eMedicine Specialties > Plastic Surgery > Craniofacial
Craniofacial, Pharyngoplasty and Pharyngeal Flaps: Treatment
Updated: Feb 23, 2009
Treatment
Medical Therapy
Acquisition of objective, quantitative, preoperative, and postoperative evaluation data allows for a rational informed decision regarding surgical and nonsurgical intervention. Determining the precise etiology of the velopharyngeal dysfunction (VPD) is paramount prior to embarking on treatment modalities.
Van Demark and Hardin discussed the effectiveness of exclusive articulation therapy in children with cleft palate and noted less improvement and slower improvement then expected.8 Perceptual speech evaluation by a qualified speech pathologist who has experience and expertise in cleft pathology is the mainstay of any evaluation and ongoing treatment, since the goal of therapy is the ability to communicate successfully using speech. In patients with cleft palate, residual articulation abnormalities associated with hypernasality should be corrected after palate closure but before secondary surgery for VPD. Ruscello reviewed nonsurgical palatal training procedures such as articulation therapy, sucking and blowing exercises, electrical and tactile stimulation, speech appliances, and biofeedback techniques.9 Learned compensatory misarticulations must be addressed and corrected through focused intervention with a trained speech pathologist.
The prosthetic speech bulb is most useful in patients with little or no VP motion. VP movement is essential to surgical success for the VP flap procedure or sphincteroplasty. Patients with little VP movement are good candidates for prosthetic management. A VP speech prosthesis can elevate the velum (lift), fill the residual velopharyngeal gap (obturator), or both (lift-orator).
A lift is usually effective in patients with a long supple velum and a normal ratio of velar length to nasopharyngeal depth with myoneural dysfunction. An obturator is usually necessary when the velum is short and scarred, and the ratio of velar length to nasopharyngeal depth is excessive, such as seen in some patients with repaired cleft palate. A combined prosthesis is useful when elevation of the velum alone is not sufficient to achieve closure. Such speech prostheses are fit under endoscopic control with an interdisciplinary team, which includes a prosthodontist, a speech/language pathologist, and an endoscopist.
One study that compared speech outcomes using prosthetic versus surgical management showed no difference for patients who complied with the prosthesis.10 However, because nearly 30% of patients referred for prosthesis did not comply, surgery was more efficacious overall.
Surgical Therapy
The goals of surgery are to eliminate the symptoms of hypernasality and eliminate audible nasal emissions without causing complete obstruction of the VP port, allowing for nasal breathing and nasal resonance. Multiple procedures have been described. Studies indicate that the success of repair depends on selecting the appropriate procedure based on the anatomy and the movement of the VP port.
Pharyngeal flap
The pharyngeal flap has been the most common method for secondary management of VPD for the past 3 decades. This procedure seems to benefit patients with satisfactory lateral pharyngeal wall motion with sagittal or circular closure patterns who have a residual velopharyngeal gap of moderate size. Tissue from the posterior pharyngeal wall is attached to the soft palate, creating a midline subtotal obstruction of the oral and nasal cavities with 2 small lateral openings, or ports, that ideally remain patent during respiration and nasal consonant production and close for oral consonants.
The soft palate is incised in the sagittal midline from the uvula toward the junction of the soft and hard palate. The superiorly based pharyngeal flap is elevated off the prevertebral fascia. The flap is inset to the soft palate and sutured to the nasal side of the soft palate with interrupted sutures. The donor site is partially closed with 3-0 Vicryl sutures. Nasopharyngeal airways are placed through each lateral pharyngeal port for sizing and postoperative airway support. With the flap inset and the nasal side closed, the soft palate musculature is further dissected and approximated as indicated. The oral side of the soft palate is then closed with interrupted sutures (see Image 2).
Through the years, several problems and complications have been identified with the pharyngeal flap procedure. As a result, it has undergone several modifications. The problems include construction of the appropriate width of flap, the use of a superiorly or inferiorly based flap, and whether the flap should be lined. A higher surgical success rate can probably be achieved by taking into account an individual patient's pattern of VPD. How to precisely tailor the flap to balance speech and airway is patient-dependent and objectively difficult to elucidate.
Sphincter pharyngoplasty
Patients with poor posterior pharyngeal wall movement and smaller VP ports tend to benefit more from this procedure. Sphincter pharyngoplasty involves reduction of the lateral and posterior aspects of the VP ports while maintaining the centric opening. The palatopharyngeus muscle is incised, and a flap is constructed from the posterior tonsillar pillar. These bilateral superiorly-based musculomucosal flaps are juxtaposed in the midline of the posterior pharyngeal wall (see Image 1). This procedure is advantageous in that it potentially recreates a functional sphincter, and the incidence of postoperative nasal obstruction is less than that with the pharyngeal flap.
Palatal lengthening
The primary goals of this procedure are to lengthen the palate, occlude a small gap in the VP port, and retrodisplace the palate in a more physiologically normal place. The most commonly used procedure for palatal lengthening is known as the V-Y pushback procedure (Veau-Wardill-Kilner operation). It is designed to displace the palatal mucoperiosteum and velar musculature after a primary palatoplasty has been performed. Because this procedure does not obstruct the nasal airway, VP valving may be achieved without the troublesome adverse effects of complete nasal obstruction (eg, chronic mouth breathing, sleep apnea). However, numerous problems are reported in association with the use of lengthening procedures. The extensive mucoperiosteal stripping the technique requires may have a deleterious effect on long-term facial growth. High rates of fistulization have been reported, and the ultimate length gain with this surgical maneuver is unpredictable.
During the last 20 years, the Furlow double-opposing Z-plasty palatoplasty has become accepted as a means of gaining palatal length and restoring the velar musculature anatomically.11 It provides for closure of the hard and soft palates in one procedure without pushback or lateral relaxing incisions. Modifications of this procedure from the Children's Hospital of Philadelphia include lateral relaxing incisions. The unique repair of the soft palate is achieved with mirror-image musculo-mucosal Z-plasties to retroposition and overlap the soft palate muscles to recreate the palatal muscular sling. The Z-plasties provide length to the velum without borrowing tissue from the hard palate.
Intraoperative Details
The detailed operative techniques for each procedure have been described by Witt in the eMedicine article Craniofacial, Postpalatoplasty Speech Dysfunction.
Postoperative Details
Patients are routinely hospitalized for 24 hours postoperatively for airway observation. The diet is advanced initially from liquids for the first 24-48 hours, followed by mechanically soft foods for approximately 2 weeks after the procedure. Perioperative intravenous antibiotics are continued for 24 hours, followed by an oral equivalent elixir for a total of 5 days. Patients are instructed to sleep with their heads elevated on several pillows for 2 weeks. Oral hygiene is encouraged.
Follow-up
Postsurgical VP assessment is performed at 3 and 12 months postoperatively and consists of the same perceptual, nasoendoscopic, fluoroscopic, and airway evaluations performed preoperatively. Follow-up with a speech pathologist is essential to continue reinforcement of correct speech and to help prevent residual articulation errors.
Complications
Acute obstructive sleep apnea occurs in approximately 15% of patients with pharyngeal flaps and in slightly less with sphincter pharyngoplasty. A history of perinatal respiratory dysfunction, early age at sphincter pharyngoplasty, upper respiratory tract infections, and microretrognathia are risk factors. The severity of this complication diminishes with time, partially because of a reduction in edema and postoperative inflammation.
Dehiscence correlates inversely with surgical experience and directly with a previous history of tonsillectomy or adenoidectomy. Either of these procedures may result in compromised blood flow to the palatopharyngeal flaps during performance of a sphincter pharyngoplasty.
Persistent hypernasality usually results from a port size that is too large. Hyponasality is caused by constriction of the port, overtightening of the port, or closure from contracture or scar formation.
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References
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Further Reading
Keywords
velopharyngeal dysfunction, VPD, velopharyngeal insufficiency, velopharyngeal inadequacy, velopharyngeal incompetence, VPI, VP inadequacy, VP incompetence, VP insufficiency, VP augmentation, velopharyngeal augmentation, cranio-facial surgery, cranio-facial pharyngoplasty, craniofacial pharyngoplasty, pharyngeal flap, speech disorder, resonance disorder, hypernasality, misarticulation, escape of air through the nose, nasal emissions, aberrant facial movements, grimacing, cleft palate repair, cleft palate, structural palate deficiency, myasthenia gravis, cerebrovascular accident, upper motor neuron lesion, lower motor neuron lesion, head trauma, short palate, scarred palate, tightened palate, levator palatini dysfunction, levator palatini malposition, poor pharyngeal wall mobility, misarticulated speech, palatal prosthesis, velar lift, VP obturator, velopharyngeal obturator
