To systematically review advances in surgical techniques for secondary cleft palate repair, emphasizing their impact on velopharyngeal function, speech outcomes, and the methodological validity of speech assessments used in published studies.
Design
Following PRISMA 2021 guidelines, six electronic databases were searched for articles from January 2012 to February 2025 using MeSH terms related to secondary cleft palate repair, velopharyngeal insufficiency, palatoplasty, and speech outcomes. Eligible studies included clinical reports with ≥10 patients undergoing secondary repair. Data on surgical methods, outcomes, and complications were extracted and qualitatively synthesized due to heterogeneity across studies.
Setting
All published clinical studies evaluating secondary cleft palate repair outcomes.
Patients/Participants
Individuals presenting with residual velopharyngeal insufficiency, recurrent fistula, or speech dysfunction following primary palatoplasty.
Main Outcome Measures
Speech resonance and intelligibility, velopharyngeal closure rate, fistula recurrence, donor-site morbidity, and obstructive sleep apnea risk.
Results
Fourteen studies met the inclusion criteria. Palate-based re-repair with Furlow double-opposing Z-plasty and buccal myomucosal flaps improved resonance and closure in small to moderate gaps. Pharyngeal flap and sphincter pharyngoplasty achieved satisfactory closure in larger defects but increased the risk of airway obstruction. However, most studies lacked validated speech protocols or controlled for articulatory errors and fistula effects, limiting confidence in the interpretation of outcomes.
Conclusions
While secondary repairs often improve resonance and velopharyngeal competence, evidence remains constrained by heterogeneity and non-validated assessment methods. Future multicenter research integrating standardized, speech pathologist-verified protocols is essential to establish evidence-based algorithms for secondary cleft palate repair.
NagappanNMadhanmohanRGopinathanNM, StephenSR, PillaiDDM, TirupatiN. Oral health-related quality of life and dental caries Status in children with orofacial cleft: An Indian outlook. J Pharm Bioallied Sci. 2019;11(Suppl 2):S169–S174.
2.
MurugananthamJKVeerabathiranR. Genetic variability of IRF6 polymorphisms in non-syndromic cleft lip/palate: a meta-analysis across diverse populations. Cleft Palate Craniofac J. 2024(Nov). doi:10.1177/10556656241300841
3.
LeviBBrugmanSWongVWGrovaMLongakerMTWanDC. Palatogenesis: Engineering, pathways and pathologies. Organogenesis. 2011;7(4):242–254.
4.
PitkanenVVGeneidASaarikkoAMHakliSAlaluusuaSA. Diagnosing and managing velopharyngeal insufficiency in patients with cleft palate after primary palatoplasty. J Craniofac Surg. 2025;36(3):1008–1016.
5.
NagappanNJohnJ. Periodontal Status among patients with cleft lip (CL), cleft palate (CP) and cleft lip, alveolus and palate (CLAP) in chennai, India. A comparative study. J Clin Diagn Res. 2015;9(3):ZC53–ZC55.
6.
MartinSMcBrideMMcGarryKHillC. Burden of cleft surgery—a 21-year follow-up of patients with cleft lip and palate. Eur. J. Plast. Surg. 2020;43(4):365–370.
7.
PlonkowskiATChoiDGNaiduPTurkMYaoCAMageeWP3rd. The rate of secondary speech surgery after cleft palate repair: A systematic review. Plast Reconstr Surg Glob Open. 2025;13(2):e6465.
8.
RudaJMKrakovitzPRoseAS. A review of the evaluation and management of velopharyngeal insufficiency in children. Otolaryngol Clin North Am. 2012;45(3):653–viii.
9.
RothermelATLundbergJNSamsonTD, TseRW, Allori AC, BezuhlyM, BealsSP, SitzmanTJ. A toolbox of surgical techniques for palatal Fistula repair. Cleft Palate Craniofac J. 2021;58(2):170–180.
10.
RavishankerR. Furlow's palatoplasty for cleft palate repair. Med J Armed Forces India. 2006;62(3):239–242.
11.
VranckxJJHondtMD. Tissue engineering and surgery: From translational studies to human trials. Innov Surg Sci. 2017;2(4):189–202.
12.
KhismatraoVNPopatSPSharmaPGuptaA. Versatility of facial artery musculomucosal (FAMM) flap for reconstruction of oral cavity defects. J Maxillofac Oral Surg. 2023;22(Suppl 1):44–50.
13.
Yesilli-PuzellaDegniCrescioBraccialeLoretiRizzoBussu . Acoustic voice analysis as a tool for assessing nasal obstruction: A systematic review. Appl Sci.2025 ; 29;15(15):8423.
14.
JohnsonKBWeiWQWeeraratneD, FrisseME, MisulisK, RheeK, ZhaoJ, SnowdonJL. Precision medicine, AI, and the future of personalized health care. Clin Transl Sci. 2021;14(1):86–93.
15.
ShamseerLMoherDClarkeM, GhersiD, LiberatiA, PetticrewM, ShekelleP, StewartLA. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. Br Med J. 2015;350(2):g7647.
16.
BoothAClarkeMGhersiDMoherDPetticrewMStewartL. An international registry of systematic-review protocols. Lancet. 2011;377(9760):108–109.
17.
AliAAAHasanMHO. Outcomes of facial artery musculomucosal flap in repair of post-palatoplasty Fistula - A retrospective study. Ann Maxillofac Surg. 2024;14(2):180–186.
18.
SohailMBashirMMKhanFAAshrafN. Comparison of clinical outcome of facial artery myomucosal flap and tongue flap for closure of large anterior palatal fistulas. J Craniofac Surg. 2016;27(6):1465–1468.
19.
ShettyRLambaSGuptaAK. Role of facial artery musculomucosal flap in large and recurrent palatal fistulae. Cleft Palate Craniofac J. 2013;50(6):730–733.
20.
Rossell-PerryPArrascueHM. The nasal artery musculomucosal cutaneous flap in difficult palatal fistula closure. Craniomaxillofac Trauma Reconstr. 2012;5(3):175–184.
21.
AbdaliHYaribakhtM. Assessment of outcomes and complications of posterior pharyngeal wall augmentation with dermal fat graft in patients with velopharyngeal insufficiency (VPI) after primary cleft palate repair: A pilot study. JPRAS Open. 2018;19:6–18.
22.
BonanthayaKJalilJSasikumarAVShettyPN. Furlow palatoplasty for velopharyngeal dysfunction management: Auditing and predicting outcomes. Cleft Palate Craniofac J. 2022;59(9):1097–1106.
23.
SitzmanTJPerryJLSnodgrassTDTemkitMSinghDJWilliamsJL. Comparative effectiveness of secondary furlow and buccal myomucosal flap lengthening to treat velopharyngeal insufficiency. Plast Reconstr Surg Glob Open. 2023;11(11):e5375.
24.
KohKSKimSCOhTS. Management of velopharyngeal insufficiency using double opposing z-plasty in patients undergoing primary two-flap palatoplasty. Arch Plast Surg. 2013;40(2):97–103.
25.
LamASKirkhamEMDahlJPKinterSLPerkinsJASieKCY. Speech outcomes after sphincter pharyngoplasty for velopharyngeal insufficiency. Laryngoscope. 2021;131(6):E2046–E2052.
26.
ChinMHajMVersnelSLde GierHHWolviusEB. Obstructive sleep apnea following secondary velopharyngeal insufficiency in children with non-syndromic cleft palate: A systematic review. CMTR. 2025 ;3;18(1):6.
27.
MathadVCSchererNChapmanKLissJMBerishaV. A deep learning algorithm for objective assessment of hypernasality in children with cleft palate. IEEE Trans. Biomed. Eng. 2021;68:2986–2996.
28.
JungCWSeoHJChoiYSBaeYC. Incidence of velopharyngeal insufficiency after primary cleft palate repair: A 27-year assessment of one surgeon's experience. Arch Plast Surg. 2024;51(3):284–289.
29.
BullerMJodehDQamarFWrightJMHalseyJNRottgersSA. Cleft palate Fistula: A review. Eplasty. 2023;23:e7.
30.
Youssef ArkoubiA. Investigating the effectiveness of buccal flap for velopharyngeal insufficiency: A systematic review article. J. Clin. Med. 2025;10;14(8):2593.
31.
KurnikNMWeidlerEMLienKM, CorderoKN, WilliamsJL, TemkitM, BealsSP, SinghDJ, SitzmanTJ. The effectiveness of palate Re-repair for treating velopharyngeal insufficiency: A systematic review and meta-analysis. Cleft Palate Craniofac J. 2020;57(7):860–871.
32.
HenningssonGEIsbergAM. Velopharyngeal movement patterns in patients alternating between oral and glottal articulation: A clinical and cineradiographical study. Cleft Palate J. 1986;23(1):1–9.
33.
KarlingJLarsonOHenningssonG. Oronasal fistulas in cleft palate patients and their influence on speech. Scand J Plast Reconstr Surg Hand Surg. 1993;27(3):193–201.
34.
TachimuraTHaraHKohHWadaT. Effect of temporary closure of oronasal fistulae on levator veli palatini muscle activity. Cleft Palate Craniofac J. 1997;34(6):505–511.
35.
AskarSMEl-AnwarMWElaassarAS, QuribaAS, AnanyA, ElmaltA, ElsayedAI, Abd El-AzeemMS. Cephalic de-mucosalized superiorly-based pharyngeal flap: A modified mucosa-preserving technique for velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol. 2018;115:65–70.
36.
AskarSMQuribaAS. Palatal sphincter pharyngoplasty with cephalic Mucosa preservation in selected cases of velopharyngeal insufficiency. Ann Otol Rhinol Laryngol. 2019;128(5):460–466.
37.
YsunzaAPamplonaCRamírezEMolinaFMendozaMSilvaA. Velopharyngeal surgery: A prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg. 2002;110(6):1401–1407.
38.
LipiraABGramesLMMolterDGovierDKaneAAWooAS. Videofluoroscopic and nasendoscopic correlates of speech in velopharyngeal dysfunction. Cleft Palate Craniofac J. 2011;48(5):550–560.
39.
PetMAMarty-GramesLBlount-StahlMSaltzmanBSMolterDWWooAS. The furlow palatoplasty for velopharyngeal dysfunction: Velopharyngeal changes, speech improvements, and where they intersect. Cleft Palate Craniofac J. 2015;52(1):12–22.
40.
TanakaSACoombsDMTuncerFB, ShikhmanA, KeenanP, McNinchNL, MurthyAS. Square-root palatoplasty: Comparing a novel modified-furlow double-opposing Z-palatoplasty technique to traditional straight-line repair. Plast Reconstr Surg Glob Open. 2021;9(8):e3777.
41.
RochlinDHSheckterCCKhoslaRKLorenzHP. Rates of revision and obstructive sleep apnea after surgery for velopharyngeal insufficiency: A longitudinal comparative analysis of more than 1000 operations. Plast Reconstr Surg. 2021;148(2):387–398.
42.
ChinMGRocaYHuangKX, MoghadamS, LaGuardiaJS, BedarM, WilsonLF, LeeJC. Long-term outcomes of sphincter pharyngoplasty in patients with cleft palate. J Plast Reconstr Aesthet Surg. 2024;88:24–32.
43.
PanizzaRGhiglioneMZingarelliEM, MassaM, CarliniC, ArnoldiR, PratoAP, ScarroneS, VaccarellaF. Autologous fat grafting in the treatment of velopharyngeal insufficiency: Clinical outcomes and treatment tolerability survey in a case series of 21 patients. Indian J Plast Surg. 2018;51(2):145–154.
44.
HenningssonGIsbergA. A cineradiographic study of velopharyngeal movements for deviant versus nondeviant articulation. Cleft Palate Craniofac J. 1991;28(1):115–118.
45.
GarciaAFMarinoVCPegoraro-KrookMIGuerraTALaurisJRDutkaJC. Nasalance during use of pharyngeal and glottal place of production. Codas. 2014;26(5):395–401.
46.
MasonKNBotzEGampperT. Differential diagnosis of a pharyngeal fricative and therapeutic monitoring of velopharyngeal function using magnetic resonance imaging. Am J Speech Lang Pathol. 2025;34(1):1–11.
47.
CrerandCEConradALAlbertM, BellucciCC, HeppnerCE, SheikhF, WoodardS, Kapp-SimonKA. The americleft psychosocial outcomes project: A multicenter approach to advancing psychosocial outcomes for youth with cleft lip and palate. Clin Pract Pediatr Psychol. 2017;5(1):65–76.
48.
ShawWCSembGNelsonPBrattströmVMølstedKPrahl-AndersenBGundlachKK. The eurocleft project 1996–2000: Overview. Journal of Cranio-Maxillofacial Surgery. 2001;29(3):131–140.
49.
AskarSMLabib AlnakibNQuribaASSweedAHEl ShoraM. Review of current techniques of cleft palate repair concerning palatal innervation: A preliminary assumption. Cleft Palate Craniofac J. 2025;62(9):1598–1604.
50.
RabahSM, AlkahtaniFS, JarmanA, AljoharL, AlharganA, AlmalaqAA. Effectiveness of the superiorly based pharyngeal flap in treating velopharyngeal insufficiency. Plast Reconstr Surg Glob Open. 2022;10(12):e4696. doi:10.1097/GOX.0000000000004696
51.
PerryJLMasonKSuttonBPKuehnDP. Can dynamic MRI be used to accurately identify velopharyngeal closure patterns?Cleft Palate Craniofac J. 2018;55(4):499–507.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
