INTRODUCTION
Velopharyngeal insufficiency (VPI) is the inability to close the velopharyngeal sphincter
during phonation and/or feeding that can be a consequence of an enlarged velopharyngeal
gap and a diminished muscular contraction of the velum and posterolateral pharyngeal
walls.[[1 ]] The causes of VPI can be either congenital or iatrogenic. Moreover, VPI can be
linked to over 400 recognised syndromes[[2 ]] and a correct pre-operative diagnosis is mandatory in terms of a proper clinical
orientation. The most common causes of VPI are cleft palate, submucous cleft, velar
hypoplasia, velar paralysis or paresis, after coma paralysis, velar hemiparesis, VPI
post-adenoidectomy and the outcomes of velar resection for cancer.
The first-line treatment is speech therapy, but in cases of insufficient improvement,
surgery may be indicated. Different surgical strategies are described in the literature:
sphincter pharyngoplasty, palatal pushback, velopharyngoplasty (VPP) with posterior
pharyngeal flap and pharyngeal posterior wall augmentation with different kind of
fillers. In recent years, the autologous fat grafting has been proposed, and in the
last 20 years, different studies have been published, with the aim to clarify the
role of this technique that, in selected patients, allows to improve voice resonance
and reduces nasal air escape without modifying the anatomy of the velopharyngeal port.
Furthermore, this surgical approach can be used to improve the outcomes after major
surgery. Despite its simplicity, that allows to perform multiple procedures in the
same patient, it is of a paramount importance not to forget the potentially severe
complications described in the literature. Therefore, a multidisciplinary approach
is mandatory in VPI assessment and management.
MATERIALS AND METHODS
A total of 21 patients were involved in this retrospective study (14 males and 7 females),
ages 4–23 (mean 9, 43 years, median 7 years and range 19 years) affected by mild-to-moderate
velopharyngeal insufficiency and treated with the augmentation of the posterior pharyngeal
wall with autologous fat injection between May 2012 and December 2016, in the Department
of Plastic and Reconstructive Surgery of the Hospital SS. Antonio e Biagio e Cesare
Arrigo of Alessandria, Italy. All the patients were evaluated with a multidisciplinary
approach. After a period of at least 1 year of speech therapy, the patients were operated
by an experienced team composed of plastic surgeons of the Department of Plastic and
Reconstructive Surgery and paediatric surgeons of the Department of Pediatric Surgery
of the Hospital SS. Antonio e Biagio e Cesare Arrigo of Alessandria (Italy). Written
informed consent was obtained from adult patients and from both parents in children
patients. The pre- and post-operative assessment included clinical examination, phoniatrician
evaluation and nasofibroscopy. The follow-up ranged from 6 to 60 months.
Inclusion criteria
The inclusion criteria were as follows:
Clinical evidence of mild-to-moderate hypernasal speech (Borel–Maisonny score 1/2,
2/1 2b, 2 m 2/3)
Velar mobility allowing a velopharyngeal closure of at least 50%
Long-term speech therapy (at least 1 year).
Exclusion criteria
The following criteria were excluded from this study:
Contraindication to general anaesthesia
Severe articulatory defect and bad intelligibility (Borel–Maisonny score: 3)
Severe cognitive deficiency.
The aetiology was primary VPI for 11 patients, secondary VPI after surgical correction
of cleft palate for 9 patients (1 patient was affected by Pierre Robin syndrome),
VPI after adenotonsillectomy for adenotonsillar hypertrophy for 1 patient (affected
by Down syndrome). One patient had a previous pharyngoplasty. One patient had a pharyngoplasty
14 months later.
Patient's details are reported in [Table 1 ].
Table 1
Patient's details
Patient
Age
Sex
VPI aetiology
VPP
Harvesting
Injected Amount
BM pre-operative
BM post-operative
VPI: Velopharyngeal insufficiency, VPP: Velopharyngoplasty, BM: Borel Maisonny
1
5
Male
Primary
-
Thigh
5
2m
1
2
23
Male
Cleft palate
-
Abdomen
5
2/1
1
3
15
Female
Primary
-
Abdomen
10
2b
1/2
4
14
Male
Adenotonsillectomy (Down syndrome)
-
Abdomen
16
2/1
1
5
7
Female
Primary
-
Gluteal region
9
2b
1/2
6
6
Male
Primary
-
Gluteal region
5
2/1
1
7
7
Female
Cleft palate
-
Abdomen
8
2b
1
8
10
Female
Cleft palate (Pierre Robin syndrome)
-
Abdomen
8
2/3
1/2
9
20
Male
Cleft lip and palate
-
Abdomen
12
2m
n.d.
10
4
Male
Primary
-
Thigh
5
2b
1/2
11
7
Male
Cleft lip and palate
-
Abdomen
8
2m
1/2
12
7
Male
Cleft lip and palate
-
Gluteal region
6
1/2
1
13
8
Male
Cleft palate
+ (pre)
Abdomen
9
2/1
1
14
4
Male
Primary (congenital bilateral auris atresia and speech delay)
+ (post)
Abdomen
6
2m
2m
15
11
Female
Cleft palate
-
Thigh
11
2m
1/2
16
9
Male
Primary
-
Gluteal region
5
2/1
1/2
17
5
Male
Cleft palate
-
Gluteal region
5
2b
1/2
18
5
Male
Primary
-
Abdomen
4
2m
2/1
19
9
Male
Primary
-
Abdomen
5
2m
2/1
20
6
Female
Primary
-
Gluteal region
5
2/3
2b
21
16
Female
Primary
-
Abdomen
20
2b
2/1
Patient selection and pre- and post-operative assessment
Patient selection was performed by a multidisciplinary team composed by a paediatric
surgeon, a plastic surgeon, a specially trained phoniatrician and a speech therapist.
The pre- and post-operative evaluations included: the clinical examination of the
voice and the videonasopharyngoscopy. The perceptual evaluation of the voice was performed
by the phoniatrician that analysed spontaneous speech, repetition of sentences and
phonemes to assess resonance, audible air escape and turbulence, articulation defects.
The hypernasality was assessed according to the Borel–Maisonny score [[Table 2 ]]. The videonasopharyngoscopy was performed by using a flexible endoscope in all
the patients. In younger patients, a small diameter (<3 mm) fibroscope was used.
Table 2
Borel-Maisonny score: Perceptive evaluation of hypernasality
Score
Definition
1
Normal phonation, no nasal air emission
1/2
Good phonation, intermittent nasal air emission, good intelligibility
2/1
Phonation with partially corrected nasal air emission
2b
Phonation with continuous nasal emission but good intelligibility and no social discomfort
2m
Phonation with continuous nasal emission and poor intelligibility
2/3
Phonation with continuous nasal emission with compensatory articulation, poor intelligibility
3
Continuous compensatory articulation and bad intelligibility
The patients were asked to produce the phonemes ‘a’, ‘i’ and ‘s’ with the aim to evaluate
the velar mobility and the degree of velopharyngeal closure. The morphology of the
pharynx, the presence of a submucosal cleft, adenoid rests and compensatory signs
were evaluated. The post-operative evaluation was performed 6 months after surgery.
Moreover, we investigated the parental perception of the outcomes, their satisfaction
rate and its impact on their child's speech and quality of life after surgery. We
interviewed the parents of 19 treated patients. All the interviews were conducted
through telephone by a trainee doctor of our team. The interview form is reported
in [Table 3 ]. The interviews were performed between 6 and 60 months after surgery.
Table 3
Interview questions
A lower score has been related to a higher level of satisfaction
What was your child speech like before the surgery?
Unintelligible
Somewhat unintelligible
Somewhat intelligible
Intelligible
What was the speech like after the surgery?
Definitely better than before
Slightly better than before
The same than before
Worse than before
Were you satisfied with their speech after the surgery?
Yes
No
Were there any complication after the surgery?
No
Yes
Do you think the results have remained the same since the surgery?
Yes
No
Do you think the quality of life of your child has improved after the surgery?
Yes
No
Would you suggest the surgical procedure to other patients?
Yes
No
The Wilcoxon test allowed us to compare the pre- and post-treatment values of the
Borel–Maisonny score and the intelligibility scores obtained with the interview.
The statistical analysis was performed using the software SOFA (version 1.4.6. www.sofastatistics.com , Paton-Simpson & Associates Ltd).
Protocol of treatment
On the basis of the results of the clinical examination of the voice and videonasopharyngoscopy,
we followed this therapeutic approach. Patients with a velopharyngeal gap <50% with
a Borel–Maisonny score between 1/2 and 2/3 were considered candidates for lipofilling
(only after at least 1 year of speech therapy), whereas patients with velopharyngeal
gap >50% with continuous compensatory articulation and bad intelligibility of the
speech (Borel–Maisonny score: 3) were candidates for pharyngoplasty. Borderline patients
(Borel–Maisonny score: 2 m and 2/3) were informed before the surgery that there may
be the possibility to perform more than one procedure of fat grafting or a pharyngoplasty,
in case of unsatisfactory improvement.
Surgical treatment
The procedure was always performed under general anaesthesia. The fat was harvested
from the abdomen or, in thin patients, from the thigh and from the gluteal area, after
local infiltration with a 2% mepivacaine with epinephrine solution. A 2-mm skin incision
was performed with an 11 blade and the anaesthetic solution was infiltrated using
a multiple-hole infiltration cannula. A 3-mm, 3-hole blunt cannula connected to a
10 mL Luer-lock syringe was used to harvest the fat [[Figure 1 ]]. The harvested fat was always centrifuged at 3000 bpm for 3 min. The skin incision
was sutured with a 5/0 nylon suture. An elastic dressing was placed in the donor area.
The fat was transferred to a 2 mL Luer-lock syringe using a specific Luer-lock adapter.
With the patient in a supine position with the neck hyperextended, a Dingman mouth
gag [[Figure 2 ]] was placed and the fat was injected into the posterior pharyngeal wall, superficial
to the pre-vertebral fascia. Concerning the fat injection into the pharyngeal wall,
we performed 1 incision in the midline of the posterior pharyngeal wall with an 11
blade and we placed the fat [[Figure 3 ]] using a slightly curved 20-Gauge cannula, suturing the entry point with a 5/0 absorbable
suture. The level of the incision is represented by the anterior tubercle of the atlas
at the level of the odontoid process. The cannula is advanced in a cranial and lateral
direction and the fat is placed in the midline and paramedian. All the patients were
discharged the day after the surgery. Prophylactic antibiotic treatment was administered
in every case (amoxicillin/clavulanic acid based on the weight).
Figure 1: The fat harvesting site
Figure 2: The operative field after placement of a Dingman mouth gag
Figure 3: Fat injection into the posterior pharyngeal wall
RESULTS
A total of 21 patients (14 males and 7 females), ages 4–23 affected by mild-to-moderate
velopharyngeal insufficiency were included in the study. The mean injected fat volume
was 7, 95 cc (median 6 cc, min 4 cc, max 20 cc and range 16 cc). The follow-up ranged
from 6 to 60 months. One patient was lost at the follow-up. There were no major complications
(bleeding, infection, obstructive sleep apnoea and embolism). After the surgery, most
patients reported mild pain in the region of the neck and at the site of fat harvesting.
In all these patients, the pain disappeared with intravenous administration of acetaminophen
on the basis of the weight. There were no complications in the harvesting site and
there were no complaints regarding the scars. The nasality was improved in all patients
except in the case n° 14 (injected fat volume: 6 cc).
The pre- and post-operative Borel–Maisonny scores are reported in [Table 1 ]. The Wilcoxon test showed that the improvement was statistically significant.
Regarding the phone interviews, a trainee doctor of our department contacted the parents
of 19 patients (all the patients under 18 years old). He could not contact 2 over
18-year-old patients: the case 2 lost at the follow-up and the case 9 who did not
answer. In 16 cases (84,2%), the parents of the treated patients reported a high level
of satisfaction with a general improvement of the intelligibility of speech and quality
of life. In the case 16, the mother of the patient referred that, despite an initial
improvement of the speech, the results did not remain the same after surgery. In the
cases 4 and 14, the parents did not observe any improvement in the intelligibility
after surgery.
Regarding the parental perception of the intelligibility before and after the surgery,
the speech of the patients of this case series was somewhat unintelligible in 10 of
19 patients. After the surgery in these patients, the speech was intelligible in 3
patients and somewhat intelligible in 6 patients. In one patient, the speech remained
somewhat unintelligible. In the other 9 patients, the speech was somewhat intelligible
before surgery, intelligible after surgery in 7 patients and remained somewhat intelligible
in 2 patients. In one case of these 9 patients (case 16), the intelligibility worsened
about 2 months after surgery and the mother did not refer any improvement.
The interviews scores are reported in [Table 4 ]. The Wilcoxon test showed that there was a statistically significant improvement
in the parental perception of the intelligibility from the pre-operative to the post-operative.
Table 4
Interview scoring
Patient
Age
Sex
Months after surgery
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
1
5
Male
60
3
1
1
1
1
1
1
2
23
Male
NA
-
-
-
-
-
-
-
3
15
Female
58
3
2
1
1
1
1
1
4
14
Male
58
2
2
2
1
2
2
2
5
7
Female
58
3
2
1
1
2
1
1
6
6
Male
57
2
1
1
1
1
1
1
7
7
Female
57
2
1
1
1
1
1
1
8
10
Female
52
3
1
1
1
1
1
1
9
20
Male
NA
-
-
-
-
-
-
-
10
4
Male
48
2
1
1
1
1
1
1
11
7
Male
44
3
2
1
1
1
1
1
12
7
Male
44
2
1
1
1
1
1
1
13
8
Male
37
2
1
1
1
1
1
1
14
4
Male
31
3
3
2
1
NA
2
2
15
11
Female
31
3
1
1
1
1
1
1
16
9
Male
11
2
1
1
1
2
2
2
17
5
Male
11
2
1
1
1
1
1
1
18
5
Male
11
2
1
1
1
1
1
1
19
9
Male
9
3
2
1
1
1
1
1
20
6
Female
6
3
2
1
1
1
1
1
21
16
Female
6
3
2
1
1
1
1
1
DISCUSSION
VPI can be defined as the inability of the soft palate to completely close the posterior
wall of the pharynx during speech and/or swallowing. It manifests clinically as abnormal
resonance, rhinolalia and/or hypernasality and occasionally nasal regurgitation, with
the related psychological effects on the patients and their families. The goals of
the augmentation of the posterior wall of the pharynx with the lipofilling are to
improve voice resonance and correct nasal air escape by reducing the velopharyngeal
gap. As reported in the literature,[[1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]] the lipofilling allows to create a neo-Passavant's pad improving the intelligibility
of the speech in cases of mild-to-moderate VPI. This technique has been reported to
have good results since the first published works of Dejonckere in 2001[[9 ]] and Bardot et al . in 2007.[[10 ]]
The patient selection is a critical step and a multidisciplinary pre-operative assessment
is mandatory. In our department, patients are evaluated by a dedicated team composed
by a paediatric surgeon, a plastic surgeon, a specially trained phoniatrician and
a speech therapist. The pre-operative evaluation includes a complete physical examination,
the perceptual speech assessment and the videonasopharyngoscopy.
A comprehensive physical examination is a requisite for all children with VPI to identify
the presence of syndromic stigmata, craniofacial dysmorphisms and cardiac abnormalities.
The head-and-neck examination includes an assessment of the middle-ear status. An
oral examination is performed to identify the presence of a cleft and status of repair.
The perceptual speech assessment is considered the most reliable method of VPI[[11 ]] diagnosis and serves as the basis for all instrumental evaluations.
Videonasopharyngoscopy is nowadays recognised as one of the recommended examinations
for surgical planning[[11 ]] of VPI. The other major tool used is the multiview videofluoroscopy but, as reported
in the literature[[12 ]] and in the authors’ clinical experience, videonasopharyngoscopy may be superior
for assessing the degree of VPI. However, endoscopy is rarely possible in children
under the age of 4 years, while videofluoroscopy can be carried out in very young
patients.[[13 ]]
Fluoroscopy can also be useful when additional information is needed and in children
who have limited cooperation for a functional endoscopic assessment.
The augmentation of the posterior pharyngeal wall is indicated in cases of mild-to-moderate
VPI. The use of different materials has been described since 1900: vaseline,[[14 ]] paraffin, teflon,[[15 ]] silicone,[[16 ]] proplast,[[17 ]] collagen,[[18 ]] autologous cartilage,[[19 ]] mucosal and muscle flaps.[[20 ]] These techniques have been abandoned because of migration, extrusion and/or foreign
body reaction. Nowadays, the autologous fat is widely used and can be considered the
best filler available[[21 ]] for the treatment of different pathologies also in paediatric patients.[[22 ]] Lipofilling for the treatment of VPI has been proposed since 2001 and at our knowledge
in the literature are present 13 published articles.[[1 ]
[10 ]
[23 ]
[24 ]
[25 ]] All the cited studies reported good results, and despite the potential major risks
(obstructive sleep apnoea, fat embolism and/or injuries to the internal carotid artery),
many authors insist on the safety of the procedure and on the possibility of its repetition
in case of partial improvement.
Furthermore, according to some authors, the autologous fat grafting can also be proposed
to patients with aberrant courses of internal carotid arteries,[[26 ]] as can occur in the velocardiofacial syndrome.[[27 ]] As reported in the literature,[[26 ]] about 5% of the population has internal carotid arteries aberrant course.
However, in this case series of patients, we did not observe any patient with this
anatomic variation.
Surgical technique
Lipotransfer can be divided into four steps: infiltration, lipoaspiration, fat processing
and injection. Different modifications of the original technique have been described
in the last decades with the aim to preserve the fat viability.
Infiltration
Lipoaspiration can be carried out after injecting a physiological solution. The standard
ratio for infiltration is commonly 1 cc infiltrated for 1 cc of fat tissue removed.
The amount of the needed fat in the treatment of VPI is generally small (4–20 mL in
our case series), so we generally use about 20 mL of a solution that contains mepivacaine
to avoid post-operative pain and epinephrine to prevent bleeding.
Lipoaspiration
In this case series, the fat was harvested from the abdomen, from the inner thigh
and knee, and no differences were found concerning the outcomes. As reported in the
literature, at present, there is no evidence of a preferred donor site for fat viability.[[28 ]
[29 ]
[30 ]] Regarding the lipoaspiration cannula and syringe, we used a 3 mm, 3-hole blunt
cannula connected to a 10 mL Luer-lock syringe. A smaller cannula diameter could affect
the viability of the fat.[[31 ]
[32 ]] Moreover, the negative pressure caused by aspiration is a critical factor in graft
survival,[[33 ]] therefore, pulling the plunger should be carried out with caution.
Fat processing
In this case series, we always centrifuged the harvested fat at 3000 bpm for 3 min
to separate and remove blood, cell debris and the oily layer according to the Coleman
technique. Recently, we have started to use new protocols to purify the fat by decantation
and centrifugation and multiple washing with the aim to optimise the technique on
the basis of recently published researches.[[34 ]
[35 ]] No differences in the short-term outcomes were found, but we need more data and
long-term follow-up to make conclusions.
Injection
The injection technique is of paramount importance and should be performed very carefully
with the aim to limit the risk of complications such as embolism[[7 ]
[36 ]] and obstructive sleep apnoea.[[37 ]] The patient should be placed supine and the ventilation tube should pass through
the mouth. A Dingman mouth gag depresses the tongue and allows to have a good operative
field. It is important to maintain the patient's neck hyperextended during the fat
injection, with the aim to reduce the risk of vascular injuries by making more straight
and lateral the course of the internal carotids arteries. The assistance of an endoscope
can be useful to better visualise the operating field.[[7 ]] It is also essential to pull the plunger back of the syringe before fat injection,
in order to avoid fat embolism.
Regarding the outcomes, we admit that this study presents some limitations. First
of all, we injected a variable amount of fat only in the posterior pharyngeal wall.
Moreover, we did not perform any instrumental evaluation to determine the fat resorption
that could be related with the evolution of the functional results. However, according
to the results published in the literature, in our case series of patients affected
by mild-to-moderate VPI treated with lipofilling, we have reported a general improvement
of the Borel–Maisonny score and intelligibility of the speech with a clinical reduction
of the air escape. In patient n° 14 (injected fat volume: 6 cc), we did not observe
any improvement probably because of the severity of the VPI and co-morbidity (congenital
aural atresia with speech delay). He had pharyngoplasty 14 months after lipofilling.
In this study, the mean injected fat volume was 7.95 cc (median 6 cc, min 4 cc, max
20 cc, range 16 cc). The volume of injected fat varied on the basis of the gap. In
the case 21 (16-year-old patient), we injected 20 cc of fat reporting a partial improvement
of the post-operative Borel–Maisonny score. However, a big amount of fat in the same
spot may not survive and it could be counterproductive.
Injection site
Based on the literature data, different sites of fat injection are described. In 2007,
Bardot et al . performed the injection under the mucosa of the lateral and posterior pharyngeal
wall.[[10 ]] In 2009, Leuchter et al . identified the main injection site in the middle of the posterior pharyngeal wall.[[2 ]] In 2011, Teixera et al . reported a particular case of obstructive sleep apnoea after fat injection in the
soft palate. After the second fat injection in a paediatric patient, they had to perform
a fat debulking procedure. Other authors in 2011 published their experience of injection
in the velum in the posterior and in the lateral pharyngeal walls without complications.[[3 ]
[8 ]] Cao et al . in 2013 described their technique of injection only in the posterior pharyngeal
wall.[[4 ]] Filip et al . in 2013 reported the injection of the velum, palatopharyngeal arches and posterior
pharyngeal wall.[[5 ]] In 2015, Boneti et al . described their modality of injection in the soft palate alone.[[6 ]] In the same year, Piotet presented a case series of 22 patients with cleft palate
treated with lipofilling performed in the posterior pharyngeal wall through the soft
palate. Mazzola et al . clarified the level of the fat placement into the submucosal plane of the posterior
pharyngeal wall performing two stab incisions respecting the midline.[[7 ]] Since 2012, when we started to treat VPI with lipofilling we have been injecting
the fat only into the posterior pharyngeal wall (in multiple tunnels in the midline
and paramedian), performing one incision in the midline with the aim to reduce the
risk of major complications such as obstructive sleep apnoea and embolism as highlighted
by Bishop et al .[[25 ]] in their review. This could explain the poor results obtained in some patients
of this case series. Hence, we have recently started to inject the fat into the velum
with the aim to soften scars contractures in cases of secondary VPI (after cleft repair
and after VPP) with preliminary good results.
Fat resorption
The main drawback of the lipofilling is fat resorption. The literature are reported
fat resorption rates from 30% to 80% for clinical evaluations and from 50% to 90%
for the experimental evaluation.[[38 ]] However, in patients affected by VPI, an overcorrection could be counterproductive
and could cause obstructive sleep apnoea.[[37 ]] The role of lipofilling in the VPI treatment is to reduce the velopharyngeal gap
(a small amount of fat is generally required) and to soften scar contractures after
cleft palate repair, facilitating the approximation of the velum to the posterior
pharyngeal wall.[[7 ]] Recent studies have confirmed the important role of the stromal vascular fraction
of the injected fat in the angiogenesis and regeneration for fibrotic scar treatment.[[39 ]]
In the author's experience and according to the literature,[[10 ]] the outcomes after the fat injection can be considered stable after three months.[[38 ]] In this case series, all the patients underwent one procedure of fat injection.
As reported in the literature, a further procedure can be performed in cases of partial
improvement and/or worsening of the speech intelligibility during children growing
up. In the presented case series, in three patients, the results have not remained
the same since the surgery probably because of fat resorption. It is difficult to
detect the survival of the transplanted fat, especially in young patients. Cao et al . in their recent work performed a pre- and post-operative magnetic resonance imaging
(MRI) in a case series of 11 patients, reporting good survival fat rates.[[4 ]] Good outcomes were reported also by Filip et al . in their case series of patients because they did not find a statistical correlation
between the change of the velopharyngeal distance or the velopharyngeal gap area and
the change of the speech parameters.[[5 ]] We have recently started to perform pre- and post-operative MRI to obtain more
data about the survival of the transplanted fat, however, in this case series, we
cannot produce any data. Moreover, pre-operative MRI could also be useful to identify
more precisely the injection site.
Parent perception survey
In the authors’ opinion, the role of parents is very significant in the management
of VPI in paediatric patients. Despite the possible bias due to the modality of the
interview (performed by a trainee doctor of our team), our research allows us to conclude
that the lipofilling of the pharyngeal wall is well tolerated by children and accepted
by their families. On the basis of the phone interviews, the parents’ perception of
the procedure is satisfying in 16 cases. In these 16 cases, the interviewed parents
consider their children's quality of life (including eating, drinking, friendship,
confidence and social interactions) improved after the treatment and in 15 cases,
in their opinion, the lipofilling has provided long-term successful outcomes. In 16
cases, the children parents would suggest the treatment with lipofilling to other
patients affected by VPI. This data in our opinion are very important, especially
when we have to explain to parents the surgical alternatives and the possible necessity
of more than one surgical session. We reported the interview results on the information
model that patients and/or parents have to read before signing the informed consent.
CONCLUSIONS
Despite the possible provisional nature of the outcomes, due to the reported limitations
of this study, the augmentation of the posterior pharyngeal wall in addition to speech
therapy improved the Borel–Maisonny score and the intelligibility of this case series
of patients. This technique allowed us to avoid major surgical procedures that would
modify the anatomy of the velopharyngeal port. However, prospective comparative studies
or randomised controlled trials could be useful to compare fat grafting with VPP techniques,
with the aim to clarify indications and to define a specific treatment protocol.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
