From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.
Ann Plast Surg. 2022 May 1;88(3 Suppl 3):S152-S155. doi: 10.1097/SAP.0000000000003198.
Velopharyngeal insufficiency (VPI), a stigmatizing hallmark of palatal dysfunction, occurs in a wide spectrum of pediatric craniofacial conditions. The mainstays for surgical correction include palate repair and/or pharyngeal surgery. However, primary pharyngoplasty has a failure rate of 15% to 20%. Although revision pharyngoplasty may be necessary in those with persistent VPI, little is known regarding the indications for and outcomes after such procedures. The purpose of this study is to describe the authors' experience with indications for and outcomes after revision pharyngoplasty.
A single-center retrospective review was performed of all patients undergoing revision pharyngoplasty between 2002 and 2019. Demographic data and Pittsburgh Weighted Speech Scores, diagnoses, comorbidities, and complications were tabulated. Two-tailed Student t test was used, and a P value of 0.05 or less was considered statistically significant.
Thirty-two patients (65.6% male) met inclusion criteria for this study. The most common diagnoses included cleft palate (68.8%), submucous cleft palate (SMCP, 18.8%), and congenital VPI (6.3%, likely occult SMCP). Most patients (84.4%) underwent palatoplasty before their initial pharyngoplasty. The primary indication for initial pharyngoplasty was VPI (mean age 7.1 ± 4.6 years). The most common indication for revision pharyngoplasty (mean age 11.2 ± 5.1 years) included persistent VPI (n = 22), followed by obstructive sleep apnea (OSA) (n = 11). Persistent VPI (n = 8) and OSA (n = 6) were the most common complications after secondary pharyngoplasty. Thirteen patients (40.6%) within the revision pharyngoplasty cohort required additional surgical intervention: 4 underwent tertiary pharyngoplasty, 4 underwent takedown for OSA (n = 3) or persistent VPI (n = 1), 3 underwent takedown and conversion Furlow for persistent VPI (n = 2), OSA (n = 2) and/or flap dehiscence (n = 1), and 2 underwent palatal lengthening with buccal myomucosal flaps for persistent VPI. Of the 4 patients who required a tertiary pharyngoplasty, the mean age at repair was 6.6 ± 1.1 years and their speech scores improved from 13.5 to 2.3 after tertiary pharyngoplasty (P = 0.11). The overall speech score after completion of all procedures improved significantly from 19 to 3.3.
Patients who fail primary pharyngoplasty represent a challenging population. Of patients who underwent secondary pharyngoplasty, nearly half required a tertiary procedure to achieve acceptable speech scores or resolve complications.
腭咽闭合不全（VPI）是腭部功能障碍的一个特征性标志，可发生于广泛的儿科颅面畸形中。手术矫正的主要方法包括腭修复和/或咽成形术。然而，原发性咽成形术的失败率为 15%至 20%。尽管对于持续存在 VPI 的患者可能需要进行修正性咽成形术，但对于此类手术的适应证和术后结果知之甚少。本研究旨在描述作者在修正性咽成形术中的适应证和术后结果。
对 2002 年至 2019 年间进行修正性咽成形术的所有患者进行了单中心回顾性研究。记录了人口统计学数据、匹兹堡语音重量评分、诊断、合并症和并发症。采用双尾学生 t 检验，P 值<0.05 被认为具有统计学意义。
32 名患者（65.6%为男性）符合本研究的纳入标准。最常见的诊断包括腭裂（68.8%）、黏膜下腭裂（SMCP，18.8%）和先天性 VPI（6.3%，可能为隐匿性 SMCP）。大多数患者（84.4%）在初次咽成形术前接受过腭成形术。初次咽成形术的主要适应证是 VPI（平均年龄 7.1±4.6 岁）。修正性咽成形术的主要适应证（平均年龄 11.2±5.1 岁）包括持续存在的 VPI（n=22），其次是阻塞性睡眠呼吸暂停（OSA）（n=11）。继发性咽成形术后最常见的并发症是持续存在的 VPI（n=8）和 OSA（n=6）。在修正性咽成形术队列中，有 13 名患者（40.6%）需要进一步的手术干预：4 名患者接受了三级咽成形术，4 名患者因 OSA（n=3）或持续存在的 VPI（n=1）接受了拆除手术，3 名患者因持续存在的 VPI（n=2）、OSA（n=2）和/或瓣裂开（n=1）接受了拆除和 Furlow 修复术，2 名患者因持续存在的 VPI 接受了腭延长和颊肌黏膜瓣。需要进行三级咽成形术的 4 名患者中，修复时的平均年龄为 6.6±1.1 岁，三级咽成形术后语音评分从 13.5 提高至 2.3（P=0.11）。所有手术完成后的总体语音评分从 19 提高至 3.3，显著提高。
初次咽成形术失败的患者代表了一个具有挑战性的群体。在接受二级咽成形术的患者中，近一半的患者需要进行三级手术才能获得可接受的语音评分或解决并发症。
