Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 5 Issue: 1

Autologous Fat Graft for the Correction of Minor Velopharyngeal Insufficiency

Ouattassi N*, Remacle M, Lawson G, Vorst SVD, Bachy V and Prasad VMN
Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital of Mont-Godinne, Louvain University, Yvoir, Belgium
Corresponding author : Ouattassi N
Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital of Mont-Godinne, Louvain University, Yvoir, Belgium
Tel: +212 669702342
E-mail: [email protected]
Received: September 09, 2015 Accepted: January 06, 2016 Published: January 11, 2016
Citation: Ouattassi N, Remacle M, Lawson G, Vorst SVD, Bachy V, et al. (2016) Autologous Fat Graft for the Correction of Minor Velopharyngeal Insufficiency. J Otol Rhinol 5:1. doi:10.4172/2324-8785.1000264

Abstract

Objective: Retrospective study on autologous fat injection for minor velopharyngeal insufficiency correction.

Methodology: We report our experience regarding autologous fat injection for the correction of minor velopharyngeal insufficiency. Our indications includes: gaps from short velum, complement of surgical repairing of anatomical velopharyngeal defect after poor speech therapy results. Our series includes eleven patients, seven male and four female ranging in age from 7 to 68 years old (Median: 37.5 years old, mean age of 27 years old). The main symptoms were hypernasality and nasal food regurgitation. Pre-operative evaluation is mainly based on nasendoscopy and subjective scale based speech evaluation performed by the speech therapist’s opinion. All patients underwent fat injection under general anesthesia and 0° and 30° telescope control with a Davis mouth gag. The injection was performed through a 16 G Tuohy needle that secures a Luerlocker syringe. The harvesting site was mainly peri-umbilical. Borele Maisonny scores were used aside with nasendoscopy during the post operative follow up. Also, all patients were contacted by phone for long term subjective appraisal of phonation and speech results.

Results: An average of 11cc of autologous fat was injected (6 to 14cc) for minor velopharyngeal insufficiency correction. Post operative course was uneventful except for one patient who had a retropharyngeal cellulitis that resolved under antibiotics. Minor complains such as otalgia and cervical pain were reported by most of the patients and were managed by paracetamol and non- steroids anti-inflammatory drugs. Long term outcome were estimated satisfactory for most of the patients.

Conclusion: Autologous fat injection is an effective method to correct minor velopharyngeal insuffisancy after poor speech therapy results or as a complement for major velopharyngoplasties.

Keywords: Minor velopharyngeal Insufficiency; Autologous fat injection; Pharynx; Lipostructure

Keywords

Minor velopharyngeal Insufficiency; Autologous fat injection; Pharynx; Lipostructure

Introduction

Velopharyngeal insufficiency (VPI) is characterized by incomplete velopharyngeal closure resulting in unwanted communication between the oral and nasal cavities during phonation, sucking and deglutition. It can also affect middle ear function resulting in otitis media with effusion (OME). VPI often presents with symptoms of hypernasality, nasal regurgitation or compensatory articulation related to the use of atypical oral and pharyngeal sites for phoneme production. VPI is most commonly due to congenital soft palate abnormalities, mainly as a result of cleft palate repair. Also it might be iatrogenic, idiopathic or stress VPI (in musicians for instance). Surgical management of VPI is traditionally based on velopharyngoplasties, including local flaps, sphincter reconstruction or the advancement of the posterior pharyngeal wall. These procedures aim to narrow the gap between the naso-and oropharynx [1]. Prosthetic treatment using a pharyngeal obturator may also be considered as a temporary solution for speech and feeding problems before surgery or as the only available alternative for patients who have a poor prognosis for surgical correction [2]. Velopharyngoplasties lead to excellent results in terms of reducing hypernasality and improving voice resonance and speech articulation but may also cause post-operative pain and bleeding [3]. Post-operative snoring is also seen frequently and obstructive sleep apnea can be a temporary or persistent complication [4,5]. The use of implants to augment the profile of the posterior pharyngeal wall has been proposed as a less invasive alternative to major surgical procedures for minor velopharyngeal insufficiency or to complement surgery and/or speech therapy.
Several different materials have been used to augment the posterior pharyngeal wall. Permanent materials such as hydroxyapatite, GoretexTM, TeflonTM or silicone have been associated with migration, infection and extrusion. Resorbable materials expectedly provide a temporary improvement [6]. The transplantation of autologous tissue can avoid these drawbacks [7].
Autologous fat injection in the posterior pharyngeal wall, using an external approach, was originally suggested by Gaza [8], but was subsequently abandoned. The advent of liposuction led to autologous fat grafts being proposed as a means of increasing the posterior nasopharyngeal wall in patients with mild VPI [7,9,10].
Aim
The aim of this paper is to present our technique and results based on patient satisfaction with autologous fat injection of the posterior pharyngeal wall for minor velopharyngeal insufficiency.

Patients and Methods

Eleven patients (7 male, 4 female) underwent autologous fat graft injection to correct velopharyngeal insufficiency at our tertiary referral center between 2003 and 2014 (Table 1). Our cohort included both children and adults (age range: 5 years - 68 years) and all cases were operated on by either of our senior authors (MR, GL).
Table 1: Our series patient’s breakdown chart. CPS: Cleft palate surgery (1: yes, 0: no). M: male, F: female. BMS: Borele Maisonny score.
All patients but one presented with symptoms of hypernasality. In fact, the last patient (number 11, Table 1), a 68 year-old male, was included for nasal regurgitation following oropharygeal cancer surgery for a T1 right tonsillar carcinoma
Preoperative assessment involved a thorough history and examination by both speech and swallowing nasendoscopy, a voice recording, a lateral cineradiography of velopharyngeal activity during speech and swallowing (Figure 1) and the speech pathologist’s opinion. Subjective speech assessment was performed through a Borel Maisonny scale. Patient’s selection was based on persistent speech and/or swallowing problems despite cleft palate surgery and appropriate speech therapy or an abnormally short velum with normal muscular function, patients with velopharyngeal gap of 0.5 to 1.5 cm were included. Post operative follow up was performed regularly at 3 months, 6 months and a year and includes nasendoscopy assessment of velopharyngeal gap during speech and swallowing with speech subjective evaluation by the speech pathologist. For our study we’ve contacted all the patients recently by phone and have assessed their satisfaction level over their speech and swallowing results through a questionnaire. Patients estimate their level of satisfaction from 0 to 10 as, zero corresponding to complete dissatisfaction and 10 corresponding to complete satisfaction. We arbitrarily categorized a score of less than 5 to be ‘poor’, 5-7 - fairly good, 7-8 – good; greater than 8-very good.
Figure 1: lateral view of cineradiography that shows a rhino-pharyngeal regurgitation (yellow arrow).
Harvesting of fat
All patients underwent a general anaesthesia and fat was harvested according to the technique proposed by Coleman [11], commercially known as the LipostructureTM technique. All patients had fat harvested from their surgically prepared and draped abdomen through a small peri-umbilical incision. The device used for fat harvesting was 3 mm in diameter and 15 cm long. It consisted of a 2-hole distal opening blunt-tipped cannula attached to a 10ml syringe. After subcutaneous infiltration of 50 ml of normal saline solution, a 5 mm incision (large enough to allow the insertion of the cannula connected to the syringe) was made in the inferior rim of the umbilicus using a No. 15 blade. Care was taken when inserting the cannula for fat harvesting by pinching the skin firmly between the thumb and fingers in order to avoid penetrating the abdominal cavity. The plunger of the syringe was gently retracted to provide negative pressure throughout the suction man oeuvre. The procedure was performed as a traumatically as possible in order to avoid damaging the fragile adipocytes. The incision was then closed using one or two stitches of Dermal on 3/0 after the fat injection was completed adequately.
Separation and purification
The equipment used to separate and purify the harvested fat included a centrifuge with a sterilisable central rotor [Thermo Scientific IEC Medelite MicrocentrigueusTM: Medilite 6PL, 004490F, serial R29U-424508-RU]. The plugged syringes were placed in the centrifuge, protected by sterile metal sleeves. The lipoaspirate was centrifuged at 1,200J for 3 minutes to separate three components: the upper layer mainly consisting of oil from ruptured adipocytes, the middle layer of viable adipocytes and the lower- a mainly aqueous layer containing blood, saline solution etc. The upper layer was discarded as was the aqueous component which was released by removing the plug from the syringe. The refined fatty layer was then loaded on the placement syringe.
Injection techniques and devices
All patients had an orotracheal intubation. The ventilation tube was passed through the mouth and fixed at the lower lip in a manner similar to a tonsillectomy. This allowed for displacement of the tongue and access to the posterior pharyngeal wall. As such, a Boyle-Davis mouth gag and retractor was positioned accordingly. Digital pressure over the velum was found to be helpful in assessing the gap between the velum and the posterior pharyngeal wall. It also allowed us to check major vessels presence. Thereafter, the velum was retracted upwards and the fat injection performed through the mouth under 0° rigid endoscopic control. The fat was injected through a 16 gauge PortexTM Tuohy needle that was secured to a 10 ml LuerTMlocked syringe. The needle was inserted into the submucosa of the posterior pharyngeal wall at the pre-determined contact area. Fat was injected in front of the fibrous layer behind the pharyngeal mucosa. Several injection points were necessary to achieve a good pad of fat and raise a transverse ridge across the posterior wall (Passavant’s ridge). Some fat was found to have migrated inferiorly before the rest was integrated into the soft tissue (Figures 2 and 3). The principle site for injection was the mid-point horizontally, where the fibrous anterior spinal ligament is the toughest. To complete restoration of Passavant’s ridge, fat injections were made at one or two laterally situated points in the posterior pharyngeal wall (Figures 4a & 4b). We found that lateral injections were less efficient as the fibrous spinal ligament is less dense and where there are three axes of discontinuity between the constrictor muscles that require larger fat quantities to reach the same results. Also, there is a major risk of vascular fat embolism. Between 6 and 8ml of fat were usually necessary for children and between 9 to 11 ml for adults.
Figure 2: pharyngeal endoscopic view showing a bifid uvula (white arrow) and passavant’s ridge (black arrow).
Figure 3: pharyngeal endoscopic view showing the post operative aspect of passavant’s ridge.
Figure 4: (a: left) several injection points into the posterior pharyngeal wall to rise a good passavant’s ridge. (b: right) the autologous fat injection technique into the posterior pharyngeal wall in front of the fibrous tunic of the pharynx.
Post-operative care
All patients were discharged on the same day after recovering from the anesthetic and regaining adequate swallow and speech. Post-operative medication included 24 hours’ of antibiotics, analgesia (paracetamol and codeine) and non-steroidal anti-inflammatory drugs for 5 days.

Results

Of the eleven patients who underwent autologous fat graft injection for velopharyngeal insufficiency, none reported a poor outcome for either speech or swallow (Table 1). Only one patient had a post-operative complication (retro-pharyngeal cellulitis) that resolved completely with antibiotics. All patients complained of a varying level of otalgia and cervical pain triggered by head motion, both of which were related to prevertebral fascia irritation. Those symptoms resolved spontaneously after few days. Thus far, all the patients improved after fat injection into Passavant’s ridge. Some remodeling of the fat pad during the initial 2 to 3 weeks was observed because of the posterior pharyngeal wall muscular activity. Thereafter, the shape remained unchanged.
All patients were subjectively satisfied (mean follow up 31 months (5 to 56 months). Hypernasality was completely corrected in all patients except for patients 5 and 7 who had only partially improved but declined a second injection. Nasal food regurgitation in patients number 3 and 11 (Table 1) was completely resolved.
All patients were subjectively satisfied (mean follow up 31 months (5 to 56 months). Hypernasality was completely corrected in all patients except for patients 5 and 7 who had only partially improved but declined a second injection. Nasal food regurgitation in patients number 3 and 11 (Table 1) was completely resolved.

Discussion

The first transplantation of samples of arm adipose tissue was performed in the nineteenth century. Thereafter, several authors [12] reported the advantages of fat injection for various indications in functional, reconstructive and cosmetic surgery. However, the technique fell out of favor because of several sequlae including graft resorption, cyst development and near complete replacement by fibrous tissue making the results unpredictable. However in the 1990s, Coleman [11] developed an atraumatic technique for the harvesting and injection of fragile adipocytes he described as LipostructureTM. Since then, the outcome of various applications such as restoring volume, correcting asymmetries and scars improved considerably as a consequence of the dramatic decrease in the reabsorption rate of the injected material.
Although autologous fat grafting to the velopharynx has been described for treatment of velopharyngeal insufficiency for over a decade, there has been little agreement on the best method for evaluating the graft site or the amount of fat required to achieve a notable improvement in speech. Over the eleven studies that have been conducted on autologous fat grafting for VPI [13] only three [9,14,15] were interested in isolated posterior pharyngeal wall augmentation for VPI. Patient’s assessment was performed by nasendoscopy to determine the amount of fat to be grafted as well as graft location. Speech evaluation was performed by nasometry and/ or perceptual speech evaluation. Also long term post operative results were evaluated using a telephone questionnaire. Regarding speech results assessment, we preferred perceptual evaluation performed by the speech therapist. In fact, perceptual assessment of nasality is the gold standard for assessment of speech disorders related to cleft palate and velopharyngeal dysfunction [16]. Hayden and Klimacka [17] studied inter-rater reliability for simple categorical scale of hypernasality and reported good correlations for experienced listeners ranging from 0.88 to 0.97. Nasometry measures are usually useful for supplementing the speech and language therapist’s perception of hypernasal resonance in patients with velopharyngeal insufficiency. However, results of previous studies have indicated that factors such as language, dialect and the speech stimuli influence the scores obtained on the nasometer [18,19].
MRI (without contrast) of velopharyngeal activity during vocal rest and phonation using /e/ might also be performed preoperatively to assess not only the velopharyngeal gap, but also the vascular anatomy in the posterior pharyngeal wall as performed by Filip [20]. However, it was not a routine test for VPI appraisal in our cohort.
The choice of the harvesting site important is primarily the lower abdomen, followed by the inner thigh and the inner knee (we generally prefer to avoid the lateral thigh). While harvesting fat, it is essential to pinch the skin firmly between the thumb and the other fingers in order to avoid penetrating the abdominal cavity or the saphenous vein (if the inner thigh is used). Autologous fat injection can also be performed through a Brunings’ injection device that secures a fat- containing tuberculin syringe or through a LuerTM- lock syringe with a curved 16 G or 18 gauge Tuohy needle [21].
Some undesirable side-effects of permanent materials (i.e. hydroxyapatite, GoretexTM, silicone) such as migration and extrusion can be avoided using fat injection. Moreover, temporary improvement obtained with re- absorbable materials (hyaluronic acid, collagen) is also avoided [7].
It has recently been demonstrated that adipose tissue is a valuable source of mesenchymal stem cells that are able to differentiate into mesenchymal-type cells. Also at a molecular and cell biological level, the dynamic and regenerative nature of fat grafts has been established. Clinical practice has also shown that the long-term outcomes of fat injection can include rejuvenation of skin texture [22,23].
With regards to the measurement tool used to gauge speech outcomes. Most of the studies used some manner of perceptual speech assessment, albeit with different scales (most frequently the Borele Maisonny scale), to assess hypernasality, nasal emission, and intelligibility [13].
Regarding the safety of autologous fat grafting there were two reports of serious side-effects. The first one is an obstructive sleep apnea [24]. This had occurred after two rounds of autologous fat injection to the velopharynx (posterior pharyngeal wall, arches and soft palate) in an eight year-old boy that developed a rapid and significant weight gain with subsequent hypertrophy of the fat grafts so the patient developed severe obstructive sleep apnea. The second is an unpublished British report described a middle cerebral artery infarct due to presumed fat embolism in a young female patient following fat injection for VPI [13]. Therefore, Filip and al. recommend doing the injection after a preoperative MRI assessment of the vascular structure of the pharynx or the use of preoperative ultrasound doppler (Intraoperative Probe Re-Sterilisable 8 MHz, Huntleigh Technology Plc., Cardiff, U.K) of the posterior pharyngeal wall to exclude vessels at the site of injection [20]. We recommend that injections in the posterior pharyngeal wall should be performed only in the very close proximity of the midline and directly under the mucosa with previous careful digital palpation of the injection site.

Conclusion

Autologous fat injections are an effective, straightforward and usually minimally-invasive technique for treating minor velopharyngeal insufficiency that significantly reduces hypernasality and improves overall speech quality in pediatric and adult patients. It can be used primarily or as an adjunct to surgical correction of palatal defects. It can also be performed several times and does not affect subsequent velopharyngoplasties.

References

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