Surgical treatment of patients with cleft palate to achieve velopharyngeal competence

Background. The goal of primary cleft repair is to attain normality in speech, maxillofacial growth, hearing with avoidance of otitis media, appearance, and occlusion. Development of normal speech with velopharyngeal competence (VPC), one of the most important aspects of cleft treatment, is possible with an anatomically and functionally intact palate. Velopharyngeal insufficiency (VPI) results from abnormal palatal anatomy caused by palatal shortening, scar contracture, insufficient palatal muscle function, and fistulas. VPI manifests as hypernasal vocal resonance, nasal emissions, soft pressure consonants, and compensatory articulation. Treatment of VPI may be conservative (speech therapy or prosthetic devices), surgical, or a combination of both. Between 1997 and 2014, three protocols, including Protocol 1: soft palate and lip closure at first stage; Protocol 2: lip closure at first stage; Protocol 3: hard palate and lip closure at first stage, have been used for primary repair of unilateral cleft lip and palate (UCLP) in the Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital, Finland. Since 2008, the standard VPI surgery method has been double-opposing Z-plasty with palatal re-repair. Aims. The first aim was to evaluate whether three primary surgery protocols and timing of primary palatoplasty had an influence on the incidence of VPI and the number of secondary surgeries in 160 patients with UCLP. The second aim was to evaluate the results of double-opposing Z-plasty with palatal re-repair as a secondary surgery in treating VPI in 109 patients with UCLP and 130 patients with isolated cleft lip and palate (ICP). The third aim was to examine whether moderate-to-severe VPI at 3 years of age in 90 patients with cleft palate (CP) predicts VPI surgery and clarified whether speech therapy prior to VPI surgery is beneficial for moderate-to-severe VPI speech characteristics. Methods. The study was retrospective, and the material comprised 1006 cleft palate patients treated between 1997 and 2017, including patients with all cleft types between 2000 and 2017 and also UCLP patients from 1997 to 2000, at the Cleft and Craniofacial Center, Department of Plastic surgery, Helsinki University Hospital. Of the 1006 patients, we included 489: The first study comprised 160 UCLP patients undergoing primary palatoplasty between 1997 and 2014. The second and third studies together comprised 239 patients with UCLP and ICP undergoing double-opposing Z-plasty for VPI between 1997 and 2017. The fourth study comprised 90 CP patients born between 2000 and 2014 with moderate-to-severe VPI after palatoplasty at age 3 years with none undergoing VPI surgery before age 5 years. Results. Three protocols for primary palatoplasty for UCLP achieved similar results in VPC at 3 and 5 years of age, but Protocol 1 (soft palate and lip repair at first stage) caused more fistulas. Moreover, double-opposing Z-plasty with palatal re-repair as VPI surgery proved to be a successful and safe treatment option with a success rate of 81% in ICP patients and 84% in UCLP patients, but the method did not appear to be as effective in syndromic patients. Finally, moderate-to-severe VPI did not improve from 3 to 5 years of age or improved but subsequently relapsed in CP patients, and speech therapy alone did not seem to eliminate the characteristics of moderate-to-severe VPI.