Pediatric plastic and reconstructive surgery

Julia finds her voice through soft palate surgery

A child working with a speech language pathologist
Julia Crandell, right, works on speech with Becky Johnson, a UW Health speech and language pathologist.

Julia Crandell is a fun, sometimes goofy 8-year-old with a little extra rambunctiousness thrown in. Hardly a shy girl, Julia usually knows what she wants and is not afraid to tell you.

The only problem is that for the first few years of her life, it was often hard to understand her words. Her extremely nasally voice often made her incomprehensible.

“She sounded something like a cross between the ‘Minions’ and Fran Drescher’s character from ‘The Nanny,’” says Julia’s mom, Heather Crandell of Verona, Wisconsin. “Most people understood a simple ‘yes’ or ‘no’ but I often got inquisitive looks from others like, ‘What did she say?’”

Julia began speech services through her early childcare program starting at age 2. By the time Julia was almost 6, her UW Health pediatrician, Dr. Jeffrey Sleeth, recommended more intensive speech therapy.

At American Family Children’s Hospital in Madison, Julia soon became fast friends with Becky Johnson, a UW Health speech and language pathologist.

“After spending an hour with Julia,” Johnson recalls, “it was pretty clear that there was something bigger going on. It wasn’t just a case of mispronouncing words.”

In September 2021, Julia went through a diagnostic procedure called a nasopharyngoscopy. After a thin camera was carefully inserted into her nose, speech experts asked Julia to say phrases with hard consonant sounds such as “Pet the puppy,” “Take the turtle,” and “Go get the cookie.”

“Phrases like these require a buildup of air in the mouth,” Johnson says, “so the camera lets us observe the roof of Julia’s mouth and back of her throat in action while she speaks,” Johnson says. “The procedure confirmed that too much air was escaping through her nose and too little air was coming out of her mouth. That is why she sounded so nasally.”

Johnson immediately spoke with Dr. Catharine Garland, a UW Health pediatric plastic and reconstructive surgeon, who reviewed Julia’s history and test results.

“By then,” says Dr. Garland, “Becky sensed that all the speech therapy in the world wasn’t going to fix Julia’s problem, namely that her soft palate, in the roof of her mouth, was too short at birth. The fancy name for this condition is velopharyngeal insufficiency, or VPI.”

“Normally, speaking triggers the soft palate and throat to form a tight seal, forcing air and sound out through the mouth,” Dr. Garland says. “Because Julia’s soft palate was abnormally short, it left a gap that allowed too much air out her nose as she spoke.”

Surgery was the only solution

The only way to close the gap was through surgery, not exactly the solution the Crandells hoped for. Still, they were relieved that the problem was accurately diagnosed and a permanent fix was available.

“The surgery we recommended is fairly new and has yielded good results with others,” Dr. Garland says. “It leaves no scarring on the face. We take muscle and lining from inside both cheeks and use it to lengthen the soft palate. This plugs the gap, so the air that was escaping through the nose now comes out of the mouth.”

Dr. Garland performed the highly advanced surgery, known as palatal lengthening with buccal myomucosal flaps, in February 2022, when Julia was 6. After coming home from a three-night hospital stay, Julia spent the next several weeks recovering.

“Her mouth was pretty sore for the first several weeks,” Heather says, “so her diet was only liquids at first and then soft foods. Julia is also dairy-free and can only have low-sugar foods, so we had to get creative. Overcooked risotto with chicken stock and coconut egg custard were two of her favorites.”

Heather and her husband Bradley alternated taking time off from work for several weeks. Julia’s Grandma Kirk also came from Florida to provide plenty of support.

With her structural problem fixed, Julia faced the challenge of learning how to make her sounds correctly. She also had to “un-learn” old speaking habits, such as saying “wed wabbit” instead of “red rabbit.”

Johnson, the speech therapist, credits Julia and her family for their diligence and compliance.

“Heather is an occupational therapist herself,” Johnson says. “She is very dedicated and it shows with Julia’s progress over the past year. She practices her speech at home as much as any kid I’ve worked with in seven years.”

Self-confidence keeps growing

Her parents not only relish the improvement in Julia’s speech but in her growing self-confidence.

“Julia has a strong sense of who she is … what she likes and what she doesn’t like,” Heather says. “I’m always amazed at how easily she cultivates new friends. We were at a Homecoming Parade and I overheard some kids I’ve never met asking, ‘Is that Julia’s mom?’ I call her my little cult leader.”

Julia’s story also illustrates the unique capability of a comprehensive, highly specialized approach for children with rare conditions.

“It started with Julia’s pediatrician, who encouraged the family to pursue speech therapy,” Dr. Garland says. “When Becky suspected that therapy alone wouldn’t solve the problem, she brought the pediatric plastic and reconstructive surgery team in. That’s the beauty of having so many highly trained doctors, nurses and therapists working closely together.”

Julia continues to progress with her speech while her family, which includes sister Kate, is grateful for their daughter’s care.

“Once we got into Dr. Garland’s clinic,” Heather says, “the coordination of care was unreal. They did an amazing job with Julia and we’re excited that even better days are ahead for her.”