The Horizontal Split Technique for Posterior Pharyngeal Flap Surgery: Speech and Airway Outcomes in 220 Patients

Objective The purpose of this 10-year retrospective review was to report our single-center outcomes using the posterior pharyngeal flap (PPF) horizontal split technique to treat patients with syndromic and non-syndromic velopharyngeal dysfunction (VPD). Design Retrospective review (2011-2021). Setting A tertiary pediatric institution. Patients Patients with VPD (4-21 years old). Interventions PPF surgery using the horizontal split inset technique by 2 surgeons. Main Outcome Measures Evaluated factors included demographics, VPD characteristics, and pre-operative speech evaluation. Evaluated outcomes included complications, revisional VPD surgery rates, post-operative resonance, nasometry scores, and the apnea-hypopnea index (AHI). Results Two hundred and twenty children (median age: 6.9 years) underwent surgery. The median operative time was 47 min. Most patients (95%) achieved improved resonance, with 89% achieving mild or no hypernasality. Median nasalance scores significantly decreased (pre-operative: 42, post-operative: 18). Of 137 patients who underwent a post-operative polysomnogram, 18 patients had an AHI ≥5; 2 patients with syndromic diagnoses underwent PPF takedown. Ten patients underwent revisional VPD surgery. Patients with 22qDS (22q11.2 deletion syndrome) or non-cleft VPD had an increased risk of demonstrating significant residual hypernasality requiring revisional surgery. Conclusions This simple, reproducible PPF surgical technique yields reliably improved resonance in patients with syndromic and non-syndromic VPD. Patients with 22qDS and those with non-cleft VPD may have higher odds of demonstrating residual hypernasality and needing additional surgery. Although there is low risk of flap takedown for obstructive sleep apnea (OSA), long-term airway monitoring remains essential.