Research

Original Investigation Revision Rates and Speech Outcomes Following Pharyngeal Flap for Velopharyngeal Insufficiency

Dhave Setabutr, MD; Christina T. Roth, MS, CCC-SLP; David D. Nolen, MD; Brian Cervenka, MD; Jonathan M. Sykes, MD; Craig W. Senders, MD; Travis T. Tollefson, MD, MPH

IMPORTANCE Velopharyngeal insufficiency in children with cleft (and other causes) contributes to difficulty with communication and quality of life. The pharyngeal flap is a workhorse to address hypernasality and nasal air escape. However, there is a paucity of literature on the characteristics of cases that require revision.

OBJECTIVE To measure the revision rate of pharyngeal flaps, compare the preperceptual and postperceptual speech scores, and identify the characteristics of those patients who required revision.

DESIGN, SETTING, AND PARTICIPANTS A retrospective medical record review was completed for patients who underwent from June 1, 2008, through January 31, 2013, at a tertiary academic center.

MAIN OUTCOMES AND MEASURES Perceptual speech analyses and surgical revision rates. Perceptual speech patterns before and after surgery were compared using nasal air emission and resonance scores. The association between requiring revision surgery and covariates was analyzed using multivariable mixed-effects logistic regression.

RESULTS Sixty-one patients were identified, including 24 boys (39%) and 37 girls (61%). The mean (SD) patient age at the time of pharyngeal flap surgery was 8.2 (6.8) years (range, 3-55 years). Velopharyngeal insufficiency was associated with cleft palate in 51 patients (84%), and 17 patients (28%) had a syndrome. The mean (SD) time to surgery after the speech evaluation was 225 (229) days (range, 14-1341 days). The mean (SD) nasal air emission scores decreased by −1.1 (2.0 [1.1] preoperatively to 0.8 [1.1] postoperatively). The mean (SD) resonance score decreased by −1.5 (2.4 [1.1] preoperatively to 0.9 [1.1] postoperatively; P < .001). Flaps were revised in 12 patients (20%), including port revision in 9, complete flap revision in 2, and flap takedown in 1. The only covariate that was significantly associated with revision rates was increased age at surgery, which was associated with a higher probability of revision surgery (odds ratio, 1.31; 95% CI, 1.03-1.66; P = .04).

CONCLUSIONS AND RELEVANCE Pharyngeal flap surgery, when appropriately selected, was effective at improving speech with a revision rate of 20%, which is comparable to previously published studies. Increased age at the time of the pharyngeal flap surgery was associated with an increased need for revision surgery, supporting evidence that cleft centers should encourage early childhood speech evaluations with consistent documentation and prompt treatment.

Author Affiliations: Department of LEVEL OF EVIDENCE 3. Otolaryngology–Head and Neck Surgery, University of California, Davis, Sacramento. Corresponding Author: Travis T. Tollefson, MD, MPH, Department of Otolaryngology–Head and Neck Surgery, University of California, Davis, 2521 Stockton Blvd, Ste 7200, Sacramento, CA 95817 JAMA Facial Plast Surg. 2015;17(3):197-201. doi:10.1001/jamafacial.2015.0093 ([email protected] Published online April 2, 2015. .edu).

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elopharyngeal dysfunction (VPD) necessitating sur- large may narrow the nasal airway and require flap take- gery occurs in approximately 15% to 45% of patients down. Patients are followed up clinically for OSA symptoms, V with a cleft palate after primary .1 During which would warrant a sleep study. phonation, the velopharyngeal closure pattern contributes to Some patient characteristics (eg, cleft size or timing of pri- balanced oronasal resonance.2 Velopharyngeal insufficiency mary palatoplasty) have been investigated in patients with per- (VPI) describes the inability to close the velopharyngeal sphinc- sistent VPI after speech surgery, but specific characteristics that ter because of an anatomical or structural deficit during the may predispose patients to revision pharyngeal flap are sparsely production of oral sounds during speech. Complete closure ne- reported.4,16 Bohm et al17 compared surgical and perceptual cessitates coordinated movement of the soft palate and the lat- speech outcomes in patients treated with pharyngeal flap, eral and posterior pharyngeal walls.3 Patients with VPI pre- sphincter pharyngoplasty, or combined Furlow palatoplasty sent with nasal air escape and hypernasality during phonation. and sphincter pharyngoplasty. Better speech outcomes were The patient’s quality of life can be negatively affected by de- noted after pharyngeal flap or combined sphincter and Fur- creased overall speech intelligibility from VPI.4 low procedures compared with the sphincter pharyngoplasty The pharyngeal flap came into common use by surgeons in alone; however, the patients who underwent pharyngeal flap the 1950s, although Schoenborn originally described it as early required more revisions (29%). as 1876.5 Today it remains one of the most commonly used There is a paucity of literature on the characteristics of speech operations for VPI.6 The goal of a successful pharyn- those patients with VPI who undergo revision of their pri- geal flap is to create a central subtotal velopharyngeal obstruc- mary pharyngeal flap surgery. The objectives of this study were tion. Residual nasal airflow passes through lateral ports be- to (1) measure the revision rate noted in this sample popula- tween the oral and nasal cavities.5 The size and placement of tion, (2) compare the preperceptual and postperceptual speech the pharyngeal flap are chosen to maintain nasal airflow while scores, and (3) identify the characteristics of those patients who facilitating velopharyngeal closure for speech. The lateral pha- required revision. ryngeal wall movement controls the airflow through these ports. In 2008, Cole et al7 reviewed their experience with 222 con- secutive patients undergoing pharyngeal flap surgery and con- Methods cluded that the flap was a safe and reliable option with rela- tively rare complications. Apart from having a favorable safety After University of California, Davis, institutional review board profile, the pharyngeal flap was effective in improving speech approval, we performed a retrospective review of all patients outcomes, which is equally supported with published im- with VPI who underwent a superiorly based pharyngeal flap provements in perceptual and objective analysis.8-10 performed by surgeons on the University of California, Davis, The evaluation of a patient with repaired cleft palate in- cleft team (J.M.S., C.W.S., and T.T.T.) from June 1, 2008, through cludes perceptual speech assessment by a trained speech- January 31, 2013. Exclusion criteria included lack of 12 months language pathologist with familiarity with patients with cleft.11 of postoperative follow-up, previous pharyngeal flap at an out- Speech-language pathologists typically identify and docu- side institution, or other secondary speech surgery proce- ment resonance, nasal air emission (NAE), consonant produc- dure (eg, sphincter pharyngoplasty or Furlow double- tion errors, speech intelligibility, and speech acceptability.12 opposing z-plasty palatoplasty). Data points included age, sex, Speech articulation errors may be adequately addressed with presence of syndrome, comorbidities, need for revision sur- the use of intensive speech therapy. gery, age at time of surgery, age at time of revision, time be- Hypernasality and VPI, on the other hand, often require tween speech evaluation and flap surgery, and the standard- surgical management. The speech-language pathologist and ized preoperative and postoperative perceptual speech cleft surgeon complete a standardized VPD evaluation. The ve- evaluations. lopharyngeal closure pattern is assessed with standardized na- sopharyngeal endoscopy and the treatment plan jointly Operative Technique formulated.13 At our institution, the secondary speech sur- All surgeons used the following surgical technique for the su- gery treatment is planned based on the VPD evaluation. The periorly based pharyngeal flap (with only minor variations). velopharyngeal closure pattern and size of the velopharyn- and adenoidectomy are completed approxi- geal gap are 2 of the factors that guide the surgical plan to mately 3 months before the flap. The velum is split in the mid- include (1) pharyngeal flap (large central gap with sagittal clo- line to the level of the hard palate. The triangular, nasal myo- sure and adequate lateral wall movement), (2) Furlow double- mucosal flaps are elevated and hinged posteriorly to determine opposing z-plasty palatoplasty (small central gap with notched the port size on either side. Red rubber catheters are placed soft palate, indicating levator veli palatini malpositioning), or oronasally and exchanged for stents (endotracheal tubes or (3) sphincter pharyngoplasty (coronal closure pattern). nasopharyngeal trumpets) to determine the port size. The The pharyngeal flap is designed to fit the defect seen on pentagon-shaped, superiorly based myomucosal pharyngeal nasopharyngeal endoscopy as described by Shprintzen et al.14,15 flap is elevated in the plane above the prevertebral fascia The choice of the flap size must include respect for the poten- and elevated as high into the nasopharynx as possible (with tial unintended consequence of nasal obstruction and obstruc- care to protect the torus tubarius). The pharyngeal flap is tive (OSA). Thus, if too small of a flap is chosen, a then inset into the oral and nasal flaps and the palatal split revision procedure may be necessary, whereas a flap that is too reconstructed.

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Table 1. Severity Scale for Nasal Air Emission and Resonance Table 2. Patient Demographic and Surgical Characteristics

Score Definition Characteristic All Patients (N = 61)a 0 Within normal limits Sex, No. 1 Mild Male 34 2 Mild to moderate Female 27 3 Moderate Age at surgery, y 4 Moderate to severe Mean (SD) 8.2 (6.8) 5 Severe Median (range) 7 (3-55) Cleft palate type, No. (%) None 10 (16) Speech Assessment Submucous 6 (10) Standardized preoperative perceptual speech assessment and Soft palate–uvula 2 (3) VPD assessment with nasopharyngoscopy was documented by Soft palate 4 (7) the cleft team speech-language pathologist and surgeon. The Partial hard palate 15 (25) NAE and resonance severities were graded using the vali- Complete unilateral 16 (26) dated Pittsburgh Weighted Values for Speech Symptoms As- Complete bilateral cleft palate 8 (13) 18 sociated with Velopharyngeal Incompetence Instrument Syndrome, No. (%) (Table 1). The resonance severity is scored as follows: 0, within No 44 (72) acceptable limits; 1, mild hypernasality; 2, mild to moderate Yes 17 (28) hypernasality; 3, moderate hypernasality; 4, moderate to se- Time to surgery after speech evaluation, db vere hypernasality; and 5, severe hypernasality. Hyponasal Mean (SD) 225 (229) resonance was assigned a score of 0 and mixed resonance a Median (range) 168 (14-1341) score of 2 as per the protocol.19 Revision surgery, No. (%) The secondary speech surgery plan is developed by the No 49 (80) consistent interdisciplinary team evaluation, which included at least the following factors: perceptual speech evaluation, Yes 12 (20) nasopharyngeal closure pattern seen on nasopharyngeal en- a Data are presented as number (percentage) of patients unless otherwise doscopic examination, previous surgical treatments, palatal indicated. b length, comorbidities, and airway obstruction symptoms. Data available for 57 patients.

Statistical Analysis quence was seen in 9 patients. Seventeen patients (28%) had The NAE and resonance scores before and after surgery were been diagnosed as having a syndrome or developmental or neu- compared using paired t tests. The association between re- rologic deficit that could affect velopharyngeal function. The quiring revision surgery and patient characteristics was ana- most common condition was velocardiofacial syndrome (n = 7), lyzed using multivariable mixed-effects logistic regression, in- followed by developmental delay (n = 4), Stickler syndrome cluding a random effect for surgeon in the model. Confounding (n = 3), cerebral palsy (n = 1), Kabuki syndrome (n = 1), and Dia- clinical characteristics were selected based on a priori knowl- mond-Blackfan syndrome (n = 1). The mean (SD) time to sec- edge. Analyses were conducted using the statistical software ondary speech surgery (which includes time before tonsillec- environment R, version 3.1.1. The mixed-effects logistic re- tomy and adenoidectomy and ≥90 days healing time before gression model was fitted using the R function glmmPQL. pharyngeal flap surgery) after the perceptual speech evalua- tion was 225 (229) days (range, 14-1341 days).

Results Speech Outcomes Complete presurgery and postsurgery perceptual speech data Patient Demographics sets were available for 37 patients. Table 3 gives the preopera- After exclusion criteria, 61 patients with surgically managed tive and postoperative speech outcomes. The preoperative NAE VPI were identified. Table 2 gives the demographic and surgi- and resonance scores were 3 or higher (moderate to severe) in cal characteristics for all patients. The mean (SD) age was 8.2 16 (43%) of 37 patients and 19 (51%) of 37 patients. All patients (6.8) years (range, 3-55 years), including 34 boys (39%) and 27 who did not require revision surgery had a decrease or no girls (61%). Fifty-one (84%) had undergone an orofacial cleft change in the NAE and resonance scores after surgery. The NAE and previous palatoplasty, whereas 10 patients (16%) had VPI and resonance scores decreased significantly after surgery. The of a noncleft origin. Complete clefts of the hard palate were mean (SD) preoperative NAE score of 2.0 (1.1) decreased to 0.8 the most common, occurring in 16 patients (26%), followed by (1.1) postoperatively. The mean (SD) resonance score of 2.4 (1.1) partial clefts of the hard palate in 15 patients (25%), bilateral decreased to 0.9 (1.1) (P < .001). complete cleft lip and palate in 8 patients (13%), submucous Revision pharyngeal flap surgery was completed in 12 pa- cleft palate in 6 patients (10%), soft palate clefts in 4 patients tients (20%) with port revisions in 9, complete flap revisions (7%), and cleft of the uvula in 2 patients (3%). Pierre Robin se- in 2, and flap takedown in 1 (due to OSA). Eleven of these 12

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increased. The mean age of patients at time of pharyngeal flap Table 3. Speech Outcomesa in our study is significantly older than the recommended age, No. of Mean (SD) Mean Score P which is typically 4 to 6 years old.14,15 At this age, the child’s Time Point Patientsb Score Change Valuec Nasal airway emission ability to cooperate with nasopharyngeal endoscopy and ac- Preoperative 37 2.0 (1.1) quisition of consistent speech samples is the rate-limiting step, <.001 but earlier interventions seem to be related with better speech Postoperative 37 0.8 (1.1) −1.1 outcomes. Fukushiro and Trindade9 suggested that patients Resonance 6 to 12 years of age had better outcomes than their older coun- Preoperative 37 2.4 (1.1) <.001 terparts. Our study also has an older age range and mean age Postoperative 37 0.9 (1.1) −1.5 forpatientsatthetimeofpharyngealflapthanthestudyby a Nasal airway emission and resonance as graded in the perceptual speech Bohm et al,17 who found a mean (SD) patient age of pharyn- evaluation. geal flap surgery of 7.3 (3.6) years (range, 3.1-15.6 years). b Patients with both preoperative and postoperative data. Older children who had not had adequate velopharyngeal c Paired t test. port function with which to develop balanced resonance and the oral air pressure needed for speech sounds are unable to re- Table 4. Multivariable Mixed-Effects Logistic Regression Analysis train their developed speech patterns after surgery. Several fac- of Revision tors may have contributed to the increased age and the pro- Covariate Odds Ratio (95% CI) P Value longed time from speech assessment to surgery in our sample Age at surgery 1.31 (1.03-1.66) .04 population, which may include medical comorbidities, poor fa- Cleft type 1.40 (0.81-2.43) .26 milial adherence and follow-up due to socioeconomic re- Syndrome (yes vs no) 0.28 (0.03-2.56) .29 straints, and overseas adoptions of older children who present Preoperative score with unrepaired primary cleft palate. Late primary palato- Nasal airway emission 0.62 (0.26-1.48) .32 plasty increases VPI rates and deserves additional research 17 Resonance 1.34 (0.59-3.06) .51 attention. Surgeons and speech-language pathologists should counsel at-risk patients and families on the increased risks as- Time to surgery after speech evaluation 0.99 (0.98-1.00) .10 sociated with increasing age. The flap revision rate may be related to increasing age in this patients underwent further surgery secondary to persistent study, but a better or worse speech outcome was not identified VPI, which was not adequately improved as measured by the with increasing age. The revision rate included predominantly NAE and resonance scores in the perceptual speech evalua- port revisions. One could surmise that surgical factors, which tion. Of these revisions, none had velocardiofacial syndrome were uncommon, influenced the need for a complete flap re- or another syndrome. One pharyngeal flap was divided in a vision. These factors may include wound healing, surgical tech- middle-aged adult with VPD of unknown cause. Postopera- nique, infection, or patient dietary adherence, which could be tive nasal airway obstruction and sleep apnea were resolved addressed in a large cohort study. after division. A few potential explanations for the observed effect of in- The association between requiring revision surgery and pa- creasing age on an increased flap revision rate can be hypoth- tient characteristics was analyzed using multivariable mixed- esized but not proved with this study. These explanations may effects logistic regression, including a random effect for sur- include the following: (1) longer exposure to the inability to cre- geon in the model. The model was fitted with the following ate adequate velopharyngeal function, limiting the develop- covariates: age at surgery, cleft type, presence of syndrome, ment of balanced resonance and the oral air pressure needed and time to surgery after speech evaluation. Table 4 gives the for speech sounds to train the speech patterns; (2) delayed flap results of the multivariable mixed-effects logistic regression surgery, a secondary effect of children waiting until a later date analysis of revision. Increased age at surgery was associated for their pharyngeal flap surgery because of outstanding cir- with a higher probability of revision surgery (odds ratio, 1.31; cumstances as described above; and (3) potential increased 95% CI, 1.03-1.66; P = .04). Other covariates were not signifi- pharyngeal muscular strength capable of affecting the flap’s cantly associated with requiring revision surgery. Presence of healing in older patients and possible nonadherence of an adult a syndrome (eg, velocardiofacial syndrome) was not associ- who can choose his or her own diet, thereby affecting the vi- ated with revision surgery. ability of the flap. A dreaded secondary effect of pharyngeal flap is OSA. In this series, only one adult developed symptomatic nasal ob- Discussion struction and sleep apnea symptoms. Children and adults are at risk for OSA after a pharyngeal flap. Liao et al19 reported no The results of this study are consistent with and extend from association between the width of the pharyngeal flap and re- previous reports5,17 on the effectiveness of speech improve- sulting severity of OSA. We prefer to completely take down the ment and revision rates after pharyngeal flap. Although NAE flap in the setting of OSA, although others may selectively open and resonance scores improved after pharyngeal flap proce- the port size as a first step. dures, a higher likelihood of needing revision surgery was seen This analysis of our cleft center’s experience has limita- as age of the patient at the time of the pharyngeal flap surgery tions that affect the generalizability of the results to other cen-

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ters that may prefer other procedures (eg, sphincter pharyn- and surgeon evaluation. The cleft team social workers will goplasty). Specifically, there is an aspect of selection bias also be automatically notified to contact patients and families because we only evaluated patients who underwent pharyn- who miss follow-up appointments. geal flap surgery, excluding those patients who underwent sphincter pharyngoplasty or double-opposing z-plasty for VPI. A future study could evaluate the speech outcomes and co- Conclusions variates among centers that have different preferences. We are also interested in reducing variability and bias Velopharyngeal insufficiency is effectively treated with pha- and have incorporated a masked surgeon and speech- ryngeal flap surgery with a comparable revision rate (20%) language pathologist evaluation for future prospective to similarly published reports. Older age at the time of pha- speech perception and surgical outcome evaluations. Pro- ryngeal flap was related to an increased need for revision spectively collected perceptual speech analysis, which is surgery, which supports the consistent, standardized per- recorded and reviewed in a masked setting, has been imple- ceptual speech evaluation of children with repaired cleft mented at our center to improve the structured documenta- palate to allow appropriate intervention during speech tion. Objective data collection with videotaped speech development. Possible confounding variables, such as over- assessments, nasometry, and standardized data collection for seas adoptions, socioeconomic limitations, and inconsistent the electronic medical record should allow future compara- speech assessments, may affect the timing of surgery. Cleft tive studies. In a proactive step set to improve consistent centers may implement systems improvements to docu- speech evaluation follow-up, we are developing an electronic ment consistent speech assessments and encourage cleft meta-registry. This added redundancy in the cleft team follow-up in these children to allow early identification and scheduling system will send reminders for concurrent speech treatment.

ARTICLE INFORMATION 2. Barbosa DA, Scarmagnani RH, Fukushiro AP, 11. Rudnick EF, Sie KC. Velopharyngeal Accepted for Publication: January 5, 2015. Trindade IE, Yamashita RP. Surgical outcome of insufficiency: current concepts in diagnosis and pharyngeal flap surgery and intravelar veloplasty on management. Curr Opin Otolaryngol Head Neck Surg. Published Online: April 2, 2015. the velopharyngeal function. Codas. 2013;25(5): 2008;16(6):530-535. doi:10.1001/jamafacial.2015.0093. 451-455. 12. Henningsson G, Kuehn DP, Sell D, Sweeney T, Author Contributions: Drs Tollefson and Setabutr 3. Skolnick ML, Shprintzen RJ, McCall GN, Rakoff S. Trost-Cardamone JE, Whitehill TL; Speech had full access to all the data in the study and take Patterns of velopharyngeal closure in subjects with Parameters Group. Universal parameters for responsibility for the integrity of the data and the repaired cleft palate and normal speech: reporting speech outcomes in individuals with cleft accuracy of the data analysis. a multi-view videofluoroscopic analysis. Cleft Palate palate. Cleft Palate Craniofac J. 2008;45(1):1-17. Study concept and design: Setabutr, Roth, Nolen, J. 1975;12:369-376. doi:10.1597/06-086.1. Sykes, Tollefson. Acquisition, analysis, or interpretation of data: 4. Leclerc JE, Godbout A, Arteau-Gauthier I, 13. Golding-Kushner KJ, Argamaso RV, Cotton RT, Setabutr, Roth, Nolen, Cervenka, Senders, Lacour S, Abel K, McConnell EM. We can predict et al. Standardization for the reporting of Tollefson. postpalatoplasty velopharyngeal insufficiency in nasopharyngoscopy and multiview Drafting of the manuscript: Setabutr, Tollefson. cleft palate patients. Laryngoscope. 2014;124(2): videofluoroscopy: a report from an International Critical revision of the manuscript for important 561-569. Working Group. Cleft Palate J. 1990;27(4):337-347. intellectual content: All authors. 5. Witt PD, Myckatyn T, Marsh JL. Salvaging the 14. Shprintzen RJ, Lewin ML, Croft CB, et al. Statistical analysis: Cervenka, Tollefson. failed pharyngoplasty: intervention outcome. Cleft A comprehensive study of pharyngeal flap surgery: Administrative, technical, or material support: Palate Craniofac J. 1998;35(5):447-453. tailor made flaps. Cleft Palate J. 1979;16(1):46-55. Setabutr, Roth, Cervenka, Sykes, Tollefson. 6. Armour A, Fischbach S, Klaiman P, Fisher DM. 15. Shprintzen RJ. Conceptual framework for Study supervision: Setabutr, Senders, Tollefson. Does velopharyngeal closure pattern affect the pharyngeal flap surgery. In: Bardach J, Morris HL, Conflict of Interest Disclosures: None reported. success of pharyngeal flap pharyngoplasty? Plast eds. Multidisciplinary Management of Cleft and Funding/Support: This study was supported by Reconstr Surg. 2005;115(1):45-52. Palate. Philadelphia, PA: WB Saunders; 1990: grant UL1 TR000002 from the National Center for 7. Cole P, Banerji S, Hollier L, Stal S. Two hundred 806-809. Advancing Translational Sciences, National twenty-two consecutive pharyngeal flaps: an 16. Zhao S, Xu Y, Yin H, et al. Incidence of Institutes of Health. analysis of postoperative complications. JOral postoperative velopharyngeal insufficiency in late Role of the Funder/Sponsor: The funding source Maxillofac Surg. 2008;66(4):745-748. palate repair. J Craniofac Surg. 2012;23(6):1602-1606. had no role in the design and conduct of the study; 8. Morris HL, Bardach J, Jones D, Christiansen JL, 17. Bohm LA, Padgitt N, Tibesar RJ, Lander TA, collection, management, analysis, and Gray SD. Clinical results of pharyngeal flap surgery: Sidman JD. Outcomes of combined Furlow interpretation of the data; preparation, review, or the Iowa experience. Plast Reconstr Surg. 1995;95 palatoplasty and sphincter pharyngoplasty for approval of the manuscript; and the decision to (4):652-662. velopharyngeal insufficiency. Otolaryngol Head submit the manuscript for publication. 9. Fukushiro AP, Trindade IEK. Nasometric and Neck Surg. 2014;150(2):216-221. Disclaimer: The content is solely the responsibility aerodynamic outcome analysis of pharyngeal flap 18. McWilliams BJ, Philips BJ. Velopharyngeal of the authors and does not necessarily represent surgery for the management of velopharyngeal Incompetence: Audio Seminars in Speech Pathology. the official views of the National Institutes of insufficiency. J Craniofac Surg. 2011;22(5):1647-1651. Philadelphia, PA: WB Saunders; 1979. Health. 10. de Buys Roessingh AS, Cherpillod J, 19. Liao YF, Chuang ML, Chen PKT, Chen NH, Yun C, Trichet-Zbinden C, Hohlfeld J. Speech outcome Huang CS. Incidence and severity of obstructive REFERENCES after cranial-based pharyngeal flap in children born sleep apnea following pharyngeal flap surgery in 1. Abdel-Aziz M, El-Hoshy H, Ghandour H. with total cleft, cleft palate, or primary patients with cleft palate. Cleft Palate Craniofac J. Treatment of velopharyngeal insufficiency after velopharyngeal insufficiency. J Oral Maxillofac Surg. 2002;39(3):312-316. cleft palate repair depending on the velopharyngeal 2006;64(12):1736-1742. closure pattern. J Craniofac Surg. 2011;22(3):813-817.

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