What's New in Cleft Palate and Velopharyngeal Dysfunction Management?

CME

What’s New in Cleft Palate and Velopharyngeal Dysfunction Management?

Sanjay Naran, M.D. Learning Objectives: After studying this article, the participant should be able Matthew Ford, C.C.C.-S.L.P. to: 1. Have a clear understanding of the evolution of concepts of velopharyn- Joseph E. Losee, M.D. geal dysfunction, especially as it relates to patients with a cleft palate. 2. Explain Pittsburgh, Pa. the subjective and objective evaluation of speech in children with velopharyngeal dysfunction. 3. On the basis of these diagnostic findings, be able to classify types of velopharyngeal dysfunction. 4. Develop a safe, evidence-based, patient-customized treatment plan for velopharyngeal dysfunction founded on objective considerations. Summary: Velopharyngeal dysfunction is improper function of the dynamic structures that work to control the velopharyngeal sphincter. Approximately 30 percent of patients having undergone cleft palate repair require secondary surgery for velopharyngeal dysfunction. A multidisciplinary team using multimodal instruments to evaluate velopharyngeal function and speech should manage these patients. Instruments may include perceptual speech analysis, video nasopharyngeal endoscopy, multiview speech videofluoroscopy, nasometry, pressure-flow, and magnetic resonance imaging. Velopharyngeal dysfunction may be amenable to surgical or nonsurgical treatment methods or a combination 2017 of each. Nonsurgical management may include speech therapy or prosthetic devices. Surgical interventions could include palatal re-repair with repositioning of levator veli palatini muscles, posterior pharyngeal flap, sphincter pharyn- RELATED DIGITAL CONTENT IS AVAILABLE ON- goplasty, or soft palate or posterior wall augmentation. Treatment interventions LINE. should be based on objective assessment and rating of the movement of lateral and posterior pharyngeal walls and the palate to optimize speech outcomes. Treatment should be tailored to specific anatomical and physiologic findings and the overall needs of the patient. (Plast. Reconstr. Surg. 139: 1343e, 2017.)

elopharyngeal dysfunction results from manipulating air pressure and sound emanat- inadequate function of dynamic structures ing from the respiratory tract into intelligible Vthat work to control the velopharyngeal speech by controlling the shape and size of, and sphincter (formed by the soft palate, the lateral directing flow of air between, the oral and nasal pharyngeal walls, and the posterior pharyngeal resonating cavities. Dysfunction of this system wall), which separates the nasal cavity from the may result in hypernasality, nasal air emission, oral cavity during speech.1 The velopharyngeal decreased intraoral air pressure for oral pressure sphincter is also often referred to as the velo- consonants, reduced speech loudness, nostril or pharyngeal port, valve, portal, or passage, but facial grimacing, and hyperfunctional phona- will hereafter be described as the sphincter. The tory changes.2 Although there are many causes levator veli palatini, tensor veli palatini, pala- toglossus, palatopharyngeus, musculus uvulae, Disclosure: Dr. Losee receives royalties from the pub- salpingopharyngeus, and superior pharyngeal lication of Comprehensive Cleft Care, for which he is constrictors all play a part in the function of the an editor. The authors have no other disclosures. velopharyngeal sphincter.1 Together, they aid in

From the Department of Plastic Surgery, Division of Pediat- Related Video content is available for this ric Plastic Surgery, University of Pittsburgh. article. The videos can be found under the Received for publication May 6, 2016; accepted November “Related Videos” section of the full-text article, 21, 2016. or, for Ovid users, using the URL citations Copyright © 2017 by the American Society of Plastic Surgeons published in the article. DOI: 10.1097/PRS.0000000000003335

of velopharyngeal dysfunction, the focus of this Classification of article is that as a result of cleft palate. Approxi- Velopharyngeal Dysfunction mately 30 percent of patients having undergone Differential causes of velopharyngeal dysfunc- cleft palate repair require secondary surgery for tion in the cleft palate patient include velopharyn- velopharyngeal dysfunction.3,4 Velopharyngeal geal insufficiency, velopharyngeal incompetency, dysfunction has been codified previously, with and mislearning, with management varying multiple published reviews from past and pres- 4,6 ent. In fact, there is very little that is truly “new” depending on cause (Fig. 1). Of note, an orona- in the management and treatment of velopha- sal fistula may cause abnormal nasal air emission ryngeal dysfunction, especially in the cleft pal- and reduced velopharyngeal sphincter closure in ate patient. That which is new includes evolving the absence of true velopharyngeal dysfunction. diagnostic tools, outcome data following surgical Velopharyngeal insufficiency is a subset of interventions, and evolved surgical techniques. velopharyngeal dysfunction secondary to insuf- As such, our goal is to present a review of estab- ficient tissue or mechanical restriction resulting lished diagnostic and management techniques, from an unrepaired cleft palate, palatopharyn- present more recent outcome data to support geal disproportion, or a previously repaired cleft their use, and present surgical techniques that palate where the soft palate may be too short or may be on the horizon.3–5 constrained by a significant amount of scar tissue,

Fig. 1. Velopharyngeal dysfunction classification. The differential diagnosis of velopharyngeal dysfunction includes velopharyngeal insufficiency (VPI), velopharyngeal incompetency, or mislearning (orange boxes). Potential causes of nasal air emission (NAE) in a patient with a cleft palate are in the green boxes. Causes in blue boxes are typically not found in patients with a cleft palate. (Reprinted with permission from Hopper RA, Tse R, Smartt J, Swanson J, Kinter S. Cleft palate repair and velopharyngeal dysfunction. Plast Reconstr Surg. 2014;133:852e–864e.)

or where the levator veli palatini muscles have not pathologist. Speech samples are obtained through been properly reoriented. Other causes of velo- a structured formalized assessment protocol and pharyngeal insufficiency include submucous cleft inclusion of spontaneous speech rating. Assess- palate, velar dysplasia, deep pharynx, irregular ment includes sampling of all speech sounds. adenoids, adenoid hypertrophy, adenoidectomy, Specific attention is made to the production of hypertrophic tonsils, maxillary advancement, post- pressure sounds, including plosives, fricatives, tonsillectomy, and oral or pharyngeal cavities.1 affricatives, and nasal consonants (Table 1). Mis- All patients with an anatomical cause of velo- articulations are analyzed for developmental type pharyngeal dysfunction will present with compen- errors, compensatory maladaptive errors, and satory misarticulations, which may persist following those that may be attributable to oral cavity or anatomical repair. It is therefore important to be dental structure abnormalities. Resonance pat- able to distinguish between compensatory misar- terns, presence of abnormal audible and visible ticulations versus mislearning misarticulations. nasal air emission, and maladaptive nostril or Compensatory misarticulations develop sponta- facial grimacing are also ascertained.9 neously to compensate for reduced intraoral air Detailed methods of perceptual speech analy- pressure because of abnormal anatomy, whereas sis are beyond the scope of this article. In brief, one mislearning misarticulations result from abnor- must first determine whether the patient’s speech mal use of the velopharyngeal mechanism despite abnormality is a result of velopharyngeal dysfunc- the absence of other abnormality. One should tion with abnormal resonance and nasal air emis- also consider hearing impairment as a cause of sion, or an abnormality of speech sound learning, velopharyngeal mislearning. A thorough auditory or both. On establishing the cause of velopharyn- evaluation is therefore essential for all patients geal dysfunction, the utility of further diagnostic that present with a speech disorder. imaging may be determined. Resonance, which is a descriptor of where sound moves and reverber- ates throughout the vocal tract, is assessed using Diagnosing Velopharyngeal voiced (resonating) sounds, including vowels, Dysfunction nasal consonants, and vocalic consonants. Abnor- Patients with velopharyngeal dysfunction mal closure of the nasal valve can result in abnor- should be managed by a multidisciplinary team, mal resonance, and may be clinically evidenced by using multimodal instruments to evaluate pre- hypernasality, hyponasality, cul-de-sac resonance, operative and postoperative speech outcomes.7 or a combination of these. This has been advocated in an effort to standard- In addition, audible nasal air emission or ize reporting of speech outcomes in cleft palate nasal turbulence with or without nostril/facial gri- patients, and to customize treatment algorithms macing may be present. Hypernasality (rhinolalia for specific patients.8 The speech pathologist is perhaps the most integral part of the multidisciplinary team at this stage of the cleft palate patient’s Table 1. Definitions of Specific Pressure Phonemes journey. Diagnostic results should be rigorously and Speech Characteristics reviewed and consensus established as to the opti- Phoneme Speech Characteristics mum course of management. Especially critical is Plosives Consonants in which the vocal tract distinguishing between abnormal speech that is is blocked so that all airflow ceases. a result of velopharyngeal sphincter dysfunction The occlusion may be made with versus behavioral speech function. Many profes- the tongue blade (/t/, /d/) or body (/k/, /g/), lips (/p/, /b/), or glottis. sionals may be able to determine whether speech Fricatives Consonants produced by forcing air “sounds normal”; however, the speech pathologist through a narrow channel made is the most qualified team member to differenti- by placing two articulators close together. These may be the lower lip ate between a speech abnormality secondary to a against the upper teeth, in the case structural anomaly that would benefit from surgi- of /f/; the back of the tongue against cal intervention versus that which would benefit the soft palate; or the side of the tongue against the molars. from behavioral speech therapy. Affricatives A consonant that begins as a stop and releases as a fricative. Perceptual Speech Analysis Misarticulations Generic term for any deviation of speech sound production (articu- After a thorough history and physical examina- lation), which is characterized by tion, perceptual speech analysis is first performed distortion, omission, or substitution by the trained ear of a certified speech-language or addition of phonemes.

aperta) results from increased vocal resonation by Pigott et al. in 1969, video nasopharyngeal through the nose during speech production endoscopy technology has advanced significantly because of inadequate or incomplete closure of and become one of the two primary state-of-the- the velopharyngeal sphincter. Conversely, hypo- art tools for examination of the upper vocal tract nasality (rhinolalia clausa) results from a lack or during speech.12,13 Video nasopharyngeal endos- reduction of nasal resonance. Audible nasal emis- copy provides optimal viewing of the velopharyn- sion and nasal turbulence or “rustling” occurs geal sphincter by enabling direct visualization of when air is lost through the velopharyngeal the degree of closure, the position and function sphincter during productions of oral pressure of the levator musculature, the length and qual- consonants. The airflow may result in “bubbling” ity of the soft palate, and the degree of motion of of nasal secretions or vibration of the tissues in the the lateral pharyngeal walls and posterior phar- velopharyngeal sphincter, resulting in the char- ynx.14 This is performed while a speech-language acteristic acoustically turbulent air and resultant pathologist guides the patient through repetition speech distortion. This can be correlated with vis- of a standardized speech sample tailored to their ible nasal air escape, detected with the assistance abilities. Video nasopharyngeal endoscopy also of a mirror held under the nares, which would fog. allows for examination of the entire vocal tract at Facial grimacing is a compensatory action used to different levels and from different angles, and for narrow the external nares to decrease nasal air visualization of the larynx to assist in identifying emission during nonnasal speech. vocal fold abnormality and the presence of hyper- Articulation assessment is a difficult part of functional phonatory disorders often associated perceptual speech evaluation, and is used to deter- with velopharyngeal insufficiency. This plays an mine the status of the patient’s speech errors. This important role when determining the appropri- is important because obligatory errors are caused ate treatment algorithm, as surgical methods of by structural or neurogenic problems, such as fis- correction should be based on specific patterns tulas or velopharyngeal dysfunction, and would of closure.15 A limitation of video nasopharyn- require surgical correction, whereas compensa- geal endoscopy is the fact that it is not possible tory articulation errors are learned articulation to quantitatively measure pertinent anatomical errors that are developed in early speech acquisi- findings, such as gap size, as image size changes tion because of an inability to generate adequate dramatically with scope position. Video nasopha- intraoral air pressure for normal production of ryngeal endoscopy may also be a very uncomfort- pressure consonants. able procedure for pediatric patients, especially Velopharyngeal mislearning includes these in the hands of an inexperienced endoscopist. compensatory errors and learned phoneme- (See Video, Supplemental Digital Content 1, specific nasal air emission with particular speech which displays a video tutorial of velopharyngeal sounds, most often /s/ and /z/, but at times assessment using the Pittsburgh Weighted Speech including other fricatives and sometimes affri- Scale. This video is available in the “Related Vid- cates. All of these learned errors are corrected eos” section of the full-text article on PRSJournal. through speech therapy only. Within the office com or, for Ovid users, at http://links.lww.com/ setting, articulation evaluation may be performed PRS/C168.) by having the patient produce a conversational Recent advances in video nasopharyngeal speech sample and structured speech tasks. There endoscopy include three-dimensional imaging, its is no standardized perceptual acoustic evalua- use in detecting syndromic cleft palate diagnoses, tion protocol that is uniformly used among all and its use while the patient is under mild seda- speech-language pathologists, despite the recom- tion.16–19 At present, video nasopharyngeal endos- mendations of the International Working Group. copy imaging is predominantly two-dimensional. Perceptual analysis may be supplemented with A single view (sagittal) and velar overlapping pre- the use of the Pittsburgh Weighted Speech Scale, clude optimum observation of lateral pharyngeal which is used in many clinics to report the severity wall motion. More recently, three-dimensional of velopharyngeal dysfunction.10,11 conceptualization of the velopharyngeal sphincter during speech using coronal, sagittal, and Video Nasopharyngeal Endoscopy axial planes has been promoted.16,17 One recent Video nasopharyngeal endoscopy uses a mag- case report highlighted the use of video nasopha- nified high-quality view to provide direct visual- ryngeal endoscopy for detecting pulsations on ization of the entire vocal tract during speech the lateral and posterior pharyngeal walls, which production. Since its earliest use and introduction prompted workup for 22q11.2 microdeletion

Video 1. Supplemental Digital Content 1 displays a video tutorial of velopharyngeal assessment using the Pittsburgh Weighted Speech Scale. This video is available in the “Related Videos” section of the full- text article on PRSJournal.com or, for Ovid users, at http://links.lww. com/PRS/C168.

syndrome.18 Given that 22q11.2 microdeletion size and closure patterns. In collaboration with syndrome is the most common syndrome associ- a radiologist, the patient is guided by a speech- ated with cleft palate and velopharyngeal insuffi- language pathologist through repetition of a ciency, this report highlights an important clinical standardized speech sample personalized to their finding that may affect workup and management abilities. This procedure is typically performed in of patients with velopharyngeal dysfunction. In both the lateral and anteroposterior views, provid- the pediatric patient, compliance during a video ing images of the posterior pharyngeal wall and nasopharyngeal endoscopy study is often challeng- Passavant ridge. (See Video, Supplemental Digital ing. A recent study assessed whether postponing Content 2, which displays a multiview speech vid- video nasopharyngeal endoscopy until the patient eofluoroscopy examination of a patient with velo- was in the operating room and under the effect of pharyngeal insufficiency. This video is available in preoperative light sedation could result in similar the “Related Videos” section of the full-text article or even better analysis than performing the pro- on PRSJournal.com or, for Ovid users, at http:// cedure awake. The authors found that procedure links.lww.com/PRS/C169.) compliance and patient comfort were improved, and the diagnostic findings dictated surgical procedures that completely corrected hypernasality in 90 percent of cases.19

Multiview Speech Videofluoroscopy Multiview speech videofluoroscopy provides two-dimensional visualization of the velopharyngeal sphincter in motion during speech by creating serial radiographs through tissues. First described by Skolnick in 1970, the procedure is flexible in that information can be obtained regarding multiple anatomical and physiologic correlates even without contrast.20,21 Velar motion, adenoid size, and cranial base angle are eas- ily ascertained. Lateral pharyngeal wall motion can also be accurately ascertained even in a very young patient. If tolerable, high-density contrast Video 2. Supplemental Digital Content 2 displays a multiview material (barium) may be syringe-injected trans- speech videofluoroscopy examination of a patient with velo- nasally during the examination to coat the tissues pharyngeal insufficiency. This video is available in the “Related of the velopharyngeal sphincter, allowing a base Videos” section of the full-text article on PRSJournal.com or, for view to be obtained with good visualization of gap Ovid users, at http://links.lww.com/PRS/C169.

Multiview speech videofluoroscopy tends to be diagnostic modality. Although nasometry may not better tolerated than video nasopharyngeal endos- be suited to diagnosing the cause of velopharyn- copy, and is often preferentially used in younger geal dysfunction, it may provide a standard objec- children who are unlikely to cooperate for a video tive measure with which to compare preoperative nasopharyngeal endoscopic examination.22 How- and postoperative speech outcomes. ever, multiview speech videofluoroscopy may over- simplify the dynamic velopharyngeal sphincter Magnetic Resonance Imaging and therefore make patterns of closure more dif- Magnetic resonance imaging has recently been ficult to assess.23 The procedure also necessitates promoted for evaluation of the velopharynx. Mag- some exposure to radiation and, like video naso- netic resonance imaging does not require radia- pharyngeal endoscopy, is limited by the patient’s tion exposure and provides the ability to acquire ability to cooperate. A recent advance is improved high-quality, reproducible, static and dynamic standardization of objective measures when using imaging of velopharyngeal structures. Function multiview speech videofluoroscopy to assess velo- may be assessed under direct visualization of the pharyngeal dysfunction. With significant reliabil- velopharynx and the direction and insertion of ity, multiview speech videofluoroscopy has been distal muscular fibers of the levator veli palatini.28 shown to provide real-size measurements by a Although a two- or three-dimensional magnetic ratio of selected distance markings and pixels and resonance imaging sequence may provide bet- therefore deliver better quantitative data regard- ter analyses and more precise measurements, it ing closure patterns.24 remains cost prohibitive. Multiview speech videofluoroscopy and video nasopharyngeal endoscopy are the two primary state-of-the-art tools for examination of the upper Treatment of Velopharyngeal vocal tract during speech, and are often used Dysfunction in conjunction to maximize objective evidence Management of velopharyngeal dysfunction is required to progress through one’s treatment dependent on specific cause and subsequent cus- algorithm decision tree. These studies should tomization of treatment to optimize speech out- be video-recorded with sound so they may be comes.25,26 Treatment may be nonsurgical (speech reviewed by a multidisciplinary team. The impor- therapy or prosthetic devices), surgical, or a com- tance of a speech-language pathologist cannot be bination of the two. The key to choosing the right emphasized enough, along with their selection therapy is proper use and analysis of velopharyn- of conversational speech sample and structured geal dysfunction diagnostic modalities described informal speech tasks. By optimally using both previously. multiview speech videofluoroscopy and video nasopharyngeal endoscopy, surgical treatment Nonsurgical Treatment may be customized individually and speech out- Prosthetic options may be used as a tempo- comes significantly improved.25,26 rary or permanent solution for nonsurgical candi- dates.29 Devices are customized and provide palatal Nasometry lift, obturation, or a combination of both. Palatal Nasometry is an objective, indirect, computer- lifts aid the soft palate in velopharyngeal sphinc- aided test used to measure air escaping past the ter closure by pushing the soft palate cranially, and velum and through the nose (nasal emission).27 It are often used in cases of hypomobility or paraly- provides a measurement of the modulation of the sis. Obturators are used to occlude either oronasal velopharyngeal sphincter, and allows for repro- fistulas or unrepaired palatal clefts. Speech bulbs ducible calculation of the ratio between nasal and can be used to occlude persistent velopharyngeal oral sound emissions (nasalance). These ratios defects after inadequate palatal repair when fur- are compared with normative values and may also ther surgery is contraindicated or undesired. be compared preoperatively and postoperatively. Although speech therapy may be beneficial Nasometry does not provide any data regarding for all patients with velopharyngeal dysfunction, the localization or quantification of velopharyn- it is the sole therapy for velopharyngeal mislearn- geal sphincter gap size. For example, nasal air ing. In cases where patients have already acquired emission may be the result of an oronasal fistula speech, those with velopharyngeal insufficiency versus velopharyngeal insufficiency but objec- benefit from speech therapy postoperatively tively would produce similar nasalance. There in helping them to learn how to use their “new have not been any recent advances in use of this anatomy.”30

Surgical Treatment may offer improved exposure and ergonomics Surgical approaches to correction of velopha- compared with traditional surgery.41,42 The use ryngeal dysfunction may be divided into broad of robotic surgical systems may therefore find a groups that either correct muscle function (pala- niche within intraoral cleft surgery in the com- tal re-repair with repositioning of the levator veli ing years. No recent studies have shown one palatini), compensate for poor function by nar- posterior pharyngeal flap technique to be supe- rowing the velopharyngeal sphincter (posterior rior to another with regard to reduction of com- pharyngeal flap, sphincter pharyngoplasty, or plications or improvement in speech outcomes. posterior wall and/or soft palate augmentation), However, recent studies have shown longevity in or both (V-Y pushback, Furlow double-opposing improvement of speech following takedown for Z-plasty). Hereafter, we will elaborate on the three posterior pharyngeal flap for obstructive sleep most widely used methods: posterior pharyngeal apnea.43,44 The mechanism by which this occurs flap, sphincter pharyngoplasty, and palatal re- may include stretching of the soft palate and/or a repair. We will touch briefly on more recent stud- thicker posterior pad after flap takedown. There ies using fat grafting for posterior wall and/or soft is significant potential morbidity associated with palate augmentation. pharyngoplasty, and although the most comprehensive reviews of complication rates are now Posterior Pharyngeal Flap dated,45,46 a recent study using the 2012 American The posterior pharyngeal flap is one of the old- College of Surgeons National Surgical Quality est and most commonly used surgical techniques Improvement Program Pediatric database identi- for treatment of velopharyngeal dysfunction. Its fied the overall perioperative complication rate evolution dates back to 1865, when Passavant first for posterior pharyngeal flap surgery to be low performed a surgical technique that sutured the (5.3 percent), and identified patients with under- posterior border of the soft palate to the poste- lying cardiac risk factors, severe American Soci- rior pharyngeal wall, and Schoenborn in 1875 ety of Anesthesiologists Physical Status class, and who performed an inferiorly based flap.31,32 More asthma as having heightened risk profiles.47 recently, the technique was popularized in the United States by Padgett in the 1930s and Hogan Sphincter Pharyngoplasty in the 1970s.33,34 In connecting the posterior phar- The sphincter pharyngoplasty has undergone incremental evolution since its first introduc- ynx to the soft palate, a musculomucosal bridge 48–50 is created, dividing the velopharyngeal sphincter tion. The surgical method still includes eleva- into two smaller ports, decreasing airflow during tion of thick vertically oriented posterior tonsillar speech. Success relies on adequate mobility of the pillar flaps (all of which include the palatopharyn- lateral pharyngeal walls to close the resulting two geus muscle) and transposing them 90 degrees lateral velopharyngeal sphincters.35 Debate con- medially to a horizontal position, against the pos- tinues regarding inferiorly based versus superiorly terior pharyngeal wall (Fig. 3). Recent advance- based flaps; however, speech outcomes are not sig- ments include augmentation of the muscle nificantly different with either technique.36–38 The sphincter created by the posterior tonsillar pillar superiorly based flap is preferentially used at our flaps with the longus capitis muscle, cerclage of institution, because it provides an unobstructed the sphincter pharyngoplasty using polypropylene sutures, and placing the pharyngoplasty higher in view of the donor site during harvest, does not 51–55 tether the soft palate inferiorly, and allows for har- the pharynx. Similar to posterior pharyngeal vest of greater length. The surgical technique has flaps, the modality of surgery has also recently not varied considerably from that popularized by been explored, with cadaveric studies investigat- ing the feasibility of transnasal endoscopy–assisted Hogan (Fig. 2); however, some variations include 56 not splitting the palate in the midline, not lining pharyngoplasty. Like the posterior pharyngeal the flap with nasal mucosa from the soft palate, flap, obstructive sleep apnea remains a significant and performing a “through-and-through” dissec- morbidity associated with sphincter pharyngoplasty, and parents should be counseled regard- tion of the soft palate for flap inset.34,39,40 Smartt ing the diagnosis and treatment of this potential et al. have recently advanced the modality of this complication. surgery by exploring the use of robotic surgical telemanipulation systems to perform a Hogan- Palatal Re-Repair with Reorientation of the style posterior pharyngeal flap on a small series Levator Veli Palatini of cadaveric human specimens. They found the Palatal re-repair has been advocated for technique to be feasible and postulated that it the secondary correction of velopharyngeal

Fig. 2. Posterior pharyngeal flap. Before any infiltration or incision, examination and palpation of the posterior pharyngeal wall should be performed to identify medialization of the carotid arteries. Analgesic/epinephrine infiltrate may be used to hydrodis- sect the submucosal layer of the posterior pharyngeal wall. (Above, left) Marked borders of the proposed flap, with distal demar- cation that may taper inferiorly to a rounded or triangular point corresponding to the site of attachment to the soft palate. The midline has been split and retraction sutures placed. (Above, center) The white prevertebral fascial plane determines the depth of the dissection of the posterior pharyngeal wall. The flap incorporates the muscle of the posterior pharyngeal wall. (Above, right) Sagittal view of the posterior pharyngeal flap raised cephalad (arrow). (Below, left) Closure of the flap donor site with bites of the prevertebral fascia incorporated to eliminate webbing and close the dead space. (Below, second from left) Insetting of the pharyngeal flap. (Below, second from right) Closure of the soft palate and approximation of the nasal mucosal flaps in the midline. (Below, right) Sagittal view of the inset and closure of the nasal mucosal lining. Design of the palatal inset will vary with technique, but will ultimately result in bridging of the velum and posterior pharyngeal wall as illustrated. The oral cavity is irrigated and suctioned dry. Alternatively, the donor site may be left to close by means of secondary intention. (Reprinted with permission from Wong KW, Klaiman PG, Forrest CR. Posterior pharyngeal flaps. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. 2nd ed. Boca Raton, Fla: CRC Press; 2015:1133–1156.)

insufficiency in patients who initially underwent The Furlow double-opposing Z-plasty has been a “straight-line palatoplasty” and/or demonstrate shown to be efficacious as a secondary treatment anterior insertion of the levator veli palatini. The for velopharyngeal dysfunction resulting from method of re-repair may be debated (Furlow dou- a previously repaired cleft.13,60,61 The geometric ble-opposing Z-plasty versus aggressive intravelar design of the Furlow double-opposing Z-plasty is veloplasty), but both emphasize the importance in achievement of its primary goal of overlapping of correction of the abnormal position of the leva- the levator veli palatini muscle bellies and placing tor veli palatini, suturing of these divided muscle them under “functional tension,” bringing the tip bellies, and removal of scar tissue.57,58 Correctly of each posteriorly based musculomucosal flap to positioning the levator veli palatini is the most the base of the contralateral levator veli palatini important factor in terms of functional speech muscle belly as it exits the skull base (Fig. 4). In outcomes in palatoplasty.59 At our institution, doing so, one achieves a precisely transverse orien- the Furlow double-opposing Z-plasty is the pre- tation of the levator veli palatini muscles, displac- ferred first-line intervention for velopharyngeal ing them anatomically to the middle 50 percent of insufficiency in a previously repaired cleft palate. the velum.62–64 There are three functional benefits

Fig. 3. Sphincter pharyngoplasty. (Above, left) The optimal insertion level in the posterior pharyngeal wall for the posterior tonsillar pillar myomucosal flap is determined preoperatively using lateral speech fluoroscopy. The dotted line represents the velum, which is displaced within the posterior pharynx to expose the inferior nasopharynx and velopharynx for the surgical approach. (Above, right) Attention is first directed to the junction of the ventral surface of the posterior tonsillar pillar and the tonsillar bed, where the mucosa is incised. A unipedicled, superiorly based myomucosal flap is developed from the posterior pharyngeal wall insertion site superiorly to an inferior length equal to the transverse width of the insertion site. This flap includes the palatopharyngeus muscle to achieve optimal function and flap survival. The superior aspect of the flap is preserved as its base, and the inferior aspect is divided. The flap is elevated until the posterior pharyngeal wall insertion site is reached. The same procedure is then repeated for the opposite pillar. (Below, left) The mucosa at the posterior pharyngeal wall insertion site is cut, connecting the superior aspects of each posterior pillar myomucosal flap donor site as a U. Only the mucosa is cut, with a minimum of underlying muscle. (Below, center) The posterior pillar flaps are rotated 90 degrees and inset into the posterior pharyngeal wall mucosa defect and to each other in a Z pattern. (Below, right) The lateral pharyngeal wall donor sites are then repaired. (Reprinted from Marsh JL, Gage EA. Sphincter pharyngoplasty. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. 2nd ed. Boca Raton, Fla: CRC Press; 2015:1157–1170.)

of Furlow double-opposing Z-plasty: (1) lengthen- outcomes when compared with posterior pharyn- ing of the velum with Z-plasties of both the nasal geal flaps and sphincter pharyngoplasties.13,65–70 and oral mucosa; (2) reorientation of the leva- Recent studies address the debate as to whether tor veli palatini muscles, resulting in the greatest Furlow double-opposing Z-plasty or intravelar vel- degree of overlap under “functional tension”; and oplasty produces superior speech results.71,72 That (3) a pharyngoplasty effect through narrowing being said, surgeon comfort will ultimately dictate of the velopharyngeal sphincter as a result of the which technique is used and will produce the best nasal lining Z-plasty. Although this technique was results in their hands. originally proposed as a method of primary cleft Augmentation of the Posterior Pharyngeal repair, it has become a very effective method of Wall and Soft Palate correction of velopharyngeal insufficiency after Augmentation of the posterior pharyn- primary cleft repair, as it not only provides con- geal wall has a long history and has used a wide siderable palatal lengthening, but also corrects range of substances.73 With higher extrusion the abnormal orientation of the levator veli pala- rates experienced with synthetic materials, more tini muscles. There is mounting evidence that the recently, autologous tissues such as fat and car- Furlow double-opposing Z-plasty offers superior tilage have become the materials of choice.74

Fig. 4. Furlow double-opposing Z-plasty. In using the double-opposing Z-plasty for correction of velopharyngeal insufficiency, the procedure is not all that different from that in primary cleft palate repair, with design based on palate anatomy, not geometry. (Above, left) Traditionally, the posteriorly based oral musculomucosal flap is elevated first. The clefted levator muscle is carefully detached from its hard palate attachment and from the nasal mucosa. Scar may complicate the medial aspect of this dissection. When the lateral extent of the dissection nears the hamulus, the palate muscles are bluntly pushed posteriorly, not laterally, from the superior constrictor, leaving the levator as a distinct muscle bundle coming into the flap from between the nasal mucosa and the superior constrictor at the posterior margin of the eustachian orifice. (Above, center) The lateral limb incision for the anteriorly based oral mucosal flap is made from the base of the uvula to just lateral to the hamulus, taking care to expose the muscle without cutting it. As the flap is elevated, care is taken to separate the mucosa form the underlying muscle. As the dissection approaches the base of the flap along the posterior edge of the hard palate, the plane should be deepened to the back of the hard palate and carefully detached from it, without damaging the greater palatine vessels. (Above, right) The anteriorly based nasal mucosal flap is incised from the base of the uvula to the superior constrictor at the point of entry of the levator. (Below, left) The posteriorly based nasal musculomucosal flap is then created by incising the nasal mucosa at 3 to 4 mm from the posterior edge of the hard palate toward the eustachian orifice for approximately 1 cm. With the tip of the flap pulled transversely, the levator muscle is released carefully from the new free margin of the nasal mucosal incision, and the lateral limb incision is extended if necessary until the tip of the flap will reach the end of the contralateral nasal mucosal flap lateral limb incision. This brings the distal end of the levator muscle against the contralateral superior constrictor and immediately under the contralateral levator. (Below, center) Flaps are then inset, beginning with the nasal musculomucosal flap, bringing the tip of the levator muscle to the contralateral superior constrictor. (Below, right) The tip of the oral musculomucosal flap is positioned at the point along the lateral limb incision over the contralateral levator muscle belly, just posterior to the hamulus, orienting the levator transversely to complete the overlapping levator sling. (Reprinted with permission from Kaye A, Kirschner RE. The Furlow double-opposing Z-plasty repair for cleft palate. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. 2nd ed. Boca Raton, Fla: CRC Press; 2015:943–958; and Kao MC, Sie KC. Correction of velopharyngeal dysfunction by double-opposing Z-plasty. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. 2nd ed. Boca Raton, Fla: CRC Press; 2015:1125–1132.)

Solid data regarding the long-term outcomes of multiview speech videofluoroscopy, and per- fat or cartilaginous augmentation are lacking, ceptual speech analysis together to diagnose with observational results varying depending on the cause of a patient’s velopharyngeal dysfunc- assessment modality, and objective measures such tion. In patients with a cleft palate previously as nasalance and fat graft “take” being reported repaired with a straight-line technique, and/or inconsistently.75 With only a small number of seri- where there is evidence of persistent abnormal ous complications being reported, including fat orientation of the levator veli palatini (vaulted embolism resulting in stroke and fat hypertrophy V-shaped pattern of velar elevation), our pre- resulting in obstructive sleep apnea, the safety of ferred first-line intervention is to perform a fat augmentation remains unproven.75,76 Retro- “conversion” Furlow double-opposing Z-plasty. spective studies of isolated posterior pharyngeal Only after this first intervention is a posterior wall augmentation reveal varied results that range pharyngeal flap (in cases of circular or sagittal from complete resorption of graft to complete closure patterns) or sphincter pharyngoplasty resolution of hypernasality. Boneti et al. per- (in cases of coronal closure patterns) explored. formed augmentation of the nasal surface of the Put alternatively, the ideal posterior pharyngeal palate in 46 patients.77 The recorded volume of fat flap candidate is one with active lateral pharyn- grafted averaged 2.4 ± 1.1 ml. Of 34 patients with geal wall motion and a large defect, whereas adequate speech follow-up, including Pittsburgh the ideal sphincter pharyngoplasty is one with Weighted Speech Scale assessment, the average poor lateral pharyngeal wall motion and a small preoperative score of 8.17 ± 3.59 was reduced defect. Given limited objective outcome data, to 5.17 ± 3.14 postoperatively. Although 26 of 34 we have not currently incorporated posterior patients (76.5 percent) had an improvement in wall and/or soft palate augmentation into our their Pittsburgh Weighted Speech Scale score, treatment algorithm. what is not provided in this study is whether any of Regardless of one’s treatment algorithm, these patients required additional surgical inter- established and emerging diagnostic modalities vention because of persistent dysfunction and a should be used to provide objective assessment lack of significant enough improvement with aug- and rating of the movement of lateral and poste- mentation alone. At this time, augmentation of rior pharyngeal walls and the palate. In this way, the posterior pharyngeal wall and/or soft palate treatment interventions can be tailored to the spe- may best be reserved for patients with small velo- cific needs of the patient, and speech outcomes pharyngeal sphincter closure defects; however, can be optimized. questions remain regarding ideal graft volume Joseph E. Losee, M.D. and location. Standardized assessment methods Division Pediatric Plastic Surgery and comparison studies against established velo- Children’s Hospital of Pittsburgh of UPMC pharyngoplasty techniques are still needed. Children’s Hospital Drive 45th and Penn Pittsburgh, Pa. 15201 Treatment Algorithm [email protected] With improved diagnostic modalities and ability to objectively assess the degree of velo- PATIENT CONSENT pharyngeal insufficiency, it is clear that a “one- The patient provided written consent for the use of size-fits-all” approach to surgical correction does her image. not produce optimal results. Anatomical and neurologic considerations must be appreciated, in addition to velopharyngeal sphincter size and REFERENCES surgeon expertise. The pattern of velopharyngeal 1. Perry JL, Kuechn DP. Anatomy and physiology of the velo- sphincter closure is important in determining the pharynx. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. 2nd ed. Boca Raton, Fla: CRC Press; 2015:475–492. optimum surgical approach. Posterior pharyngeal 2. Kummer AW. Disorders of resonance and airflow second- flaps have proved superior in cases of circular or ary to cleft palate and/or velopharyngeal dysfunction. Semin sagittal closure, and sphincter pharyngoplasty has Speech Lang. 2011;32:141–149. proved superior in cases of coronal closure pat- 3. Sell D, Mildinhall S, Albery L, Wills AK, Sandy JR, Ness AR. terns and patients with preexisting obstructive The Cleft Care UK study. Part 4: Perceptual speech out- 78 comes. Orthod Craniofac Res. 2015;18(Suppl 2):36–46. sleep apnea. 4. Hopper RA, Tse R, Smartt J, Swanson J, Kinter S. Cleft palate At the Pittsburgh Cleft Craniofacial Cen- repair and velopharyngeal dysfunction. Plast Reconstr Surg. ter, we use video nasopharyngeal endoscopy, 2014;133:852e–864e.

5. Witt PD, D’Antonio LL. Velopharyngeal insufficiency and 25. Marsh JL. The evaluation and management of velopharyn- secondary palatal management: A new look at an old prob- geal dysfunction. Clin Plast Surg. 2004;31:261–269. lem. Clin Plast Surg. 1993;20:707–721. 26. Shprintzen RJ, Marrinan E. Velopharyngeal insufficiency: 6. Kummer AW, Marshall JL, Wilson MM. Non-cleft causes of Diagnosis and management. Curr Opin Otolaryngol Head Neck velopharyngeal dysfunction: Implications for treatment. Int J Surg. 2009;17:302–307. Pediatr Otorhinolaryngol. 2015;79:286–295. 27. Kummer AW. Speech evaluation for patients with cleft pal- 7. Paniagua LM, Signorini AV, Costa SS, Collares MV, Dornelles ate. Clin Plast Surg. 2014;41:241–251. S. Velopharyngeal dysfunction: A systematic review of major 28. Perry JL, Sutton BP, Kuehn DP, Gamage JK. Using MRI for instrumental and auditory-perceptual assessments. Int Arch assessing velopharyngeal structures and function. Cleft Palate Otorhinolaryngol. 2013;17:251–256. Craniofac J. 2014;51:476–485. 8. Golding-Kushner KJ, Argamaso RV, Cotton RT, et al. 29. Reisberg DJ. Prosthetic management of velopharyngeal dys- Standardization for the reporting of nasopharyngoscopy and function. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft multiview videofluoroscopy: A report from an International Care. 2nd ed. Boca Raton, Fla: CRC Press; 2015:1309–1320. Working Group. Cleft Palate J. 1990;27:337–347; discussion 347. 30. Grames LM. Speech therapy for the child with cleft palate. 9. Marsh JL. Management of velopharyngeal dysfunction: In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. 2nd Differential diagnosis for differential management. J ed. Boca Raton, Fla: CRC Press; 2015:569–580. Craniofac Surg. 2003;14:621–628; discussion 629. 31. Passavant G. Ueber die Beseitigung der naselnden Sprache 10. McWilliams BJ, Phillips BJ. Velopharyngeal Incompetence: Audio bei angeborenen Splaten des harten und weichen Gaumens Seminars in Speech Pathology. Philadelphia: Saunders; 1979. (Gaumensegel-Schlundnacht und Ruccklagerung des 11. Dudas JR, Deleyiannis FW, Ford MD, Jiang S, Losee JE. Gaumensegels). Arch Klin Chir. 1865;6:333–349. Diagnosis and treatment of velopharyngeal insufficiency: 32. Schoenborn K. Ueber eine neue Methode der Clinical utility of speech evaluation and videofluoroscopy. Staphylorrhaphie. Verh Dtsch Ges Chir. 1875;4:235–239. Ann Plast Surg. 2006;56:511–517; discussion 517. 33. Padgett EC. The repair of cleft palates after unsuccessful 12. Ysunza Y, Merson R. Videonasopharyngoscopy of the velo- operations with special reference to cases with an extensive pharyngeal sphincter during speech and swallowing. loss of palatal tissue. Arch Surg. 1930;20:453–472. In: Grange DM, ed. Endoscopy and Endoscopic Procedures: 34. Hogan VM. A clarification of the surgical goals in cleft pal- Management, Technologies and Methods of Improvement. New ate speech and the introduction of the lateral port control York: Nova Publishers; 2014. (l.p.c.) pharyngeal flap.Cleft Palate J. 1973;10:331–345. 13. Pigott RW, Bensen JF, White FD. Nasendoscopy in the diag- 35. Argamaso RV, Shprintzen RJ, Strauch B, et al. The role of lat- nosis of velopharyngeal incompetence. Plast Reconstr Surg. eral pharyngeal wall movement in pharyngeal flap surgery. 1969;43:141–147. Plast Reconstr Surg. 1980;66:214–219. 14. Woo AS. Velopharyngeal dysfunction. Semin Plast Surg. 36. Whitaker LA, Randall P, Graham WP III, Hamilton RW, 2012;26:170–177. Winchester R. A prospective and randomized series com- 15. Witzel MA, Posnick JC. Patterns and location of velopharyn- paring superiorly and inferiorly based posterior pharyngeal geal valving problems: Atypical findings on video nasopha- flaps.Cleft Palate J. 1972;9:304–311. ryngoscopy. Cleft Palate J. 1989;26:63–67. 37. Hamlen M. Speech changes after pharyngeal flap surgery. 16. Gilleard O, Sommerlad B, Sell D, Ghanem A, Birch M. Plast Reconstr Surg. 1970;46:437–444. Nasendoscopy: An analysis of measurement uncertainties. 38. Meek MF, Coert JH, Hofer SO, Goorhuis-Brouwer SM, Cleft Palate Craniofac J. 2013;50:351–357. Nicolai JP. Short-term and long-term results of speech 17. Gart MS, Gosain AK. Surgical management of velopharyn- improvement after surgery for velopharyngeal insuf- geal insufficiency.Clin Plast Surg. 2014;41:253–270. ficiency with pharyngeal flaps in patients younger and 18. Ysunza A, Chaiyasate K, Micale MA, et al. 22q11.2 deletion older than 6 years old: 10-year experience. Ann Plast Surg. detected by endoscopic observation of pharyngeal pulsa- 2003;50:13–17. tions in a child with submucous cleft palate and persistent 39. Wong KW, Klaiman PG, Forrest CR. Posterior pharyngeal velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol. flaps. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft 2014;78:1789–1794. Care. 2nd ed. Boca Raton, Fla: CRC Press; 2015:1133–1156. 19. Ysunza PA, Repetto GM, Pamplona MC, et al. Current contro- 40. Arneja JS, Hettinger P, Gosain AK. Through-and-through versies in diagnosis and management of cleft palate and velo- dissection of the soft palate for high pharyngeal flap inset: pharyngeal insufficiency.Biomed Res Int. 2015;2015:196240. A new technique for the treatment of velopharyngeal incom- 20. Skolnick ML. Videofluoroscopic examination of the velo- petence in velocardiofacial syndrome. Plast Reconstr Surg. pharyngeal portal during phonation in lateral and base 2008;122:845–852. projections: A new technique for studying the mechanics of 41. Smartt JM Jr, Gerety P, Serletti JM, Taylor JA. Application closure. Cleft Palate J. 1970;7:803–816. of a robotic telemanipulator to perform posterior pha- 21. Skolnick ML, McCall GN. Radiological evaluation of velo- ryngeal flap surgery: A feasibility study. Plast Reconstr Surg. pharyngeal closure. JAMA 1971;218:96. 2013;131:841–845. 22. Lam DJ, Starr JR, Perkins JA, et al. A comparison of nas- 42. Smartt JM Jr, Gerety P, Taylor JA. Robotic approaches to pal- endoscopy and multiview videofluoroscopy in assessing atoplasty and the treatment of velopharyngeal dysfunction. velopharyngeal insufficiency. Otolaryngol Head Neck Surg. Semin Plast Surg. 2014;28:32–34. 2006;134:394–402. 43. Agarwal T, Sloan GM, Zajac D, Uhrich KS, Meadows W, 23. Pigott RW. An analysis of the strengths and weaknesses of Lewchalermwong JA. Speech benefits of posterior pha- endoscopic and radiological investigations of velopharyn- ryngeal flap are preserved after surgical flap division for geal incompetence based on a 20 year experience of simulta- obstructive sleep apnea: Experience with division of 12 flaps. neous recording. Br J Plast Surg. 2002;55:32–34. J Craniofac Surg. 2003;14:630–636. 24. de Stadler M, Hersh C. Nasometry, videofluoroscopy, and 44. Katzel EB, Shakir S, Naran S, et al. Speech outcomes after the speech pathologist’s evaluation and treatment. Adv clinically indicated posterior pharyngeal flap takedown.Ann Otorhinolaryngol. 2015;76:7–17. Plast Surg. 2016;77:420–424.

45. Valnicek SM, Zuker RM, Halpern LM, Roy WL. Perioperative 63. Kao MC, Sie KC. Correction of velopharyngeal dysfunction complications of superior pharyngeal flap surgery in chil- by double-opposing Z-plasty. In: Losee JE, Kirschner RE, eds. dren. Plast Reconstr Surg. 1994;93:954–958. Comprehensive Cleft Care. 2nd ed. Boca Raton, Fla: CRC Press; 46. Fraulin FO, Valnicek SM, Zuker RM. Decreasing the peri- 2015:1125–1132. operative complications associated with the superior pharyn- 64. Kaye A, Kirschner RE. The Furlow double-opposing Z-plasty geal flap operation.Plast Reconstr Surg. 1998;102:10–18. repair for cleft palate. In: Losee JE, Kirschner RE, eds. 47. Swanson JW, Johnston JL, Mitchell BT, Alcorn K, Taylor JA. Comprehensive Cleft Care. 2nd ed. Boca Raton, Fla: CRC Press; Perioperative complications in posterior pharyngeal flap sur- 2015:943–958. gery: Review of the National Surgical Quality Improvement 65. Dailey SA, Karnell MP, Karnell LH, Canady JW. Comparison Program Pediatric (NSQIP-PEDS) Database. Cleft Palate of resonance outcomes after pharyngeal flap and Furlow dou- Craniofac J. 2016;53:562–567. ble-opposing z-plasty for surgical management of velopha- 48. Hynes W. Pharyngoplasty by muscle transplantation. Br J ryngeal incompetence. Cleft Palate Craniofac J. 2006;43:38–43. Plast Surg. 1950;3:128–135. 66. Wójcicki P, Wójcicka K. Prospective evaluation of the out- 49. Skoog T. The use of periosteal flaps in the repair of clefts of come of velopharyngeal insufficiency therapy after pha- the primary palate. Cleft Palate J. 1965;2:332–339. ryngeal flap, a sphincter pharyngoplasty, a double Z-plasty 50. Orticochea M. Construction of a dynamic muscle sphincter and simultaneous Orticochea and Furlow operations. J Plast in cleft palates. Plast Reconstr Surg. 1968;41:323–327. Reconstr Aesthet Surg. 2011;64:459–461. 51. Marsh JL, Gage EA. Sphincter pharyngoplasty. In: Losee 67. Jackson O, Stransky CA, Jawad AF, et al. The Children’s JE, Kirschner RE, eds. Comprehensive Cleft Care. 2nd ed. Boca Hospital of Philadelphia modification of the Furlow double- Raton, Fla: CRC Press; 2015:1157–1170. opposing Z-palatoplasty: 30-year experience and long-term 52. Abdel-Aziz M. Palatopharyngeal sling: A new technique speech outcomes. Plast Reconstr Surg. 2013;132:613–622. in treatment of velopharyngeal insufficiency. Int J Pediatr 68. Woo AS. The Furlow palatoplasty for velopharyngeal dysfunc- Otorhinolaryngol. 2008;72:173–177. tion: Velopharyngeal changes, speech improvements, and 53. Cheng N, Zhao M, Qi K, Deng H, Fang Z, Song R. A modified where they intersect. Cleft Palate Craniofac J. 2015;52:12–22. procedure for velopharyngeal sphincteroplasty in primary 69. Sullivan SR, Vasudavan S, Marrinan EM, Mulliken JB. cleft palate repair and secondary velopharyngeal incompe- Submucous cleft palate and velopharyngeal insufficiency: tence treatment and its preliminary results. J Plast Reconstr Comparison of speech outcomes using three operative tech- Aesthet Surg. 2006;59:817–825. niques by one surgeon. Cleft Palate Craniofac J. 2011;48:561–570. 54. Sader R, Zeilhofer HF, Putz R, Horch HH. Levatorplasty, a 70. Perkins JA, Lewis CW, Gruss JS, Eblen LE, Sie KC. Furlow pal- new technique to treat hypernasality: Anatomical investiga- atoplasty for management of velopharyngeal insufficiency: A tions and preliminary clinical results. J Craniomaxillofac Surg. prospective study of 148 consecutive patients. Plast Reconstr 2001;29:143–149. Surg. 2005;116:72–80; discussion 81–84. 55. Ragab A. Cerclage sphincter pharyngoplasty: A new 71. Perez CF, Brigger MT. Posterior pharyngeal wall augmenta- technique for velopharyngeal insufficiency. Int J Pediatr tion. Adv Otorhinolaryngol. 2015;76:74–80. Otorhinolaryngol. 2007;71:793–800. 72. Timbang MR, Gharb BB, Rampazzo A, Papay F, Zins J, Doumit 56. Vadodaria S, Mowatt D, Ramakrishnan V, Jacob S, G. A systematic review comparing Furlow double-opposing Freedlander E. Trans-nasal endo-assisted pharyngoplasty: A Z-plasty and straight-line intravelar veloplasty methods of cadaver study. Br J Plast Surg. 2004;57:418–422. cleft palate repair. Plast Reconstr Surg. 2014;134:1014–1022. 57. Sommerlad BC, Mehendale FV, Birch MJ, Sell D, Hattee C, 73. Nardini G, Flores RL. A systematic review comparing Furlow Harland K. Palate re-repair revisited. Cleft Palate Craniofac J. double-opposing z-plasty and straight-line intravelar velo- 2002;39:295–307. plasty methods of cleft palate repair. Plast Reconstr Surg. 58. Rottgers SA, Ford M, Cray J, et al. An algorithm for applica- 2015;135:927e–928e. tion of Furlow palatoplasty to the treatment of velocardiofa- 74. Lypka M, Bidros R, Rizvi M, et al. Posterior pharyngeal aug- cial syndrome-associated velopharyngeal insufficiency. Ann mentation in the treatment of velopharyngeal insufficiency: Plast Surg. 2011;66:479–484. A 40-year experience. Ann Plast Surg. 2010;65:48–51. 59. Hassan ME, Askar S. Does palatal muscle reconstruction 75. Bishop A, Hong P, Bezuhly M. Autologous fat grafting for the affect the functional outcome of cleft palate surgery? Plast treatment of velopharyngeal insufficiency: State of the art. J Reconstr Surg. 2007;119:1859–1865. Plast Reconstr Aesthet Surg. 2014;67:1–8. 60. Sie KC, Tampakopoulou DA, Sorom J, Gruss JS, Eblen LE. 76. Teixeira RP, Reid JA, Greensmith A. Fatty hypertrophy cause Results with Furlow palatoplasty in management of velopha- obstructive sleep apnea after fat injection for velopharyngeal ryngeal insufficiency.Plast Reconstr Surg. 2001;108:17–25; dis- incompetence. Cleft Palate Craniofac J. 2011;48:473–477. cussion 26–29. 77. Boneti C, Ray PD, Macklem EB, Kohanzadeh S, de la Torre 61. Deren O, Ayhan M, Tuncel A, et al. The correction of velo- J, Grant JH. Effectiveness and safety of autologous fat graft- pharyngeal insufficiency by Furlow palatoplasty in patients ing to the soft palate alone. Ann Plast Surg. 2015;74(Suppl older than 3 years undergoing Veau-Wardill-Kilner pala- 4):S190–S192. toplasty: A prospective clinical study. Plast Reconstr Surg. 78. Armour A, Fischbach S, Klaiman P, Fisher DM. Does velo- 2005;116:85–93; discussion 94–96. pharyngeal closure pattern affect the success of pharyngeal 62. Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. flap pharyngoplasty? Plast Reconstr Surg. 2005;115:45–52; Plast Reconstr Surg. 1986;78:724–738. discussion 53.