampton, Southampton, UK
| | - Mary Bussell
- Spires Cleft Centre, Oxford University Hospital and SalisburyNHS Foundation Trust, Salisbury, UK
| | - Nefer Fallico
- Spires Cleft Centre, Oxford University Hospital and SalisburyNHS Foundation Trust, Salisbury, UK
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Snodgrass TD, Sitzman TJ, Che-Williams JL, Temkit H, Perry JL. Factors That Limit Evaluation of Velopharyngeal Closure During Nasopharyngoscopy. Cleft Palate Craniofac J 2025; 62:300-308. [PMID: 39648534 PMCID: PMC11913566 DOI: 10.1177/10556656241304224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2024] Open
Abstract
ObjectiveTo assess the quality of nasopharyngoscopy video recordings used for velopharyngeal insufficiency (VPI) surgical planning and identify factors that limit evaluation of velopharyngeal closure.DesignProspective observational study.SettingMetropolitan-based hospitals with craniofacial clinics in the United States and Canada.ParticipantsOne-hundred and forty-two (142) patients with VPI across 10 hospitals.Assessment(s)Nasopharyngoscopy video recordings used for VPI surgical planning .Main Outcome Measure(s)Ratability of nasopharyngoscopy video recordings, with "ratable" defined as the video (1) visualized the velum, lateral pharyngeal wall, and posterior pharyngeal walls at some point during speech production and (2) contained an oral speech sample at the phrase level or above.ResultsOne-hundred and forty-two (142) nasopharyngoscopy video recordings were obtained from patients undergoing VPI evaluation, of which 59.9% (n=85) were ratable. A multilevel logistic regression model was used to identify factors that influenced the quality of nasopharyngoscopy video recordings. Factors associated with unratable nasopharyngoscopy videos were age (P=.030), sex (P=.005*), type of scope camera used (P=.039), presence of compensatory misarticulations (P=.008), and a limited speech sample (P=.040).ConclusionsA substantial proportion of nasopharyngoscopy video recordings obtained during VPI evaluation are not sufficient for rating velopharyngeal closure. Lack of ratability could impact the surgery selected to treat VPI. Younger patients, those with limited speech samples, or patients with extensive compensatory articulations may be more successful in completing other VPI imaging techniques, such as videofluoroscopy or magnetic resonance imaging.
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Affiliation(s)
- Taylor D. Snodgrass
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Thomas J. Sitzman
- Phoenix Children’s Center for Cleft and Craniofacial Care a Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, AZ, USA
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA
- Department of Child Health, University of Arizona – Phoenix College of Medicine, Phoenix, AZ, USA
| | - Jessica L. Che-Williams
- Phoenix Children’s Center for Cleft and Craniofacial Care a Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, AZ, USA
- Department of Speech and Hearing Science, College of Health Solutions, Arizona State University, Tempe, AZ, USA
| | - Hamy Temkit
- Department of Clinical Research, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - Jamie L. Perry
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
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Garg SP, Chwa ES, Reddy NK, Shah KV, Weissman JP, Gosain AK. Distribution of Specialties Providing Surgical Management of Cleft-Related Speech Disorders in Children 3 years of Age and Older: 2004 to 2021. J Craniofac Surg 2025; 36:61-65. [PMID: 39392693 DOI: 10.1097/scs.0000000000010604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/01/2024] [Indexed: 10/13/2024] Open
Abstract
Given the overlap in specialties performing secondary correction of velopharyngeal incompetence (VPI), the present study investigated the specialty distribution for surgical providers of cleft care from 2004 to 2021. Data were obtained from 45 hospitals from 2004 to 2021 through the Pediatric Health Information System database. Cases of secondary surgical management of VPI were retrieved, identifying the year of surgery and specialty of the providing surgeon. A total of 7090 procedures were included in this study, of which 36.0% were secondary palatoplasty/lengthening, 34.1% were sphincter pharyngoplasty, and 29.8% were pharyngeal flap. Secondary management of VPI was performed by plastic surgeons (67%), otolaryngologists (31%), and oral and maxillofacial surgeons (OMFS, 12%). Palatal revision and/or lengthening procedures were the most common secondary procedure performed by plastic surgeons (42%) and OMFS (64%), whereas sphincter pharyngoplasty was the most common procedure performed by otolaryngologists (55%; P <0.001). The proportion of sphincter pharyngoplasty performed by plastic surgeons significantly decreased from 2017-2021 ( P <0.05). Plastic surgeons performed most procedures for secondary management of VPI from 2004 to 2021, followed by otolaryngologists and OMFS. The type of procedure selected for secondary management of VPI differed significantly between the provider's specialty, with otolaryngologists more likely to perform sphincter pharyngoplasty.
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Affiliation(s)
- Stuti P Garg
- Division of Plastic Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
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Smit JA, Houkes RP, Lachkar N, Don Griot JPW, van der Horst CMAM, Tse RW, Fayyaz GQ, Adams S, Breugem CC. Different Surgical Approaches to the Treatment of Cleft Palate Fistulae as Perceived by Cleft Surgeons. Cleft Palate Craniofac J 2024:10556656241286864. [PMID: 39314084 DOI: 10.1177/10556656241286864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
OBJECTIVE Palatal fistulas after palatoplasty could pose difficulties for both patients and surgeons. Numerous surgical approaches are available to treat palatal fistulas. In this manuscript, we investigate surgical treatment options for palatal fistula repair looking at the different anatomical locations, and we create a summary of surgical approaches to facilitate the decision-making process for palatal fistulae repair. DESIGN In this cross-sectional survey, nine anonymized patient cases with palatal fistulae that differed in severity and anatomical location were presented to participants from the International Cleft Master Course in Amsterdam about "Palatal Fistulas". Participants were invited to participate in this survey. A total of 141 participants reported their preferred surgical treatment options for fistula repair at different anatomical locations. RESULTS We created different options for fistula treatment, catalogued by fistula location. This overview gives the surgeon possible approaches for each location. If the soft palate is involved, this overview underscores the importance of including velopharyngeal insufficiency management into the fistula repair. For hard palate involvement, our overview lists techniques available for nasal lining repair and for oral lining repair in each region. CONCLUSIONS We provide a comprehensive overview of potential surgical approaches to repair palatal fistulae. This inventory of techniques is grouped per location to support surgeons in their decision-making process when confronted with a palatal fistula.
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Affiliation(s)
- Johannes A Smit
- Dept. of Plastic Surgery, Emma Children's Hospital, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Ruben P Houkes
- Dept. of Plastic Surgery, Emma Children's Hospital, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Nadia Lachkar
- Dept. of Plastic Surgery, Emma Children's Hospital, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - J Peter W Don Griot
- Dept. of Plastic Surgery, Emma Children's Hospital, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Chantal M A M van der Horst
- Dept. of Plastic Surgery, Emma Children's Hospital, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Raymond W Tse
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | | | - Saleigh Adams
- Division of Plastic, Reconstructive and Maxillo-Facial Surgery, The University of Cape Town, Cape Town, South Africa
| | - Corstiaan C Breugem
- Dept. of Plastic Surgery, Emma Children's Hospital, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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Marston AP, Tollefson TT. Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions. Curr Opin Otolaryngol Head Neck Surg 2024; 32:239-247. [PMID: 38837190 DOI: 10.1097/moo.0000000000000981] [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: 06/06/2024]
Abstract
PURPOSE OF REVIEW This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction. RECENT FINDINGS Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea. SUMMARY Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.
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Affiliation(s)
- Alexander P Marston
- University of California Davis Health, Department of Otolaryngology - Head and Neck Surgery, Sacramento, California, USA
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Napoli JA, Kalmar CL, Low DW, Buckley J, Bunnell HT, Vallino LD. Bilateral Buccal Flap Revision Palatoplasty to Correct Velopharyngeal Dysfunction: Perceptual Speech, Acoustic, and Aerodynamic Outcomes. Plast Reconstr Surg 2024; 153:769e-780e. [PMID: 37184507 DOI: 10.1097/prs.0000000000010677] [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: 05/16/2023]
Abstract
BACKGROUND The purpose of this study was to analyze perceptual, acoustic, and aerodynamic changes in speech and velopharyngeal function after bilateral buccal flap revision palatoplasty (BBFRP) in patients with repaired cleft palate. METHODS Ten consecutive patients ages 4 to 18 years with velopharyngeal dysfunction treated with BBFRP by a single surgeon were evaluated. Using a visual analog scale, nine blinded speech-language pathologists independently rated hypernasality, hyponasality, audible nasal emission, and speech acceptability. Measurements of the acoustic speech signal were used to quantify changes in hypernasality and nasal emission. The pressure flow technique was used to determine changes in velopharyngeal gap size. RESULTS Complete records were available for eight patients. After surgery, hypernasality decreased ( P < 0.001) and speech acceptability increased ( P < 0.001) significantly. Audible nasal emission was significantly reduced ( P < 0.001). Postoperative acoustic measures showed a reduction of nasal emission and nasalization. Velopharyngeal gap size significantly decreased after BBFRP ( P < 0.001), correlating with lower visual analog scale ratings of hypernasality ( P = 0.015). Hyponasality did not change significantly after surgery ( P = 0.964). No patient developed sleep-disordered breathing. CONCLUSION BBFRP resulted in a measurable improvement in hypernasal speech, audible nasal emission, and speech acceptability without significant changes in hyponasality or risk of obstructive sleep apnea. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Joseph A Napoli
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia
| | - Christopher L Kalmar
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia
| | - David W Low
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia
| | - James Buckley
- Division of Oral and Maxillofacial Surgery, Navy Medical Readiness and Training Command Great Lakes
| | - H Timothy Bunnell
- Center for Pediatric Auditory and Speech Sciences, Nemours Children's Health
| | - Linda D Vallino
- Center for Pediatric Auditory and Speech Sciences, Nemours Children's Health
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Monte TM, Raposo-Amaral CA, Sabbag A, Gil A, Menezes PT, Raposo-Amaral CE. Speech Outcomes After Palatal Lengthening Via Double Opposing Buccinator Myomucosal Flaps. Ann Plast Surg 2024; 92:395-400. [PMID: 38527345 DOI: 10.1097/sap.0000000000003809] [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: 03/27/2024]
Abstract
BACKGROUND Palatal lengthening is becoming a first-line treatment choice for cleft patients with velopharyngeal insufficiency (VPI). As cleft palate-related surgical outcomes are age dependent, speech outcomes may be similarly affected by patient age at the time of treatment. The primary goal of this study is to determine whether there are age-related speech outcome differences when double opposing buccinator myomucosal flaps are used as part of a palatal lengthening protocol and whether these outcome differences preclude utilization of this technique for specific patient age groups. METHODS A retrospective study was performed on consecutive nonsyndromic patients with VPI who underwent treatment using double opposing buccinator myomucosal flaps at our hospital between 2014 and 2021. Patients who completed the 15-month follow-up were stratified by age. Group A aged between 2 and 7 years (n = 14), group B aged 8 and 18 years (n = 23), and group C aged older than 18 years (n = 25) were included. Standardized perceptual speech evaluations and nasopharyngoscopy were performed. Hypernasality, soft palate mobility, and lateral palatal wall mobility were assessed both preoperatively and at a 15-month postoperative interval. Complications were also recorded. The χ2 test was used for statistical comparison. RESULTS All of the age-stratified patient groups in this study showed significant improvement in hypernasality, soft palate mobility, and lateral wall mobility (P < 0.01), with no statistically significant differences between the different patient age groups. Overall speech success was achieved in 69.4% of patients. Patients in group A achieved 78.6% speech success, patients in group B achieved 78.3% speech success, and patients in group C achieved 56% speech success, with no statistically significant differences being shown regarding speech success between the different patient age groups (P > 0.05). CONCLUSIONS Regardless of age, palatal lengthening via double opposing buccinator myomucosal flaps similarly improves speech outcomes.
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Affiliation(s)
- Thais Miguel Monte
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
| | - Cesar A Raposo-Amaral
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
| | | | - André Gil
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
| | - Priscila T Menezes
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, Brazil
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Raposo-Amaral CA, Monte TM, Raposo-Amaral CE. Treatment of Velopharyngeal Insufficiency Using Bilateral Myomucosal Buccinator Flaps. Plast Reconstr Surg 2024; 153:411e-414e. [PMID: 37053444 DOI: 10.1097/prs.0000000000010551] [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: 04/15/2023]
Abstract
SUMMARY The buccinator myomucosal flap, also referred to as a buccal myomucosal flap, is an effective technique to address velopharyngeal insufficiency after cleft palate repair. Challenges related to flap harvesting may deter plastic surgeons from incorporating this strategy as a first-line treatment. The primary objective of this study and accompanying video is to provide support regarding indications, planning, and surgical steps of the buccinator myomucosal flap technique, including important technical details for soft-palate dissection and flap harvesting.
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Affiliation(s)
- Cesar Augusto Raposo-Amaral
- From the Institute of Plastic and Craniofacial Surgery, Sobrapar Hospital
- Department of Neurology, University of Campinas
| | - Thais Miguel Monte
- From the Institute of Plastic and Craniofacial Surgery, Sobrapar Hospital
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12
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Pitkanen VV, Geneid A, Saarikko AM, Hakli S, Alaluusua SA. Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty. J Craniofac Surg 2023; 36:00001665-990000000-01192. [PMID: 37955448 PMCID: PMC12020403 DOI: 10.1097/scs.0000000000009822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/06/2023] [Indexed: 11/14/2023] Open
Abstract
Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.
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Affiliation(s)
- Veera V. Pitkanen
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Ahmed Geneid
- Department of Otolaryngology and Phoniatrics—Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki
| | - Anne M. Saarikko
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
| | - Sanna Hakli
- Department of Otolaryngology and Phoniatrics, Oulu University Hospital and PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Suvi A. Alaluusua
- Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki
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13
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Suzzi C, Di Gennaro G, Baylon H, Captier G. A Master Mind Game Code Algorithm Approach to Help Surgical Decision-Making between Retropharyngeal Fat Grafting and Pharyngoplasty for the Treatment of Velopharyngeal Incompetence. Int Arch Otorhinolaryngol 2023; 27:e351-e361. [PMID: 37125364 PMCID: PMC10147477 DOI: 10.1055/s-0043-1763501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 10/09/2022] [Indexed: 03/31/2023] Open
Abstract
Abstract
Introduction Velopharyngeal insufficiency (VPI) is a controversial pathology with many surgical options.
Objective To compare pharyngoplasty and retropharyngeal fat grafting and to build a prognostic tool to achieve perfect speech.
Methods Retrospective observational cohort study of 114 patients operated for VPI from 1982 to 2019 in a single tertiary center. The instrumental assessment was made using an aerophonoscope and nasofibroscopy. The variables sex, age, genetic syndromes, and type of diagnosis were analyzed with logistic regression model adjusted with propensity score. To generalize results and to build a surgical predictive tool, a marginal analysis concludes the study.
Results Among the patients (median [range] age 7 [4–48]), 63 (55.26%) underwent pharyngoplasty and 51 (44.74%) graft. The graft group had no complication, but it had a failure rate of 7.84%. The pharyngoplasty group had no failure, but one patient had postoperative obstructive sleep apnea. The marginal analysis demonstrated that age lower than 7 years, cleft lip and palate, absence of syndrome, and intermittent VPI were important predictive factors of good result regardless of surgical technique.
Conclusions Without a statistical demonstration of the superiority of pharyngoplasty over graft, and in the uncertainty of literature background, our perfect-speech patient profile represents an important tool for a postoperative forecast of results in which, like in the Master Mind game, every feature has to be considered not individually but as a pattern of characteristics whose association contributes to the outcome.
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14
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Bschorer F, Hornig L, Schön G, Bschorer R. Speech assessment following microsurgical soft palate repair. J Craniomaxillofac Surg 2023; 51:199-204. [PMID: 36878754 DOI: 10.1016/j.jcms.2023.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 11/01/2022] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
The aim of this study was to analyze speech intelligibility of children, who had undergone microsurgical soft palate repair according to Sommerlad. Cleft palate patients were treated by closure of the soft palate according to Sommerlad at about 6 months of age. At the age of 11, their speech was evaluated through automatic speech recognition. Word recognition rate (WR) was used as the outcome parameter of automatic speech recognition. To validate automatic speech results, an institute for speech therapy evaluated the speech samples for perceptual intelligibility. The results of this study group were compared to an age-matched control group. A total of 61 children were evaluated in this study, 29 in the study group and 32 in the control group. Study group patients had a lower word recognition rate (mean 43.03, SD 12.31) compared to the control group (mean 49.98, SD 12.54, p = 0.033). The magnitude of the difference was considered small (95% CI of the difference 0.6-13.3). The study group patients received significantly lower scores in the perceptual evaluation (mean 1.82, SD 0.58) compared to the control group mean (mean 1.51, SD 0.48, p = 0.028). Again, the magnitude of the difference was small (95% CI of the difference 0.03-0.57). Within the limitations of the study it seems that microsurgical soft palate repair according to Sommerlad at the age of 6 months might be a relevant alternative to other well established surgical techniques.
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Affiliation(s)
- Frizzi Bschorer
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393-397, 19049, Schwerin, Germany; Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, Rostock University Medical Center, Schillingallee 35, 18057, Rostock, Germany.
| | - Lena Hornig
- ISBA University of Cooperative Education, Ziegelseestr. 1, 19055, Schwerin, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, Eppendorf University Hospital, University of Hamburg, Martinistr. 52, D-20246, Hamburg, Germany
| | - Reinhard Bschorer
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393-397, 19049, Schwerin, Germany; MKG-Praxis Am Stadthafen, Schliemannstraße 18, 19055, Schwerin, Germany
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15
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Diallo-Hornez G, Khonsari RH, Mercier JM, Delaire J, Balandier S, Defay V, Isidor B, Rousteau G, Talmant JC, Perrin JP, Bertin H, Corre P. Could pharyngeal fat injection be a first-line treatment of velopharyngeal insufficiency? JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e206-e211. [PMID: 34844018 DOI: 10.1016/j.jormas.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/23/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Garance Diallo-Hornez
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Roman Hossein Khonsari
- Hôpital Necker Enfants - Malades, Service de Chirurgie Maxillo-faciale et Chirurgie Plastique, Assistance Publique - Hôpitaux de Paris, Université de Paris , Paris, France
| | - Jacques-Marie Mercier
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jean Delaire
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Sophie Balandier
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Virginie Defay
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Bertrand Isidor
- Service de Génétique clinique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Gabriel Rousteau
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jean-Claude Talmant
- Chirurgie Plastique, Reconstructrice et Esthétique, Clinique Jules Verne, Nantes, France
| | - Jean-Philippe Perrin
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Hélios Bertin
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Pierre Corre
- Clinique de Chirurgie Maxillo-faciale et de Stomatologie, Centre Hospitalier Universitaire de Nantes, Nantes, France.
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16
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Hill SE, Ickow IM, He W, Buckley RA, Steinberg JP. Design of a Novel Orthodontic Appliance to Prevent Pedicle Trauma in Patients Undergoing Double-Opposing Buccal Flaps for Palatal Lengthening. Cleft Palate Craniofac J 2022; 60:645-650. [PMID: 35450446 DOI: 10.1177/10556656211069836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To describe a novel orthodontic appliance to prevent pedicle trauma in patients undergoing double-opposing buccal flap surgery for secondary palatal lengthening. DESIGN Case series. SETTING Cleft and craniofacial clinic, Johns Hopkins Children's Center. PATIENTS, PARTICIPANTS Four patients undergoing double-opposing buccal flap surgery for repair of velopharyngeal insufficiency. INTERVENTIONS Patients were fitted with the device, which consists of a lower lingual holding arch with acrylic bite blocks. MAIN OUTCOME MEASURE Presence of pedicle trauma postsurgery and tolerability of the device. RESULTS The appliance was well tolerated in all 4 patients and no biting trauma to the pedicles was observed. CONCLUSIONS A reliable appliance has been developed to prevent biting trauma to the pedicles in patients undergoing double-opposing buccal flap surgery in the permanent dentition stage.
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Affiliation(s)
- Sarah E Hill
- 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ilana M Ickow
- 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Waverley He
- 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rae A Buckley
- 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Weaver KN, Sullivan BR, Balow SA, Hopkin S, Chini BA, Pan BS, Stottmann RW, Bender PL, Hopkin RJ, Zhang X, Saal HM. Robin sequence without cleft palate: Genetic diagnoses and management implications. Am J Med Genet A 2021; 188:160-177. [PMID: 34569146 DOI: 10.1002/ajmg.a.62515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/10/2021] [Accepted: 09/05/2021] [Indexed: 11/09/2022]
Abstract
Robin sequence (RS), the triad of micrognathia, glossoptosis, and airway obstruction, is a major cause of respiratory distress and feeding difficulties in neonates. Robin sequence can be associated with other medical or developmental comorbidities in ~50% of cases ("syndromic" RS). As well, RS is variably associated with cleft palate (CP). Previous studies have not investigated differences in clinical characteristics of children with RS based on presence or absence of CP. We retrospectively reviewed 175 children with RS and compared genetic diagnoses, medical and developmental comorbidities, severity of airway obstruction, and feeding outcomes between those with and without CP. Strikingly, 45 of 45 (100%) children with RS without CP were classified as syndromic due to presence of comorbidities unrelated to RS, while 83 of 130 (64%) children with RS with CP were classified as syndromic. Among 128 children with syndromic RS, there were no differences in severity of airway obstruction, surgical intervention rate or type, or feeding outcome at 12 months based on CP status. Our findings support the conclusion that the pathogenesis of RS without CP is distinct from RS with CP and more likely to cause additional medical or developmental problems. Alternatively, children with RS without CP and without additional anomalies present may be under recognized.
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Affiliation(s)
- K Nicole Weaver
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bonnie R Sullivan
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephanie A Balow
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sara Hopkin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barbara A Chini
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Brian S Pan
- Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rolf W Stottmann
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Patricia L Bender
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Robert J Hopkin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Xue Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Howard M Saal
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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18
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Smarius BJA, Guillaume CHAL, Slegers J, Mink van der Molen AB, Breugem CC. Surgical management in submucous cleft palate patients. Clin Oral Investig 2021; 25:3893-3903. [PMID: 33521885 PMCID: PMC8137618 DOI: 10.1007/s00784-020-03719-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/27/2020] [Indexed: 12/03/2022]
Abstract
OBJECTIVES The submucous cleft palate (SMCP) is considered to be the most subtle type of cleft palate. Early detection is important to allow on time intervention by speech therapy and/or surgical repair before the children already develop compensatory speech mechanisms. The purpose of this study was to investigate at what time children with a SMCP present, to determine when children are operated, and to analyze the postoperative outcomes for in SMCP children. PATIENT AND METHODS Medical records from 766 individuals registered in the cleft registry in the Wilhelmina's Children's' Hospital, Utrecht, were retrospectively reviewed. Inclusion criteria were children diagnosed with SMCP. The following data were collected: age at diagnosis, physical examination, age at surgery, surgical technique, speech therapy pre- and post-surgery, otitis media, secondary cleft surgery, family history, syndromes, and other anomalies. RESULTS In total, 56 SMCP children were identified. The mean age of diagnosis was 44.0 months (range 0-150, SD = 37.0). In 48 children (85.7%), surgical intervention was performed (Furlow plasty, intravelar veloplasty, pharyngoplasty, or Furlow combined with buccal flap). CONCLUSION This retrospective study reconfirms that SMCP often presents late, even in a country with a modern healthcare system and adequate follow-up of all newborns by the so-called youth doctors in "children's healthcare centers" up to the age of 4 years old. Almost 86% of patients ultimately needed palate surgery when SMCP was suspected. CLINICAL RELEVANCE Any child presenting with repeated episodes of otitis media, nasal regurgitation, or speech difficulties should have prompt consideration for SMCP as diagnosis.
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Affiliation(s)
- B. J. A. Smarius
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
| | - C. H. A. L. Guillaume
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
- Department of Plastic Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Pediatric Plastic Surgery, Emma Children’s Hospital, University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - J. Slegers
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
| | - A. B. Mink van der Molen
- Department of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, 3508 AB Utrecht, The Netherlands
- Department of Plastic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - C. C. Breugem
- Department of Plastic Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Pediatric Plastic Surgery, Emma Children’s Hospital, University Medical Center Amsterdam, Amsterdam, The Netherlands
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19
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Kara M, Calis M, Kara I, Kulak Kayikci ME, Gunaydin RO, Ozgur F. Comparison of speech outcomes using type 2b intravelar veloplasty or furlow double-opposing Z plasty for soft palate repair of patients with unilateral cleft lip and palate. J Craniomaxillofac Surg 2021; 49:215-222. [PMID: 33485752 DOI: 10.1016/j.jcms.2021.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 08/29/2020] [Accepted: 01/02/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of this study is to compare speech outcomes, fistula rates, and rates of secondary speech surgeries after palatoplasty using Furlow palatoplasty or type 2b intravelar veloplasty for soft palate repair. PATIENTS AND METHODS Patients with unilateral cleft lip and palate who had either Furlow palatoplasty or intravelar veloplasty for soft palate repair were retrospectively evaluated for demographic and perioperative variables and speech outcomes. Fistula rate, secondary surgical intervention for improved speech results, and findings of speech assessment were further reviewed for the patients who met the inclusion criteria. RESULTS A total of 76 patients, 36 in the Furlow palatoplasty group and 40 in the intravelar veloplasty group, were included in the study. In the speech assessment, nasalance values were statistically similar between the two groups. Also, there was no statistically significant difference between the groups in velopharyngeal motility (p = 0.103). The total rates of secondary surgeries and fistula were statistically similar between the groups (p = 0.347 and 0.105, respectively). CONCLUSION The similar outcomes of speech and surgical evaluation between the two groups make the surgeon's preference determinant in the selection of the surgical technique for soft palate repair.
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Affiliation(s)
- Murat Kara
- Hacettepe University Faculty of Medicine, Department of Plastic Reconstructive and Aesthetic Surgery, Cleft Lip and Palate and Craniomaxillofacial Disorders Treatment and Research Center, Ankara, Turkey
| | - Mert Calis
- Hacettepe University Faculty of Medicine, Department of Plastic Reconstructive and Aesthetic Surgery, Cleft Lip and Palate and Craniomaxillofacial Disorders Treatment and Research Center, Ankara, Turkey.
| | - Ilkem Kara
- Hacettepe University Faculty of Health Sciences, Department of Speech and Language Therapy, Cleft Lip and Palate and Craniomaxillofacial Disorders Treatment and Research Center, Ankara, Turkey
| | - Mavis Emel Kulak Kayikci
- Hacettepe University Faculty of Health Sciences, Department of Speech and Language Therapy, Cleft Lip and Palate and Craniomaxillofacial Disorders Treatment and Research Center, Ankara, Turkey
| | - Riza Onder Gunaydin
- Hacettepe University Faculty of Medicine, Department of Otolaryngology, Cleft Lip and Palate and Craniomaxillofacial Disorders Treatment and Research Center, Ankara, Turkey
| | - Figen Ozgur
- Hacettepe University Faculty of Medicine, Department of Plastic Reconstructive and Aesthetic Surgery, Cleft Lip and Palate and Craniomaxillofacial Disorders Treatment and Research Center, Ankara, Turkey
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20
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Liu BY, Chen XX, Cao J, Lu Y. Analysis of velopharyngeal function and speech outcomes of Sommerlad palatoplasty combined with sphincter pharyngoplasty in surgical repair of older patients with cleft palate:experience from a major craniofacial surgery centre in eastern China. Br J Oral Maxillofac Surg 2020; 58:819-823. [PMID: 32456995 DOI: 10.1016/j.bjoms.2020.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
We aimed to evaluate velopharyngeal function and speech outcomes of Sommerlad palatoplasty combined with sphincter pharyngoplasty in surgical repair of cleft palate in patients over five years old. Fifty-eight patients were reviewed between the years 2013 and 2017, 31 of whom were treated with Sommerlad palatoplasty combined with sphincter pharyngoplasty, (mean age 15 (range 9 - 22) years), and 27 were treated with Sommerlad palatoplasty alone (mean age 18 (range 10-25) years). Velopharyngeal function was evaluated by radiographic lateral cephalometry and nasoendoscopy. Hypernasality, nasal emissions, and intelligibility were used to assess speech. The rate of velopharyngeal competence was 20/31 in the palatoplasty plus pharyngoplasty group and 7/27 in the palatoplasty alone group after surgical treatment (p=0.003). The improvements in hypernasality (p=0.024), air emission (p=0.004), and speech intelligibility (p=0.004) in the palatoplasty plus pharyngoplasty group was better than that in the palatoplasty alone group. It has been suggested that the surgical approach with the palatoplasty together with the sphincter pharyngoplasty has a higher rate of success in surgical repair of older patients with cleft palate.
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Affiliation(s)
- B Y Liu
- Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital, Medical School of Nanjing University, No. 30 Zhong Yang's Road, Xuan Wu, Nanjing 210008, Jiangsu Province
| | - X X Chen
- Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital, Medical School of Nanjing University, No. 30 Zhong Yang's Road, Xuan Wu, Nanjing 210008, Jiangsu Province
| | - J Cao
- Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital, Medical School of Nanjing University, No. 30 Zhong Yang's Road, Xuan Wu, Nanjing 210008, Jiangsu Province
| | - Y Lu
- Department of Oral and Maxillofacial Surgery, Affiliated Stomatology Hospital, Medical School of Nanjing University, No. 30 Zhong Yang's Road, Xuan Wu, Nanjing 210008, Jiangsu Province.
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21
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Kurnik NM, Weidler EM, Lien KM, Cordero KN, Williams JL, Temkit M, Beals SP, Singh DJ, Sitzman TJ. The Effectiveness of Palate Re-Repair for Treating Velopharyngeal Insufficiency: A Systematic Review and Meta-Analysis. Cleft Palate Craniofac J 2020; 57:860-871. [PMID: 32070129 DOI: 10.1177/1055665620902883] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness. METHODS PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale. RESULTS Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes (P = .6572). CONCLUSIONS Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.
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Affiliation(s)
- Nicole M Kurnik
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Erica M Weidler
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Kari M Lien
- Department of Speech and Hearing Science, Arizona State University, Tempe, AZ, USA.,Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
| | - Kelly N Cordero
- Department of Speech and Hearing Science, Arizona State University, Tempe, AZ, USA.,Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
| | - Jessica L Williams
- Department of Speech and Hearing Science, Arizona State University, Tempe, AZ, USA.,Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
| | - M'hamed Temkit
- Department of Clinical Research, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Stephen P Beals
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA.,Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA
| | - Davinder J Singh
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA.,Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA.,Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Thomas J Sitzman
- Division of Plastic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA.,Barrow Cleft and Craniofacial Center, Phoenix, AZ, USA.,Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
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22
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Shetty KR, Ward LM, Levi JR, Grillone G. Novel treatment for mild and moderate velopharyngeal insufficiency using implantable AlloDerm for posterior pharyngeal wall augmentation and review of surgical repair techniques. Am J Otolaryngol 2019; 40:102274. [PMID: 31444004 DOI: 10.1016/j.amjoto.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 10/26/2022]
Abstract
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.
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23
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Abstract
BACKGROUND Velopharyngeal insufficiency is one of the most frequent complications after cleft palate repair. PURPOSE To evaluate the results and complications of unilateral Buccinator flap (BMF) in velopharyngeal insufficiency. MATERIALS AND METHODS During 4 years the authors performed unilateral BMF in all short palates. Age, sex, demographic data, length of palate, cause of short palate, nasopharyngoscopy and videofluroscopy results, hyper nasality, nasal escape, nasal emission, nasal fluid leak, speech evaluation and results, outcome and complications of the treatment were surveyed before surgery and in 1, 3, 6 months after treatment. RESULTS The authors had 43 patients, 29 below 8 years old and 14 adults. Velopharyngeal gap was between 10 and 27 mm, mean 21 mm. Buccinator flap were measuring 15 to 19 mm in width and 32 to 56 mm in length. The operation time was 80 to 100 minutes, mean 86 minutes.Nasal emission, nasal escape, and nasal leak were treated in all patients.Hyper nasality was completely improved in all of the patients below 8 years old (29 patients) and in 10 patients of the adults (totally 39 patients, 90.6%). And it was improved significantly in other 4 patients (9.4%). The speech evaluation reported between 70% and 86% improvements.The lengthening of the palate was between 12 and 19 mm, mean 17 mm.The satisfaction of the patients was as 0% poor, 2.3% fair, 72.1% good, and 25.6% excellent. CONCLUSION Unilateral BMF is reliable, promising, and safe flap for lengthening of short palate and it can lengthen the palate up to 19 mm. The time of surgery is very short compared with other methods. It is an anatomical treatment versus pharyngeal flap which is not an anatomical one. Speech improvement will achieve in 70% to 86% patients.
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The use of throat packs in pediatric cleft lip/palate surgery: a retrospective study. Clin Oral Investig 2018; 22:3053-3059. [PMID: 29473105 PMCID: PMC6224011 DOI: 10.1007/s00784-018-2387-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 02/08/2018] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Throat packs are commonly used to prevent ingestion or aspiration of blood and other debris during cleft lip/palate surgery. However, dislodgement or (partial) retainment after extubation could have serious consequences. The aim of the present study was to investigate the effect of omitting pharyngeal packing during cleft lip/palate surgery on the incidence of early postoperative complications in children. MATERIALS AND METHODS A retrospective study was performed on all children who underwent cleft lip/palate surgery at the Wilhelmina Children's Hospital. This study compared the period January 2010 through December 2012 when pharyngeal packing was applied according to local protocol (group A) with the period January 2013 till December 2015 when pharyngeal packing was no longer applied after removal from the protocol (group B). Data were collected for sex, age at operation, cleft lip/palate type, type of repair, lateral incisions, length of hospital stay, and complications in the first 6 weeks after surgery. Early complications included wound dehiscence, postoperative bleeding, infection, fever, upper respiratory tract infection (URTI), and lower respiratory tract infection (LRTI). RESULTS This study included 489 cleft lip/palate operations (group A n = 246, group B n = 243). A total of 39 (15.9%) early complications were recorded in group A and a total of 40 (16.5%) in group B. There were no significant differences (P = 0.902) in complications between the two groups; however, there was a significant difference (P < 0.001) in length of hospital stay between the two groups (group A 3.6 days vs group B 3.2 days). CONCLUSION Omitting routine placement of throat packs in cleft lip/palate surgery was not associated with an increased early postoperative complication rate. Therefore, the traditional, routine placement of a throat pack during cleft lip/palate surgery can be questioned. CLINICAL RELEVANCE The traditional, routine placement of a throat pack during cleft lip/palate surgery can be questioned.
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Denadai R, Sabbag A, Raposo-Amaral CE, Filho JCP, Nagae MH, Raposo-Amaral CA. Bilateral buccinator myomucosal flap outcomes in nonsyndromic patients with repaired cleft palate and velopharyngeal insufficiency. J Plast Reconstr Aesthet Surg 2017; 70:1598-1607. [PMID: 28739170 DOI: 10.1016/j.bjps.2017.06.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 06/01/2017] [Accepted: 06/09/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of this study was to assess speech outcomes and complication rate in nonsyndromic repaired cleft palate patients undergoing bilateral buccinator myomucosal flaps for velopharyngeal insufficiency management. METHODS A prospective study of consecutive repaired cleft palate patients with velopharyngeal insufficiency who underwent bilateral buccinator myomucosal flaps was conducted. Three experienced evaluators performed a blinded perceptual speech evaluation (hypernasality, audible nasal emission, and intraoral pressure). Successful speech outcome was defined as normal or borderline sufficient velopharyngeal function at 15 months postoperatively. Obstructive sleep apnea screening tools were applied preoperatively and postoperatively. Complication rate was also collected. RESULTS Fifty-three patients were included. There were 11 (21%) surgical complications, with no complete flap loss, snoring, sleep disturbance, and/or mouth breathing. All patients presented low pre- and postoperative risk for obstructive sleep apnea. At 15 months postoperatively, hypernasality (0.4 ± 0.6), audible nasal emissions (0.2 ± 0.4), and intraoral pressure (0.1 ± 0.3) were significantly (all p < 0.05) lower than preoperative measurements (hypernasality: 2.7 ± 0.5; audible nasal emissions: 2.2 ± 0.8; and intraoral pressure: 0.9 ± 0.3). Forty-five (85%) patients presented successful speech outcome. CONCLUSION The bilateral buccinator myomucosal flap is an effective and safe surgical strategy for the management of persistent velopharyngeal insufficiency.
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Affiliation(s)
- Rafael Denadai
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, São Paulo, Brazil
| | - Anelise Sabbag
- Department of Speech and Language Pathology, SOBRAPAR Hospital, Campinas, São Paulo, Brazil
| | | | - Joao Carlos P Filho
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, São Paulo, Brazil
| | - Mirian H Nagae
- Department of Speech and Language Pathology, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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