title: Progressive Tightening of the Levator Veli Palatini Muscle Improves Velopharyngeal Dysfunction in Early Outcomes of Primary Palatoplasty.
abstract: BACKGROUND
  Management of the levator veli palatini with intravelar veloplasty has been shown to improve speech resonance. The senior author has introduced a more aggressive procedure where the levator is separately dissected, overlapped, and tightened. This study compares resonance results from four levator management protocols: non-intravelar veloplasty, Kriens intravelar veloplasty, radical intravelar veloplasty, and overlapping intravelar veloplasty.
  
  
  METHODS
  Retrospective chart review was conducted on 252 patients who underwent primary palatoplasty with speech follow-up at 3 years of age. Velopharyngeal function was evaluated with perceptual speech examinations, and subjects were scored on a four-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; and 3 = severe hypernasality, surgical intervention recommended). Fisher's exact test was used to compare outcomes.
  
  
  RESULTS
  A single surgeon performed all the non-intravelar veloplasty (n = 92), Kriens intravelar veloplasty (n = 103), and radical intravelar veloplasty (n = 31), whereas the senior author performed the overlapping intravelar veloplasty (n = 26). Cleft severity proportions were equivalent across the four methods (p = 0.28). Patients who underwent overlapping intravelar veloplasty demonstrated significantly better velopharyngeal function, and none required further imaging or secondary surgery compared with the other three procedures (p < 0.001).
  
  
  CONCLUSIONS
  Speech resonance outcomes at 3 years of age are improved and need for secondary velopharyngeal dysfunction management is reduced with more aggressive levator dissection and reconstruction during primary one-stage palatoplasty. Results were best when the muscle was overlapped.
  
  
  METHODS
  Therapeutic, III.
authors.affiliation: St. Louis, Mo. From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine; the Cleft Palate-Craniofacial Institute, St. Louis Children's Hospital; the Cleft Lip/Palate and Craniofacial Deformities Center, Mercy Children's Hospital; and the Division of Plastic Surgery, St. Louis University School of Medicine.
authors.forename: Dennis C
authors.initials: DC
authors.lastname: Nguyen
authors.forename: Kamlesh B
authors.initials: KB
authors.lastname: Patel
authors.forename: Gary B
authors.initials: GB
authors.lastname: Skolnick
authors.forename: Rachel
authors.initials: R
authors.lastname: Skladman
authors.forename: Lynn M
authors.initials: LM
authors.lastname: Grames
authors.forename: Mary B
authors.initials: MB
authors.lastname: Stahl
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Marsh
authors.forename: Albert S
authors.initials: AS
authors.lastname: Woo
mesh_terms: D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D018482:Muscle, Skeletal / Q000601:surgery*; D010160:Palate, Soft / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013064:Speech Disorders / Q000209:etiology; D016896:Treatment Outcome; D014681:Velopharyngeal Insufficiency / Q000150:complications / Q000601:surgery*