Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 459e461

Prospective evaluation of the outcomeof velopharyngeal insufficiency therapy afterpharyngeal flap, a sphincter pharyngoplasty,a double Z-plasty and simultaneous Orticocheaand Furlow operations

Piotr Wojcicki*, Karolina Wojcicka

University Clinic of Medical Academy in Wrocław, Department of Plastic Surgery SCM in Polanica Zdroj, ul. Jana Pawła II 2,57-320 Polanica Zdroj, Poland

Received 26 January 2010; accepted 25 June 2010

KEYWORDSSimultaneous;Furlow operation;Sphincterpharygoplasty;VPI

* Corresponding author. Tel.: þ48 74E-mail address: p.wojcicki@c

(P. Wojcicki).

1748-6815/$-seefrontmatterª2010Bridoi:10.1016/j.bjps.2010.06.020

Summary Between 2001 and 2006 treated 84 patients with VPI. The patients were qualified forpharyngeal flap, Orticochea and Furlow’s operations. Since 2007e2009 there were 22 consecu-tive patients who were qualified for Orticochea and Furlow operations performed at the sameoperation-stage. The best results were obtained by using Orticochea and Furlow operations.ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

The aim of the prospective study was to evaluate theeffectiveness of therapy in patients with velopharyngealinsufficiency treated with different methods and by simul-taneously performed Furlow and Orticochea operations.

Material and method

Between 2001 and 2006 in the Hospital of Plastic Surgery inPolanica Zdroj treated 84 patients. The patients with

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tishAssociationofPlastic,Reconstruc

cicatrised, little mobile palate were qualified for pharyn-geal flap (28�). Orticochea (15�) were usually performedin patients with mobile palate and transverse position ofthe levator muscle.

Furlow’s operations (45�) were performed in patientswith short soft palate, oblique position of the levatormuscles but with mobile pharyngeal walls.

Since May 2007 to March 2009 there were 22 consecutivepatients with VPI who were qualified for Orticochea andFurlow operations performed at the same operation-stage.All the operations were performed by the author (P.W.).

All the patients were consulted before and 6 monthsafter the operation. The anatomical conditions and thequality of speech were evaluated on the basis of directexaminations as well as nasofiberscopy and nasometry

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Table 1 Data (pre operation)

Velopharyngeal closurenumber of patients/percentage

Speech intelligibilitynumber of patients/percentage

Hypernasality numberof patients/percentage

Nasometry numberof patients/percentage

No Classification 4/5 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 av.

<50% 50e80% >80% 100%

1. Pharyngeal flap (18) (8) (2) (2) (9) (17) (13) (13) (2) (28) 44%64% 29% 7% 7% 32% 61% 46% 46% 7% 100%

2. Oper. Orticochea (6) (8) (1) (2) (8) (5) (6) (7) (2) (15) 43%40% 53% 7% 13% 53% 33% 40% 47% 13% 100%

3. Oper.Furlow (25) (16) (4) (4) (19) (20) (2) (19) (22) (4) (45) 43%56% 35% 9% 9% 42% 44% 5% 42% 49% 9% 100%

4. Oper.Orticocheaþ Furlow (14) (7) (1) (5) (12) (3) (2) (14) (5) (3) (22) 44%64% 32% 4% 23% 55% 14% 8% 64% 23% 11% 100%

Table 2 Data (post operation)

Velopharyngealclosure numberof patients/percentage

Speech intelligibilitynumber of patients/percentage

Hypernasality numberof patients/percentage

Nasometry numberof patients/percentage

Complication Results

No Classification 4/5 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 av. apnoea fistula bad improvement very good

<50% 50e80% >80% 100%

1. Pharyngealflap

(2) (24) (2) (5) (4) (15) (4) (4) (2) (7) (11) (4) 27% 3 (6) (7) (15)7% 86% 7% 18% 14% 54% 14% 15% 7% 25% 38% 15% 21% 25% 54%

2. Oper.Orticochea (2) (6) (7) (1) (3) (7) (4) (1) (6) (5) (3) (3) (4) (2) (6) 25% 1 (3) (4) (8)13% 40% 47% 7% 20% 47% 27% 7% 40% 33% 20% 30% 27% 13% 40% 20% 27% 53%

3. Oper.Furlow (4) (19) (21) (10) (15) (20) (4) (13) (18) (10) (4) (14) (15) (12) 25% 1 (4) (17) (24)9% 43% 48% 22% 33% 45% 9% 29% 40% 22% 9% 31% 33% 27% 9% 38% 53%

4. Oper. Orticocheaþ Furlow

(2) (6) (14) (2) (9) (11) (2) (5) (8) (7) (1) (5) (7) (9) 24% 2 (2) (5) (15)9% 27% 64% 9% 41% 50% 9% 23% 36% 32% 4% 23% 32% 41% 9% 23% 68%

460P.

Wojcicki,

K.Wojcicka

Prospective evaluation of the outcome of velopharyngeal insufficiency therapy after pharyngeal flap 461

The severity of velopharyngeal insufficiency was estab-lished on the basis of criteria presented by InternationalWorking Group.

The evaluation of speech intelligibility, hypernasalityand nasalance ratio were classified on a 1e5 point scale.Patients in whom all three parameters were at least ata good level were considered a very good outcome oftreatment. If none of the parameters was less than ‘three’,the outcome of treatment was considered as improvement.Poor outcome of treatment included cases in which evenone parameter was evaluated as ‘four’ or ‘five’ (Table 1).

Pharyngeal flap, sphincter pharyngoplasty and Furlow’swas performed in a routine way.

Sphincter pharyngoplasty and Furlow’ performedsimultaneously.

After double Z-plasty, the soft palate was elevatedupwards and the level of the incision on the posteriorpharyngeal wall was determined marking the closure plane.A ring formed from the mucomuscular flaps elevated fromthe palatopharyngeal folds was located in the plane. Theflaps were big enough to allow the soft palate to close thevelopharyngeal space during phonation and to be open inresting conditions.1

Results

Comparison of the results of initial and final examinationsshowed that the severity of VPI was similar in individualstudy groups (p> 0.05) and the outcomes of treatment didnot differ much. Among patients after pharyngeal flap,Orticochea, Furlow and Orticochea and Furlow operationsgood or very good outcome was achieved in 54%, 53%, 53%,68%; improvement in 25%, 27%, 38%, 23% and 21%, 20%, 9%,9% respectively were considered a poor outcome despiteslight improvement of their condition2 (Table 2).

There were not observed any severe early complications.Six patients exhibited light sleep apnoea, mainly in the earlypostoperative period, which gradually decreased with time.Statistically significant improvement was observed aftersurgery with use of evaluated methods of treatment.

The best results were obtained by using Orti-cocheaþ Furlow plasty. However chi square test for inde-pendence revealed no statistically significant correlationsbetween surgical method and the result of treatment(c26Z 5.04; pZ 539).

Results of treatment achieved by using Orti-cocheaþ Furlow plasty were statistically better only incomparison with the pharyngeal flap and Orticochea(p< 0.05)

Discussion

Since May 2007 all the patients with severe form of thedeformity have been qualified for double Z-plasty and

sphincter pharyngoplasty performed in one operation. Insuch cases it was believed that there was an effectivepossibility to lengthen the palate and improve itsfunction.2

Furlow operation improves mobility, but not alwaysenables satisfactory elongation of the soft palate.3 In ouropinion additional narrowing of the velopharyngeal spacefrom the back and the sides improves anatomical conditionsand enables almost physiological reconstruction of thearticulatory mechanisms.4,5

This management was based on the following premise:all the patients in whom posterior wall flap phar-yngoplasty is not necessary (mainly due to tissue deficit)and where there is a real chance to improve the perfor-mance of the palate, qualify for double Z-plasty. Simul-taneously performed Orticochea operation improves theefficacy of treatment and is almost free from any addi-tional risk.

1. One-stage operation is an effective modality in thetherapy of VPI.

2. The outcomes after one-stage Furlow operation andsphincter pharygoplasty were better (not statistically)than the different results

3. Indications for pharyngeal flap should be rather limitedto the patients with deficit of the palatine tissue.

Conflict of interest

None.

Funding

None.

References

1. Wojcicki P, Wojcicka G. Prospective evaluation of the outcomeof velopharyngeal insufficiency therapy after simultaneousdouble Z-plasty and sphincter pharyngoplasty Folia PhoniatrLogop 518 DOI 10.1159.

2. Wojcicki P. Evaluation of the efficacy of treatment of post-surgical velopharyngeal insufficiency in cleft palate. AkademiaMedyczna we Wroc1awiu; 2007.

3. Sie KC, Tampakopoulou DA, Sorom J. Results with Furlow Pala-toplasty in management of velopharyngeal insufficiency. PlastReconstr Surg 2001;108:17e25.

4. Wojcicki P, Wojcicka G. The management of velopharyngealinsufficiency with Furlow double-opposing Z-plasty procedure.E J Plast Surg 2008;31:115e21.

5. Gosain AK, Arneja JS. Management of the black hole in velo-pharyngeal incompetence: combined use of a Furlow palato-plasty and sphincter pharyngoplasty. Plast Reconstr Surg 2007;119:1538e45.