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

Speech Outcomes After PPF Takedown

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

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

Hyponasality

Hypernasality/hyponasality

OSA

History of previous

History of a straight-line palatoplasty

Furlow palatoplasty

Plan for midface advancement

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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