1. Copyright restrictions may apply Recent Advances in Surgical Pharyngeal Modification Procedures for the Treatment of Velopharyngeal Insufficiency in Patients With Cleft Palate Saman M, Tatum SA III. Recent advances in surgical pharyngeal modification procedures for the treatment of velopharyngeal insufficiency in patients with cleft palate. Arch Facial Plast Surg. 2012;14(2):85-88.

2. Copyright restrictions may apply Introduction Velopharyngeal insufficiency (VPI) is a problematic issue for both the patient and the treating surgeon.

3. Copyright restrictions may apply Purpose This review article of the recent literature examines recent advances in pharyngeal modification procedures for the treatment of VPI in patients with cleft palate after primary repair. Advantages and disadvantages of the various pharyngoplasty techniques as well as their safety and efficacy are discussed.

4. Copyright restrictions may apply Relevance to Clinical Practice and Public Health The negative effect of VPI on patients’ quality of life has long been known, and over the years numerous techniques have been described to correct or improve this problem. –VPI can result in hypernasal voice. –Severe cases can be associated with nasal regurgitation problems with swallowing. –Surgical treatment for VPI can result in airway obstruction.

5. Copyright restrictions may apply Summary of Major Findings Velopharyngeal competence is best accomplished at primary palate repair. Residual VPI is a surgical challenge. Several surgical approaches exist to achieve improvement. Proper selection of the method depends on the severity and anatomy of the VPI. Visualization studies reveal the orientation of the velopharyngeal gap present when the port does not close, on a continuum from coronal to sagittal.

6. Copyright restrictions may apply Description of Evidence Pharyngoplasty –Palatopharyngeal folds are transposed posteriorly and superiorly onto the posterior pharyngeal wall. –Narrows the velopharyngeal port leaving the center port. –Also creates some posterior wall augmentation. –More commonly used for a coronal pattern of closure. –Less potential for obstruction. –Can be loosened or tightened as needed.

7. Copyright restrictions may apply Description of Evidence Pharyngeal Flap –Superiorly based on the posterior pharyngeal wall. –Transposed forward and sewn to the back of the soft palate. –Obturates the center of the velopharyngeal port. –Leaves lateral ports on each side. –Depends on lateral pharyngeal wall movement to achieve closure. –Flap width is determined by the degree of lateral wall motion. –Poor motion requires a wide flap and increases the risk of airway obstruction. –More commonly used for a sagittal pattern of closure so the flap can be narrower. –Lateral ports can be dilated or tightened if needed.

8. Copyright restrictions may apply Controversies and Consensus Consensus exists in the goals of normal speech and no obstruction. Studies comparing outcomes do not use uniform speech evaluations. Definition of success varies from improvement to normal speech. Diligence in the search for obstructive complications varies. Small-gap VPI is easily corrected by many methods. Large-gap VPI is difficult and better stratifies the utility of compared procedures.

9. Copyright restrictions may apply Discussion Implications for Patients and Health Care Providers –Currently, patients must search for those providers with the best reported outcomes, but they have no way of comparing nonstandardized outcomes. –Currently, providers must make management decisions based on disparate data. Implications for Health Policy –Groups such as the American Cleft Palate–Craniofacial Association could facilitate consensus conferences and multi-institutional studies.

10. Copyright restrictions may apply Discussion Implications for Future Research in This Area –Consensus on parameters: Visualization studies: nasendoscopy, fluoroscopy. Perceptual analysis. –Consensus on speech outcomes. –Consensus on measuring obstruction. –Randomized controlled studies comparing techniques: Degree of VPI (size of gap). Diagnoses: genetic, neurologic, etc.

11. Copyright restrictions may apply Conclusions Several techniques are successful in treating VPI. The large-gap cases are more difficult and may be better managed with pharyngeal flap, although obstruction remains a concern. Proper presurgical analysis with perceptual speech evaluation and visualization studies is critical. Patients should be followed up postoperatively for the development of obstructive symptoms.

12. Copyright restrictions may apply Contact Information If you have questions, please contact the corresponding author: –Masoud Saman, MD, Department of Otolaryngology–Head and Neck Surgery, New York Eye and Ear Infirmary, 310 E 14th St, Sixth Floor, New York, NY 10003 (m.saman@live.com).