Clinical and Surgical Predictors of Velopharyngeal Insufficiency After Le Fort I in Patients With Cleft Palate

Velopharyngeal insufficiency (VPI) is a recognized complication following palatoplasty in patients with cleft palate and may also occur after orthognathic surgery. Although risk factors for VPI after palatoplasty are well established, those contributing to VPI following orthognathic procedures remain unclear. This retrospective cohort study aimed to identify clinical and surgical predictors of VPI in patients with repaired cleft palates undergoing orthognathic surgery. Conducted at a single tertiary pediatric hospital, the study included nonsyndromic individuals who underwent Le Fort I osteotomy between 1991 and 2024. Subjects with submucous clefts or fewer than 6 months of follow-up were excluded. Predictor variables included demographic data, cleft classification, operative details, and history of palatal fistulas. The primary outcome was the development of VPI after orthognathic surgery; the secondary outcome was the need for surgical correction of VPI. Univariable and multivariable analyses identified independent risk factors, and receiver operating characteristic curve analysis determined a threshold for maxillary advancement length. Among 123 patients (mean age: 17.6 y), 22% developed postoperative VPI and 5.7% required additional surgery. Veau class IV clefts (P=0.014), recurrent palatal fistulas (P=0.001), and increased length of maxillary advancement (P<0.001) were independently associated with a higher risk of VPI. An advancement length of 7.5 mm was identified as a threshold above which VPI risk increases significantly. These findings underscore the need for thorough preoperative assessment in this population to optimize outcomes.