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ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 68-72

Evolution of a safe and effective management protocol for velopharyngeal incompetence: Seeking good speech without airway compromise


1 Department of Surgery, Division of Plastic Surgery, UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama, United States of America
2 Department of Hearing and Speech, UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama, United States of America
3 Department of Surgery, Division of Plastic Surgery, UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama, United States of America; Department of Plastic Surgery, Sohag Cleft and Craniofacial Unit, Sohag University Hospital, Sohag, Egypt

Correspondence Address:
John H Grant
UAB Cleft and Craniofacial Center, Children's of Alabama Hospital, Birmingham, Alabama; Division of Plastic Surgery, University of Alabama, 1600 7th Avenue South, Lowder 322, Birmingham, AL 35233
United States of America
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_76_17

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Objective: To document an evidence based evolution of VPI management over an 18 year period with the goal of optimizing speech while minimizing complications and need for re-operation. Design: An institutional review board approved, retrospective 18-year single surgeon, single-center series of 370 patients undergoing surgery for velopharyngeal incompetence (VPI). Methods: A review of our database between the years of 1997 and 2015 identified 370 patients who underwent surgical procedures for VPI. Records were reviewed for types of procedures performed each year. Procedures were evaluated for safety and efficacy as regards to speech outcome. The study population was divided into an earlier period (1997–2009) and a later period (2010–2015). Results: We demonstrated a reduction in the use of airway obstructive procedures such as sphincter pharyngoplasty from 25.2% of VPI surgeries in the early period to 10.4% in the late period. There has been a progressive shift toward more physiologic procedures such as re-repair with intravelar veloplasty (IVVP). The extent of IVVP has become more aggressive over the time period of the study. In our re-repair population, 89.7% of patients had improvement of the speech scores with 64.5% of all the re-repair patients achieving normal speech postoperatively. Autologous fat augmentation of the palate was introduced in the second period and represents about half of the procedures in the later period. Focused autologous fat augmentation of the palate resulted in statistically significant improvement in speech in 75.7% of cases. Conclusion: This study demonstrates an evidence-based evolution in management, shifting away from potentially airway obstructive procedures and toward a more physiologic approach to velopharyngeal competence. We outline the steps taken to reach the author's current approach to VPI management based on periodic outcome audits, specific anatomic findings, and goal-directed surgical interventions. With correct diagnosis and patient selection, VPI can be safely eliminated in over 70% of patients with a single procedure. We believe that this anatomic and physiologic approach improves safety while minimizing risks of airway obstruction.


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