Planificación quirúrgica de colgajo faríngeo a medida para insuficiencia velofaríngea secundaria a fisura de paladar: reporte de caso y revisión de literatura / Surgical planning of a tailor-made pharyngeal flap for velopharyngeal insufficiency secondary to a cleft palate: case report and literature review

Resumen La insuficiencia velofaríngea (IVF) es una de las principales secuelas estructurales tras la palatoplastía primaria en casos de fisura de paladar. La IVF se caracteriza por la ausencia de tejido suficiente para lograr un cierre adecuado del mecanismo velofaríngeo durante el habla, lo que conlleva a una resonancia hipernasal y la emisión nasal de aire durante la producción de sonidos orales. Al respecto, el tratamiento ideal para corregir la IVF es quirúrgico, dentro de los cuales el colgajo faríngeo de pedículo superior es uno de los procedimientos más utilizados en nuestro país. Para su realización es fundamental determinar el ancho necesario, lo cual puede ser determinado mediante una videofluoroscopía multiplano (VFMP). Por esto, con el objetivo de potenciar el trabajo multidisciplinario en la corrección quirúrgica de la IVF, a continuación, se presentan los procedimientos de evaluación fonoaudiológica, videonasofaríngoscopía flexible y videofluoroscopía multiplano utilizados para la planificación quirúrgica de un colgajo faríngeo en un adolescente chileno diagnosticado con IVF secundaria a fisura palatina operada. Además, se describe el uso de la VFMP en la planificación quirúrgica del colgajo faríngeo mediante una revisión de literatura.

Abstract Velopharyngeal insufficiency (VPI) is one of the main structural sequelae after primary palatoplasty in cases of cleft palate. VPI is characterized by the absence of sufficient tissue to achieve adequate closure of the velopharyngeal mechanism (VFM) generating hyper-nasal resonance and nasal emission during the production of oral sounds. In cases of cleft palate, the ideal treatment to correct VPI is surgery. The upper pedicle pharyngeal flap is one of the most widely used procedures. To plan it, is essential to determine the appropriate width, which can be determined by means of multiplane videofluoroscopy (MPVF). For this reason, and with the aim of promoting multidisciplinary approach in the surgical correction of VPI, the following procedures such as speech and language evaluation, flexible videonasopharyngoscopy and multiplane videofluoroscopy used for the surgical planning of a pharyngeal flap, in a Chilean adolescent diagnosed with VPI secondary to operated cleft palate, will be presented. In addition, the use of MPVF in pharyngeal flap surgical planning is described through a literature review.

Treatment of VPI with Customized Pharyngeal Flaps: One Size Does Not Fit All.

Failure of complete closure of the velopharyngeal sphincter results in velopharyngeal insufficiency (VPI), which may severely interfere with speech. The pharyngeal flap remains a common procedure for correcting VPI. We aimed to study whether customization of pharyngeal flaps using a dynamic preprocedural assessment can result in successful outcomes in the surgical treatment of VPI, despite variations in surgical technique. Methods: This is a retrospective review of patients between the ages 4 and 18 years old with VPI who underwent surgical correction by one of four surgeons at our institution. All four surgeons used a superiorly based pharyngeal flap (SBPF) with slight variations in operative technique. All patients also received an evaluation by the speech and language pathologist that included nasometry, multiplanar videofluoroscopy, and flexible videonasopharyngoscopy. Individualized preoperative planning was performed based on the findings. Results: In total, 158 patients (92%) demonstrated overall successful correction of VPI, defined by a normal post-operative mean nasalance. Thirteen patients (8%) presented with resonance improvement but persistent abnormal mean nasalance. The most common causes of failed VPI correction were inferior migration and/or shrinking of the pharyngeal flap. There was a nonsignificant association between surgical technique and unsuccessful corrections. Conclusions: The optimal surgical approach for performing pharyngeal flaps to correct VPI is individualized, customizing the procedure based on preoperative imaging. This study demonstrates that despite variations in surgical techniques for performing SBPF, high rates of success can be achieved when adequate surgical planning is based on imaging findings.