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

Discussion

Intravelar veloplasty reinforced velar muscle power, and the palatal lengthening with modified bilateral buccinator sandwich pushback posteroinferiorly elongated the soft palate. However, these procedures appeared not to enhance closure of the velopharyngeal port. The patient's gradual reduction of VPI after an extended period of time suggested that the anticipated postoperative shrinkage of the ringed fascia lata without peritendinous areolar tissue played a more prominent role than the intravelar veloplasty and the palatal lengthening with modified bilateral buccinator sandwich pushback. The shrunken ringed fascia lata appeared to function as an intravelar palatal lift[10–12] and maintained the soft palate in the raised and posteriorly displaced position as well as the lateral and posterior pharyngeal walls in the medially and anteriorly displaced positions. Since nasometry results indicated that hypernasality had reduced but hyponasality did not worsen, the postoperative narrowing of the velopharyngeal port appeared to be optimal.

Although infrequent, VPI following primary cleft palate repair can present a severe problem for patients with deep nasopharynx and powerless velopharyngeal muscles, as seen in this case. The pharyngeal flap procedure is the most popular and reliable technique for postoperative VPI, but it is sometimes accompanied by respiratory complications such as hyponasality, difficulty with nasal respiration, and sleep apnea, all of which may be difficult to secondarily adjust.[13–17] We showed how a ringed fascia lata graft encircling the velopharyngeal muscles may be an additional surgical method to narrow postoperative deep atonic nasopharynx with less risk of respiratory complications (Fig 4).

Figure 4.

Oblique translucent (a) and lateral (b) views of the schematic correlation between the muscles and the ringed fascia lata graft (green). L: levator veli palatini muscle; S: superior pharyngeal constrictor muscle.

Klippel-Feil syndrome is a complex disorder of osseous and visceral anomalies that include the classical clinical triad of short neck, limitation of head and neck movements, and low posterior hairline. Cleft palate associated with Klippel-Feil syndrome is reported to be common, and speech results are relatively poor as anomalies of the upper cervical column and cranial base, including the palatal shelves, impede velopharyngeal valving.[18] Since our patient with Klippel-Feil syndrome had poor palatal and lateral and posterior pharyngeal wall movements, we used a ringed fascia lata sling in the velopharyngeal wall as an intravelar palatal lift instead of a pharyngeal flap. Although her pharyngeal port closure pattern was coronal, there was little compensative movement of the lateral and posterior walls during phonation and even while blowing. Therefore, if we had performed pharyngeal flap surgery, a very broad flap would have been needed to functionally close the pharyngeal port and the procedure would have had a relatively high risk of respiratory complications.

The method of a ringed fascia lata graft for velopharyngeal closure has already been established. Thompson et al and other groups reported a palmaris longus muscle graft for palatal function repair expected reinnervated muscle contraction[19–21] and obtained good speech results with a better functioning palatal reconstruction. The effectiveness of their procedure seemed to depend on the static sling, which narrowed the pharyngeal port by cicatricial contracture of tendon and muscle and functioned in the same way as our ringed fascia lata procedure, using postoperative shrinkage. Gold and Song[22] also described a palmaris longus tendon transplant without the muscle portion for pharyngopalatoplasty, using a method that greatly influenced our own. Although their 13 patients achieved good results, the authors described the necessity of functional, contractile muscle in the soft palate for this technique to augment the dynamic sphincter mechanism. Indeed, functional muscle contributes significantly to any pharyngoplasty, even the pharyngeal flap. Our fascia lata sling procedure combined with intravelar veloplasty and palatal lengthening with modified bilateral buccinator sandwich pushback could render the atonic velopharyngeal muscles active not by squeezing the velopharyngeal port but by an intravelar palatal lift. There is another report that describes the use of the fascia lata for functional correction of persistent VPI by reconstruction of palatal aponeurosis.[23] However, this surgical concept is fundamentally different from our own.

The ringed fascia lata graft for an intravelar palatal lift seems to have multiapplicational possibilities for other clinical conditions, such as congenital VPI and submucosal cleft palate with deep pharynx. This graft also has the advantage of being adjustable; if the narrowing of the velopharyngeal port is too tight, we can release or cut the fascia. Furthermore, if VPI reduction is incomplete or the patient needs the additional pharyngeal flap surgery, we can shorten the fascial sling or possibly elevate the superiorly based pharyngeal flap.

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