Musculomucosal Flap: A Technique for Correction of Velopharyngeal Insufficiency by Palate Lengthening

ABSTRACT A small but significant percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. The use of the buccinator musculomucosal (MM) flap has been described for both primary palate repair with lengthening and secondary palate lengthening for the correction of insufficient velopharyngeal closure. The MM flap was first described in 1969 for the primary repair of a wide cleft palate by Mukherji, and it was Bozola et al in 1989 who first formally described it and gave first description of its anatomy. The first report on its use to lengthen the palate in secondary velopharyngeal insufficiency (VPI) was published by Hill et al in 1999. This case report presents a patient who had correction of secondary velopharyngeal incompetence using bilateral buccinator MM flaps used as a sandwich and also gives a brief review of the literature regarding its application in cases of secondary VPI. How to cite this article Deshmukh MM, Deshpande G. Musculomucosal Flap: A Technique for Correction of Velopharyngeal Insufficiency by Palate Lengthening. J Contemp Dent 2017;7(3):174-177.

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Buccinator Sandwich Pushback: A New Technique for Treatment of Secondary Velopharyngeal Incompetence

The Cleft Palate-Craniofacial Journal ◽

10.1597/02-146.1 ◽

2004 ◽

Vol 41 (3) ◽

pp. 230-237 ◽

Cited By ~ 25

Author(s):

C. Hill ◽

C. Hayden ◽

M. Riaz ◽

A. G. Leonard

Keyword(s):

Velopharyngeal Insufficiency ◽

Case Selection ◽

Velopharyngeal Incompetence ◽

Secondary Palate ◽

Velopharyngeal Closure ◽

Primary Palate ◽

Speech Therapist ◽

Palate Repair ◽

A New Technique ◽

Speech Assessment

Objective A small percentage of patients have inadequate velopharyngeal closure, or secondary velopharyngeal incompetence, following primary palatoplasty. Use of the buccinator musculomucosal flap has been described for primary palate repair with lengthening, but its use in secondary palate lengthening for the correction of insufficient velopharyngeal closure has not been described. This study presents the results of a series of patients who had correction of secondary velopharyngeal incompetence using bilateral buccinator musculomucosal flaps used as a sandwich. Patients In this prospective study between 1995 and 1998, a group of 16 patients with insufficient velopharyngeal closure as determined by speech assessment and videoradiography were selected. Nasopharyngoscopy was carried out in addition in a number of cases. Case selection was a result of these investigations and clinical examination in which the major factor in velopharyngeal insufficiency was determined to be short palatal length. Design The patients underwent palate lengthening using bilateral buccinator musculomucosal flaps as a sandwich. All patients were assessed 6 months postoperatively. The operative technique, postoperative course, and recorded postoperative complications including partial/total flap necrosis and residual velopharyngeal insufficiency were evaluated. Preoperative and postoperative speech samples were rated by an independent speech therapist. Results Ninety-three percent (15 of 16) had a significant improvement in velopharyngeal insufficiency, and 14 patients had no hypernasality postoperatively. Both cases of persistent mild hypernasality had had a recognized postoperative complication. Conclusion The sandwich pushback technique for the correction of persistent velopharyngeal incompetence was successful in achieving good speech results.

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Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665618799906 ◽

2018 ◽

Vol 56 (5) ◽

pp. 586-594 ◽

Cited By ~ 8

Author(s):

Thomas J. Sitzman ◽

Adam C. Carle ◽

Pamela C. Heaton ◽

Michael A. Helmrath ◽

Maria T. Britto

Keyword(s):

Cleft Palate ◽

Cleft Lip ◽

Cleft Lip And Palate ◽

Primary Repair ◽

Multivariable Analysis ◽

Secondary Surgery ◽

Secondary Palate ◽

Primary Palate ◽

Cleft Palate Repair ◽

Palate Repair

Objective: To identify child-, surgeon- and hospital-specific factors at the time of primary cleft palate repair that are associated with the use of secondary palate surgery. Design: Retrospective cohort study. Setting: Forty-nine pediatric hospitals. Participants: Children who underwent cleft palate repair between 1998 and 2015. Main Outcome Measure: Time from primary cleft palate repair to secondary palate surgery. Results: By 5 years after the primary palate repair, 27.5% of children had undergone secondary palate surgery. In multivariable analysis, cleft type and age at primary palate repair were both associated with secondary surgery ( P < .01). Children with unilateral cleft lip and palate had a 1.69-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.54-1.85) compared to children with cleft palate alone. Primary palate repair before 9 months had a 3.99-fold increased hazard of secondary surgery (95% CI: 3.39-4.07) compared to repair at 16 to 24 months of age. After adjusting for cleft type, age at repair, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals ( P < .01). For children with isolated cleft palate, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 8.5% to 46.0% across surgeons and 9.1% to 49.4% across hospitals. Conclusions: There are substantial differences among surgeons and hospitals in the rates of secondary palate surgery. Further work is needed to identify causes for this variation among providers and develop interventions to reduce the need for secondary surgery.

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Successful primary repair of chronic latissimus dorsi rupture: a case report and review of the literature

Journal of Shoulder and Elbow Surgery ◽

10.1016/j.jse.2016.12.072 ◽

2017 ◽

Vol 26 (4) ◽

pp. e97-e101 ◽

Cited By ~ 2

Author(s):

Jennifer Misenhimer ◽

Nicholas A. Kusnezov ◽

Mark P. Pallis ◽

Brian R. Waterman

Keyword(s):

Case Report ◽

Latissimus Dorsi ◽

Primary Repair ◽

Review Of The Literature

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Treatment of Velopharyngeal Insufficiency After Cleft Palate Repair Depending on the Velopharyngeal Closure Pattern

Journal of Craniofacial Surgery ◽

10.1097/scs.0b013e31820f3691 ◽

2011 ◽

Vol 22 (3) ◽

pp. 813-817 ◽

Cited By ~ 20

Author(s):

Mosaad Abdel-Aziz ◽

Hassan El-Hoshy ◽

Hassan Ghandour

Keyword(s):

Cleft Palate ◽

Velopharyngeal Insufficiency ◽

Velopharyngeal Closure ◽

Cleft Palate Repair ◽

Palate Repair

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Velopharyngeal insufficiency, submucous cleft palate and a phonological disorder as the associated clinical features which led to the diagnosis of Jacobsen syndrome. Case report and review of the literature

International Journal of Pediatric Otorhinolaryngology ◽

10.1016/j.ijporl.2013.06.007 ◽

2013 ◽

Vol 77 (9) ◽

pp. 1601-1605 ◽

Cited By ~ 5

Author(s):

Antonio Ysunza ◽

Kenneth Shaheen ◽

David J. Aughton ◽

Mark A. Micale ◽

Richard Merson ◽

...

Keyword(s):

Case Report ◽

Cleft Palate ◽

Clinical Features ◽

Velopharyngeal Insufficiency ◽

Review Of The Literature ◽

Jacobsen Syndrome ◽

Submucous Cleft Palate

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Acute isolated velopharyngeal insufficiency in children: case report and systematic review of the literature

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s00405-012-2215-0 ◽

2012 ◽

Vol 270 (7) ◽

pp. 1975-1980 ◽

Cited By ~ 5

Author(s):

Victorine Walter ◽

Lluís Nisa ◽

Igor Leuchter

Keyword(s):

Systematic Review ◽

Case Report ◽

Velopharyngeal Insufficiency ◽

Review Of The Literature

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Predictive Factors for Velopharyngeal Insufficiency Following Primary Cleft Palate Repair

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211026861 ◽

2021 ◽

pp. 105566562110268

Author(s):

Brady J. Anderson ◽

Kasra N. Fallah ◽

Austin A. Lignieres ◽

Joseph K. Moffitt ◽

Kim-Loan Luu ◽

...

Keyword(s):

Primary Repair ◽

Velopharyngeal Insufficiency ◽

Speech Language Pathology ◽

Straight Line ◽

Multidisciplinary Clinic ◽

Cleft Palate Repair ◽

Language Pathology ◽

Palate Repair ◽

Birth Type

Objective: Velopharyngeal insufficiency (VPI) remains a known complication of primary palatoplasty. We sought to identify factors associated with the incidence of VPI and create a predictive model for VPI development in our population. Design: A single-institution, retrospective review. Setting: Multidisciplinary clinic in a tertiary academic institution. Patients: A total of 453 consecutive patients undergoing primary palatoplasty from 1999 to 2016 were reviewed. Inclusion required follow-up past age 5. Patients who were non-verbal, and thus unable to undergo speech evaluation, were excluded. Main Outcome Measures: Primary outcome was VPI, defined as revision palatoplasty or recommendation by speech-language pathology. Results: Of 318 patients included, 179 (56%) were male. Median age at primary repair was 1.0 years (0.9-1.1) with a median age of 8.8 years at last follow-up. One hundred nineteen (37%) patients developed VPI at a median age of 5.0 years (3.8-6.5). Higher rates were seen with posterior fistula (65% vs 14%, P <.01) and straight-line repair (41% vs 9%, P <.01), with lower rates in patients with Veau I clefts (22% vs 39%, P <.05). Patients with VPI were older at last follow-up. Following multivariate regression, factors remaining significant were posterior fistula (odds ratio [OR]: 11.3, 95% CI: 6.1-22.0), primary Furlow repair (OR: 0.18, 95% CI: 0.03-0.68), genetic diagnoses (OR: 2.92, 95% CI: 1.1-7.9), and age at last follow-up (OR: 1.11, 95% CI: 1.01-1.2). Conclusions: Length of follow-up, posterior fistulae, and genetic diagnoses are associated with VPI formation. Furlow repair may protect against formation of VPI. Use of allograft, Veau class, birth type, birth weight, and race are not independently associated with VPI formation.

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