Secondary functional veloplasty: a non-obstructive approach to valopharyngeal insufficiency
Veloplastia funcional secundaria: una alternativa no obstructiva en el tratamiento de la insuficiencia velofaríngea

The article "Veloplastia funcional secundaria" reviews the results of 15 secondary veloplasties acc. to Delaire in the treatment of velopharyngeal insufficiency. The patients were between 8 and 22 years of age. Inclusion criteria comprised patients with a short velum and with sufficient muscle bulk.

The purpose of any speech improving surgery in the pharynx of cleft patients, is to reduce nasal air emission, nasal rustle and hypernasality. The authors state that a velopharyngoplasty with posterior flap closes the nasopharyngeal airway in a static way and may cause obstructive sleep apnea. One may wonder if velar lengthening, such as proposed by the authors, may not result in a similar condition. After all, with increasing age, the reconstruction of a dynamic sphincter is becoming more and more an illusion, and results are being obtained from static lengthening (or obstruction) only.

Authors’ indications are a short velum with adequate muscle volume. The authors do not indicate how they diagnose the muscle volume. Clinical inspection, intra-orally or with nasendoscopy, may be insufficient. Magnetic resonance imaging would be a possibility.

The next issue concerns the surgical technique. The authors describe midline incisions and suturing of all layers. Inevitably, this may lead to sagittal scar contraction, with secondary shortening of the velum. Alternatively, a secondary Furlow palatoplasty might avoid these contractions¹ and the two cases I have treated this way, also ended up with an improvement of speech as appreciated by the speech therapist. I admit that the children were younger than 6 years.

Indeed, one may question the indication regarding age. Patients between 8 and 22 years are normally not considered to be sensitive to posterior flap surgery.² The authors are to be congratulated with the good results they obtained with muscular sling reconstruction in this age group.

Finally, soft palate clefts primary treated with the Von Langenbeck technique, without intravelar veloplasty, are rather exceptions in contemporary cleft care.

M. Mommaerts
FEBOMS, FICS, Director Cleft Palate & Craniofacial.
Center Brugge, Belgium

Bibliografía

1. Mommaerts MY, Kablan F, Sheth S, Laster Z. Early maxillary growth in complete cleft lip, alveolus and palate patients following Widmaier-Perko’s, or a modified Furlow’s technique of soft palate repair. J Cranio Maxillofac Surg 2003;31:209.

2. Meek MF, Coert JH, Hofer SO, Goorhuis-Brouwer SM, Nicolai JP. Short-term and long-term results of speech improvement after surgery for velopharyngeal insufficiency with pharyngeal flaps in patients younger and older than 6 years old: 10-year experience. Ann Plast Surg 2003;50:13.