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PEDIATRIC/CRANIOFACIAL Pharyngeal Flap Outcomes in Nonsyndromic Children with Repaired Cleft Palate and Velopharyngeal Insufficiency Stephen R. Sullivan, M.D., Background: Velopharyngeal insufficiency occurs in 5 to 20 percent of children M.P.H. following repair of a cleft palate. The pharyngeal flap is the traditional secondary Eileen M. Marrinan, M.S., procedure for correcting velopharyngeal insufficiency; however, because of M.P.H. perceived complications, alternative techniques have become popular. The John B. Mulliken, M.D. authors’ purpose was to assess a single surgeon’s long-term experience with a Boston, Mass.; and Syracuse, N.Y. tailored superiorly based pharyngeal flap to correct velopharyngeal insufficiency in nonsyndromic patients with a repaired cleft palate. Methods: The authors reviewed the records of all children who underwent a pharyngeal flap performed by the senior author (J.B.M.) between 1981 and 2008. The authors evaluated age of repair, perceptual speech outcome, need for a secondary operation, and complications. Success was defined as normal or borderline sufficient velopharyngeal function. Failure was defined as borderline insufficiency or severe velopharyngeal insufficiency with recommendation for another procedure. Results: The authors identified 104 nonsyndromic patients who required a pharyngeal flap following cleft palate repair. The mean age at pharyngeal flap surgery was 8.6 Ϯ 4.9 years. Postoperative speech results were available for 79 patients. Operative success with normal or borderline sufficient velopharyngeal function was achieved in 77 patients (97 percent). Obstructive sleep apnea was documented in two patients. Conclusion: The tailored superiorly based pharyngeal flap is highly successful in correcting velopharyngeal insufficiency, with a low risk of complication, in non- syndromic patients with repaired cleft palate. (Plast. Reconstr. Surg. 125: 290, 2010.) peech to a pediatric plastic surgeon should If the velopharyngeal sphincter is incompetent, be like vision to an ophthalmologist. Normal speech is characterized by hypernasal resonance, velopharyngeal closure, the goal of palato- possible audible nasal emission, and decreased in- S 2,3 plasty, depends on dynamic apposition of the ve- traoral pressure for pressure consonants. These lum and lateral and posterior pharyngeal walls. audible hallmarks of an incompetent velopharyn- The velopharyngeal sphincter opens to allow nasal geal sphincter (known as velopharyngeal insuffi- respiration and transmission of acoustic energy ciency) are found in 5 to 20 percent of patients 4–12 into the nasal cavities for nasal consonant produc- following repair of a cleft palate. tion (n, m, and ng in English). The sphincter closes Secondary operations to correct velopharyngeal to prevent nasal airflow and acoustic energy into insufficiency include pharyngeal flap, sphincter pha- the nasal cavities during oral sound production ryngoplasty, double-opposing Z-palatoplasty, and and to prevent food and liquid from entering the palatal muscle retropositioning. The superiorly nose during swallowing.1,2 based pharyngeal flap, with width tailored to lateral pharyngeal wall motion, is considered to be the From the Department of Plastic and Oral Surgery and the Craniofacial Centre, Children’s Hospital and Harvard Med- ical School, and the Central New York Cleft and Craniofacial Center, Upstate Medical University Hospital. Disclosure: None of the authors has any commer- Received for publication May 27, 2009; accepted July 28, cial associations, supporting funds, or financial 2009. disclosures that might pose or create a conflict of Copyright ©2009 by the American Society of Plastic Surgeons interest with information presented in this article. DOI: 10.1097/PRS.0b013e3181c2a6c1 290 www.PRSJournal.com Volume 125, Number 1 • Pharyngeal Flap Speech Outcomes standard treatment, with reported long-term suc- ciated with velopharyngeal insufficiency (e.g., cess rates of 78 to 98 percent.13–23 The goal of the glottal stops, pharyngeal fricatives, and laryngeal pharyngeal flap procedure is to enable velopha- fricatives) were identified and a therapeutic plan ryngeal closure for speech without causing ob- outlined to eliminate these patterns and to establish struction of the upper airway. This is a delicate normal oral placement for consonant production. balance, as a pharyngeal flap that is too wide can Speech assessment was based on three struc- lead to nasopharyngeal obstruction and sleep ap- turally correctable variables: resonance (nor- nea; this complication has been reported to occur mal, hyponasal, mixed hyponasal/hypernasal, in up to 20 percent of patients.17,20,24–28 Another mildly hypernasal, moderately hypernasal, or se- untoward effect of a pharyngeal flap is hypona- verely hypernasal), intraoral pressure (normal sality in 5 to 27 percent of patients.15–17,20,22,24 On or decreased), and nasal emission (normal, visi- the other end of the spectrum, a pharyngeal flap ble, audible, or turbulent). Overall velopharyn- that is too narrow may fail to correct velopharyn- geal competence was graded as follows: (1) nor- geal insufficiency.19 For these reasons, sphincter mal (normal or mildly hyponasal resonance, pharyngoplasty, double-opposing Z-palatoplasty, absence of visible nasal emission by mirror exam- and palatal muscle retropositioning have in- ination, and normal intraoral pressure); (2) bor- creased in popularity. derline sufficiency (inconsistent mildly hyperna- Our purpose was to audit a single surgeon’s sal, visible or inconsistent audible nasal emission, long experience using a tailored superiorly based normal intraoral pressure, and no personal or so- pharyngeal flap as a secondary operation to cor- cial problems); (3) borderline insufficiency (con- rect velopharyngeal insufficiency in nonsyn- sistent mildly hypernasal resonance, audible or dromic children with a repaired cleft palate. The turbulent nasal emission or inconsistent de- outcome measures were perceptual speech results creased intraoral pressure, and a personal or so- and complications. cial problem); and (4) insufficiency (moderate or severe hypernasal resonance, audible or turbulent PATIENTS AND METHODS nasal emission, and decreased intraoral pressure). All patients underwent preoperative multiview Patient Population videofluoroscopy. Patients usually must be 4 to 5 After approval by the Institutional Review years of age or older to participate in Board of the Committee on Clinical Investigation, videofluoroscopy.9,23,30,31 The plastic surgeon and we identified and reviewed the charts of all pa- speech pathologist reviewed the studies together tients who had a palatoplasty and were subse- before final consideration for a pharyngeal flap. quently diagnosed with velopharyngeal insuffi- The lateral pharyngeal wall motion (estimated ciency and treated with a pharyngeal flap under percentage of velopharyngeal sphincter closure by the supervision of the senior author (J.B.M.) at medial movement of the lateral walls), symmetry Children’s Hospital Boston between 1981 and of lateral wall motion, palatal length (very short, 2008 (n ϭ 72). Children who had primary pala- short, normal, or long), velopharyngeal gap size toplasty executed by another surgeon or at an- (pinhole, small, moderate, or gross), and defect other institution were also included (n ϭ 32). pattern (coronal, sagittal, or circular) were con- Exclusion criteria were submucous cleft palate, sidered in planning flap width (narrow, medium, identified syndrome/association, and Robin se- wide, very wide, or subobstructing).14,22,32 An oto- quence. Data collected included birth date, sex, rhinolaryngologist evaluated the tonsils preoper- hearing loss, cleft palate type, age at pharyngeal atively; tonsillectomy was performed at least 8 flap surgery, preoperative and postoperative weeks before the pharyngeal flap if tonsils were speech assessment, videofluoroscopic results, enlarged (2ϩ or greater). Thirty-seven of 104 chil- postoperative complications, history of tonsillec- dren (36 percent) had a tonsillectomy and 10 (10 tomy or adenoidectomy or both, recommenda- percent) also had an adenoidectomy. tion for another corrective procedure, and inter- val to most recent follow-up evaluation. A speech pathologist, specializing in cleft pal- Operative Technique ate, completed a preoperative perceptual speech The technique was modified from methods assessment on each patient using the Pittsburgh described previously.18,22,33–35 The velum was split Weighted Values for Speech Symptoms Associated in the midline from the uvula to approximately with Velopharyngeal Incompetence instrument.29 halfway to the hard palatal junction. Trapezoid- Deviant compensatory articulation patterns asso- shaped nasal mucosal flaps were incised and sep- 291 Plastic and Reconstructive Surgery • January 2010 arated from the oral mucosa of the velum. A su- as mean Ϯ SD. We compared proportions of pre- periorly based flap (narrow, medium, wide, very operative and postoperative speech characteristics wide, or subobstructing)14,22,32 was elevated off the using Fisher’s exact test. We used the Wilcoxon buccopharyngeal fascia to above the level of the signed rank test to compare preoperative and post- soft palate. Flap dimension was determined by operative Pittsburgh Weighted Values scores.29 All lateral pharyngeal wall motion and was relative to calculated p values were two-tailed and considered the size of the pharynx. The differences between significant for values of p Ͻ
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