Arrow Palatoplasty: A Technique of Concurrent Soft Palate Revision and Lengthening for Patients with Velopharyngeal Insufficiency and a Large Pharyngeal Gap

BACKGROUND: Up to 30% of patients undergoing primary palatoplasty require secondary surgery due to velopharyngeal insufficiency. In patients with a large pharyngeal gap seen on nasoendoscopy, surgical intervention may risk the development of obstructive sleep apnea. This study reports a novel Arrow Revision Palatoplasty (ARP), a technique that combines revision palatoplasty and buccal flaps to concurrently reconstruct the levator sling and lengthen the palate without the creation of obstructive flaps within the pharynx. METHODS: A retrospective chart review of all patients undergoing ARP by the senior author between 06/2021 and 06/2024 was performed. Preoperative video speech nasopharyngeal endoscopy were rated by a certified speech language pathologist who also performed perceptual speech analysis on all patients, and rated their hypernasality, hyponasality, and audible nasal emission in accordance with the Americleft Speech Clinical Rating Form. Speech scores were described using median (IQR), and postoperative scores for patients were treated as paired data and assessed using paired samples Wilcoxon test. p<0.05 was considered statistically significant. RESULTS: Eleven patients were included in this study. Average age at time of ARP was 16 (SD 7) years. Patients on average underwent 1.5 (SD 0.7) prior palatal surgeries. Nasoendoscopies were available for 9 (82%) patients preoperatively and 6 (55%) patients postoperatively. The median ratio of velopharyngeal sphincter closure was 0.4 preoperatively and increased to 0.95 postoperatively. Perceptual speech analysis was available for 4 (36%) patients preoperatively and 7 (64%) patients postoperatively. Median preoperative hypernasality was 2.25, which corresponds to mild-moderate hypernasality and improved to 1 (borderline/minimal) postoperatively. Hyponasality was consistently 0 (absent) for all patients. Median audible nasal emission was 2 (frequently noted) preoperatively and improved to 1 (occasionally/seldom noted) postoperatively. CONCLUSION: Arrow revision palatoplasty can improve pharyngeal gap and speech outcomes in patients with a cleft and velopharyngeal insufficiency associated with a large pharyngeal deficiency. This technique should be considered for patients with challenging velopharyngeal insufficiency that is at higher risk for developing surgical-induced obstructive sleep apnea.