Submucous Cleft Palate and Velopharyngeal Insufficiency: Comparison of Speech Outcomes Using Three Operative Techniques by One Surgeon

OBJECTIVE: Our purpose was to compare speech outcomes among three primary procedures for symptomatic submucous cleft palate (SMCP): two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap. DESIGN: Retrospective review. SETTING: Tertiary hospital. PATIENTS, PARTICIPANTS: All children with SMCP treated by the senior author between 1984 and 2008. INTERVENTIONS: One of three primary procedures: two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap. MAIN OUTCOME MEASURES: Speech outcome and need for a secondary operation were analyzed among procedures. Success was defined as normal or borderline competent velopharyngeal function. Failure was defined as persistent borderline insufficiency or velopharyngeal insufficiency with recommendation for a secondary operation. RESULTS: We identified 58 patients with SMCP who were treated for velopharyngeal insufficiency. We found significant differences in median age at operation among the procedures (p < .001). Two-flap palatoplasty with muscular retropositioning (n = 24), double-opposing Z-palatoplasty (n = 19), and pharyngeal flap (n = 15) were performed at a median of 2.5, 3.6, and 9.5 years, respectively. There were significant differences in success among procedures (p = .018). Normal or borderline competent function was achieved in 6/20 (30%) patients who underwent two-flap palatoplasty, 10/15 (67%) following double-opposing Z-palatoplasty, and 11/12 (92%) following pharyngeal flap. Among patients treated with palatoplasty, success was independent of age at operation (p = .16). CONCLUSIONS: Double-opposing Z-palatoplasty is more effective than two-flap palatoplasty with muscular retropositioning. For children older than 4 years, primary pharyngeal flap is also highly successful but equally so as a secondary operation and can be reserved, if necessary, following double-opposing Z-palatoplasty.