2017 Sec 1 Green Book

Annals of Plastic Surgery • Volume 77, Number 4, October 2016

Katzel et al

TABLE 2. Patients Who Had a Regression in PWSS After PPF Takedown

Additional Speech Surgery (Operation: PWSS Postoperatively)

Pretakedown PWSS

Posttakedown PWSS

Delta PWSS

Reason for Takedown Sex

Age at Takedown, y

Follow-up, mo

Pt

Surgery

1

3

5

2 OSA/Lefort I

Male

16 PPF takedown +

No

29

Conversion Furlow

2

2

5

3

OSA Male

15 PPF takedown +

No

26

Conversion Furlow

3

3

4

1

OSA Female

10 PPF takedown +

No

53

Conversion Furlow

4

0

1

1

Recurrent VPI

Male

9 PPF takedown +

No

49

Conversion Furlow

5

23

27

4

OSA Male

17 PPF takedown +

No

28

Conversion Furlow

6

0

3

3 OSA/Lefort I

Male

20 PPF takedown +

No

55

Conversion Furlow

7 8

0 0

4 7

4 7

OSA Female OSA Male

19 Takedown alone 11 Takedown alone

No

10 60

Yes (delayed conversion Furlow Palatoplasty: 3)

9

0 0 0 0 0 4

3 3 1 1 3

3 OSA/hyponasal Female

10 Takedown alone 12 Takedown alone 8 Takedown alone 15 Takedown alone 9 Takedown alone 7 Takedown alone

No No No No No

78 16 53

10 11 12 13 14

3 1 1 3

OSA Female OSA Male OSA Male OSA Female

1

19

10

6 OSA/hyponasal Female

Yes (delayed conversion Furlow Palatoplasty: 4)

104

15 16

2 3

3 4

1 1

OSA Male OSA Male

19 Takedown alone 11 Takedown alone

No No

2 2

(Fig. 2). For patients undergoing PPF takedown with conversion to Furlow palatoplasty, PWSS significantly improved postoperatively (3.1 ± 4.1 [range, 0 – 27]) compared to preoperative PWSS (6.4 ± 6.7 [range, 0 – 26]). When stratified by surgical intervention, no significant deterioration in postoperative PWSS occurred ( P = 0.79). No surgical complications occurred after PPF takedown. Sixteen (25.0%) patients had deterioration in PWSS after PPF takedown (n = 10 [55.6%] in the PPF takedown alone group versus 6 [13.0%] in the conversion to Furlow palatoplasty group) (Table 2). For patients whose speech deteriorated, mean deterioration in PWSS was 2.8 ± 1.8 (range, 1 – 7) (Fig. 3). For patients who had deterioration after PPF takedown alone, mean deterioration in PWSS was 3.0 ± 2.2 (range, 1 – 7). For patients who had deterioration after PPF takedown with conversion to Furlow palatoplasty, the mean deterioration in PWSS was 2.2 ± 1.3 (range, 1 – 4). Two patients (3.1%) in the study, representing 11.1% of the PFF takedown alone cohort, experienced clinically significant (defined as affecting intelligibility) deterioration in PWSS that required further speech resonance surgery after PPF takedown. These patients (patients 8 and 14) (Table 2) progressed to delayed conversion to Furlow palatoplasty. No patients required readmission for surgical- related or OSA-related complications after PPF takedown or PPF takedown with conversion to Furlow palatoplasty. DISCUSSION This study suggests clinically indicated PPF takedown results in minimal deleterious speech outcomes, highlighting its potential effi- cacy in the treatment of PPF-related OSA. The retrospective nature of the study results in potential limitations that must be addressed. Speech pathologists were not blinded to their patients, which may introduce a

degree of rater bias when comparing preoperative and postoperative speech scores. Additionally, although blinded listener ratings of preop- erative and postoperative speech samples do not exist, the speech rating reliability of the institution's speech pathologists has been previously validated and published. 21 Additionally, as our institution did not perform all initial surgeries, data regarding the initial PPF surgeries remain inaccessible. However, based on chart reviews from the authors' institution, all PPFs were in place for at least 5 years before takedown. Additionally, the mean age at takedown in this study was 12.4 years, and most PPFs are placed when the child is between the ages of 3 and 4 years. Thus, we can conclude that the flaps in this study were in place for at least 5 years and on average closer to 10 years. The OSA rates have been reported to be as high as 30% after PPF surgery. 4,12,19,22,23 The proper treatment of OSA in these patients is controversial, and there is no established treatment algorithm or

FIGURE 3. Change in PWSS for the 16 patients who had a regression in PWSS following PPF takedown. A positive score indicates a regression in PWSS from pre-takedown to post-takedown.

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