Cleft Palate and Velopharyngeal Insufficiency-Natural History and Evolution of Treatment Options.

Cleft palate closure, first carried out by the German Gräfe (1787-1840) and by the Frenchman Roux (1780-1854) in 1816 and in 1818, respectively, and later improved by the German Langenbeck (1810-1887) in 1861, did not always achieve successful outcome regarding speech. Often the velum remained too short or reopened partially, without reaching the posterior pharyngeal wall and maintaining an air escape through the nose. This condition is known as hypernasality or velopharyngeal insufficiency, whose term was coined by the French otolaryngologist Lermoyez (1858-1929) in 1892. To improve speech and minimize hypernasality, numerous solutions have been proposed over the years by different surgeons. Among them by the German surgeon Passavant (1813-1893), who advocated either the elongation of the soft palate by suturing the palatopharyngeus muscle along the midline, beyond the uvula, or the outlining of a velopharyngeal flap, the so-called velopharyngoplasty, or the advancement of the posterior pharyngeal wall. The latter option was performed initially by positioning an implant in the retropharyngeal space. Nowadays, in the presence of medium to moderate velopharyngeal insufficiency, autologous fat, injected in the posterior pharyngeal wall, represents the solution of choice. It possesses the regenerative potential mediated by the pluripotent stem cells, present in the stromal vascular fraction. Fat injection is a less invasive alternative to major surgery with favorable results. Speech therapy is crucial after cleft palate surgery to improve speech results and voice quality.