The primary goals of cleft palate repair are to PEDIATRIC/CRANIOFACIAL

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1 PEDIATRIC/CRANIOFACIAL Evaluation of Two Palate Repair Techniques for the Surgical Management of Velopharyngeal Insufficiency Albert S. Woo, M.D. Gary B. Skolnick, B.S. Neil S. Sachanandani, M.D. Lynn M. Grames, M.A., C.C.C.-S.L.P. St. Louis, Mo. Background: The Furlow palatoplasty is commonly used for the correction of velopharyngeal insufficiency in cleft patients. An alternative procedure is introduced involving a single Z-plasty with overlapping intravelar veloplasty (Woo palatoplasty). This study compared the results of both techniques in the correction of velopharyngeal insufficiency. Methods: After institutional review board approval, a retrospective chart review was performed of all patients who had undergone secondary palatoplasty for the correction of velopharyngeal insufficiency. All nonsyndromic patients with imaging data were evaluated. Data elements included preoperative and postoperative velopharyngeal gap size and perceptual speech examination results. Results: Fifty-two subjects were included: 30 subjects had undergone Furlow palatoplasty and 22 underwent Woo palatoplasty. Overall, a larger proportion of Woo (95 percent) than Furlow subjects (63 percent) did not require secondary surgery (p = 0.005). However, mean presurgery closure was significantly different between groups (p = 0.042). For a more refined assessment, only those with 80 percent or greater preoperative closure were evaluated. Successful results were achieved in 67 percent (10 of 15) in Furlow and in 100 percent (19 of 19) in Woo. Again, this finding was significant (p = 0.005). Linear regression analysis suggested a significant effect of cleft type (β = 2.3, p = 0.013) on closure after repair, with decreased closure in cases with isolated cleft palate. Conclusions: The Woo palatoplasty compared favorably with Furlow palatoplasty for correction of velopharyngeal insufficiency. The technique appears to be a viable alternative for palatal re-repair, especially in circumstances when Furlow palatoplasty cannot be performed. (Plast. Reconstr. Surg. 134: 588e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. The primary goals of cleft palate repair are to optimize feeding and to normalize speech. Despite successful closure of the palate, 5 to 40 percent of patients suffer from abnormal speech resonance because of residual anatomical structural abnormalities. 1 This disorder is referred From the Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine; and the Cleft Palate-Craniofacial Institute, St. Louis Children s Hospital. Received for publication September 27, 2013; accepted January 30, Presented at the 12th International Congress on Cleft Lip/ Palate and Related Craniofacial Anomalies, in Lake Buena Vista, Florida, May 5 through 10, Copyright 2014 by the American Society of Plastic Surgeons DOI: /PRS to as velopharyngeal insufficiency, defined as the inability of the soft palate to close completely against the posterior pharynx during speech production. The Furlow double-opposing Z-plasty is a surgical technique that elegantly addresses the short palatal length and levator muscle malposition thought to be associated with subideal speech outcomes after palatoplasty. 2 Originally introduced as a method for primary repair, it has been quickly adopted for the management of velopharyngeal Disclosure: The salary for Gary B. Skolnick, B.S., is paid for in part by the St. Louis Children s Hospital Foundation Children s Surgical Sciences Institute. The authors have no financial interest to declare in relation to the content of this article. 588e

2 Volume 134, Number 4 Velopharyngeal Insufficiency insufficiency and serves as a first-line treatment option at many institutions. Numerous studies have documented results of Furlow palatoplasty for correction of velopharyngeal insufficiency, noting success rates ranging from 49 to 89 percent. 3 6 A decreased risk of airway obstruction when compared with other surgical options 7 9 was also noted. Based on a review of available data, Furlow suggested that his procedure be considered when velar closing ratios are between 80 and 99 percent. 10 Despite the apparent success of Furlow palatoplasty for the correction of velopharyngeal insufficiency, it is notable that this procedure is contraindicated when previous intravelar veloplasty has been performed. As such, it can be offered when records clearly document nonrepair of the levator or nasendoscopy demonstrates levator diastasis identified by longitudinal notching over the soft palate. 11 This limitation prevents offering the procedure to patients with unclear examinations regarding the status of the levator musculature. In others, it cannot be performed when documentation of previous intravelar veloplasty exists. To address these issues, the author has developed a technique for cleft palate repair that incorporates the concept of radical intravelar veloplasty with the palatal lengthening and levator muscle overlap inherent in the Furlow palatoplasty. Following radical levator dissection, rather than the direct reapproximation described classically, 12,13 both ends are overlapped to create a tight muscular sling. The nasal mucosa is closed longitudinally and the oral mucosa is repaired by means of a single Z-plasty to achieve palatal lengthening. For simplicity, the procedure is referred to as the Woo palatoplasty. The goal of this retrospective study was to compare the results of these two palatal rerepair techniques for the management of velopharyngeal insufficiency. It was our hypothesis that the Woo palatoplasty would be equally effective as Furlow palatoplasty in the correction of velopharyngeal insufficiency. PATIENTS AND METHODS Study Design A retrospective review was conducted for all patients who had undergone palatal rerepair procedures (Furlow or Woo palatoplasty) for the correction of velopharyngeal insufficiency at St. Louis Children s Hospital. All subjects diagnosed with an overt cleft palate (with or without cleft lip deformity) were included in the study; each had clinical findings consistent with velopharyngeal dysfunction and demonstrated incomplete velopharyngeal closure on videonasendoscopy and/or videofluoroscopy. Cases of submucous cleft palate were excluded from analysis, as studies had demonstrated poorer overall success in this specific cohort. 14 Preoperative and postoperative imaging and perceptual speech evaluations were also required for inclusion. A postoperative perceptual speech examination with normal resonance was also considered acceptable and recorded as complete closure. In these instances, the patient was considered to have normal resonance if there was no evidence of abnormal coupling of oral and nasal cavities or passive/obligatory nasal emission, turbulence, or grimacing in spontaneous and elicited speech samples. 15 Patients were excluded for syndromic diagnosis and for a history of any previous pharyngeal procedures for correction of velopharyngeal insufficiency. They were also excluded if pharyngeal procedures were performed concurrently (i.e., Furlow palatoplasty and sphincter pharyngoplasty together), as the additional operation was considered a confounding factor. Data elements included date of birth, sex, race, type of cleft lip deformity, age at primary operation, primary operation performed, preoperative and postoperative velopharyngeal gap size on speech imaging (including degree of palatal elevation and lateral pharyngeal wall movement), preoperative and postoperative speech assessment, postoperative complications, need for a secondary operation, and secondary operation performed (if any). Cases were deemed successful if no further surgical intervention was recommended by the velopharyngeal team (which included two speech pathologists, three plastic surgeons, and one otolaryngologist), who reviewed the perceptual speech examinations and imaging studies as a group to form consensus. The Institutional Review Board at Washington University School of Medicine approved this study. Perceptual Speech Examination and the Grading of Velopharyngeal Dysfunction Speech imaging evaluations were performed in three parts, all of which were completed in a single day. The first component of the assessment was a video-recorded perceptual speech evaluation conducted by one of two speech pathologists, both of whom had greater than or equal to 15 years of experience. A standard speech examination was used for perceptual speech testing from a published protocol. 16 The first part of the examination consisted of imitated consonant-vowelconsonant syllables. Once the child s consonant 589e

3 Plastic and Reconstructive Surgery October 2014 repertoire was determined, appropriate additional words, phrases, and simple sentences were imitated. Misarticulations were eliminated as being unrepresentative of true velopharyngeal functioning. Conversational speech sampling was also performed, and in the case of children with intact articulation, oral reading and rapid forward and backward counting was also used. If present, palatal fistulae were plugged with lubricated cotton during perceptual speech assessment and imaging studies. 17 Compensatory or maladaptive misarticulations (i.e., glottal stops, nasal fricatives, pharyngeal stops, and pharyngeal fricatives) were not imaged, as they have been shown to be invalid for assessment of velopharyngeal function. 18 Consequently, a child was required to have at least one allophonic pair of appropriately articulated oral pressure consonants to be considered for velopharyngeal imaging. Some of the children were evaluated and imaged on the basis of correct use of [p,b] in word and phrase imitations. Others presented with much larger or even complete oral consonant repertoires. Speech Imaging All patients underwent preoperative and postoperative speech imaging, with both videonasendoscopy and multiview videofluoroscopy. The speech sample used was determined by the results of the perceptual speech examination, and the speech pathologist was present throughout both studies. Endoscopic sample length was dependent on speech sample used, patient cooperation, and adequate visualization of structure and movement. An abbreviated sample was selected for the videofluoroscopy, with the goal of completing the necessary sample within 90 seconds. Closure from both imaging studies was estimated and reported as a percentage representing the ratio of maximum closure to rest position, as recommended by the international working group. 19 A View-Master (Fisher-Price, Inc., East Aurora, N.Y.) was used to minimize head rotation and movement for younger patients. 20 Surgical Techniques Furlow Double-Opposing Z-Plasty The operative technique performed was consistent with that described by Furlow. 10 As a secondary procedure, incisions were limited to the soft palate, which was divided at the midline. Double-opposing musculomucosal flaps were elevated and transposed as described classically. Woo Overlapping Intravelar Veloplasty with Oral Z-Plasty The novel technique developed by the senior author (A.S.W.) has not previously been published and is therefore reported in detail. As a secondary procedure, the soft palate is initially divided at the midline. Similar to a palatal rerepair described by Sommerlad et al., 13 Veau s cleft muscle is identified and dissected out separately from the surrounding mucosa (Fig. 1). The levator veli palatini musculature is released and isolated from surrounding muscular attachments, including the palatopharyngeus, palatoglossus, and tensor veli palatini 21 (Fig. 2). Once separated, the muscle is round and tubular in structure, taking the appearance similar to that of a lumbrical of the hand. Dissection continues laterally until its origin is encountered at the petrous portion of the temporal bone, along the skull base. Before muscle repair, the nasal mucosa is then sutured closed directly, in longitudinal fashion. The oral Z-plasty is then incised and elevated (Fig. 3). With maximal retropositioning of the levator, a significant degree of laxity is identified (Fig. 4). The levators are then overlapped on each other, with both ends anchored to the body of the opposite muscle (Figs. 5 and 6). The oral Z-plasty is then transposed and sutured, with the final appearance similar to that of the Furlow technique (Fig. 7). Statistical Analysis Statistical analysis was performed as follows. Between-group comparisons of the means of continuous variables were performed using independent samples two-tailed t tests. The mid-p correction value of Fisher s exact test was used to compare the proportions of categorical variables, such as cleft type. Binary logistic regression analysis with forced entry of covariates was used to compare the need for secondary surgery, taking into account cleft type, age at repair, and baseline palatal closure. Linear regression analysis was used to determine the impact of parameters on palatal closure after repair. The independent variables entered into the linear regression models were repair technique, cleft type, age at repair, and baseline palatal closure. Baseline palatal closure was not included in the regression models of the subset of patients with high baseline closure (80 to 100 percent); as the range of baseline closure had already been restricted, this covariate was excluded to keep the number of covariates in the model in line with the smaller sample size. 590e

4 Volume 134, Number 4 Velopharyngeal Insufficiency Fig. 1. Veau s cleft muscle is identified and separated from surrounding mucosa. In vivo images on the right demonstrate the progressive operative steps and were all photographed during the same procedure (except Fig. 4). Fig. 2. Separation of levator muscle and retropositioning to a transverse orientation. Note the tubular appearance of the levator once it has been dissected from surrounding structures. Fig. 3. The nasal mucosa is closed and oral Z-plasty incisions are made. When reasonable laxity is noted, the nasal mucosa need not be violated. When severe scarring and contracture are present, an opposing Z-plasty can be performed. For all tests, values of p < 0.05 were considered significant. Fisher s exact tests were performed using MatLab R2011B (MathWorks, Natick, Mass.). All other statistical analysis was performed using IBM SPSS Version 20 (IBM Corp., Armonk, N.Y.). 591e

5 Plastic and Reconstructive Surgery October 2014 Fig. 4. Following dissection of the levators, significant redundancy can be seen before overlapping of the musculature. Results The records of 52 patients were adequate for inclusion in this study. Thirty subjects had undergone Furlow palatoplasty (group F) and 22 had undergone the Woo procedure (group W). In group F, 14 were male and 16 were female patients. In group W, 14 were male and eight were female patients. The average age at the time of palatal reoperation was 7.2 years (group F, 6.9 years; group W, 7.7 years), with an age range from 3.3 to 30.9 years. Twenty-three had an original diagnosis of isolated cleft palate, 22 had unilateral cleft lip cleft palate, and seven had bilateral cleft lip cleft palate. The breakdown in demographic and clinical parameters is shown in Table 1. Maximal (versus habitual) closure before surgery ranged from 10 to 100 percent, with a mean of 74 percent. None of the patients suffered notable complications postoperatively, including localized infections or fistulas. Overall, a significantly larger proportion of group W subjects (95 percent) than group F subjects (63 percent) did not require secondary surgery (p = 0.005) and were deemed successful. Logistic regression analysis showed a trend toward less need for surgery in group W (p = 0.059). Fig. 5. The tip of the left levator has been inset into the body of the opposite muscle. Fig. 6. Both levator muscles have been overlapped on each other and sutured together. Frequently, additional tightening is performed. 592e

6 Volume 134, Number 4 Velopharyngeal Insufficiency Fig. 7. The appearance of the palate on completion of the procedure is similar to that of the Furlow palatoplasty repair. Table 1. Clinical Characteristics of All Patients Included in the Study Palatoplasty Furlow Woo p Demographics No NA Sex 14 male, 16 female 14 male, 8 female Race 2 Asian, 28 Caucasian 4 African-American, 1 Asian, 17 Caucasian Clinical characteristics Cleft diagnosis 15 isolated, 10 unilateral, 8 isolated, 12 unilateral, 2 bilateral 5 bilateral Closure pattern 9 circular, 21 coronal 1 asymmetric, 2 bowtie, 4 circular, 14 coronal, 1 sagittal 0.127* Mean age at repair ± SEM, yr 6.9 ± ± VNE, mo after repair 10.7 ± ± VPI after primary repair No leak 13 (43) 18 (82) Small leak 6 (20) 3 (14) Needs repair 11 (37) 1 (5) Suggested secondary repair Pharyngeal flap 1 NA Sphincter pharyngoplasty 9 NA Woo palatoplasty 1 NA NA, not applicable; VNE, videonasendoscopy; VPI, velopharyngeal insufficiency. *Fisher s exact Monte Carlo method. Cleft type (p = 0.175), baseline palatal closure (p = 0.112), and age at surgery (p = 0.785) were not significant factors. The entry of covariates into the model was significant overall (p = 0.013), and the regression model correctly predicted outcome in 81 percent of the cases. Linear regression analysis showed a significant effect of baseline palatal closure on closure after repair (β = 0.226, p = 0.002). There was a trend toward increased closure after repair with group W (β = 5.71, p = 0.091). Cleft type (p = 0.501) and age at repair (p = 0.292) were not significant factors. However, mean group F closure before surgery (69 ± 5 percent) (mean ± SEM) was significantly lower than that for group W (81 ± 4 percent) (p = 0.042). Group F also included a greater proportion of patients with less than 80 percent closure (p = 0.006). To better normalize the groups, similar analysis was performed only on patients with greater than or equal to 80 percent velopharyngeal closure preoperatively (Table 2). Mean baseline closure was 92.0 ± 1.7 in group F and 87.9 ± 1.3 in group W. These means were not significantly different (p = 0.062). Postrepair closure was 96.3 ± 1.3 in group F and 99.2 ± 0.4 in group W. These results were also not significantly different (p = 0.060). Among these patients, successful results were achieved in 67 percent (10 of 15) in group F and in 100 percent (19 of 19) in group W. The difference in proportions was statistically significant (p = 0.005). In this subset of subjects, logistic regression analysis suggested that none of the covariates was significantly related to the need for surgery: 593e

7 Plastic and Reconstructive Surgery October 2014 Table 2. Clinical Characteristics of Patients with Preclosure Greater Than or Equal to 80 Percent Palatoplasty Furlow Woo p Demographics No NA Sex 7 male, 8 female 11 male, 8 female Race 1 Asian, 14 Caucasian 3 African American, 1 Asian, 15 Caucasian Clinical characteristics Cleft diagnosis 10 isolated, 2 unilateral, 3 bilateral 7 isolated, 10 unilateral, 2 bilateral Closure pattern 4 circular, 11 coronal 1 asymmetric, 2 bowtie, 4 circular, 11 coronal, 1 sagittal 0.700* Mean age at repair ± SEM, yr 8.1± ± VNE, mo after repair 15.4 ± ± VPI after primary repair No leak 8 (53) 16 (84) Small leak 2 (13) 3 (16) Needs repair 5 (33) 0 (0) Suggested secondary repair Pharyngeal flap 1 NA Sphincter pharyngoplasty 3 NA Woo palatoplasty 1 NA NA, not applicable; VNE, videonasendoscopy; VPI, velopharyngeal insufficiency. *Fisher s exact Monte Carlo method repair type (β = 20.1, p = 0.998), cleft type (isolated, β = 20.5, p = 0.999; unilateral, β = 1.5, p = 1.000; bilateral, p = 1.000), and age at surgery (p = 0.901). However, all five of the cases requiring secondary surgery had isolated cleft palates and were in group F. Given this perfect separation in predictors, the logistic regression lacked good fit. Linear regression analysis in this subset suggested a significant effect of cleft type (β = 2.3, p = 0.013) on closure after repair, with decreased closure in cases with isolated cleft palate. There was a trend toward increased closure after repair in group W (β = 2.4, p = 0.053). Age at repair (β = 0.01, p = 0.458) was not a significant factor. DISCUSSION The Furlow palatoplasty has firmly established itself as a mainstay of treatment for the management of velopharyngeal dysfunction. Despite its advantages, it cannot be offered in all cases of velopharyngeal insufficiency. To address these issues, the senior author (A.S.W.) has developed a novel procedure that incorporates concepts advocated by Furlow and those of radical intravelar veloplasty. A single Z-plasty is performed of the oral mucosa, whereas the more elastic nasal mucosa is sutured in linear fashion. Doing so largely avoids overlapping scars. Moreover, the oral Z-plasty provides lengthening despite the fact that it is performed only on the oral mucosa layer. The procedure also calls for radical intravelar veloplasty. The levator is separately identified and dissected from tethering anterior muscular attachments toward its origins along the skull base. Doing so allows for clear identification of the levator and maximal retropositioning. The final, unique element to this procedure involves overlapping the levators to optimally tighten the muscular sling. In cleft patients, it is has been documented that the levator muscle abnormally inserts along the bony palatal margins. This results in a longer levator than one that is in a normal transverse position. 22 Geometrically, it stands to reason that transposition of the levators from an oblique, anterior insertion to a transverse orientation would naturally lead to overlap of the two sides. This concept is elegantly put into practice by Furlow s innovative procedure, where musculomucosal flaps are serendipitously overlapped during transposition of the flaps. In contrast, radical intravelar veloplasty techniques advocate endto-end approximation of the levators. 23 The new palatoplasty offers advantages when compared with the Furlow procedure. Most notably, the Woo palatoplasty can be performed regardless of previous history of intravelar veloplasty. Because the muscle is treated individually and dissected out separately from the mucosal flaps, the technique can be offered to all patients who might benefit from additional tightening of the levator sling regardless of initial muscle positioning. The procedure thereby eliminates some of the decisional quandaries that clinicians may face when considering Furlow palatoplasty as a surgical option. In addition, the Woo palatoplasty allows the 594e

8 Volume 134, Number 4 Velopharyngeal Insufficiency surgeon to maximally retroposition the muscle and manipulate the levator musculature independent of associated mucosa. Some critics of the Furlow palatoplasty have noted that mobilization of the levator is limited by one s ability to transpose the musculomucosal flaps. Because of the treatment of the muscle and mucosa as a single unit, optimal retropositioning of the levator musculature may not be achieved in all cases of Furlow palatoplasty. There are some disadvantages to this surgery as well. The learning curve is steep, primarily secondary to the radical intravelar dissection whereby the levator musculature is individually identified and dissected to its origins. Most clinicians are more comfortable performing a standard Kriens intravelar veloplasty, 24 in which the musculature is not separated and dissection is limited to the cleft edges. Beyond this, the additional work to isolate the tissue layers and repair each separately (including a Z-plasty of the oral mucosa) adds time and complexity to the procedure. Discussion of the theoretical advantages of a procedure are largely moot without proven clinical efficacy. Therefore, the purpose of this study was to compare the results of the Woo procedure against those obtained by an accepted standard: Furlow palatoplasty. Despite the inherent limitations of a retrospective study, the results are promising. When all patients who underwent palatal rerepair with Furlow (group F) and Woo (group W) techniques were evaluated, group F had an overall success rate of 63 percent compared with group W s 95 percent. Success was defined as closure of the velopharynx without recommendations for additional surgery based on imaging studies and perceptual speech evaluation. In contrast, failure was noted when additional surgery was recommended to correct residual velopharyngeal insufficiency. Among those requiring secondary surgery in group F, three underwent pharyngeal flap surgery and five underwent sphincter pharyngoplasty. Five others were lost to follow-up. Interestingly, one patient who had initially failed surgery by Furlow palatoplasty had subsequent successful correction by means of Woo palatoplasty. In group W, one patient failed management and required secondary surgery. In this subject, closure was noted at 50 percent preoperatively and increased to 95 percent postoperatively. However, residual persistent leakage was noted and the patient was treated successfully with pharyngeal flap surgery. Despite the initial positive findings in favor of the Woo procedure, it is readily recognized by the authors that the two groups were not equivalent. Most notably, group F had more patients with larger baseline palatal defects. Attempting to standardize the groups further, only those patients who had a preoperative velopharyngeal closure of greater than or equal to 80 percent were evaluated, based on Furlow s suggestion that doubleopposing Z-plasty be considered in such situations. Under this more refined subgroup analysis, the results again proved promising for the Woo palatoplasty. Group F had successful results in 67 percent, whereas group W demonstrated 100 percent success. Small sample sizes, especially in this subset of subjects with baseline closure of greater than or equal to 80 percent, limited the power of the study. Based on these results, the senior author (A.S.W.) continues to perform the Woo palatoplasty exclusively when palatal rerepair is warranted. Thus far, no complications (e.g., fistula, dehiscence, infection) have been noted in the secondary palatoplasty population, and no patients have noted any new signs of sleep apnea. Given the limitations of this study, further work is warranted to better assess this technique and define the optimal indications for success. Conclusions A novel technique for palatal rerepair (Woo palatoplasty) is noted to be a safe and effective procedure for the management of velopharyngeal insufficiency. In this study, the results of Woo palatoplasty compared favorably with Furlow palatoplasty in achieving velopharyngeal competence postoperatively. The technique appears to be a viable alternative for secondary palate surgery, especially in circumstances when the Furlow palatoplasty cannot be performed. Albert S. Woo, M.D. Division of Plastic and Reconstructive Surgery Washington University in St. Louis 660 South Euclid Avenue Campus Box 8238 St. Louis, Mo wooa@wustl.edu acknowledgments Research reported in this publication was supported by the St. Louis Children s Hospital Foundation Children s Surgical Sciences Institute. references 1. Sell D, Grunwell P, Mildinhall S, et al. Cleft lip and palate care in the United Kingdom: The Clinical Standards 595e

9 Plastic and Reconstructive Surgery October 2014 Advisory Group (CSAG) Study. Part 3: Speech outcomes. Cleft Palate Craniofac J. 2001;38: Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986;78: Perkins JA, Lewis CW, Gruss JS, et al. Furlow palatoplasty for management of velopharyngeal insufficiency: A prospective study of 148 consecutive patients. Plast Reconstr Surg. 2005;116:72 80; discussion Chen PK, Wu JT, Chen YR, et al. Correction of secondary velopharyngeal insufficiency in cleft palate patients with the Furlow palatoplasty. Plast Reconstr Surg. 1994;94: ; discussion Lindsey WH, Davis PT. Correction of velopharyngeal insufficiency with furlow palatoplasty. Arch Otolaryngol Head Neck Surg. 1996;122: Deren O, Ayhan M, Tuncel A, et al. The correction of velopharyngeal insufficiency by Furlow palatoplasty in patients older than 3 years undergoing Veau-Wardill-Kilner palatoplasty: A prospective clinical study. Plast Reconstr Surg. 2005;116:85 93; discussion Lesavoy MA, Borud LJ, Thorson T, et al. Upper airway obstruction after pharyngeal flap surgery. Ann Plast Surg. 1996;36:26 30; discussion Liao YF, Noordhoff MS, Huang CS, et al. Comparison of obstructive sleep apnea syndrome in children with cleft palate following Furlow palatoplasty or pharyngeal flap for velopharyngeal insufficiency. Cleft Palate Craniofac J. 2004;41: Ettinger RE, Oppenheimer AJ, Lau D, et al. Obstructive sleep apnea after dynamic sphincter pharyngoplasty. J Craniofac Surg. 2012;23: Furlow LT Jr. Correction of velopharyngeal insufficiency by double-opposing Z-plasty. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. New York: McGraw-Hill; 2009: Witt PD, D Antonio LL. Velopharyngeal insufficiency and secondary palatal management: A new look at an old problem. Clin Plast Surg. 1993;20: Cutting CB, Rosenbaum J, Rovati L. The technique of muscle repair in the cleft soft palate. Oper Tech Plast Reconstr Surg. 1995;2: Sommerlad BC, Henley M, Birch M, et al. Cleft palate rerepair: A clinical and radiographic study of 32 consecutive cases. Br J Plast Surg. 1994;47: Sommerlad BC, Fenn C, Harland K, et al. Submucous cleft palate: A grading system and review of 40 consecutive submucous cleft palate repairs. Cleft Palate Craniofac J. 2004;41: Peterson-Falzone S, Trost-Cardamone S, Karnell M, Hardin- Jones M. The Clinician s Guide to Treating Cleft Palate Speech. St. Louis: Mosby; Lipira AB, Grames LM, Molter D, et al. Videofluoroscopic and nasendoscopic correlates of speech in velopharyngeal dysfunction. Cleft Palate Craniofac J. 2011;48: Isberg A, Henningsson G. Influence of palatal fistulas on velopharyngeal movements: A cineradiographic study. Plast Reconstr Surg. 1987;79: Henningsson GE, Isberg AM. Velopharyngeal movement patterns in patients alternating between oral and glottal articulation: A clinical and cineradiographical study. Cleft Palate J. 1986;23: Golding-Kushner KJ, Argamaso RV, Cotton RT, et al. Standardization for the reporting of nasopharyngoscopy and multiview videofluoroscopy: A report from an International Working Group. Cleft Palate J. 1990;27: ; discussion Sommerlad B, Rowland N, Harland K. Lateral videofluoroscopy: A modification to aid in velopharyngeal assessment and measurement. Cleft Palate Craniofac J. 1994;31: Huang MH, Lee ST, Rajendran K. Anatomic basis of cleft palate and velopharyngeal surgery: Implications from a fresh cadaveric study. Plast Reconstr Surg. 1998;101: ; discussion Randall P, Jackson O. A short history of cleft lip and cleft palate. In: Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. New York: McGraw-Hill; 2009: Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112: Kriens OB. An anatomical approach to veloplasty. Plast Reconstr Surg. 1969;43: e