Elongated pharyngeal flap in extensive clefts of the hard and soft palate

In some cases of extensive palatal defects surgical closure may be regarded as unfeasible, and the condition treated with an obturator prosthesis. In such a case the cleft can be closed in one operation by means of a pharyngeal flap elongated through a pharyngotomy according to Bengt Johanson (1966). Eleven patients who had used obturators were operated on between 1957 and 1978. The mean age of the patients was 39 years. All patients were cleft lip and palate or cleft palate cases; two unilateral, five bilateral, and four with an isolated cleft palate. In most of these patients a temporary tracheostomy was performed after which the pharynx was opened through a neck incision. A flap was created which reached the alveolar ridge. For oral closure, mucoperiosteal flaps were used. Anterior palatal fistulas developed in two cases; one closed spontaneously and the other remained as a 3-mm fistula behind the alveolar ridge. Three patients had postoperative transient dysphagia. Phoniatric evaluation showed that two patients had better speech after operation than before with an obturator. Gross speech improvement at this late age should not be expected and is not the primary goal of the procedure. The aim of surgical closure with an elongated pharyngeal flap is to replace the obturator.     

改良腭黏膜瓣整复软腭裂的临床观察

目的:探讨整复软腭裂的新术式,重建腭咽闭合的效果。方法:采用腭黏膜瓣后推术对25例软腭裂患者进行整复治疗,并对其进行随访,以了解术后腭咽闭合的情况。结果:所有患者术后腭部创口愈合良好,瘢痕不明显,软腭的活动度良好,且均有良好的腭咽闭合功能。结论:对先天性软腭裂的患者实施该术式整复,能较好地恢复腭咽闭合功能,是较为理想的手术整复方法之一。     

Long-term evidence for favorable midfacial growth after delayed hard palate repair in UCLP patients.

OBJECTIVE: To investigate whether delayed hard palate repair resulted in better midfacial growth in the long term than previously achieved with "conventional" surgical methods of palatal closure. DESIGN AND SETTING: Long-term cephalometric data from patients with unilateral cleft lip and palate were available from two Scandinavian cleft centers. The patients had been treated by different regimens, particularly regarding the method and timing of palatal surgery. Patients were analyzed retrospectively, and one investigator digitized all radiographs. PATIENTS: Thirty consecutively treated subjects from each center, with cephalograms taken at three comparable stages between 10 and 16 years of age. RESULTS AND CONCLUSIONS: Patients whose hard palates were repaired late (early soft palate closure followed by delayed hard palate repair at the stage of mixed dentition) had significantly better midfacial development than patients in whom the hard palate was operated on early with a vomer flap, and then during the second year of life, the soft palate was repaired with a push-back procedure. As the growth advantage in the delayed hard palate repair group was accomplished without impeding long-term speech development, the delayed repair regimen proved to be a good alternative in surgical treatment of patients with unilateral cleft lip and palate.     

A cephalometric study of the stability of the base of the pharyngeal flap following a modified ‘unified velopharyngoplasty procedure’

A cephalometric study was conducted on 12 patients with repaired cleft palate to evaluate the stability in level and length of the base attachment of the velopharyngeal complex following pharyngeal flap surgery by a modified velopharyngoplasty. Complete velopharyngeal closure and normal articulation with a speech appliance were confirmed in all patients prior to pharyngeal flap surgery, which was performed on patients 10 years of age and above. Cephalometric radiographs were taken immediately, 1 year, 2 years and 3 years postoperatively. Cephalometric analysis revealed that although the level and length of the base of the velopharyngeal complex showed changes during the first postoperative year, they remained stable when compared with the palatal plane during the last two years. This indicated therefore that the base of a velopharyngoplasty should be attached at the same level of the palatal plane, namely the level of velopharyngeal closure, and that the procedure appeared useful in producing a stable velopharyngeal complex.     

Buccinator sandwich pushback: a new technique for treatment of secondary velopharyngeal incompetence.

OBJECTIVE: A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich. PATIENTS: In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length. DESIGN: The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist. RESULTS: Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication. CONCLUSION: The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.     

腭帆提肌重建联合岛状颊黏膜肌瓣在先天性腭裂中的应用

目的:探讨一种对上颌骨发育影响较小且具有良好腭咽闭合功能的腭裂修补术的临床应用。方法:采用腭帆提肌重建联合岛状颊黏膜肌瓣术,共修补37例腭裂患者。结果:所有患者均一期愈合,随诊1～3年,语音清晰度满意,无腭瘘发生。结论:腭帆提肌重建联合岛状颊黏膜肌瓣术较好地恢复了腭帆提肌正常的解剖结构和位置,获得了良好的腭咽闭合,有效降低了腭瘘的发生率,是一种值得推荐的功能性腭裂修复术。     

软腭全层五瓣旋转推进修复腭裂的初步报告

目的 探讨腭裂功能性修复的新方法。方法 在先天性腭裂３７例的裂隙两侧软腭区设计１个矩形瓣和４个三角形瓣。切开后将各瓣旋转并向对侧推进,交错插入后逐层缝合。结果 采用该法治疗腭裂达到了关闭裂隙并延长软腭长度、形成软腭动力性肌环的兼备要求,３１例经０．５～２年随访证实手术效果稳定。结论 本术式在修复裂隙的同时,增加了软腭长度,恢复了腭咽闭合所需的软腭后退及上提功能,可视为腭裂功能性修复的较好方法之一。     

Speech outcome after closure of oronasal fistulas with bone grafts.

PURPOSE: The purpose of this prospective study was to evaluate the outcome of speech after complete closure of oronasal fistulas with bone grafts and to determine the possible relationship between outcome of speech and the size and location of the oronasal fistulas. PATIENTS AND METHODS: Ten unilateral cleft lip and palate patients with postoperative oronasal fistulas, ranging in age from 7 to 14 years, underwent secondary alveolar cleft repair and closure of the oronasal fistulas with an iliac bone graft. All patients underwent videofluoroscopic evaluation of the velopharyngeal valve, audiologic assessment, and speech evaluation (resonance, nasal emission, articulation, intelligibility, and nasalance) preoperatively. The examinations were repeated 3 months postoperatively. RESULTS: Six patients had preoperative velopharyngeal competency (60%). Of the 4 patients with slight to mild velopharyngeal incompetency preoperatively, 2 developed velopharyngeal competency postoperatively. All patients had satisfactory audiologic function preoperatively. Every patient also was intelligible before and after surgery. Eight patients (80%) showed nasal emission before surgery and 7 of these patients improved postoperatively (P <.01). Nine patients had articulation errors before surgery, with no significant improvement postoperatively. Nasalance was significantly improved in selected sequences. All patients had variable levels of nasality preoperatively; 8 showed a significant decrease of nasality postoperatively (P <.002). The results were not related to location or size of the oronasal fistulas. CONCLUSION: A significant improvement in speech is noticeable after closure of oronasal fistulas. Early oronasal fistula closure might prevent permanent speech distortions acquired by the cleft palate patients at an early age.     

Use of rotation flap in repair of cleft palate and velopharyngeal insufficiency

Although cleft palate anomaly is frequent, the criterion standards in surgical treatment have not been determined yet. There are a few techniques described for cleft palate repair owing to the limited tissue in the palatal mucosa, the rigid structure of the palatal mucosa, and the limited vascularity of the hard palate. In this study, a novel cleft palate repair technique based on separating the soft palate from the hard palate as a musculomucosal flap and using it as a rotation flap has been described. The operation is evaluated individually for each anomaly because variations occur in the surgical technique according to the extension of the cleft toward the teeth in the palate. This operation was performed on a total of 28 patients (17 girls and 11 boys) aged between 1.5 and 16 years and presented to our clinic. Patients were assessed for speech analysis outcomes, tympanogram values, hearing functions, magnitude of palatal lengthening during the operation, and rate of fistulae. Statistically significant differences in values of the speech analysis and the audiometric assessment were determined between before and 6 months after surgery. Complete recovery of otitis was observed 1 month after surgery without another treatment in 9 (42.8%) of 21 patients who were detected to have serous otitis media preoperatively. Tension-free closure, lower risk of fistula, good restoration of velopharyngeal functions, ability to be performed on all types of cleft palate, ability to provide a good intraoperative exposure, and being a single stage seem to be the most important advantages of this technique.     

腭帆提肌重建联合咽后壁瓣术在先天性腭裂中的临床应用

目的　探讨腭帆提肌重建联合咽后壁瓣术在先天性腭裂中的临床应用。方法　采用腭帆提肌重建联合咽后壁瓣术,共修补47例先天性腭裂患者,其中单侧完全性腭裂21例,不完全性腭裂26例。结果　所有患者均一期愈合,未出现腭瘘,随诊1~3年,语音清晰度满意。结论　腭帆提肌重建联合咽后壁瓣术较好地恢复了腭帆提肌正常的解剖结构和位置,获得了良好的腭咽闭合,并有效地降低了术后腭瘘的发生率,是一种值得推荐的功能性腭裂修复方法。     

An effect comparison between Furlow double opposing Z-plasty and two-flap palatoplasty on velopharyngeal closure

The aim of this study was to compare velopharyngeal closure between patients who underwent Furlow palatoplasty and two-flap palatoplasty. A retrospective review of 88 patients with incomplete palate cleft was performed. 48 patients (17 males; 31 females) aged 2-28 years received Furlow palatoplasty. 40 patients (17 males; 23 females) aged 2-21 years received two-flap palatoplasty. Velopharyngeal function was categorized as adequate, marginal or inadequate. Complications associated with the operation were documented. Statistically significant differences were not found amongst sex distribution, age at operation, follow-up time, and preoperative speech intelligibility. After primary repairs using Furlow and two-flap palatoplasty, the surgeon's incidence of postoperative palatal fistula was 0%. The complications were not significantly different between the two groups. The authors achieved the lowest reported incidence of postoperative palatal fistulas in primary Furlow palatoplasty. The outcomes of the velopharyngeal closure were better in patients who received Furlow palatoplasty (P<0.05). Furlow palatoplasty was more effective than two-flap palatoplasty in obtaining perfect velopharyngeal closure. A probable explanation may be that Furlow palatoplasty can reposition and overlap the divergent palatal muscle and lengthen the soft palate.     

两种腭裂修复方式治疗过宽不完全腭裂的临床效果比较

目的:比较兰氏法和改良兰氏法修复过宽不完全腭裂的临床效果。方法:选取2012年1月~2014年12月于徐州医科大学附属徐州市立医院接受腭裂修复术的不完全腭裂患儿40例,年龄2~5岁,裂隙宽度均大于2.5 cm,按接受腭裂修复的不同方式分为2组,实验组:20例,行改良兰氏法(兰氏法联合颊肌黏膜瓣)修复腭裂,对照组:20例,行兰氏法修复腭裂。2017年1月~2019年9月(术后5~7年)进行随访,此时两组患者年龄7~9岁,平均年龄为8岁。分别观察两组患者术区恢复状态,应用锥形束CT(CBCT)观察比较上颌骨发育情况,使用头颅侧位片评价腭咽闭合功能,并且进行语音清晰度评估。结果:相比于对照组,实验组的患者恢复较好,术区瘢痕轻微,上颌骨发育好,腭咽闭合完全,语音清晰度高。结论:对于裂隙过宽的腭裂患者,使用联合颊黏膜瓣的兰氏法可有效避免裸露的骨面,减轻了瘢痕增生,有利于上颌骨发育,增进腭咽闭合,提高了语音清晰度是一种更为值得推广的腭裂新手术方法。     

皮罗序列征患儿腭裂的改良手术治疗：12例临床分析

目的 探讨治疗皮罗序列征患儿腭裂安全、有效的功能性外科方案。方法 选择12例重度皮罗序列征腭裂患儿,腭裂修复术前,为纠正重度缺氧,均实行下颌骨牵张成骨。采用软腭不后退腭帆提肌重建的改良手术进行腭裂修复。结果 12例患皮罗序列征的腭裂患儿,经软腭不后退提肌重建的改良手术后,随访10~12个月,均获得了腭咽闭合功能恢复又不造成呼吸困难的临床效果。结论 对皮罗序列征的腭裂患儿进行腭裂修复手术,有别于一般的腭裂修复手术,应防止腭瓣后徙引起的呼吸窘迫。     

Speech outcomes in isolated cleft palate: impact of cleft extent and additional malformations.

OBJECTIVE: The purpose of the study was to study the speech outcome in a series of 5-year-old children born with an isolated cleft palate and compare the speech with that of noncleft children and to study the impact of cleft extent and additional malformation on the speech outcome. DESIGN: A cross-sectional retrospective study. SETTING: A university hospital serving a population of 1.5 million inhabitants. SUBJECTS: Fifty-one patients with an isolated cleft palate; 22 of these had additional malformations. Thirteen noncleft children served as a reference group. INTERVENTIONS: A primary soft palate repair at a mean of 8 months of age and a hard palate closure at a mean age of 4 years and 2 months if the cleft extended into the hard palate. MAIN OUTCOME MEASURES: Perceptual judgment of seven speech variables assessed on a five-point scale by three experienced speech pathologists. RESULTS: The cleft palate group had significantly higher frequency of speech symptoms related to velopharyngeal function than the reference group. There were, however, no significant differences in speech outcome between the subgroup with a nonsyndromic cleft and the reference group. Cleft extent had a significant impact on the variable retracted oral articulation while the presence of additional malformations had a significant impact on several variables related to velopharyngeal function and articulation errors. CONCLUSION: Children with a cleft in the soft palate only, with no additional malformations, had satisfactory speech, while children with a cleft palate accompanied by additional malformations or as a part of a syndrome should be considered to be at risk for speech problems.     

同期咽后壁组织瓣转移修复后大龄腭裂患者语音改善效果的评价

目的探讨咽后壁瓣转移修复术对大龄腭裂患者语音效果的影响。方法选择2006年8月～2008年8月就诊于青岛大学医学院附属医院口腔颌面外科的大龄腭裂患者37例,20例采用两瓣法关闭裂隙并同期行咽后壁瓣转移修复术;17例单纯关闭裂隙。比较手术前后腭咽闭合不全率（RVPI）,单元音[i]三个共振峰频率,辅音[ka]、[pa]、[si]、[qi]冲直条和擦音乱纹及语音清晰度变化,并与健康儿童20例对照。结果所有患者均达到临床Ⅰ期愈合,两手术组术后RVPI均显著降低,语音也有不同程度改善,且关闭裂隙同期行咽后壁瓣转移修复术组明显优于单纯关闭裂隙组。结论大龄腭裂患者同期行腭裂修复术和咽后壁瓣转移修复术能显著改善患者的腭咽闭合功能,可作为大龄腭裂患者常规术式。     

A pilot study of the effects of transpalatal maxillary advancement on velopharyngeal closure in cleft palate patients

BACKGROUND AND AIMS: Impaired velopharyngeal closure function is sometimes a complication of a standard Le Fort I maxillary advancement in cleft palate patients. The transpalatal Le Fort I osteotomy has been suggested as an alternative technique that may avoid this problem. The aim of this pilot study was to examine the effects of the transpalatal approach on velopharyngeal function in a series of cleft palate patients. PATIENTS: Sixteen consecutive patients with a history of cleft palate exhibiting maxillary hypoplasia who underwent a transpalatal Le Fort I osteotomy. METHODS: All patients had a simultaneous audio/video speech recording and nasopharyngoscopy examination prior to maxillary advancement, followed by a repeat of the same examinations at least 1 year post-operatively. Velopharyngeal function was measured in two ways: by direct observation using nasopharyngoscopy, and indirectly by means of perceptual assessment. Reliability studies of the two measures were performed with satisfactory results. RESULTS: No statistically significant difference was found between the pre- and post-operative data in either the perceptual speech assessment or nasopharyngoscopy examination. CONCLUSION: These results indicate that maxillary advancement by transpalatal Le Fort I osteotomy does not adversely affect velopharyngeal closure function.     

Use of vomer flap in palatoplasty: revisited.

OBJECTIVE: To present a new comprehensive and simple classification of vomerine flaps for palatoplasty. DESIGN: This classification has been developed on the basis of a literature search and our clinical experience. The vomerine flaps have been classified into three types, each with A and B subtypes. PATIENTS, PARTICIPANTS: Vomerine tissue has been used in more than 1000 palatoplasties over the past 17 years. The analysis includes 678 cleft palate patients for whom detailed records were available. Type II-A vomerine flaps were used most commonly in unilateral cleft palate patients, whereas Type II-B1 flaps were used in bilateral cleft palate patients. RESULTS: The overall fistula rate at the hard and soft palate junction was 2.95%. Although facial growth pattern was not recorded, obvious midface growth abnormalities were not observed in any of these patients. CONCLUSIONS: Vomerine tissue is available in the vicinity of the palatal defect. Raising of the vomerine flap is simple and safe. If properly designed, it can be used judiciously for closure of the nasal and oral defects in the cleft palate. We have used these flaps only to augment the nasal mucosal defect. This comprehensive classification will be useful in understanding, designing, and implementing these small, but very important, flaps.     

The buccal flap--a useful technique in cleft palate repair?

OBJECTIVE: To evaluate speech quality and oronasal fistula after primary palate repair using a buccal mucosal flap. DESIGN: Retrospective study cohort of patients with cleft palate. SETTING: Primary care center for treatment of craniofacial congenital anomalies. PATIENTS AND METHODS: One hundred fifty-six nonsyndromic patients underwent palatoplasty with the buccal myomucosal flap by the senior surgeon between 1989 and 2002. The preoperative workup, surgical technique, and other factors that might affect the outcome were identical in every case. Oronasal fistula and variables affecting speech quality were analyzed. RESULTS: The most common type of cleft was unilateral cleft lip and palate (43.5%). The median follow-up was 5.8 years (0.4 to 21 years), and the median age at repair was 6.2 months. The overall fistula formation was 3.6%, decreasing progressively: 1989 to 1994: 2.9%, 1995 to 2002: 0.7% (p <.05). Velopharyngeal incompetence (VPI) occurred in 8.8% of the patients, decreasing from 5.3% to 3.5% in the last years. VPI and oronasal fistulae were observed mainly in unilateral and bilateral clefts of the lip and palate. Velopharyngeal adequacy occurred in 91.1% of the children, and resonance was normal in 91.1 %. None of the patients had severe hypernasality or hyponasality. Articulation was normal in 97.9% of the children. Speech quality was good in 89% of the patients. CONCLUSIONS: The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, lengthening of the nasal layer, and palatal closure without raw areas. The technique, early repair, and surgeon's skills were the most important variables for good outcomes regarding speech and fistula formation.     

Palatal lengthening by double opposing buccal flaps for surgical correction of velopharyngeal insufficiency in cleft patients

AimTo assess the efficacy of double opposing buccal flap in lengthening the soft palate for velopharyngeal insufficiency correction, and its potential complications in different age groups.Case seriesFrom March 2016 to June 2019, 50 patients (24 children, 12 adolescents and 14 adults) underwent palatal lengthening using double opposing buccinator myomucosal flaps. Postoperative complications were assessed by two surgeons and the speech outcomes were evaluated by two speech-language pathologists after assessing changes in the hypernasality and intelligibility using a scoring approach. Following the procedure, mild-to-moderate surgical complications were seen, mostly among the adults. There was a significant improvement in hypernasality and intelligibility in all the groups. None of the patients showed hyponasal speech postoperatively.ConclusionTo conclude, the double opposing buccal flap technique is an effective and safe surgical treatment option for the management of velopharyngeal insufficiency in all age groups of patients.     

Versatility of the buccinator myomucosal flap in atypical palate reconstructions

Initially described for the treatment of cleft palate, the anatomical bases of the buccinator myomucosal flap were described by Bozola et al. (1989). A meticulous search found several reports of its use for the correction of post-palatoplasty oronasal fistulas, with only a few reports of its use for other palate-related pathologies.A retrospective analysis was undertaken of patients treated by the Plastic Surgery Units at the Rio de Janeiro Federal University Hospital (HU-UFRJ) and the São Paulo University Hospital (HC-USP), suffering from palatal lesions not associated with a cleft palate and treated through the use of buccinator myomucosal flaps.The average age was 47 years, with 70% of the patients being male. Assorted aetiologies were noted for palatal defects. When there was significant damage to the soft palate, a superior base pharyngeal flap was used. Of this total, in 71% of the cases only the buccinator myomucosal flap was used. In all cases, the flaps were unilateral, adequately covering the defects in question. The buccinator myomucosal flap is a good option for reconstructing medium to large palate defects, as it is a flap with good vascularization and dimension, in addition to an ample arc of rotation, with primary closure of the donor site, without adding significant morbidity.