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The Effect of Secondary Palatoplasty on Velopharyngeal Lateral Wall Motion
Dennis C. Nguyen, MD, Gary B. Skolnick, BS, Kamlesh B. Patel, MD, Lynn M. Grames, MA, CCC-SLP, Mary B. Stahl, MA, CCC-SLP, Albert S. Woo, MD.
Washington University, St. Louis, St. Louis, MO, USA.

PURPOSE:The levator veli palatini is critical to normal velopharyngeal closure, but its role in lateral wall motion (LWM) remains unclear. Overlapping intravelar-veloplasty (IVV) is a technique that dissects out and overlaps the levator and has been utilized successfully at our institution. We evaluated whether overlapping of the levator results in improved LWM.
METHODS:A retrospective chart review was performed on all non-syndromic patients who underwent secondary palatoplasty with either double-opposing Z-plasty or overlapping-IVV between 2005-2012. Velopharyngeal dimensions were measured from preoperative and postoperative videofluoroscopy. Velopharyngeal insufficiency data were obtained from perceptual speech examinations.
RESULTS:Average age at re-repair was 6.9±2.9 years-old for double-opposing Z-plasty (n=16) and 9.0±4.6 years-old for overlapping-IVV (n=18) (p=0.134). Preoperatively, cleft severity, LWM (Z-plasty 42±18% vs. overlapping-IVV 49±21%), and resonance severity were equivalent between the two techniques (0.12≤p≤0.51). Postoperative LWM for double-opposing palatoplasty was 56±17%, while overlapping-IVV was 81±15%. After controlling for age and preoperative LWM, the postoperative LWM for overlapping-IVV remained significantly greater (p<0.001). Additional procedures for persistent velopharyngeal insufficiency was 44% in double-opposing Z-plasty and was 11% in overlapping-IVV (p=0.036). Need for additional surgery was inversely related to postoperative LWM (p=0.023).
CONCLUSION:Lateral wall motion is significantly improved with any overlapping procedure of the levator. This is seen in the double-opposing Z-plasty and even more so in the overlapping-IVV technique. The degree of LWM appears to correlate with the aggressiveness in overlap and retropositioning of the levator. Patients with greater postoperative LWM were less likely to require additional surgery.


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