Salvage of Speech with Secondary Tissue Augmenting Furlow

Salvage of Speech with Secondary Tissue Augmenting Furlow Palatoplasty Erin Anstadt MD 1, Wendy Chen MD MS 1, Fady Paul Marji MD 2, Sean Herman MD 2, James Fisher Ph. D 3, Jesse Goldstein MD 2, Joseph Losee MD 2 of Pittsburgh Department of Plastic Surgery, 2 Children’s Hospital of Pittsburgh of UPMC, 3 University of Pittsburgh School of Medicine Background dehiscence, oronasal fistulas and the associated velopharyngeal incompetence (VPI) impact speech and can necessitate secondary palatoplasty or pharyngoplasty. § This study reviews the results of using autologous tissue to augment secondary palatoplasty as a strategy to salvage speech prior to pharyngoplasty. **Authors have no relevant financial or non-financial relationships in the products or services described, reviewed, evaluated or compared in this presentation. Methods § Design: Retrospective review using tissue augmentation in secondary § § palatoplasty procedures, 2017 to 2019. Population: Pediatric patients who underwent revision or conversion Furlow palatoplasty with tissue augmentation (buccal myomucosal flap, buccal fat pad flap, and/or structural fat grafting) for persistent or recurrent VPI Data: Demographic and clinical data were collected, including cleft palate classification and surgical history, medical comorbidities, indications for revision palatoplasty, and complications. Outcomes: Pre-and post-op speech was assessed using the Pittsburgh Weighted Speech Score (PWSS) and perceptual speech assessments by Speech-Language Pathologists. Statistical analysis was performed using SPSS and paired T-tests of the means; significance was set at p<0. 05 12 patients were eligible for inclusion. § 50% female, 58% syndromic (Figure 1. ) § 2 patients had Veau I, III, and IV clefts (17% each); 3 had submucous clefts and Veau II clefts (25% each) In secondary palatoplasty: § 10 patients got buccal fat flaps (83%) § 5 got buccal myomucosal flaps (42%) § 2 got structural fat grafts (17%; mean volume of 1. 4 m. L) Mean (±SD) age at revision was 9. 4 (± 4. 3) years. Mean (±SD) length of follow-up was 12. 7 (± 8) months. Pittsburgh Weighted Speech Score Outcomes: 30, 00 Pre-Operative Post-Operative 25, 00 20, 00 15, 00 10, 00 5, 00 should be considered prior to pharyngoplasty in patients with preserved levator function. 1 5. 6 M Veau IV 2 3. 8 F Veau III 3 3. 4 M Veau III None 4 7. 7 M Veau IV 5 13. 9 M Veau II None Pierre Robin Sequence 6 7 8 12. 8 9 18. 5 F F F SMCP Veau I 9 9. 6 F SMCP 10 8. 6 M Veau II 11 10. 1 M Veau I 12 Mean (SD) 10. 1 F Veau ii post op 10 8 6 4 2 0 Length of follow-up Tissue Augmentation 30 -day complication (months) L Buccal Myomucosal Flap B/L Buccal Fat Flaps B/L Buccal Furlow palatoplasty Myomucosal Flaps, B/L with ADM Secondary Furlow Buccal Fat Flaps R Buccal Myomucosal Flap, Structural Fat SLR Conversion Furlow Graft SLR Conversion Furlow 22 q 11 Deletion Furlow palatoplasty None SLR 10 q 26. 3 deletion, NOS SLR Pierre Robin Sequence SLR 22 q 11 Deletion SLR 16 q 11 Deletion, NOS Furlow Palatoplasty Revision Furlow Conversion Furlow None 18. 6 None 21. 6 None 16. 1 None 15. 8 B/L Buccal Fat Flaps None B/L Buccal Fat flaps, Structural Fat Graft, L Buccal hematoma Buccal Myomucosal requiring evacuation Flap in OR L Buccal Fat Flap None B/L Buccal Fat Flap None 4. 1 19. 8 25. 6 3 Conversion Furlow B/L Buccal Fat Flaps None 6. 3 Conversion Furlow B/L Buccal Fat Flaps None 12. 1 Conversion Furlow B/L Buccal Fat. Flaps None 3. 9 Conversion Furlow B/L Buccal Fat Flaps None 5 9. 425 12. 66 Perceptual Speech Evaluation Outcomes: Pre-Operative Intraoral Air Pressure Patterns Post-Operative Intraoral Air Pressure Patterns . Reduced with Sibilants, Fricatives, and Plosives Incompetent Borderline Incompetent Competent 1 Reduced with Sibilants and Fricatives Figure 2. Individual speech scores pre and post operatively. Reduced with Sibilants alone Figure 5. Pre-operatively; 11/12 patients had reduced IOAPs (left). Post-revision, all patients had normal IOAPs (right). Nasal Resonance Scores 10 pre op 12 Number of Patients § As an important adjunct to secondary palatoplasty, tissue augmentation Mean (±SD) PWSS preoperatively was 13. 9 (± 6. 8). Post-revision scores significantly improved to 3. 4 (± 1. 8), (p≤ 0. 0003). Overall Assessment of Velopharyngeal Competence obliteration of dead space, lengthening of the velum, and reduced tension on closures. Primary Palatoplasty Syndrome Procedure 2º Procedure Furlow palatoplasty, b/l unipedicled mucoperiosteal None flaps with ADM Secondary Furlow FGFR 1 Receptor Furlow palatoplasty Mutation with ADM Revision Furlow Normal IOAPs 1 2 3 4 5 6 7 8 9 10 11 12 Patient ID § Augmenting secondary palatoplasty with vascularized tissue facilitates likely due to increased velar length and reduced scar contracture. Gender Cleft Classification 0, 00 Conclusions § Consistent improvements were seen in speech outcomes with this technique, ID Age at 2º Surgery (years) Figure 1. Patient demographic and surgical characteristics. Pittsburgh Weighted Speech Score § Following primary palatoplasty, factors such as scar contracture, tissue Results Figure 3. The overall assessment of patients velopharyngeal competence pre- and post -op. All patients showed improved VP competence post-op. Number of Patients 1 University Pre-Operative Post-Operative 8 6 4 2 0 Moderately- Mildly. Hyponasality Mild Severe hypernasality Moderate hypernasality Figure 4. The majority of patients pre-operatively had severe or moderately- severe hypernasality; Post-revision, all patients had improved nasal resonance scores. Mixed Normal hypernasality : University of Pittsburgh Department of Plastic Surgery