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protocol.1,8,13–19,24 Although there is concern that PPF takedown in
these patients may lead to speech deterioration and recurrent VPI, to
date, there are no studies in the literature that investigate outcomes
after clinically indicated PPF takedown.
It can be rationalized that speech could be maintained in patients
undergoing PPF takedown with conversion to Furlow palatoplasty.
For example, a patient who initially underwent straightline palatoplasty
and later developed VPI requiring a PPF to improve speech. If this
patient developed subsequent sleep apnea, he could be treated with
PPF takedown and conversion to Furlow palatoplasty with minimal
speech change because of palatal lengthening due to the conversion
to Furlow palatoplasty.
However, it remains unclear why a patient would not experience
a clinically significant deterioration in speech with a PPF takedown
alone when that patient previously required the PPF for speech correc-
tion. Several theories for conserved speech gains after PPF takedown
alone can be presented in an additive fashion. First, the authors hypoth-
esize that PPFs likely work in part by permanently altering the anatomy
of the upper airway by secondary scarring and narrowing of the
velopharyngeal port. Despite the PPF takedown, there may exist resid-
ual bulk on the posterior velum and posterior pharyngeal wall. Second,
as most PPFs are placed during growth of the velum and pharynx, their
tethering nature may result in an expansion effect on the velum that may
allow for preserved speech function after flap takedown. Third, learned
speech mechanisms and techniques may also aid in preserving speech
function after flap division.
When analyzing data for the patients in the PPF takedown alone
cohort, 10 (56%) experienced a regression in PWSS, with a mean
change of only 0.28; and, 49% of patients experienced an improvement
in their PWSS. Importantly, only 2 patients (3%) of the entire study
and 10% of the PPF takedown alone cohort had a clinically significant
deterioration in speech and progressed to a delayed conversion to
Furlow palatoplasty. In these select patients (n = 2), delayed conversion
to Furlow palatoplasty, improved speech scores from 7 to 3 and 10
to 4 (patients 8 and 14, respectively) (Table 2). A third patient
(patient 5) (Table 2) who underwent PPF takedown and conversion
Furlow palatoplasty demonstrated a clinically insignificant regression
in PWSS from 23 to 27. This syndromic patient had significant devel-
opmental, and expressive delays, and the family elected not to have a
secondary pharyngoplasty. In the 20-year experience of our institution,
approximately 90% of patients experienced no clinically significant
regression in speech after undergoing PPF takedown alone, with or
without conversion to Furlow palatoplasty,
Given the efficacy of clinically indicated PPF takedown in the
preservation of speech, we highlight the protocol used at the Children's
Hospital of Pittsburgh of University of Pittsburgh Medical Center that
has produced consistent results (Table 3). Based on a single institutional
experience that performs over 100 PPFs yearly, clinical indications for
takedown alone include: (1) malpositioned and/or inferiorly tethered
PPF, (2) hyponasality, (3) OSA, and (4) history of previous Furlow
palatoplasty. Indications for PPF takedown with conversion to Furlow
palatoplasty include: (1) malpositioned and/or inferiorly tethered PPF,
(2) hypernasality/hyponasality, (3) OSA, (4) history of a straightline
palatoplasty, and (5) plan for midface advancement.
CONCLUSIONS
This study presents a quaternary care institution's 20-year expe-
rience in critically analyzing speech changes after clinically indicated
PPF takedown. Not only does the study quantify speech changes using
the validated PWSS, but it also demonstrates the efficacy of performing
PPF takedown procedures in the treatment of PPF-related OSA. Neither
PPF takedown alone nor PPF takedown with conversion to Furlow
palatoplasty significantly worsened speech outcomes. Specifically, PPF
takedown with conversion to Furlow palatoplasty resulted in significantly
improved PWSS postoperatively. The data collectively suggest that
speech outcomes do not regress after clinically indicated PPF takedown.
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TABLE 3. The Current Indications at Our Institution for
PPF Takedown Alone and Takedown With Conversion
to Furlow Palatoplasty
Indications for PPF
Takedown Alone
Indications for Takedown With
Conversion to Furlow Palatoplasty
Malposition and/or inferiorly
tethering PPF
Malposition and/or inferiorly tethering PPF
Hyponasality Hypernasality/hyponasality
OSA OSA
History of previous
Furlow palatoplasty
History of a straight-line palatoplasty
Plan for midface advancement
Annals of Plastic Surgery • Volume 77, Number 4, October 2016 Speech Outcomes After PPF Takedown
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