A Study On Surgical Treatment For Velopharyngeal Insufficiency

Objective:Perform anatomic study on longus capitis and provide theoretical basis for the design and operative procedure of longus capitis muscle flaps.Introduce the clinical application of longus capitis muscle flaps,buccinator musculomucosal island flaps and posterior pharyngeal wall augmentation with autologous fat for cleft palate or velopharyneeal insufficiency.Methods:Perform anatomical investigations in fourteen sides cadavers.Observe the position,morphology,size,adjaceney,blood supply.nerve inner- vations of longus capitis.Design longus capitis muscle flaps pedicled superiorly or inferiorly.Transplantation of longus capitis muscle flaps were performed in four cleft palate patients to narrow velopharyngeal space and reconstruct the velopharyngeal sphincter.Transplantation of buccinator musculomucosal island flaps were performed in eleven cleft palate patients and twenty-two velopharyngeal insufficiency patients. Posterior pharyngeal wall augmentation with autologous fat were performed in four cleft palate patients and six velopharyngeal insufficiency patients.Results:Four cleft palate patients were treated with longus capitis muscle flaps.Three patients got satisfactory results without complications such as infection.hematoma.cervical sympathetic trunk injury and obstructive sleep apnea.One patient got cleft relapse at uvula and soft palate.The cleft was repaired with a transferred buccinator musculomucosal island flap immediately,but a cleft reccurred at the soft palate and it healed after another soft palate repair performed one year later.Two patients followed up and both got definitive increases in movement of soft palate and pharyngeal wall and got significant enhancement in velopharyngeal closure function.Thirty-three patients were treated with buccinator musculomucosal island flaps.Twenty-one patients followed up.Two got fistulae at the soft palate because of partial necrosis at the end of buccinator musculomucosal flaps but no further treatment were demanded because the diameter of fistulae were both no more than two millimeter.The other patients had no severe complications such as facial nerves injuries.limitation in mouth opening or mastication difficulty.The follow-up results shew that the patients got definitive decrease of hypernasality and increases in speech articulation.length of soft palate,and got significant enhancement in velopharyngeal closure function.Ten patients were treated with posterior pharyngeal wall augmentation with autologous fat.All the ten patients follwed up.Nine the patients got satisfactory results in thicking posterior pharyngeal wall without complications such as infection,hematoma,and obstructive sleep apnea.One patient had not obvious result because of less volume of transpanted fat.Conclusions:The longus capitis muscle flaps are rich in blood supply,easily survived and have movement function to narrow velopharyngeal "space and reconstruct the velopharyngeal sphincter.The longus capitis muscle flaps pedicled superiorly are designed for cleft palate or velopharyngeal insufficiency with large velopharyngeal space or weak mobility of pharyngeal wall and soft palate.The longus capitis muscle flaps pedicled superiorly are also suitable to repair defect of soft palate and skull base.The longus capitis muscle flaps pedicled inferiorly are suitable to repair the defect of pars oralis pharyngis,tongue base and posterior portion of tongue body.The buccinator musculomucosal island flaps pedicled posteriorly are rich in blood supply,easily survived and can prolong the soft palate significantly,no need for wearing teeth pad or a second stage operation of pedicle division.This method is designed for cleft palate or velopharyngeal insufficiency with large cleft and short soft palate but with good mobility of pharyngeal wall.Autologous fat is a good kind of filling material because it has rich resources,can be obtained easily and has no rejection.Posterior wall augmentation with autologous fat can result in thickening and forwards-moved posterior wall.This method is suitable for velopharyngeal insufficiency with small velopharyngeal gap no more than five millimeter,and it's also suitable for larger gap combined with other conventional operation.