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ORIGINAL ARTICLE - EVALUATIVE STUDY
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 62-66

Postoperative evaluation of the folded pharyngeal flap operation for cleft palate patients with velopharyngeal insufficiency


1 Department of Oral Care for Systemic Health Support, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
2 Department of Maxillofacial Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
3 Department of Stomatology and Oral Surgery, Graduate School of Medicine, Gunma University, Gunma, Japan

Date of Web Publication20-Jul-2015

Correspondence Address:
Yutaka Sato
Department of Maxillofacial Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8549
Japan
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DOI: 10.4103/2231-0746.161066

PMID: 26389036

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  Abstract 

Background: Velopharyngeal function is very important for patients with cleft palate to acquire good speech. For patients with velopharyngeal insufficiency, prosthetic speech appliances and speech therapy are applied first, and then pharyngeal flap surgery to improve velopharyngeal function is performed in our hospital. The folded pharyngeal flap operation was first reported by Isshiki and Morimoto in 1975. We usually use a modification of the original method. Purpose: The purpose of this research was to introduce our method of the folded pharyngeal flap operation and report the results. Materials and Methods: The folded pharyngeal flap operation was performed for 110 patients with velopharyngeal insufficiency from 1982 to 2010. Of these, the 97 whose postoperative speech function was evaluated are reported. The cases included 61 males and 36 females, ranging in age from 7 to 50 years. The time from surgery to speech assessment ranged from 5 months to 6 years. In order to evaluate preoperative velopharyngeal function, assessment of speech by a trained speech pathologist, nasopharyngoscopy, and cephalometric radiography with contrast media were performed before surgery, and then the appropriate surgery was selected and performed. Postoperative velopharyngeal function was assessed by a trained speech pathologist. Results: Of the 97 patients who underwent the folded pharyngeal flap operation, 85 (87.6%) showed velopharyngeal competence, 8 (8.2%) showed marginal velopharyngeal incompetence, and only 2 (2.1%) showed velopharyngeal incompetence; in 2 cases (2.1%), hyponasality was present. Approximately 95% of patients showed improved velopharyngeal function. Conclusions: The folded pharyngeal flap operation based on appropriate preoperative assessment has been shown to be an effective method for the treatment of cleft palate patients with velopharyngeal insufficiency.

Keywords: Cleft palate, folded pharyngeal flap operation, velopharyngeal insufficiency


How to cite this article:
Yoshimasu H, Sato Y, Mishimagi T, Negishi A. Postoperative evaluation of the folded pharyngeal flap operation for cleft palate patients with velopharyngeal insufficiency. Ann Maxillofac Surg 2015;5:62-6

How to cite this URL:
Yoshimasu H, Sato Y, Mishimagi T, Negishi A. Postoperative evaluation of the folded pharyngeal flap operation for cleft palate patients with velopharyngeal insufficiency. Ann Maxillofac Surg [serial online] 2015 [cited 2019 Aug 24];5:62-6. Available from: http://www.amsjournal.com/text.asp?2015/5/1/62/161066


  Introduction Top


Velopharyngeal function is very important for patients with cleft palate to acquire good speech. Approximately 90% of patients after primary palatoplasty showed good velopharyngeal function in our hospital. For patients with velopharyngeal insufficiency, a speech appliance is applied, and speech therapy is performed first, followed by a pharyngeal flap operation to improve velopharyngeal function.

The purpose of this paper was to report our method for the folded pharyngeal flap (FPF) operation and its results.

Operative technique

The FPF operation was first reported by Isshiki and Morimoto [1] in 1975. Later, Hiramoto et al. reported its modification, [2] and we also reported its modification for patients with severe velopharyngeal insufficiency. [3] We usually use modifications of the original method. Our operative technique is as follows [Figure 1] and [Figure 2]. The incisions are placed on the posterior pharyngeal wall, and the superior-based flap is elevated following splitting of the soft palate in the middle. The flap is folded with the mucosa outside. The mucosa on the ridge of the flap is denuded for attachment of the flap to the soft palate. Incisions are made in the nasal mucosa of the soft palate. In the case of a very short palate or in the case of poor mobility of the soft palate and pharyngeal walls, the incisions are extended toward the flap base [type III in [Figure 2]. Sutures are placed between the flap and the soft palate from the lateral side to the medial side. In severe cases, sutures are placed around a 5 mm diameter suction tube. Finally, the soft palate is sutured.
Figure 1: Folded pharyngeal flap operation technique. (a) Incision. (b) The soft palate is split in the midline. (c) The flap is folded. (d) The mucosa on the ridge of the flap is denuded. (e) Incision of the nasal mucosa. (f) Suture between flap and velum. (g) Suture between flap and velum. (h) Postoperative condition

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Figure 2: Types of folded pharyngeal flap operation

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  Materials and Methods Top


The FPF operation was performed for 110 patients with velopharyngeal insufficiency from 1982 to 2010. Of these, 97 patients who underwent postoperative speech function evaluations were analyzed and reported [Table 1]. The cases included 61 males and 36 females, ranging in age from 7 to 50 years (mean 20.3 ± 10.4 years). The time from surgery to speech assessment ranged from 5 months to 6 years.
Table 1: Cleft types in patients undergoing the FPF operation

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In order to evaluate preoperative velopharyngeal function, assessment of speech by a trained speech pathologist, nasopharyngoscopy, and cephalometric radiography with contrast media were performed before surgery. For evaluation of velopharyngeal function, a test battery proposed by the Committee on Cleft Palate Speech of the Japan Society of Logopedics and Phoniatrics, [4] was used. The distance between the soft palate and the posterior pharyngeal wall was also measured in a cephalometric radiograph taken during phonation of "i" [Figure 3]. The type of FPF was selected based on [Table 2]. Type I was performed in three patients, type II was performed in 45, and type III was performed in 36, while the FPF with palatal push back operation (PB) was performed in 13 [Table 3].
Figure 3: Examination of velopharyngeal function by cephalogram with contrast medium

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Table 2: Preoperative assessment of velopharyngeal function and type of flap used

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Table 3: Types of FPF operation and number of cases

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Postoperative velopharyngeal function was assessed by a trained speech pathologist.


  Results Top


Of the 97 patients who underwent the FPF operation, 85 (87.6%) showed velopharyngeal competence, 8 (8.2%) showed marginal velopharyngeal incompetence, and only 2 (2.1%) showed velopharyngeal incompetence; hyponasality was present in 2 cases (2.1%). Approximately 95% of the patients showed improved velopharyngeal function [Table 4].
Table 4: Postoperative velopharyngeal function

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With regard to the types of FPF used, 44 (91.7%) of 48 cases of types I and II, 30 (83.3%) of 36 cases of type III, and 11 (84.6%) of 13 cases of the PB + FPF showed velopharyngeal competence [Table 5].
Table 5: Operative approach and postoperative velopharyngeal function


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With regard to the age of operation, 48 (88.9%) of 54 cases <20 years old (mean age 13.1 ± 3.7 years) showed velopharyngeal competence postoperatively, and 37 (86.0%) of 43 cases 20 years old and older (mean age 29.3 ± 8.9 years) showed velopharyngeal competence postoperatively [Table 6].
Table 6: Postoperative velopharyngeal function by age at operation


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With regard to preoperative treatment by prosthetic speech appliances, 15 (88.2%) of 17 cases with an appliance with velopharyngeal competence preoperatively showed velopharyngeal competence postoperatively, while 10 (76.9%) of 13 cases with an appliance with velopharyngeal insufficiency preoperatively showed velopharyngeal competence postoperatively [Table 7].
Table 7: Postoperative velopharyngeal function by preoperative treatment with speech appliances

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With regard to complications, snoring was reported in eight cases, a feeling of nasal obstruction was reported in five, earache was reported in one, and postoperative bleeding occurred in one, but none of these was severe [Table 8].
Table 8: Complications

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  Discussion Top


Various methods of pharyngeal flap operation and pharyngoplasty have been reported. [5],[1],[6],[7],[8],[9] They are classified as a superior-based flap, an inferior-based flap, and others. Schmelzeisen et al. [10] recommended a superior-based flap, because it has a more physiologic effect on the velum compared with an inferior-based flap. Wattanawong et al. [11] reported that the inferior-based pharyngeal flap was more effective than the superior-based flap. The FPF is a superior-based flap. The method for this operation was first reported by Isshiki and Morimoto [1] in 1975, and Hiramoto et al. later reported its modification. [2] We also reported its modification for patients with severe velopharyngeal insufficiency. [3] Rogers et al. reported a similar method for children in 2013. [12]

The advantages of the FPF include no raw surface in the flap and prevention of scar contracture of the flap, because the flap is folded. It is also possible to adjust the size of the remaining lateral apertures for each case. The disadvantage is that when a long flap is needed, it may be difficult to make a long enough flap and fold it; however, only one such case was seen 20 years ago, and a tubed flap was used. No further such cases have been seen since then.

With regard to timing of the pharyngeal flap operation, many studies reported that postoperative velopharyngeal function was better in young patients than in adult patients. [13],[14],[15] It has been assumed that the pharyngeal flap operation in adults has a generally less favorable outcome because of habitually retained compensations in articulation. [16] In our study, the postoperative velopharyngeal function of patients younger than 20-year-old seemed to be slightly better than that of patients 20 years and older. In our clinic, most patients with velopharyngeal insufficiency use a speech appliance and undergo speech therapy before the pharyngeal flap operation. Yamashita et al. [17] and Fukuda et al. [18] reported that a speech appliance was effective for improvement of velopharyngeal incompetence and hypernasality. Therefore, we think that our adult patients could acquire good speech results soon after the operation. According to the present data, cases with good velopharyngeal function with speech appliances showed better results than cases with poor velopharyngeal function with speech appliances preoperatively. Therefore, cases with poor velopharyngeal function with speech appliances should undergo a more active method, such as type III. Application of speech appliances to patients will give us useful information for selecting the operative approach.

For young children <10 years old who show velopharyngeal insufficiency after a primary palatoplasty, we try prosthetic speech appliances before secondary surgery because there are some reports that 10-40% of cases treated by speech appliances could have them removed without secondary surgeries. [17],[18]

We usually use cephalometric radiography with contrast media to measure V-P distance during pronunciation of "i" before surgery. [19] We use this measurement to decide the type of FPF to use and the length of the flap.

With regard to complications, desaturation, hemorrhage, infection, obstructive sleep apnea, flap separation, persistent significant nasal obstruction, snoring, etc. are reported. [16],[14],[20] In the present cases, snoring, a feeling of nasal obstruction, earache, and postoperative bleeding were observed, but they were not severe.

We propose that the FPF operation be used in patients at the age of about 10 years, and that patients with velopharyngeal insufficiency use a speech appliance prior to surgery. These guidelines were adopted for several reasons. First, approximately 10-40% of patients treated by a speech appliance showed improved velopharyngeal function and velopharyngeal competence without the appliance and additional surgery a few years after this treatment. Second, we can examine and assess a patient's velopharyngeal function by nasopharyngoscopy and other methods before surgery. Third, postoperative care is straightforward with this approach. Finally, a few patients under the age of 6 years who underwent pharyngeal flap surgery reportedly suffered from sleep apnea following surgery. [16],[21]


  Conclusion Top


The results of the present research demonstrate that the FPF operation based on appropriate preoperative assessment is an effective method for the treatment of cleft palate patients with velopharyngeal insufficiency.

Acknowledgments

The authors would like to thank Ms. Ayako Ohira and Ms. Michiko Mibu of the Speech Clinic, Tokyo Medical and Dental University Dental Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.

 
  References Top

1.
Cole P, Banerji S, Hollier L, Stal S. Two hundred twenty-two consecutive pharyngeal flaps : a0 n analysis of postoperative complications. J Oral Maxillofac Surg 2008;66:745-8.  Back to cited text no. 1
    
2.
Fukuda T, Wada K, Tachimura T, Tanimoto K. Effects of speech appliance for improvement of velopharyngeal incompetence and hypernasality. J Jpn Cleft Palate Assoc 1998;23:75-82.  Back to cited text no. 2
    
3.
Fukushiro AP, Trindade IE. Nasometric and aerodynamic outcome analysis of pharyngeal flap surgery for the management of velopharyngeal insufficiency. J Craniofac Surg 2011;22:1647-51.  Back to cited text no. 3
    
4.
Hiramoto M, Matsuda K, Kimura T. The folded pharyngeal flap operation as a secondary procedure for cleft palate. Part 1: Operative procedure. J Jpn Plact Reconstr Surg 1987;7:417-24.  Back to cited text no. 4
    
5.
Hirschberg J. Results and complications of 1104 surgeries for velopharyngeal insufficiency. ISRN Otolaryngol 2012;2012:181202.  Back to cited text no. 5
    
6.
Hogan VM. A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control (l.p.c.) pharyngeal flap. Cleft Palate J 1973;10:331-45.  Back to cited text no. 6
    
7.
Isshiki N, Morimoto M. A new folded pharyngeal flap. Preliminary report. Plast Reconstr Surg 1975;55:461-5.  Back to cited text no. 7
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Jackson IT, Silverton JS. The sphincter pharyngoplasty as a secondary procedure in cleft palates. Plast Reconstr Surg 1977;59:518-24.  Back to cited text no. 8
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Ohira A, Okazaki K, Ainoda N, Kato M, Tanokuchi F, Hukada T, et al. The clinical test of velopharyngeal function by Committee on Cleft Palate Speech Japan Society of Logopedics and Phoniatrics. Jpn J Logoped Phoniatr 1993;34:298-304.  Back to cited text no. 9
    
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12.
Rogers DJ, Ashland JE, Rozeboom MJ, Hartnick CJ. Modified superior pharyngeal flap for the treatment of velopharyngeal insufficiency in children. Int J Pediatr Otorhinolaryngol 2013;77:1083-7.  Back to cited text no. 12
    
13.
Rustemeyer J, Thieme V, Bremerich A. Snoring in cleft patients with velopharyngoplasty. Int J Oral Maxillofac Surg 2008;37:17-20.  Back to cited text no. 13
    
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Schmelzeisen R, Hausamen JE, Loebell E, Hacki T. Long-term results following velopharyngoplasty with a cranially based pharyngeal flap. Plast Reconstr Surg 1992;90:774-8.  Back to cited text no. 14
    
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Skoog T. The pharyngeal flap operation in cleft palate. A clinical study of eighty-two cases. Br J Plast Surg 1965;18:265-82.  Back to cited text no. 15
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Tachimura T, Wada T. A modified procedure in pharyngeal flap operation with palatal mucosal flap technique and with fibrin sealant (Tisseel). J Jpn Cleft Palate Assoc 1989;14:391-401.  Back to cited text no. 16
    
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Tachimura T, Wada T, Hamaguchi M, Kogo M, Matsuya T, Takada K, et al. Treatment of obstructive sleep apnea following pharyngeal flap operation with palatal lift prosthesis. J Jpn Cleft Palate Assoc 1990;15:29-44.  Back to cited text no. 17
    
18.
Wattanawong K, Tan YC, Lo LJ, Chen PK, Chen YR. Comparison of outcomes of velopharyngeal surgery between the inferiorly and superiorly based pharyngeal flaps. Chang Gung Med J 2007;30:430-6.  Back to cited text no. 18
    
19.
Yamashita Y, Suzuki N, Imai S, Mori K, Michi K. Long-term treatment results using speech aid appliance in cleft palate patients with velopharyngeal insufficiency. J Jpn Cleft Palate Assoc 1998;23:243-56.  Back to cited text no. 19
    
20.
Yoshida H. A roentgenographic study on configuration and function of velopharynx 1. Visualization of the soft palate, posterior pharyngeal wall and hard palate by cephalometric radiography with contrast media (author's transl). Kokubyo Gakkai Zasshi 1974;41:1-20.  Back to cited text no. 20
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Yoshimasu H, Amagasa T. Secondary treatment. In: Shioda S, Michi K, Amagasa T, editors. Operative Maxillofacial Surgery. Kyoto: Nagasue; 1996. p. 278-84.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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