The Most Efficient Surgical Technique to Treat Velopharyngeal Insufficiency After Primary Cleft Palate Repair: A Systematic Review and Meta-Analysis

Abstract

Objective

To determine the most effective surgical technique for treating velopharyngeal insufficiency (VPI) following primary cleft palate repair, based on improvement in hypernasality.

Design

Systematic review and meta-analysis of published studies evaluating surgical outcomes for secondary palatoplasty.

Setting

Isfahan Cleft Care Team, Isfahan, Iran, conducted between 2024 and 2025.

Patients/Participants

A total of 1774 patients with VPI across 31 studies were included. Syndromic patients and studies lacking original data were excluded.

Interventions

Five surgical techniques were evaluated: pharyngeal flap, sphincter pharyngoplasty, Furlow Z-plasty, buccal flap, and buccinator flap.

Main Outcome Measure(s)

Improvement in hypernasality, defined as any reduction in severity assessed by speech pathologists using perceptual and instrumental tools.

Results

Furlow palatoplasty demonstrated the highest average improvement rate (85.06%), followed by pharyngeal flap (84.50%), sphincter pharyngoplasty (83.04%), buccinator flap (77.61%), and buccal flap (59.69%). Heterogeneity was high across most surgical groups (I² up to 100%), indicating variability in study design and patient characteristics. Complication rates and quality of life outcomes varied, with pharyngeal flap associated with higher rates of obstructive sleep apnea in some studies.

Conclusions

Furlow palatoplasty and pharyngeal flap are the most effective surgical techniques for improving hypernasality in VPI patients post-primary cleft palate repair. However, significant heterogeneity and variable complication profiles underscore the need for individualized surgical planning and further prospective research.