A Ringed Fascia Lata Graft Without Peritendinous Areolar Tissue Encircling the Levator Veli Palatini and Superior Pharyngeal Constrictor Muscles Gradually Shrinks to Reduce Velopharyngeal Incompetence, Functioning as an Intravelar Palatal Lift

Kenya Fujita, MD, PhD; Kiyoshi Matsuo, MD, PhD; Shunsuke Yuzuriha, MD, PhD

Disclosures

ePlasty. 2013;13 

In This Article

Methods

The patient was a 6-year-old girl who had a cleft palate associated with Klippel-Feil syndrome but no psychomotor developmental delay. She had undergone cleft palate repair with Furlow's double opposing Z plasty at 22 months of age. However, her postoperative speech showed severe velopharyngeal incompetence (VPI) characterized by hypernasal speech and abnormal articulation. Although speech therapy was commenced at 36 months of age, neither her speech nor velopharyngeal function showed improvement. Pharyngoscopy demonstrated very weak palatal movements while speaking and blowing (Figs 1a and 1b). Her atonic velopharyngeal closure pattern was coronal and left a large gap during phonation that was not compensated for by the lateral pharyngeal walls. Her soft palate showed weak movements while speaking in videofluoroscopic observation. The velopharyngeal distance from the posterior pharyngeal wall to the nasal surface of the soft palate was 12 mm in a resting state, 9 mm on /i/ phonation, and 6 mm on /ka/ phonation (Figs 2a–2c).

Figure 1.

Pharyngoscopic views. Before surgery, resting position (a) and on phonating /i/ (b). Two years after surgery, resting position (c) and on phonating /i/ (d). The green dotted line indicates the anterior part of the ringed fascia lata graft.

Figure 2.

Videofluoroscopic views. Preoperative images at resting position (a), on phonating /i/ (b), and on phonating /ka/ (c). Two-year postoperative images at resting position (d), on phonating /i/ (e), and on phonating /ka/ (f). The diameter of the ring attached to the forehead indicates 10 mm.

We first performed palatal muscle re-repair with intravelar veloplasty[3–5] as described by Sommerlad et al,[6,7] followed by palatal lengthening with modified bilateral buccinator sandwich pushback as reported by Hill et al[8] (Fig 3a). Next, a long strip of fascia lata was harvested from her right thigh, using a tendon stripper through a 3-cm skin incision. The harvested fascia lata was 7 mm in width and 11 cm in length, from which the peritendinous areolar tissue was removed to potentially enhance gradual postoperative shrinkage (Fig 3b).[2] We then prepared a recipient tunnel for the fascia lata graft. Two parallel vertical stab incisions were made in the posterolateral pharyngeal walls to aid passing of the fascial strip. The incisions were carried down to the prevertebral fasicia and were connected by a tunnel under the posterior pharyngeal muscles in front of the atlas. The tunnel was anteriorly extended in front of the levator veli palatini and palatopharyngeus muscles, which were re-repaired. A 2-0 silk suture was then passed through the lateral and posterior tunnel. One end of the graft was tied to the suture, and then the fascia lata was carefully passed through the tunnel (Fig 3c). The ends of the fascia were sutured to each other without tension so as not to leave dead spaces around the levator veli palatini, palatopharyngeus, and superior pharyngeal constrictors muscles. Thus, the ringed fascia lata graft encircled the muscles in front of the atlas. Finally, all surgical wounds were closed with 5-0 vicryl sutures (Fig 3d).

Figure 3.

Intraoperative steps. (a) The solid and dotted lines indicate the incision line and intended palatal lengthening, respectively, and surround the square mucosal defect. (b) A strip of fascia lata. (c) The fascia lata graft ends (*) being sutured to each other under the repaired muscles after intravelar veloplasty (**). (d) After palatal lengthening, the oral and nasal mucosal defects were covered with the bilateral buccinator flaps.

Differences between pre- and postoperative velopharyngeal closure were evaluated by pharyngoscopy, videofluoroscopy, and nasometry, as well as by speech pathologists. Nasometry is a simple diagnostic test using a nasometer (Kay Pentax Elemetrics Nasometer II Model 6400; Lincoln Park, NJ) and provides a "nasalance" score, which is a numeric ratio of nasal to nasal-plus-oral acoustic energy (%).[9] Vowel and oral test word hypernasality were used to assess reduction of hypernasality. Nasal test word hypernasality was used to assess worsening of hyponasality.

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