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PURPOSE: VPI following primary Furlow palatoplasty presents a significant challenge, most often managed through extra-palatal procedures such as a pharyngeal flap. However, the latter procedures do not restore palatal function and have a higher incidence of nasal airway compromise than do procedures focused on the palate. The present study investigates the use of palate re-repair with a secondary Furlow palatoplasty following primary Furlow for repair of cleft palate.
METHODS: A successive series of patients from 2007 to 2010 who presented with VPI following primary Furlow palatoplasty were evaluated. All patients underwent a preoperative evaluation consisting of 1) perceptual speech assessment; 2) nasendoscopy; 3) videofluoroscopy. Velopharyngeal assessment (VPA score) was quantitated on an ascending scale from 0 to 15, in which a score of 0-2 was considered competent, 3-4 borderline, and 5-15 incompetent. Furlow re-repair was offered to patients with a velopharyngeal gap size on phonation of 7 mm or less and lateral wall motion of at least 40% normal. Surgical technique involved 1) freeing the levator muscles to the level of the lateral pharyngeal walls, excising any restricting scar tissue; 2) intraoperative muscle stimulation to identify the dynamic component of the levators; 3) posterior transposition of both myomucosal flaps and anterior transposition of both mucosal only flaps. Perceptual speech assessment was performed a minimum of 3 months postoperatively.
RESULTS: 15 patients underwent palate re-repair by secondary Furlow. 9 patients had cleft lip and palate and 6 patients had cleft palate alone. Patients ranged from age 3 to 14 years at the time of re-repair (mean age: 5.2 years). Outcomes based on VPA score are shown, indicating a highly significant reduction in nasality following re-repair (p < 0.0002).

VELOPHARYNGEAL ASSESSMENT

	BEFORE RE-REPAIR	AFTER RE-REPAIR	FINAL OUTCOME
VPA SCORE (Mean + SD)	7.1 + 3.3	*2.0 + 2.8	*1.3 + 1.5
INCOMPETENT (VPA > 5)	11	1	0
BORDERLINE (VPA 3-4)	4	4	4
COMPETENT (VPA 0-2)	0	10	11
		*p < .05 vs pre-op

14 patients showed improved VPA scores, with 10 of the 15 patients achieving VP competence (VPA score < 2). A sphincter pharyngoplasty was done as a tertiary procedure in 2 patients due to persistent nasal air emission, resulting in competence in one and borderline competence in the other. No patient had symptomatic airway compromise following secondary or tertiary management. Presence of a cleft lip, lateral wall motion, and velopharyngeal gap size did not impact the outcomes given that patients met the inclusion criteria.
CONCLUSIONS: To our knowledge this is the first series to evaluate the outcomes of palate re-repair in patients who present with VPI following primary Furlow palatoplasty. This series demonstrates that a secondary Furlow is anatomically possible and can restore function of levators encased in scar tissue following primary repair. Intraoperative muscle stimulation and postoperative VPA scores confirm restoration of levator function. This approach respects anatomic principles of palatoplasty without eliminating the possibility for extra-palatal procedures should velopharyngeal competence not be achieved. A rigorous approach to post-Furlow VPI can restore the goals of the initial palatoplasty with minimal compromise in nasal airway function.