Evaluation of Two Palate Repair Techniques for the Surgical Management of Velopharyngeal Insufficiency

Woo, Albert S.; Skolnick, Gary B.; Sachanandani, Neil S.; Grames, Lynn Marty

doi:10.1097/prs.0000000000000506

Cited by 42 publications

(43 citation statements)

References 19 publications

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“…This idea is supported by success of the doubleopposing Z-plasty technique being attributed to LVP tightening 38 and the recently reported high success rates of aggressive overlapping combined with the RIVV technique. 14 The model prediction that LVP overlap can be beneficial is a result of the physics of skeletal muscle force generation (Fig. 2).…”

Section: Discussionmentioning

confidence: 99%

“…The radical intravelar veloplasty (RIVV) has a wide range of possible overlap distances because of the radical dissection of the LVP. One technique 6 uses RIVV and does not overlap, whereas another technique 14 uses RIVV and an aggressive amount of overlap. The Kriens-style 8 intravelar veloplasty does not dissect the muscle as far laterally and therefore cannot overlap as much as an RIVV.…”

Section: Discussionmentioning

confidence: 99%

“…13 A more recent procedure that emphasizes aggressive LVP overlap has shown very promising results in prevention of VPI. 14 The extent of muscle overlap has been thought to contribute significantly to speech outcomes owing to the reconstruction of the LVP sling, 10 yet the mechanism and extent of this contribution are poorly understood. Is there an optimal amount of overlap to achieve maximum capacity for VP closure?…”

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confidence: 99%

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A Computational Model of Velopharyngeal Closure for Simulating Cleft Palate Repair

Inouye¹,

Pelland

Lin³

et al. 2015

Journal of Craniofacial Surgery

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The levator veli palatini (LVP) muscle has long been recognized as the muscle that contributes most to velopharyngeal (VP) closure and is therefore of principal importance for restoring normal speech in patients with a cleft palate. Different surgical reconstructive procedures can utilize varying degrees of LVP overlap, and this study developed a new finite-element model of VP closure designed to understand the biomechanical effects of LVP overlap. A three-dimensional finite-element model was created from adult anatomical dimensions and parameters taken from the literature. Velopharyngeal function was simulated and compared with experimental measurements of VP closure force from a previous study. Varying degrees of overlap and separation of the LVP were simulated, and the corresponding closure force was calculated. The computational model compares favorably with the experimental measurements of closure force from the literature. Furthermore, the model predicts that there is an optimal level of overlap that maximizes the potential for the LVP to generate closure force. The model predicts that achieving optimal overlap can increase closure force up to roughly 100% when compared with too little or too much overlap. The results of using this new model of VP closure suggest that optimizing LVP overlap may produce improved surgical outcomes due to the intrinsic properties of muscle. Future work will compare these model predictions with clinical observations and provide further insights into optimal cleft palate repair and other craniofacial surgeries.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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A Computational Model of Velopharyngeal Closure for Simulating Cleft Palate Repair

Inouye¹,

Pelland

Lin³

et al. 2015

Journal of Craniofacial Surgery

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“…Gradually, cleft surgeons began to appreciate the importance of dissection and retropositioning of the levator on improving speech outcomes 11-13 . The senior author (ASW) has introduced a more aggressive procedure where the levator is separately dissected, significantly overlapped upon itself, and the muscular sling is tightened, termed Overlapping-IVV 14 . The authors believe this creates a tighter sphincter than generated in IVV techniques where the muscles are simply reapproximated in the midline.…”

Section: Introductionmentioning

confidence: 99%

Progressive Tightening of the Levator Veli Palatini Muscle Improves Velopharyngeal Dysfunction in Early Outcomes of Primary Palatoplasty

Nguyen

Patel

Skolnick

et al. 2015

Plastic and Reconstructive Surgery

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Background Velopharyngeal dysfunction is a major morbidity associated with a cleft palate diagnosis. Management of the levator veli palatini with intravelar veloplasty (IVV) has been shown to improve speech resonance. The senior author (ASW) has introduced a more aggressive procedure where the levator is separately dissected, overlapped and tightened. This study compares speech resonance results from 4 separate levator management protocols: Non-IVV, Kriens-IVV, Radical-IVV, and Overlapping-IVV. Methods Retrospective chart review was conducted on 252 patients who underwent primary palatoplasty with speech follow-up at 3 years of age. Postoperative velopharyngeal function was evaluated with perceptual speech examinations, and subjects were scored on a 4-point scale (0 = normal resonance; 1 = occasional hypernasality/nasal emission/turbulence/grimacing – no further assessment warranted; 2 = mild hypernasality/intermittent nasal turbulence/grimacing – velopharyngeal imaging suggested; 3 = severe hypernasality – surgical intervention recommended). Fisher's exact test was used to compare outcomes. Results A single surgeon performed all the Non-IVV (n=92), Kriens-IVV (n=103) and Radical-IVV (n=31) procedures while the senior author performed the Overlapping-IVV technique (n=26). Cleft severity proportions were equivalent across the four methods (p = 0.28). Patients who underwent Overlapping-IVV demonstrated significantly better velopharyngeal function and none required further velopharyngeal imaging or secondary surgery when compared to the other three procedures (p < 0.001 for all comparisons). Conclusions Speech resonance outcomes at 3 years of age are improved and the need for secondary VPD management is reduced with more aggressive levator dissection and reconstruction during primary one-stage palatoplasty. Results were best when the muscle was overlapped. Level of Evidence III – Retrospective cohort/comparative study.

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“…These have been documented for both primary cleft palate repairs in our current article under discussion and for palatal re-repair operations for velopharyngeal insufficiency. 8 …”

Section: Sirmentioning

confidence: 97%

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Nguyen

Patel

Woo

2016

Plastic and Reconstructive Surgery

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Evaluation of Two Palate Repair Techniques for the Surgical Management of Velopharyngeal Insufficiency

Abstract: Therapeutic, III.

Cited by 42 publications

References 19 publications

A Computational Model of Velopharyngeal Closure for Simulating Cleft Palate Repair

A Computational Model of Velopharyngeal Closure for Simulating Cleft Palate Repair

Progressive Tightening of the Levator Veli Palatini Muscle Improves Velopharyngeal Dysfunction in Early Outcomes of Primary Palatoplasty

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