PEDIATRIC/CRANIOFACIAL

A Treatment Protocol for Velopharyngeal

Insufficiency and the Outcome
Kazuaki Yamaguchi, M.D.
Daniel Lonic, M.D.
Che-Hsiung Lee, M.D.
Shu-Hui Wang, M.A.
Claudia Yun, M.S., D.D.S.
Lun-Jou Lo, M.D.
Taoyuan, Taiwan
Background: A simple algorithm is applied to treat velopharyngeal insufficien-
cy. The purpose of this study was to assess its success rate and complications.
Methods: The diagnosis includes speech perceptual assessment and nasopha-
ryngoscopy, focusing on velopharyngeal closure ratio. The treatment is com-
posed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency
or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A
retrospective chart review was conducted for 84 consecutive nonsyndromic
postpalatoplasty patients undergoing velopharyngeal insufficiency surgery
from August of 2007 to December of 2014. The demographic, perioperative,
and follow-up data were collected. Statistical analyses were performed.
Results: Mean age at velopharyngeal insufficiency surgery was 7.0 years. The
overall improvement rate for patients was 86.9 percent. Nine patients in the
double-opposing Z-plasty group and two patients in the pharyngeal flap group
were refractory to velopharyngeal insufficiency surgery. The improvement rates
for each surgical group were 80.4 percent for the double-opposing Z-plasty
group and 94.7 percent for the pharyngeal flap group. There were no signifi-
cant differences in postoperative velopharyngeal function between the coro-
nal and noncoronal groups. Airway-associated complications were observed
in nine patients (10.7 percent). The complications in the double-opposing
Z-plasty group were observed in two patients (4.3 percent), and none of the
patients presented obstructive sleep apnea. Seven patients (18.4 percent) in
the pharyngeal flap group showed postoperative snoring, and one (2.6 per-
cent) of them presented with obstructive sleep apnea.
Conclusion: The authors’ algorithm is a simple patient- and surgeon-friendly
strategy to obtain satisfactory improvement of velopharyngeal function for
velopharyngeal insufficiency patients, with a low risk of airway complica-
tions.  (Plast. Reconstr. Surg. 138: 290e, 2016.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

V
elopharyngeal insufficiency can severely
hinder speech intelligibility. It is character-
ized by hypernasal resonance and nasal air
emission with a possible negative impact on the
patient’s quality of life.1,2 It was reported that the
velopharyngeal insufficiency rate after cleft palate
repair varies between 5 and 36 percent.3 There
are several surgical options for this problem, such
as pharyngeal flap, sphincter pharyngoplasty,
posterior pharyngeal wall augmentation, and
the Furlow method of double-opposing Z-plasty.
From the Department of Plastic and Reconstructive Surgery
and the Craniofacial Research Center, Chang Gung Memo-
rial Hospital, Chang Gung University.
Received for publication November 6, 2015; accepted March
22, 2016.
Copyright © 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002386
Pharyngeal flap and sphincter pharyngoplasty
have been reported to be effective for correc-
tion of velopharyngeal insufficiency but are also
associated with certain morbidities. In contrast,
double-opposing Z-plasty provides a good suc-
cess rate for moderate cases with lower morbid-
ity, but seems to be less effective for severe cases.
Randomized controlled trials were conducted to
select the ideal surgical procedure for velopha-
ryngeal insufficiency, revealing that each method
had its disadvantage and was unlikely to correct
all problems on its own.4–7 Possible reasons for the
inconclusive outcomes are manyfold, including
Disclosure: None of the authors has any sources
of financial or other support or any financial or
professional relationships that might pose a competing
interest.

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 Volume 138, Number 2 • Velopharyngeal Insufficiency Treatment
velar length, muscle direction, scar constriction,
and velopharyngeal dimension and movement.8
To balance both the anatomical and functional
complexity of velopharyngeal insufficiency, differ-
ent treatment algorithms have been established,
using nasopharyngoscopic or videofluoroscopic
examination for evaluation and planning.9 The
treatment protocol was based mainly on velopha-
ryngeal gap size and closure pattern. Choosing an
ideal surgical protocol is important for a satisfac-
tory functional recovery and minimal morbidity.
However, the reported algorithms often involve
multiple procedures with inconsistent results, and
lack adequate evidence or large data support. We
have used a treatment protocol for patients with
velopharyngeal insufficiency in which nasopha-
ryngoscopy was performed for confirmation of
the diagnosis and procedure selection between
double-opposing Z-plasty and pharyngeal flap.
This retrospective study evaluated the outcome of
our treatment protocol with regard to its success
rate and complications.
PATIENTS AND METHODS
This retrospective study received an approval
from our institutional review board (institutional
review board no. 104-4546B). A retrospective chart
review included all consecutive nonsyndromic
patients who underwent velopharyngeal insuf-
ficiency surgery following a primary cleft palate
repair. The velopharyngeal insufficiency opera-
tions were conducted by a senior surgeon (L.J.L.)
at the Craniofacial Center, Chang Gung Memorial
Hospital, between August 1, 2007, and December
31, 2014. The following exclusion criteria were
used: (1) age younger than 4 or older than 16
years by the time of surgery, (2) submucous cleft
palate, (3) congenital velopharyngeal insuffi-
ciency without cleft palate, (4) syndromic patients
(e.g., velocardiofacial syndrome, Pierre Robin
sequence), (5) velopharyngeal insufficiency after
orthognathic surgery, (6) follow-up records less
than 6 months, and (7) incomplete data. A total
of 84 patients fulfilled the above-mentioned cri-
teria and were included in the study. Data collec-
tion involved gender, type of cleft (i.e., unilateral
cleft lip/palate; bilateral cleft lip/palate; isolated
cleft palate), age at the time of surgery, follow-up
period, type of primary palatoplasty, type of velo-
pharyngeal insufficiency surgery, preoperative/
postoperative velopharyngeal function, velopha-
ryngeal closure ratio and closure pattern under
nasopharyngoscopy, postoperative complications,
and velopharyngeal insufficiency surgery revision.
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Indication of surgical intervention and choice of
procedure were determined following the proto-
col. If the patient prioritized preventing sleep dis-
turbance, including obstructive sleep apnea, over
velopharyngeal function, the treatment option
was adjusted to double-opposing Z-plasty instead
of the narrow pharyngeal flap (Fig. 1).
Speech Assessment and Complications
Speech assessments were performed by trained
and experienced speech pathologists (S.H.W. and
C.Y.) using standardized perceptual assessment
from the age of 2.5 years.10 Objective evaluation
using nasopharyngoscopy was performed after
age 4 years when signs of hypernasality or nasal
emission were noted. In case of marginal or inad-
equate function, velopharyngeal closure ratio
(from 0 to 1.0) and velopharyngeal closure pat-
tern (i.e., coronal, circular, or sagittal) were evalu-
ated with nasopharyngoscopy.11,12 A perceptual
speech assessment was performed postoperatively
by the same speech pathologists. Nasopharyngos-
copy was indicated to assess velopharyngeal func-
tion if there was any sign of hypernasality during
follow-up. A comparison of preoperative and post-
operative velopharyngeal function for each surgi-
cal procedure was carried out.
Postoperative airway complications were
assessed for each patient by the surgeon and
speech pathologists, including severe snoring,
sleep disturbance, and obstructive sleep apnea for
each patient. During longitudinal follow-up, the
incidences of severe snoring and/or sleep distur-
bance were evaluated by taking a thorough family
history. Severe snoring was defined as being loud to
a degree that other family members were worried.
Sleep disturbance indicated that a patient found
or was found to have wake-ups at night more fre-
quently than before surgery. If snoring and sleep
disturbance were prominent or caused daytime
sleepiness, polysomnography was performed for
the diagnosis of obstructive sleep apnea.
Surgical Technique
Double-Opposing Z-Plasty
Incisions in the soft palate are marked from
the junction between the soft and hard palate
toward the uvula, with each limb spreading to the
base of the hamulus (Fig. 2). After infiltration, the
central limb is incised through all layers, and the
lateral limbs partially. The anterior-based palatal
mucosal flap is dissected on the patient’s right
side, leaving the underlying tissue as a posterior-
based nasal musculomucosal flap. On the left side,
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 Plastic and Reconstructive Surgery • August 2016

Fig. 1. Treatment algorithm for patients with velopharyngeal insufficiency. DOZ, double-opposing Z-plasty; LPW, lateral pha-
ryngeal wall; NPS, nasopharyngoscopy; P, soft palate; PF, pharyngeal flap; PPW, posterior pharyngeal wall; VPF, velopharyngeal
function.

Fig. 2. Surgical procedures of the double-opposing Z-plasty. (Left) Pre-

operative design. (Right) After the operation showing lengthening of
the soft palate. Muscle reconstruction was achieved.

the palatal layer is dissected as a musculomucosal to sustain integrity. On the nasal side, the right
flap, leaving the underlying layer as an anterior- posterior-based musculomucosal flap is incised
based nasal layer mucosal flap. It is advised to at 60  degrees toward the lateral side of soft pal-
keep thin muscle fibers in the nasal mucosal flap ate. The left anterior-based nasal mucosal flap is

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 Volume 138, Number 2 • Velopharyngeal Insufficiency Treatment

incised at 60 degrees to achieve a corresponding
limb. The flaps were aligned as a Z-plasty, with
the central limb perpendicular to the midline
and sutured at appropriate tension with 4-0 Vic-
ryl (Ethicon, Inc., Somerville, N.J.). Suturing the
musculomucosal flaps at appropriate tension is
important for obtaining a secure muscle sling; this
can be achieved by taking a good bite of muscle
and a small bite of mucosa. In case of excess tissue
tension at the tip of the Z flap, a small raw sur-
face at the corner can be left to minimize tension
(Fig. 2). Closure is then continued on the palatal
side, where the Z-plasty is placed in the opposite
direction with the musculomucosal flap trans-
posed posteriorly. Adequate tension is maintained
on both sides of the repair. Complete closure was
usually achieved.
Pharyngeal Flap
The width of the pharyngeal flap is deter-
mined based on the nasopharyngoscopic findings.
A narrow width is designed using half (50 percent)
of the width of the posterior pharyngeal wall, a
medium width using two-thirds (66 percent),
and a wide flap using 90 to 100 percent (Fig. 3).
The flap pedicle is superior-based at least 10 mm
above the first cervical vertebra and usually up to
the adenoid border. After marking and infiltra-
tion with epinephrine-containing local anesthetic
solution, the pharyngeal flap is incised and ele-
vated from inferior to superior at the level of the
prefascial areolar layer. The donor site is closed
in an interrupted and horizontal mattress fashion
using 4-0 Vicryl sutures. In case of a wide pharyn-
geal flap, it is not possible to achieve donor-site
closure; however, interrupted sutures are applied
to reduce the raw surface. The soft palate is split
in the midline. On each side, a distal-based muco-
sal flap is harvested from the nasal side of the
soft palate and transposed in a back-flip fashion
to cover the pharyngeal flap raw surface. The

Fig. 3. Surgical procedure of the pharyngeal flap. (Above, left) The width of the flap was chosen from half, two-thirds, or all of the
distance between the midline and lateral border of the posterior pharyngeal wall. (Above, right) The pharyngeal flap is transposed
to the nasal side of soft palate with the pedicle superior to the C1 level. (Below, left) Design of the pharyngeal flap. (Below, second
from left) Donor-site closure and harvesting of back-flip mucosa flaps from the nasal side of the soft palate. (Below, second from
right) Coverage of the raw surface of the pharyngeal flap with the mucosa flaps from the left and right sides. (Below, right) Comple-
tion of surgery. Blue arrows indicate the lateral ports on either side of the flap. C, cervical spine; PPW, posterior pharyngeal wall.

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 Plastic and Reconstructive Surgery • August 2016

pharyngeal flap is then sutured to the nasal side
of the soft palate at the anterior margin of the soft
palate and two points on each limb using horizon-
tal mattress sutures. All stitches are kept untied
to ensure flexibility for tissue manipulation. After
the pharyngeal flap is positioned loosely into the
correct place, the elevated back-flip mucosa flaps
are placed and sutured to cover the raw surface of
the pharyngeal flap. The sutures on the soft palate
are subsequently tied with optimal tension. The
midline wound on the palatal side is closed with
simple interrupted sutures.
Statistical Analysis
Descriptive statistics are presented as mean
and standard deviation for continuous variables,
and counts and percentages are given for cate-
gorical variables. One-way analysis of variance was
used to compare the mean values of age at the
time of surgery, follow-up duration, and preopera-
tive average closure ratio among the cleft types.
The chi-square test was used for the distribution
of operative methods among the closure patterns,
for comparison of surgical procedures and pre-
operative velopharyngeal function between cleft
types, and for comparison of perioperative velo-
pharyngeal function between coronal and non-
coronal closure types. Fisher’s exact test was used
for the postoperative velopharyngeal function
following Cochrane’s condition. The unpaired
t test was used to compare the means of age at the
time of surgery and for comparison of preopera-
tive average closure ratios between coronal and
noncoronal closure types. A value of p < 0.05 was
considered a significant difference. All statistical
analyses were performed using IBM SPSS Version
21.0 (IBM Corp., Armonk, N.Y.).
Results
Eighty-four nonsyndromic patients were
included in the study. The patient demograph-
ics are listed in Table  1. The mean age at velo-
pharyngeal insufficiency surgery was 7.0 ± 3.5
years. The timing of surgical treatment showed
a bimodal distribution, with a peak incidence
between 4 and 6 years and another peak between
9 and 10 years. The average follow-up period
was 38.2 ± 24.3 months. The mean preoperative
velopharyngeal closure ratio was 0.60 ± 0.29 for
all cases. There were no significant differences of
preoperative velopharyngeal function or average
closure ratio between the cleft types (chi-square,
p = 0.28; one-way analysis of variance, p = 0.79,
respectively) (Table  2). In terms of preoperative
velopharyngeal function in total cases, 43 patients
(51.2 percent) had marginal function and 41
patients (48.8 percent) were diagnosed with inad-
equate function (Table  2). The overall improve-
ment rate for patients after the treatment was
86.9 percent (73  of 84) (Table  3). Postoperative
velopharyngeal function showed that 68 patients
(81.0 percent) gained adequate competence and
14 patients (16.7 percent) achieved marginal
function (chi-square, p = 0.04) (Table 2). Eleven
patients (13.1 percent) (nine patients in the
double-opposing Z-plasty group and two patients
in the pharyngeal flap group) were refractory to
velopharyngeal insufficiency surgery (Table  3).
Three of the nine patients in the double-oppos-
ing Z-plasty group had a narrow pharyngeal flap

Table 1.  Patient Characteristics, Overall and by Cleft Type

UCLP (%) BCLP (%) CP (%) Total (%) p
No. of patients 42 15 27 84
Age at the time of surgery, yr 0.91*
 Mean 7.0 6.7 7.2 7.0
 SD 3.5 2.6 3.5 3.3
Sex 0.73†
 Male 29 (69.0) 11 (73.3) 12 (44.4) 52 (61.9)
 Female 13 (31.0) 4 (26.7) 15 (55.6) 32 (38.1)
Follow-up, mo 0.14*
 Mean 40.6 26.9 40.8 38.2
 SD 24.5 22.4 23.3 24.3
Primary palatoplasty type
 Langenbeck 1 (2.4) 2 (13.3) 4 (14.8) 7 (8.3)
 Two-flap 8 (19.0) 3 (20.0) 5 (18.5) 16 (19.0)
 Sommerlad 14 (33.3) 5 (33.3) 4 (14.8) 23 (27.4)
 Furlow with Langenbeck 1 (2.4) 0 (0.0) 0 (0.0) 1 (1.2)
 Furlow with two-flap 3 (7.1) 2 (13.3) 1 (3.7) 6 (7.1)
 Not mentioned 15 (35.7) 3 (20.0) 13 (48.1) 31 (36.9)
BCLP, bilateral cleft lip/palate; CP, cleft palate only; UCLP, unilateral cleft lip/palate.
*One-way analysis of variance.
†χ2.

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 Volume 138, Number 2 • Velopharyngeal Insufficiency Treatment

Table 2.  Preoperative and Postoperative Velopharyngeal Function, Overall and by Cleft Type
UCLP (%) BCLP (%) CP (%) Total (%) p
Surgical procedure 0.42*
 DOZ 24 (57.1) 7 (46.7) 15 (55.6) 46 (54.8)
 Narrow PF 11 (26.2) 6 (40.0) 11 (40.7) 28 (33.3)
 Medium PF 7 (16.7) 2 (13.3) 1 (3.7) 10 (11.9)
 Wide PF 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Preoperative VP function 0.28*
 Marginal 24 (57.1) 5 (33.3) 14 (51.9) 43 (51.2)
 Inadequate 18 (42.9) 10 (66.7) 13 (48.1) 41 (48.8)
Closure ratio 0.79†
 Average 0.60 0.58 0.64 0.60
 SD 0.60 0.28 0.27 0.29
Postoperative VP function 0.08‡
 Adequate 31 (73.8) 11 (73.3) 26 (96.3) 68 (81.0)
 Marginal 9 (21.4) 4 (26.7) 1 (3.7) 14 (16.7)
 Inadequate 2 (4.8) 0 (0.0) 0 (0.0) 2 (2.4)
Secondary VPI surgery 3 (7.1) 0 (0.0) 0 (0.0) 3 (3.6)
UCLP, unilateral cleft lip/palate; BCLP, bilateral cleft lip/palate; CP, cleft palate only; DOZ, double-opposing Z-plasty; PF, pharyngeal flap;
VP, velopharyngeal; VPI, velopharyngeal insufficiency.
*χ2.
†One-way analysis of variance.
‡Fisher’s exact test.

as salvage surgery with a good result, whereas the Table 3.  Preoperative and Postoperative
remaining six patients with marginal velopharyn- Velopharyngeal Function, Overall and by Surgical
geal function were still under observation because Procedure
of their reluctance to undergo surgery. As for two Preoperative
refractory cases in the narrow pharyngeal flap Improvement
Adequate Marginal Inadequate Rate (%)
group, one case (initial pharyngeal flap ratio, 0.1)
was repaired with hemipharyngoplasty as a salvage Total (n = 84) 86.9
  Postoperative
operation with a good outcome.13 The other case   Adequate 0 34 34
(initial pharyngeal flap ratio, 0.6) was still under   Marginal 0 9 5
  Inadequate 0 0 2
observation in a state of inadequate velopharyn- DOZ (n = 46) 80.4
geal function. The improvement rates for each  Postoperative
surgical group were 80.4 percent for the double-   Adequate 0 33 4
  Marginal 0 9 0
opposing Z-plasty and 94.7 percent for the pha-   Inadequate 0 0 0
ryngeal flap group (Table 3). PF (n = 38) 94.7
Thirty-nine patients (46.4 percent) had a coro-  Postoperative
  Adequate 0 1 30
nal and 45 patients (53.6 percent) had a noncoro-   Marginal 0 0 5
nal closure pattern (Table 4). Both the preoperative   Inadequate 0 0 2
average closure ratios and preoperative velopha- DOZ, double-opposing Z-plasty; PF, pharyngeal flap.
ryngeal function of the coronal and noncoronal
groups were significantly different (t test, p < 0.01; presenting sleep disturbance or obstructive sleep
chi-square, p = 0.03, respectively) (Table  4). The apnea. Contrary to this, seven patients (18.4 per-
coronal group contained more patients with pre- cent) in the pharyngeal flap group showed snoring,
operative marginal velopharyngeal function than with two (5.3 percent) of them having sleep distur-
the noncoronal group. Therefore, double-oppos- bance. Of the two patients with sleep disturbance,
ing Z-plasty was used more often in the coronal one was diagnosed with obstructive sleep apnea by
and pharyngeal flap group than in the noncoronal polysomnography, and the other complained of
group (chi-square, p = 0.04). Postoperative velo- inconsistent sleep disturbance associated with sea-
pharyngeal function showed no significant differ- sonal allergic rhinitis and was kept under regular
ences between the two groups. observation without polysomnography.
Airway-related problems were observed in nine
patients (10.7 percent) in this study (Table 5). The
complications in the double-opposing Z-plasty Discussion
group were observed in two patients (4.3 percent) The ultimate goal of velopharyngeal insuf-
with severe snoring, with none of the patients ficiency surgery is to achieve competent

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 Plastic and Reconstructive Surgery • August 2016

Table 4.  Demographic Data of Patients by Closure double-opposing Z-plasty or superior-based pha-
Pattern ryngeal flap. The results showed an overall success
Coronal Noncoronal
rate of 86.9 percent. Based on the indications, the
(%) (%) p individual success rates were 80.4 percent in the
No. 39 45
double-opposing Z-plasty group and 94.7 percent
Age at surgery, yr 0.99* in the pharyngeal flap group, being as good as or
 Mean 7.0 7.0 better than rates reported previously.4,5,16–19 Atten-
 SD 3.5 3.5 tion should be paid to the complication rate (10.7
Closure ratio <0.01*
 Average 0.70 0.51 percent). Although studies on surgical complica-
 SD 0.23 0.31 tions were constantly hindered by selection and
Preoperative VP function definition bias, a literature review regarding com-
 Marginal 25 (64.1) 18 (40.0) 0.03†
 Inadequate 14 (35.9) 27 (60.0) plications of velopharyngeal insufficiency surgery
Surgical method demonstrated the following: 13 of 148 patients (8.8
 DOZ 26 (66.7) 20 (44.4) 0.04† percent) showed late complications, including
 PF 13 (33.3) 25 (55.6)
Postoperative VP function snoring and obstructive sleep apnea in a prospec-
 Adequate 32 (82.1) 36 (80.0) 0.95† tive study regarding the double-opposing Z-plasty
 Marginal 6 (15.4) 8 (17.8) procedure.5 A retrospective study described an
 Inadequate 1 (2.6) 1 (2.2)
DOZ, double-opposing Z-plasty; PF, pharyngeal flap; VP, velopharyngeal.
overall complication rate of 31.6 percent in the
*t test. pharyngeal flap group, 20 percent in the sphinc-
†χ2. ter pharyngoplasty group, and 21.1 percent in the
combined procedures group.17 Considering these
velopharyngeal closure with minimal complica- data, our protocol showed a comparable or lower
tions and morbidity. Reports have described vari- complication rate (4.3 percent for the double-
ous surgical techniques and their success rates; opposing Z-plasty group and 18.4 percent for the
however, there is no single solution to fully achieve pharyngeal flap group). The results show that our
the goal. In general, the double-opposing Z-plasty surgical protocol balances surgical effectiveness
method is able to close the velopharyngeal port and complication risk. In contrast, our cohort
with a lower complication rate and less morbid- was strictly limited to nonsyndromic patients
ity, whereas pharyngeal flap surgery is an effective excluding velocardiofacial syndrome, Pierre
method for velopharyngeal closure at the expense Robin sequence, congenital velopharyngeal insuf-
of increased morbidity and higher risk of airway ficiency, and others. Therefore, wide pharyngeal
complication.4–7 To balance effectiveness and flap surgery was not performed in this patient
morbidity, a structured treatment protocol can be group because of absence of very severe velopha-
one of the solutions. By using our algorithm, we ryngeal insufficiency. An interesting study about
can suggest the appropriate surgical option and obstructive sleep apnea incidence in middle-age
estimate the functional recovery and the risk of patients with cleft lip/palate revealed that a signif-
complications.9 icant number of cleft palate patients had obstruc-
To assess the outcome of our algorithm, the tive sleep apnea and related symptoms with or
patient cohort was strictly defined. Because of the without a pharyngeal flap surgery20; another study
diverse causes of velopharyngeal insufficiency, found no correlation between obstructive sleep
only East Asian patients with cleft lip/palate and a apnea and flap width.21 The pharyngeal flap itself
previous cleft palate repair were studied, exclud- might not have a long-term effect on the devel-
ing submucous cleft palate, congenital velopha- opment of obstructive sleep apnea. However, it is
ryngeal insufficiency, and syndromic cases.14,15 certainly a contributing factor to the postopera-
The selected patients were treated by either tive airway narrowing and influences the patient’s
quality of life.
Table 5.  Postoperative Complications, Overall and by Our velopharyngeal insufficiency treatment
Surgical Procedure algorithm is composed of two sections, one for
Complication
diagnosis and the other for selection of the surgi-
cal procedure. The diagnosis section is simplified
No. Snoring (%) Sleep Disturbance (%) OSA (%)
and includes only speech perceptual assessment
DOZ 46 2 (4.3) 0 (0.0) 0 (0.0) and an evaluation of velopharyngeal closure ratio,
PF 38 7 (18.4) 2 (5.3) 1 (2.6)
Total 84 9 (10.7) 2 (2.4) 1 (1.2) without the need for multiview videofluoroscopy
OSA, obstructive sleep apnea; DOZ, double-opposing Z-plasty; PF, or consideration of the closure pattern. Further-
pharyngeal flap. more, the treatment section is also simplified to

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 Volume 138, Number 2 • Velopharyngeal Insufficiency Treatment

choose either double-opposing Z-plasty or pharyn-
geal flap. The whole process is simple compared
with the treatment protocol in different cleft cen-
ters (Table 6).7,9,12,22–26 A previous report described
the inferiority of the pharyngeal flap for coronal
closure with a lower success rate compared with
pharyngeal flap surgery for noncoronal closure,
therefore suggesting sphincter pharyngoplasty
as an alternative procedure.12 In contrast, a pro-
spective, randomized, controlled study compar-
ing pharyngeal flap and sphincter pharyngoplasty
against two homogenous groups of velopharyn-
geal insufficiency patients showed no significant
difference in the postoperative speech outcome.6
Furthermore, in both pharyngeal flap and sphinc-
ter pharyngoplasty, the flaps were proven to have
no muscle activity after surgery.22 We hypothe-
sized that the key factor for obtaining competent
velopharyngeal function could be the balance
between the narrowed velopharyngeal space
rather than the closure pattern and the residual
muscle function around the velopharyngeal port.
Thus, the pharyngeal flap could be applied even
to patients with a coronal pattern by adjusting the
width of the pharyngeal flap according to the clo-
sure ratio. Our outcome indicated that the closure
pattern was not related to the postoperative velo-
pharyngeal function (Table  4). The coronal pat-
tern groups showed a higher mean closure ratio
of the velopharyngeal port than the noncoronal
group (0.70 versus 0.51). The poorer preopera-
tive velopharyngeal function in the noncoronal
group might suggest that the pharyngeal flap
could be more effective in this pattern. However,
there is no significant difference in postoperative
velopharyngeal function between the groups fol-
lowing our treatment protocol.
We focused on describing a good algorithm
for the decision if a more invasive procedure than
double-opposing Z-plasty is needed; the merit of
our study is not limited to decide whether sphinc-
ter pharyngoplasty, pharyngeal flap, or double-
opposing Z-plasty is the best procedure. Collins
et al. described in their meta-analysis that no
significant differences between sphincter pha-
ryngoplasty and pharyngeal flap were seen after

Table 6.  Algorithms for Treatment of Velopharyngeal Insufficiency in Different Centers

Multicenter St. John’s Sick Kids‡, Lurie
(25 Centers)*, Mercy Health Toronto, Children’s CHOP‖, CGMH,
CSGBI, United Center†, Ontario, Hospital§, Philadelphia, Taoyuan,
Center Kingdom St. Louis, Mo. Canada Chicago, Ill. Pa. Taiwan
Algorithm — Yes Yes Yes Yes Yes
Speech assessment Always, 4/25 Perceptual Perceptual PWSS PWSS Perceptual
(GOSPASS or
CAPS-A)
Nasometry Always, 8/25; often Yes Yes Yes NA No
or rarely, 11/25;
never, 6/25
NPS Often, 20/25; Yes Yes Yes Yes Yes
always, 2/25
Videofluoroscopy Always, 22/25 Yes Yes Yes Less often No
Aerodynamic Infrequent, 13/25; Yes NA NA NA No
investigation rarely or never,
8/25
Closure-related NA NA Yes (coronal/ Yes Yes No
protocol noncoronal)
Surgical procedures
 Re-repair Often, 20/25 IVV PF DOZ DOZ DOZ
 SP Often, 14/25 PF SP PF PF PF
 DOZ Often, 12/25 SP SP SP
 PF Rarely, 15/25 DOZ and SP
CAPS-A, Cleft Audit Protocol for Speech-Augmented; CHOP, The Children’s Hospital of Philadelphia; CSGBI, Craniofacial Society of Great
Britain and Ireland; CGMH, Chang Gung Memorial Hospital; DOZ, double-opposing Z-plasty; GOSPASS, Great Ormond Street Speech Assess-
ment Scale; IVV, intravelar veloplasty; NPS, nasopharyngoscopy; PF, pharyngeal flap; PWSS, Pittsburgh Weighted Speech Scale; SP, sphincter
pharyngoplasty; NA not available.
*Hodgins N, Hoo C, McGee P, Hill C. A survey of assessment and management of velopharyngeal incompetence (VPI) in the UK and Ireland.
J Plast Reconstr Aesthet Surg. 2015;68:485–491.
†Marsh JL. The evaluation and management of velopharyngeal dysfunction. Clin Plast Surg. 2004;31:261–269.
‡Armour A, Fischbach S, Klaiman P, Fisher DM. Does velopharyngeal closure pattern affect the success of pharyngeal flap pharyngoplasty? Plast
Reconstr Surg. 2005;115:45–52; discussion 53.
§Ysunza A, Pamplona MC. Velopharyngeal function after two different types of pharyngoplasty. Int J Pediatr Otorhinolaryngol. 2006;70:1031–1037.
‖Gart MS, Gosain AK. Surgical management of velopharyngeal insufficiency. Clin Plast Surg. 2014;41:253–270; Basta MN, Silvestre J, Stran-
sky C, et al. A 35-year experience with syndromic cleft palate repair: Operative outcomes and long-term speech function. Ann Plast Surg.
2014;73(Suppl 2):S130–S135; and Kennedy WP, Mudd PA, Maguire MA, et al. 22q11.2 Deletion syndrome and obstructive sleep apnea. Int J
Pediatr Otorhinolaryngol. 2014;78:1360–1364.

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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • August 2016
12 months but that, after 3 months, the pharyn-
geal flap patients were three times as likely as
the sphincter pharyngoplasty patients to have a
resolution of the problems.27 However, both pro-
cedures are also shown to be very dependent on
the surgeon, and our results with pharyngeal flap
surgery have been much better than with sphinc-
ter pharyngoplasty, so that for many years we have
been using the pharyngeal flap solely. Regarding
repeated double-opposing Z-plasty after primary
Furlow palatoplasty, we previously reported that
the main purpose of conversion double-opposing
Z-plasty does not seem to be muscle reconstruc-
tion but elongation of velar length, so that dou-
ble-opposing Z-plasty can be applied according to
the velopharyngeal closure ratio.10
Our study was not without limitations. The
study design was retrospective in nature and there-
fore subject to confounding errors. Although
none of other potential risk factors were associ-
ated with velopharyngeal function and complica-
tions, we cannot exclude residual confounding
from unmeasured or undetected factors. The
ideal study design should be a prospective cohort
with a control arm to assess the effectiveness of
the algorithm. Further evaluation is ongoing, but
the comprehensive approach using the algorithm
instead of a single surgical procedure for velopha-
10. Hsu PJ, Wang SH, Yun C, Lo LJ. Redo double-opposing
ryngeal insufficiency is reasonable and beneficial,
considering the complexity of the disease.
Conclusions
This study demonstrates the overall success
rate of our velopharyngeal insufficiency treatment
algorithm for patients with previous repaired cleft
palate of 86.9 percent and a relatively low compli-
cation rate (10.7 percent) of airway problems. This
treatment algorithm is composed of two simple
assessment steps using perceptual speech assess-
ment and nasopharyngoscopy, and two surgical
procedures (double-opposing Z-plasty and supe-
rior-based pharyngeal flap). In our study, the clo-
sure pattern was not significantly correlated with
the postoperative velopharyngeal function. The
findings support the belief that our algorithm is
a simple patient- and surgeon-friendly strategy to
gain satisfactory improvement of velopharyngeal
function with a low risk of airway complications.
Lun-Jou Lo, M.D.
Department of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
5 Fu-Shin Street
Kwei Shan, Taoyuan 333, Taiwan
lunjoulo@cgmh.org.tw
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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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