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Systematic Review of Postoperative
Velopharyngeal Insufficiency: Incidence
and Association With Palatoplasty Timing
and Technique
Meredith D. Xepoleas, BA,*Priyanka Naidu, MBChB, MSc,*
†
Eric Nagengast, MD, MPH,*
†
Zach Collier, MD,*
†
Delaney Islip, BS,
‡
Jagteshwar Khatra, BS,
‡
Allyn Auslander, PhD,*
§
Caroline A. Yao, MD, MS,*
∥
David Chong, MBBS,
¶
and William P. Magee, III, MD, DDS
†§∥
Abstract: Cleft palate is among the most common congenital
disorders worldwide and is correctable through surgical inter-
vention. Sub-optimal surgical results may cause velopharyngeal
insufficiency (VPI). When symptomatic, VPI can cause hyper-
nasal or unintelligible speech. The postoperative risk of VPI
varies significantly in the literature but may be attributed to
differences in study size, cleft type, surgical technique, and op-
erative age. To identify the potential impact of these factors, a
systematic review was conducted to examine the risk of VPI
after primary palatoplasty, accounting for operative age and
surgical technique. A search of PubMed, Embase, and Web of
Science was completed for original studies that examined speech
outcomes after primary palatoplasty. The search identified 4740
original articles and included 35 studies that reported mean age
at palatoplasty and VPI-related outcomes. The studies included
10,795 patients with a weighted mean operative age of
15.7 months (range: 3.1–182.9 mo), and 20% (n =2186) had
signs of postoperative VPI. Because of the heterogeneity in re-
porting of surgical technique across studies, small sample sizes,
and a lack of statistical power, an analysis of the VPI risk per
procedure type and timing was not possible. A lack of data and
variable consensus limits our understanding of optimal timing
and techniques to reduce VPI occurrence. This paper presents a
call-to-action to generate: (1) high-quality research from
thoughtfully designed studies; (2) greater global representation;
and (3) global consensus informed by high-quality data, to
make recommendations on optimal technique and timing for
primary palatoplasty to reduce VPI.
Key Words: Velopharyngeal insufficiency, cleft palate, palato-
plasty, timing, technique
(J Craniofac Surg 2023;34: 1644–1649)
Orofacial clefts are among the most common congenital
anomalies worldwide. The global prevalence of cleft
palate globally ranges from 1.4 per 10,000 births in Cuba to
25.3 per 10,000 births in Canada.
1
This congenital anomaly is
correctable through cost-effective surgical interventions.
2–4
One study estimated that the repair of cleft lip or palate has
the same cost effectiveness of vaccines in low-income and-
middle-income countries.
5
Cleft-related speech impairment
can be profound for the patient, impacting ability to seek
gainful employment and ultimately resulting in significant
economic impact for households and communities.
2,4
The primary goals of the cleft palate repair are to restore
functional anatomy, to close the defect, and restore normal
speech. Unfortunately, maxillary growth deficiency, palatal
fistulae, and inadequate speech are still common complications.
Delayed surgery, improper surgical technique, and scarring can
produce sub-optimal surgical outcomes, which may result in
velopharyngeal insufficiency (VPI).
6,7
Velopharyngeal in-
sufficiency occurs as a result of a short, immobile soft palate
that does not close adequately against the back of the throat,
resulting in hypernasal or unintelligible speech.
8
The rate of VPI
after primary palatoplasty varies between 5% and 30%
9–16
in
the literature, which may be attributed to differences in study
size, cleft severity, surgical technique, and operative age of the
study populations.
17
There is still no international consensus on the appropriate
timing of cleft palate repair and technique preferences are still
debated.
18,19
Most literature suggests primary palatoplasty
performed after 18 months leads to worse speech and a higher
risk of developing VPI.
9,20–24
However, some centers still ad-
vocate for delayed palatoplasty to limit midface hypoplasia.
25
Cleft palate can present in varying degrees of severity with or
without cleft lip involvement, which makes it difficult for one
From the *Operation Smile Inc, Virginia Beach, VA; †Division of
Plastic and Reconstructive Surgery, Keck School of Medicine of
USC; ‡University of California, Los Angeles, School of Dentistry;
§Division of Plastic and Maxillofacial Surgery, Children’s Hospital
Los Angeles; ∥Department of Plastic Surgery, Shriners Hospital for
Children, Los Angeles, CA; and ¶Royal Children’s Hospital, Mel-
bourne, VIC, Australia.
Received June 8, 2021.
Accepted for publication May 19, 2023.
The authors report no conflicts of interest.
Address correspondence and reprint requests to William P Magee III,
MD, DDS, Children’s Hospital Los Angeles, 4650 Sunset Blvd. MS
#96. Los Angeles, CA 90027; E-mail: wmagee@chla.usc.edu
Supplemental Digital Content is available for this article. Direct URL
citations are provided in the HTML and PDF versions of this article
on the journal’s website, www.jcraniofacialsurgery.com.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health,
Inc. on behalf of Mutaz B. Habal, MD.
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000009555
ORIGINAL ARTICLE
1644 The Journal of Craniofacial Surgery Volume 34, Number 6, September 2023
singular surgical technique to repair all presentations.
26
Sur-
geons are often taught one cleft palate repair technique through
mentorship and utilize or modify that one technique for the
entirety of their careers. The reluctance to change from a
technique one gains proficiency in and undertake a new learning
curve discourages change in a surgeon’s approach. Fur-
thermore, technique variations and modifications make com-
paring surgical outcomes challenging. Surgeon skill itself is
another major factor pivotal to postoperative outcomes.
27
The timing of cleft palate repair is also difficult to control as
it depends on timely presentation of the patient to care, which is
often delayed in resource-limited settings.
28
Furthermore, the
assessment of VPI is not standardized, is subjective, and can
vary across languages and settings, confounding the comparison
of post-palatoplasty outcomes.
29
Understanding appropriate timing and technique in cleft
palate repair is imperative in minimizing the negative compli-
cations, yet consensus on both is still variable. We hypothesize
that there is a lack of high-quality data to standardize recom-
mendations. This systematic review aimed to (1) objectively
summarize existing data on potential impact of primary pala-
toplasty operative age and surgical technique on the risk of
developing postoperative VPI, and (2) comment on whether this
data can be used to inform best practice and provide recom-
mendations for next steps.
MATERIALS AND METHODS
A systematic review of the literature was conducted after the
Preferred Reporting Items for Systematic Reviews and Meta
Analyses (PRISMA) guidelines.
30
A detailed protocol was
registered to PROSPERO (CRD42020193982).
31
Information Sources and Search Strategy
A search of PubMed, Embase, and Web of Science was
conducted on April 6, 2020 and included twelve search terms
(Supplemental Appendix 1, Supplemental Digital Content 1,
http://links.lww.com/SCS/F263). The search terms focused on
the speech outcomes and the associated surgical interventions of
the palate. There was no restriction on publication date. Gray
literature was not searched and there was no contact with study
authors.
Eligibility Criteria and Study Selection
Eligibility criteria included full-text articles published in
English that recorded VPI speech measures after primary pal-
atoplasty. All cleft palate phenotypes were included. The studies
were required to include mean age at primary palatoplasty and
a measure of either VPI, hypernasality, or a rate of secondary
surgical intervention for speech outcomes. Studies were required
to have complete speech outcomes correlated with mean age at
surgery for a given study population. This review only examined
non-syndromic patients to limit confounding factors in the
speech outcomes. All studies with an incorrect study focus or
missing inclusion criteria were excluded. Case reports, edito-
rials, reviews, and articles without original data were not in-
cluded in the analysis.
In the first stage, 2 unblinded reviewers (M.X. and D.I.)
screened all titles independently to assess relevance to this re-
view’s objective. In the second stage, once the discrepancies
between reviewers’lists were resolved, the 2 reviewers in-
dependently screened the remaining study abstracts for in-
clusion criteria. Discrepancies between reviewers’lists were
solved through discussion. In the final stage, 3 reviewers in-
dependently assessed full-text articles (M.X., D.I., J.K.).
Disagreements were resolved by discussion and articles that did
not meet inclusion criteria were excluded.
Data Extraction
Quantitative data were extracted from the full-text studies
including patient demographics, surgical factors, and surgical
outcomes in relation to speech. Data extracted from full-text
articles by independent reviewers (M.X., D.I., J.K.) included
author, year of publication, study design, population size, se-
verity of cleft, palatoplasty operative age (age at soft palate
repair if 2-stage), surgical technique (if available), outcomes of
the population in relation to speech (VPI, hypernasality, or
incidences of secondary surgery for speech), and age at speech
assessment. This data were aggregated into a chart created on
Microsoft Excel (Microsoft Corporation).
Data Analysis and Synthesis of Results
The data extracted from included articles were too hetero-
geneous for a meta-analysis. To determine timing as a risk for
VPI symptoms after primary palatoplasty, the study population
was divided into 4 quartiles based on mean operative age: 0 to
6 months (Q1), >6 to 12 months (Q2), >12 to 24 months (Q3),
and over 24 months (Q4). To determine the risk of VPI symp-
toms after primary palatoplasty by surgical technique, a sub-
group analysis was attempted using data from studies that
reported common palatoplasty techniques (Supplemental
Appendix 1, Supplemental Digital Content 1, http://links.lww.
com/SCS/F263). Patients qualified as having VPI symptoms for
our analysis through 3 different criteria: those with post-
operative VPI, hypernasality, or who underwent a second
speech surgery. Patients with normal speech outcomes were
considered not to have any evidence of VPI. Data were ana-
lyzed using descriptive statistics, χ
2
tests, and Kruskal-Wallis
tests. Significance was set at P<0.05.
Quality Assessment
Three authors (M.X., D.I., J.K.) assessed 4 factors of study
methodology to determine the risk of bias present in the in-
cluded studies. Judgements were made by one of the authors
and checked by one other. The factors included:whether the
speech assessor was unblinded to the patient’s surgical or
medical history (detection bias), whether there were speech as-
sessment outcomes not reported for the entire study population
(attrition bias), whether there were any speech assessments de-
scribed in the methods that were not reported in the results
(reporting bias), and whether a formal speech protocol was used
for the speech assessments (other bias). Each bias was rated as
either high risk, low risk or unable to be assessed. Selection and
performance bias were not assessed as this review covered sur-
gical interventions. The authors believed it to be likely that
random sequence generation and allocation concealment would
not be present in the included studies, as this would mean
withholding the appropriate surgical treatment from some pa-
tients. In addition, for performance bias, the authors believed it
to be unlikely that the patients and study personnel would be
blinded to type of surgical interventions. Therefore, the authors
assumed selection and performance bias to be present in the
included studies. Publication bias was assumed to be present as
the authors only assessed published peer-reviewed studies.
RESULTS
Study Selection
The search identified 4740 original articles (Fig. 1). A total of
4636 were excluded and 104 full-text articles were separately
The Journal of Craniofacial Surgery Volume 34, Number 6, September 2023 Systematic Review of Postoperative VPI
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD. 1645
reviewed by 3 authors (M.X., D.I., and J.K.). Sixty-nine of the
104 were excluded for failure to report age at primary
palatoplasty (n =16), failure to report complete speech
outcomes after primary palatoplasty (n =36), or reporting the
presence of a syndrome in their populations (n =17). The 35
included studies reported mean age at palatoplasty and VPI-
related outcomes.
Quality Assessment
Quality assessment of the 35 included studies is shown in
Fig. 2. Most studies (n =28, 80%) failed to specify whether
speech assessment was blinded. All studies were low risk for
reporting bias. Six (17%) did not include speech assessment
results for the entire study population. Formal speech
assessment protocols were reported in 26 studies (74%).
Study Characteristics
Twenty-one included studies (60%) were retrospective and 14
(40%) were prospective. Most were published between 2010 and
2020 (n =27, 77%) (Supplemental Appendix 1, Supplemental
Digital Content 1, http://links.lww.com/SCS/F263). The authors
of these 35 studies were associated with institutions in 16
countries, with the majority (n =11, 31%) having authors af-
filiated with institutions in the United States of America (Sup-
plemental Appendix 1, Supplemental Digital Content 1, http://
links.lww.com/SCS/F263). The speech outcome used to measure
VPI presence was reported as hypernasality in 10 studies (29%),
incidence of secondary surgery in 18 studies (51%), and VPI in 7
studies (20%). The majority of studies with speech assessments
(n =33, 94%) examined speech outcomes at age 4 years or older
(n =29, 88%). This age group is unlikely to develop subsequent
VPI and earlier assessment is often unreliable due to age.
32
Operative Age
The 35 included studies had 10,795 patients with a weighted
mean operative age of 15.7 months (range: 3.1–182.9 mo)
(Supplemental Appendix 1, Supplemental Digital Content 1,
http://links.lww.com/SCS/F263), and 20% (n =2186) had signs
of postoperative VPI. The majority (n =8489, 78.6%) had pal-
atoplasty between age 6 and 12 months (Q2) (Supplemental
Table 1, Supplemental Digital Content 2, http://links.lww.com/
SCS/F264), and this group had the lowest occurrence of VPI
(18.1%, P<0.010). There was a significant difference between
Q3 and Q4 (P=0.007), but not between Q4 and Q1 (P=0.409,
Supplemental Table 2, Supplemental Digital Content 2, http://
links.lww.com/SCS/F264).
Surgical Techniques
Becaues of the heterogeneity in reporting surgical technique
across studies an analysis of the VPI risk per procedure was not
possible. Nine studies (26%) mentioned only the name of the
surgical procedure used, 15 studies (43%) described the surgical
procedure in writing or diagrams, and 7 (20%) studies men-
tioned only the name of the surgical technique and cited a cleft
palate repair technique paper. An assessment of surgical tech-
niques was not applicable for 4 retrospective papers that did not
collect technique information. Eleven studies (31%) included
modifications to techniques.
DISCUSSION
This is the largest review to date examining the risk of devel-
oping VPI after primary palatoplasty with respect to operative
timing and technique; illustrating that up to 20% of primary
cleft palate patients are at risk of postoperative VPI. Previous
literature reviews report a 20% to 30% incidence of VPI after
primary palatoplasties in non-syndromic patients.
29,33
Risk of
VPI may also depend on surgical technique and expertise, cleft
phenotype, and cleft severity.
27
In previous studies, higher rates
of VPI have been suggested with more severe clefts (Veau III
and IV),
32,34
male sex, shorter palate length, large cleft width,
and patients with cleft lip and palate compared with isolated
cleft palate.
35
This analysis found that primary palatoplasty performed
between ages 6 and 12 months was associated with a sig-
nificantly lower risk of VPI; corroborating the long-standing
idea that operative age plays a significant role in postoperative
speech outcomes.
36
However, the authors cannot conclusively
advocate for 6 to 12 months as the optimal timeframe owing to
FIGURE 1. The PRISMA flowchart of results. PRISMA indicates Preferred
Reporting Items for Systematic Reviews and Meta Analyses.
FIGURE 2. Results of the risk of bias assessment.
Xepoleas et al The Journal of Craniofacial Surgery Volume 34, Number 6, September 2023
1646 Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.
a number of reasons: (1) studies included in this analysis lacked
statistical power owing to small sample sizes; (2) timing and
technique were analyzed in isolation without consideration of
other important contributing factors, such as cleft severity,
phenotype, and surgeon expertise; (3) measurement of speech
outcomes lacked standardized assessments; and (4) nearly 80%t
of patients underwent palatoplasty between 6 and 12 months,
which could indicate the influence of certain protocols. For
example, the Rule of 10s has influenced many surgeons to
perform cleft lip repair at 10 weeks of age; to ensure adequate
postoperative recovery, the cleft palate in these children was
often repaired after 6 months of age.
37,38
Our results do not indicate an advantage to early (Q1) or late
(Q4) palatoplasty. There is variable consensus on timing of
palatoplasty to optimize speech outcomes. Kaplan suggested
palatoplasty before 6 months to ensure proper anatomy at the
time of speech development at 9 to 12 months.
21
Whereas
Murthy et al. and Zhao et al. reported slightly superior speech
outcomes after late palatoplasty,
9,39
other studies report poorer
speech outcomes.
9,21–24
Many surgeons would recommend
performing primary palatoplasty before 12 months of age to
correct cleft palate anatomy before speech patterns have de-
veloped. It is theorized that younger children have more time to
learn and practice speaking with a repaired mechanism, pro-
viding an opportunity to ameliorate erroneous speech
patterns.
36
Intuitively, primary palatoplasty between 0 and
6 months would result in lower rates of VPI, particularly when
compared with primary palatoplasty after 2 years of age, con-
tradicting the findings of this analysis.
However, the benefit of palatoplasties earlier than 6 months
need to be measured against the risk of midface hypoplasia,
which has significant consequences. Furthermore, early repair
before 6 months may be difficult due to small anatomy and
airways that increase risk for anesthesia complications, airway
obstruction, and lack of respiratory reserve.
40
Variability in reporting standards among the studies limited
our analysis of the timing of cleft palate repair. Among the 35
included studies there was no consistency in (1) the scale/
measurement used to evaluate VPI; (2) reporting of VPI out-
comes; (3) reporting of operative age; and (4) reporting surgical
technique with descriptions or citations. In addition, this review
excluded 52 articles for failure to report basic demographics
within their studies such as mean operative age and complete
postoperative speech outcomes.
Timing of cleft palate repair is variable between centers
globally. This variability also exists in the United States, for
example, patients in the Midwest tend to undergo palatoplasty
later than the West (14.3 versus 13.2 mo) which is even later
than in the Northeast (12.9 mo). Eighty-five percent of centers
in the United States perform cleft palate repair after 6 months of
age. Even in our institution at the Children’s Hospital Los
Angeles/ University of Southern California there is variation
among surgeons. This variability could be attributed to what
surgeons learned during their training or the practical reasons
that occur from patient presentation to anesthesia preparation.
There are many reasons that contribute to the lack of universal
protocols for cleft palate repair. The search for optimal timing is
a meticulous investigation for optimal speech results against
known iatrogenic effects of palatal surgery demonstrated to
have variable degrees of growth disturbances.
An analysis of surgical technique was not possible owing to a
lack of standardized technique nomenclature. Techniques are
named but, are often modified (described and undescribed).
Less than half the articles included descriptions and/or diagrams
of the techniques used. This was further compounded by in-
consistent reporting on the descriptions of surgical techniques
among the studies and inadequate information to appropriately
classify and compare techniques.
Limitations
Of note, VPI is not definitely a complication of palatoplasty
owing to the natural incidence of VPI due to factors beyond the
surgeon’s control, such as soft tissue availability, cleft width,
and palatal length. These factors are highly variable and the
most extreme severity may be impossible to overcome with a
singular surgery. More data are needed to better understand the
factors that contribute to the occurrence of VPI. Despite these
inherent factors, this systematic review demonstrates that opti-
mization of technique and timing may reduce VPI. Palatoplasty
has been shown to improve articulation patterns, regardless of
the presence of VPI. However, it is important to note that re-
ducing VPI may not correct all aspects of speech development.
VPI is one component of speech development and palatoplasty
alone has been demonstrated to improve articulation patterns
regardless of VPI.
The generalizability of our report relies on the quality and
consistency of the underlying study data. Biases may result from
retrospective studies and those that did not include details about
blinding reviewers, speech assessment protocols, or surgical
details. Furthermore, confounding factors such as surgeon ex-
pertise, and cleft severity and phenotype, were not analyzed due
to inadequate data. Longitudinal data collection of patients
who undergo palatoplasty is challenging owing to poor long-
term follow-up and lack of standardized outcomes assessments
and metrics. In 2001, the Eurocleft study found that 201 Eu-
ropean cleft centers had 194 different protocols for the man-
agement of unilateral cleft palate alone.
41
Speech outcomes
were defined by rate of secondary surgery, VPI, or hypernasality
instead of a standardized single measurement. As some sur-
geons or centers are more active in treating mild or moderate
VPI, the rate of secondary surgery may not consistently repre-
sent speech outcomes. There was minimal individual patient-
level data reported in the studies, so mean ages for entire
cohorts were utilized and may be subject to outlier influences
compared with other methods of central tendency. The high
variability in operative age within the Q4 group may also
contribute to the statistical differences seen between this group
and Q2 and Q3. Furthermore, statistical power of included
studies was highly variable owing to small sample sizes. More
accurate data collected through further prospective studies is
crucial to inform timing and technique of primary palatoplasty.
The need for larger longitudinal studies was addressed by the
creation of the Universal Parameters for Reporting Speech
Outcomes, which was cited as a protocol in only in 5
studies.
9,40,42–45
Although outside the scope of this paper, we cannot deny the
role that hearing has on speech development. There is variable
consensus in the literature on the extent to which this can im-
pact speech or be a confounding factor for VPI. If we had a
better understanding of the implications of palatoplasty on
hearing and effusions, it may help to construct more sophisti-
cated treatment algorithms. As future studies are planned, it
would be ideal to include these factors to gain a more complete
understanding of the implications of an important and common
surgery.
Recommendations
The authors would recommend future studies on cleft palate
repair include the following: (1) a thorough description of the
surgical technique either through diagrams or narratives; (2) a
The Journal of Craniofacial Surgery Volume 34, Number 6, September 2023 Systematic Review of Postoperative VPI
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD. 1647
standardized assessment of resonance and articulation after the
Universal Parameters for Reporting Speech Outcomes com-
pleted by blinded speech language pathologists; and (3) a mean
age of the study population stratified by surgical technique and
cleft phenotype. Few included studies incorporated all these
elements.
9,43,46
Further recommendations include improved
data collection methods facilitated by (1) standardized metrics
of evaluation; (2) national audits completed by blinded speech
language pathologists to report on speech outcome of each cleft
center for further comparison between international centers;
and (3) central and shared databases. In addition, the tendency
for surgeons to only learn one palatoplasty technique is a lim-
iting factor for comparison of surgical techniques as surgeon
skill is a confounding factor for outcomes. In one study of this
review, surgeons were taught a second technique to serve as a
control against themselves.
47
Despite the intention, there will
still be a bias towards the technique the surgeon has more initial
experience with, making this confounding factor difficult to
account for. As technology evolves, opportunities to utilize ar-
tificial intelligence to help us more readily obtain results and
impact treatment algorithms are an option but need to be well
organized. Organizations such as Operation Smile have started
to explore ways to evaluate speech through artificial intelligence
to increase access to care low-resource settings. Further research
on this topic is required.”
Velopharyngeal insufficiency is a complication that causes
substantial morbidity and developmental delay as the child’s
ability to communicate in both social and educational settings is
impaired. This systematic review highlights the lack of high-
powered, well-designed studies in primary cleft palate repair
which limits our ability to understand optimal timing and
techniques that would limit VPI occurrence. Furthermore, low-
income and middle-income countries (86% of the world’s pop-
ulation) are highly under-represented in the literature. These
gaps in the literature should be seen as an opportunity to answer
an important question that could substantially reduce morbidity
and improve quality of life. This paper should be viewed as a
call-to-action to generate: (1) high-quality research from
thoughtfully designed studies; (2) greater global representation;
and (3) global consensus once the high-quality evidence has
been reviewed. This consensus can only be encouraged through
collaboration and working towards a common goal of ensuring
best outcomes for patients requiring primary palatoplasty.
CONCLUSION
Palatoplasty is life-changing surgery; however, our study
demonstrates that 20% of patients who undergo primary
palatoplasty are at risk of developing VPI. Despite inherent
factors that may be difficult to overcome in patients with cleft,
such as cleft width, soft tissue availability, and palatal length,
it is still important that we strive for optimal results for both
technique and timing. Although earlier cleft palate repairs
suggest diminished rates of VPI, optimal timing for primary
palatoplasty cannot be concluded from this study. Similarly,
our study did not uncover a statistically superior surgical
technique to limit postoperative VPI, and could not account
for important confounders, such as surgeon skill, cleft se-
verity, and phenotype, owing to inadequate published data.
This is further complicated by inconsistent nomenclature of
techniques and the lack of widely accepted standardized pro-
tocols and outcomes metrics for cleft surgery. This study
demonstrates the need to standardize technique classification
and speech evaluation to improve data collection and analysis.
Future studies based on more reliable data can inform
palatoplasty timing and technique to minimize VPI, while
accounting for the risk of midface hypoplasia.
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The Journal of Craniofacial Surgery Volume 34, Number 6, September 2023 Systematic Review of Postoperative VPI
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD. 1649
