Operative Technique in Plastic Surgery – Kevin C.Chung

■ Premaxillary turnover flap
• Primarily used as nasal lining flap for fistula at anterior incisive foramen in
Veau IV cleft
■ Free tissue transfer
T E C H N I Q U E S
■ Excision and Reapproximation
■ Midline oral endotracheal tube placement; head placed in headrest with
slight extension.
■ Perform proper surgical time-out.
■ Place Dingman mouth prop.
■ Prep and drape the patient.
■ Mark out medial epithelialized areas that must be excised.
■ Inject with local anesthesia of choice. Author prefers ¼% Marcaine with
1:200 000 epinephrine.
■ Excise medial portions of fistula.
■ Repair with resorbable sutures. Author prefers 4-0 chromic sutures.
■ Lateral Relaxing Incisions and Rerepair (TECH FIG
1)
Preparation for All Fistula Types
■ Midline oral endotracheal tube placement; head placed in headrest with
slight extension.
■ Perform proper surgical time-out.
■ Place Dingman mouth prop.
■ Prep and drape the patient.
■ Mark out lateral relaxing incisions (von Langenbeck style relaxing incision
on the hard palate, soft palate, or both depending upon fistula type).
■ Relaxing incisions typically need to be longer than initially thought due to
relative immobility of soft tissues.
■ Inject with local anesthesia of choice. Author prefers ¼% Marcaine with

1:200 000 epinephrine.
Pittsburgh Type II Fistula
■ Incise lateral relaxing incisions on the soft palate.
■ Incise medial fistula.
■ Separate nasal mucosa from levator muscles with sharp dissecting scissors.
■ Separate oral mucosa from levator muscles with sharp dissecting scissors.
TECH FIG 1 • A. Lateral relaxing incisions. B.
Rerepair.
■ Make certain that levator muscles are not tethered to the hard palate, if so
release sharply.
■ Repair nasal mucosa with interrupted, buried (knot on nasal side) sutures.
Author prefers 4-0 chromic.
■ Repair levator musculature with re-establishment of levator sling. Author
prefers 4-0 Monocryl.
■ Repair oral mucosa with interrupted sutures. Author prefers 4-0 chromic.
■ If augmenting closure with ADM, after muscle repair, place a thin piece of
ADM over muscle with ample coverage beyond suture line. Author uses
double-armed 4-0 Monocryl sutures suturing from underneath ADM through
oral mucosa allowing knots to easily be placed and tied on oral mucosal side.
■ Place tongue stitch and remove Dingman device.
Pittsburgh Type III Fistula
■ Incise lateral relaxing incisions on the hard and soft palate.
■ Incise medial fistula.
■ It is typically easier to recruit oral mucosa compared to nasal mucosa, so
the initial markings should be slightly on the more lateral portions of the
fistula to allow easier closure of the nasal mucosa.
■ Use Joseph Periosteal Elevator to elevate mucoperiosteal flaps from the hard
palate with care taken to preserve greater palatine vessels.
■ Release soft palate lateral relaxing incision from hamulus and junction of the
hard palate/end of alveolar ridge.

■ Dean scissors can be a useful instrument to release medial tissue off
hamulus.
■ Separate nasal mucosa from levator muscles (if present) and release nasal
mucosa from nasal side of the hard palate.
■ Separate oral mucosa from levator muscles with sharp dissecting scissors (if
present).
■ Make certain that levator muscles are not tethered to the hard palate, if so
release sharply.
■ Repair nasal mucosa with interrupted, buried (knot on nasal side) sutures.
■ Repair levator musculature with re-establishment of levator sling (if
previously released).
■ Place liberal ADM prior to closure of oral mucosal flaps.
■ Repair oral mucosa with interrupted sutures.
■ Ensure hemostasis of lateral relaxing incisions.
■ Place tongue stitch and remove Dingman.
Pittsburgh Type IV Fistula
■ Incise lateral relaxing incisions on the hard and soft palate (if necessary
depending on location of fistula in hard palate).
■ Incise medial fistula.
■ It is typically easier to recruit oral mucosa compared to nasal mucosa, so
the initial markings should be slightly on the more lateral portions of the
fistula for easier closure of the nasal mucosa.
■ Use Joseph Periosteal Elevator to elevate mucoperiosteal flaps from the hard
palate with care taken to preserve the greater palatine vessels.
■ Determine whether fistula is too large for closure and if pushback
technique will be required.
■ If pushback is required, continue lateral relaxing incisions more
proximally, depending upon the location of fistula either incise from medial
portion of fistula toward alveolus or fashion-like Veau-Wardill-Kilner–type
palatoplasty.
■ Separate/release nasal mucosa from nasal side of hard palate to allow medial
mobilization.
■ A double hockey or Pigtail instrument or Woodson can be extremely
helpful for this dissection.
■ Repair nasal mucosa with interrupted, buried (knot on nasal side) sutures.

■ Place liberal ADM prior to closure of oral mucosal flaps.
■ Repair oral mucosa with interrupted sutures.
■ Resuspend flaps to lateral relaxing incisions without placing undue tension
on medial repair.
■ Ensure hemostasis of lateral relaxing incisions.
■ Place tongue stitch and remove the Dingman device.
■ Conversion by Furlow Palatoplasty
■ Refer to Chapter on Furlow Palatoplasty (Chapter 8), for description of this
technique.
■ The CHOP modification should be encouraged if any concerns for tension
on repair exist.
■ Posterior Pharyngeal Flap
■ Please see chapter on Velopharyngeal Insufficiency (Chapter 14) for
description of this technique.
■ A palatal split technique (as described by Owsley8) should be considered
over a fish-mouth technique as described by Argamaso.9
■ Labial Mucosal Flap
■ Must be able to protect this flap from masticatory trauma by either having
space to pass through dental arch or by having temporary bite blocks placed
on the teeth.
■ Midline oral endotracheal tube placement; head placed in headrest with
slight extension.
■ Perform proper surgical time-out.
■ Placement of Dingman mouth prop.
■ Prep and drape the patient.
■ Mark out medial portions of the fistula.
■ Recruit tissue from oral side as previously described.
■ Mark out flap on labial wet vermilion (this is a hinge- or finger-type flap).
■ The base of flap and point of rotation of flap can be unipedicle or bipedicle

depending upon the location of fistula and Veau-type cleft.
■ Typically for Veau III clefts with recruitment of tissue from posterior
segment.
■ Make certain to place incision line several millimeters above the attached
gingiva so that closure of donor defect is made easier.
■ Inject with local anesthesia of choice. Author prefers ¼% Marcaine with
1:200 000 epinephrine.
■ Incise and repair medial portions of fistula as previously described.
■ Incise buccal flap and elevate with sharp scissors.
■ Elevate this flap off the orbicularis muscle to maintain as much blood
supply because this is a random pattern flap.
■ Rotate flap into defect.
■ Sew flap to raw oral mucosal edges (preferably through dental arch defect)
(TECH FIG 2).
■ Close donor defect with interrupted sutures.
■ Place tongue stitch and remove Dingman device.
TECH FIG 2 • Design of a labial mucosal flap.
■ Buccal Myomucosal Flap
■ Oral endotracheal tube placement; head placed in headrest with slight
extension.
■ Perform proper surgical time-out.
■ Prep and drape the patient.
■ Place Dingman mouth prop or dental mouth prop.

■ Place several retraction sutures on the lip to aid in retraction/visualization.
■ Identify Stensen duct.
■ The flap is caudal to the duct.
■ Mark out flap from area over ascending ramus transversely oriented to oral
commissure (stay on wet vermilion) (TECH FIG 3A,B).
■ The base of flap is about 1.5 cm.
■ Narrow the flap distally.
■ Inject with local anesthetic.
■ Incise mucosa and sharply dissect from the distal end of flap toward base of
flap (TECH FIG 3C).
TECH FIG 3 • A. Design of a buccal myomucosal flap.
B. Markings. C. Flap elevation. D. Flap inset into a
palatal defect. E. Division of base of flap.
■ A portion of the buccinator muscle is taken to improve the vascularity of
the flap (as described by Mann,3 this is an intramuscular dissection).
■ This flap can be elevated bilaterally if needed.
■ Prepare fistula site so that some nasal mucosa can be rolled in (complete
nasal mucosa closure is not critical).
■ Make certain to elevate raw edges of oral mucoperiosteal tissue to inset the

flap.
■ Rotate flap into defect and sew in place attaining excellent approximation of
mucosal edges (TECH FIG 3D).
■ Flap will need to be rotated posteriorly behind dental arch or through space
in dental arch that can be protected from masticatory trauma (can use oral
splints on teeth as well).
■ Close donor site in a single layer.
■ Place tongue stitch and remove Dingman/dental mouth prop.
■ The base of this flap may be subsequently divided after 3 to 4 weeks (TECH
FIG 3E).
■ Facial Artery Musculomucosal Flap10
■ Oral endotracheal tube placement, place head in headrest with slight
extension.
■ Perform proper surgical time-out.
■ Prep and drape the patient.
■ Placement of Dingman mouth prop or dental mouth prop.
■ Place several retraction sutures on the lip to aid in retraction/visualization.
■ Identify Stensen duct.
■ Artery and flap should be anterior to the duct.
■ Use handheld Doppler to identify the course of the facial artery.
■ An obliquely designed flap is centered over the artery from retromolar
trigone area to gingival buccal sulcus at alar base (should be anterior to
Stensen duct).
■ Flap is 1.5 to 2 cm wide.
■ Incise mucosa at distal end (either superiorly or inferiorly based) through
mucosa and buccinators.
■ Identify facial artery and ligate.
■ Elevate flap deep to the artery taking a small cuff of buccinator muscle and
orbicularis muscle (TECH FIG 4A).
■ Flap can be 8 to 9 cm in length.
■ This flap can be elevated bilaterally if needed.
■ Prepare fistula site so that some nasal mucosa can be rolled in (complete
nasal mucosa closure is not critical) (TECH FIG 4B).

■ Make certain to elevate raw edges of oral mucoperiosteal tissue to inset the
flap.
■ Rotate flap into defect and sew in place attaining excellent approximation of
mucosal edges (TECH FIG 4C).
■ Flap will need to be rotated posteriorly behind dental arch or through space
in dental arch that can be protected from masticatory trauma (can use oral
splints on teeth as well).
■ Close donor site in two layers (buccinators muscle and then mucosa) taking
care to avoid the Stensen duct.
■ Place tongue stitch and remove Dingman/dental mouth prop.
TECH FIG 4 • A. Design of a facial artery

musculomucosal flap. B. Preparation of the fistula site.
C. Flap inset.
■ Tongue Flap (Anteriorly Based)9,11
Raising and Insetting Flap
■ Oral endotracheal tube placement to the right or left side; head placed in
headrest with slight extension.
■ Perform proper surgical time-out.
■ Prep and drape the patient.
■ Place bite block mouth prop.
■ Inject palatal tissue with local anesthetic.
■ Incise and elevate around palatal mucosa to become nasal floor.
■ Plan this incision so that you can have either complete nasal floor closure
or at least significant nasal floor mucosa to place your tongue flap on.
■ Close nasal floor if possible.
■ Use the foil from a chromic stitch to make a template of the palatal defect.
■ Place a traction suture through the tip of the tongue to improve exposure.
■ Transpose the foil template onto the tongue with tip of flap at junction of
anterior two-thirds and posterior one-third of the tongue.
■ Mark out flap making certain to maintain at least a 2-cm pedicle base.
■ Can mark flap slightly larger than template for safety.
■ Use a Colorado needle-tip Bovie to incise and elevate the flap from distal to
proximal (TECH FIG 5A).
■ This dissection should include underlying longitudinal tongue musculature
but can be thinned near the tip of the flap (down to 4 mm of muscle).
■ This dissection is not a natural tissue plane and can bleed from the raw
muscle edge.
■ Inset tongue flap into edges of raw mucoperiosteal palatal flaps (TECH FIG
5B,C).
■ The use of 4-0 double-armed Monocryl sutures with the knots on the palatal
mucosa makes insetting of this flap much easier.
■ This flap cannot be completely inset into the entire fistula as the pedicle
width prevents complete inset (final inset is performed during division of

flap).
■ Closure of donor site of the tongue with horizontal mattress sutures to
prevent bleeding.
■ Extubate patient.
■ Place light elastics on orthodontic brackets for gentle MMF and patient
comfort.
■ Wait for 3 weeks for revascularization.
Division of Flap
■ A gentle rubber shod clamp can be used to test if neovascularization has
occurred in OR prior to division.
■ If concerns for insufficient vascularity, postpone division.
■ Plan division so that a portion of the pedicled base will fill remaining portion
of the palatal fistula.
■ For incomplete nasal floor closure, some secondary healing from margins
can occur.
■ Divide flap and debulk the new portion to inset (typically about 10%–15%
of flap).
■ Complete inset of flap.
■ Double-armed sutures make inset significantly easier.
■ Return unused pedicled tissue to the tongue by opening previous incision
and closing with chromic sutures.
TECH FIG 5 • A. Design of a tongue flap. Fistula
before (B) and after repair (C) with a tongue flap.
■ Premaxillary Turnover Flap (Fish-Mouth
Technique into Hard Palatal Mucoperiosteal

Flaps)12
■ Midline oral endotracheal tube placement; head placed in headrest with
slight extension.
■ Perform proper surgical time-out.
■ Place Dingman mouth prop.
■ Prep and drape the patient.
■ Mark junction of premaxillary gingiva and lingual side of incisors with
lateral markings down the premaxilla along the cleft margin (TECH FIG
6A,B).
■ Mark edge of mucoperiosteal flaps and lateral relaxing incisions along
alveolar ridge (TECH FIG 6C).
■ Inject with local anesthetic.
■ Incise junction of the gingiva and lateral premaxilla and perform
subperiosteal dissection of this flap.
■ The base of this flap narrows as you ascend toward the nasal cavity, so care
must be taken in elevation (TECH FIG 6D).
■ Use an angled blade to incise the edge of the mucoperiosteal flaps and make
lateral relaxing incisions.
■ Use a combination of periosteal elevators from lateral side and sharp scissor
or knife dissection to re-elevate the mucoperiosteal flaps.
TECH FIG 6 • A,B. Design of the premaxillary turnover

flap. C. The mucoperiosteal flap is marked just behind
the incisors and at the lateral borders of the
premaxilla. D. Flap elevation. E. Flap inset in a
parachute-type manner.
■ Care must be taken to preserve greater palatine vessels if dissection occurs
that distally.
■ Advance mucoperiosteal flaps if possible.
■ Turn over premaxillary flap for inset.
■ The premaxillary gingiva will become the new nasal mucosa, and the
periosteum of the premaxilla will be the oral side for this flap.
■ Use parachuting sutures to tack the periosteal side of flap to raw surface of
mucoperiosteal flaps.
■ The use of double-armed sutures coming through the premaxillary flap and
out the palatal mucoperiosteal flap makes inset and parachuting much
easier (see TECH FIG 6A).
■ Do not attempt to tie these sutures until all have been placed for ease of
placement.
■ Place sutures about 1 cm apart.
■ After flap has been inset distally, close lateral aspect of flap to any raw areas
of alveolus gingiva.
■ Work distally to proximally to close down posterior alveolar fistula.
■ Using a P2 needle and Castroviejo needle drivers facilitates this closure.
■ May cover this flap with a thin piece of ADM if single layer closure is being
performed.
■ Place tongue stitch and remove Dingman device.
■ Free Tissue Transfer13
■ Multiple donor sites have been described, including radial forearm free flap
(TECH FIG 7A), anterolateral thigh free flap (TECH FIG 7B), and lateral
arm flap.
■ Thorough descriptions of and surgical techniques for the various free tissue
flaps that have been described in the oncologic literature for palatal and
maxillectomy defects are found in other chapters of this book.

TECH FIG 7 • A. Radial forearm free flap for palatal
fistula closure. B. Anterolateral thigh flap for palatal
fistula closure.
PEARLS AND PITFALLS
Obtain a preoperative
retainer to protect repair for
type IV and V fistulas
■ Have this item made 2 weeks before surgery and
have patient wear it to check for compliance and
become habituated to it.
■ Meet with your orthodontist and patient with
retainer to make certain it fits but does not
compress on your repair.
Postoperative compliance
■ Must discuss and ensure proper postoperative
compliance with diet and activities in the
preoperative setting.
■ This author has had recurrence secondary to poor
postoperative compliance.
Preoperative orthodontia
for tongue flaps
■ Have orthodontic colleagues place temporary
orthodontic brackets on the permanent teeth.
■ Saves time of placing some form of appliance
while under anesthesia.
■ Use light elastics instead of true MMF to
decrease intraoral opening while attempting to
provide more comfort to the patient.
Preoperative evaluation for
sleep-disordered breathing
■ If planning posterior pharyngeal flap for type II
or III fistula, evaluate for obstructive sleep apnea

with preoperative polysomnogram.
Proper exposure and
visualization
■ Make relaxing incision longer than expected.
■ Dissect around greater palatine vessels under
direct visualization.
Mucoperiosteal flap rigidity
■ Remobilization of the mucoperiosteal flaps rarely
provides as much mobility as desired as they are
stiffer than primary repair.
POSTOPERATIVE CARE
■ Patients should be observed overnight for pain control and to monitor for any
airway issues.
■ Patients should be started on a liquid diet for 24 to 48 hours after surgery (per
surgeon’s preference).
■ Diet should then be advanced to a soft food diet for 3 to 4 weeks after surgery
(per surgeon’s preference).
■ Some surgeons implement postoperative antibiotics, but the literature is
divided about use.
■ Peridex should be used (5 to 10 mL swish and spit) after every meal.
■ Nasal precautions should be instituted.
■ No nasal suctioning while in hospital.
■ Avoid blowing of the nose.
■ Sneeze with an open mouth if possible.
■ No straws.
■ If a postsurgical splint has been made, the retainer should be worn at all times
and only taken out to clean.
■ Follow-up within 1 week to assess healing.
OUTCOMES
■ Recurrence rate is highly variable in the literature and dependent on
technique/flap chosen and location of the fistula.14
■ ADM shown to work in nine consecutive patients without recurrence for hard
palatal fistula.6
■ Buccal myomucosal flap has reported 7% to 18% failure rate for all uses.3
■ FAMM flap has failure rates of 17% to 27%.10
■ Secondary to venous congestion and flap tip necrosis
■ Lateral relaxing incisions and pushback technique have 10% failure rate.15

■ All failures are reported in bilateral cleft lip and palate.
■ Tongue flap reported failure rates range from 8% to 15%.9,16
■ Sohail et al. found no difference in complications or recurrence rates between
FAMM flaps and tongue flaps for closure of large anterior palatal fistula.
■ These authors found that the total operative time and fewer early
postoperative complications with the FAMM flap.
■ Free tissue transfer success rates are reported between 83% and 98%.13
■ Most studies did not address any donor site morbidity though.
COMPLICATIONS
■ Acute postoperative airway obstruction
■ This situation can occur during emergence from anesthesia as tongue muscle
tone can be slower to recover in patients compared with respiratory drive
(effective glossoptosis).
■ Can also occur when a tongue flap has been used.
■ Prevention is key.
• An oral airway device placed by the anesthesia team can disrupt/damage
fistula repair.
• Except in cases of tongue flap, I prefer to place a tongue stitch with 2-0 silk
tied to a Raytec for resolution of acute postoperative glossoptosis.
■ Bleeding
■ Raw surfaces are frequently left after fistula repair (particularly when
relaxing incisions have been used).
■ Ensure hemostasis with normotensive anesthesia prior to extubation.
■ Tell family/patient to expect some oozing from the mouth or nose for 24
hours.
■ If nasal bleeding is severe, an endoscope can be used in the OR to evaluate
the nasal repair.
■ Recurrence14
■ The most common complication after palatal fistula repair
■ If a flap has been employed, usually from partial or full flap loss (see
Outcomes section)
■ Obstructive sleep apnea
■ Can occur if a PPF has been employed in Pittsburgh type II or III fistula
repairs
■ May require modification, takedown of flap, or CPAP if persistent 6 months

after surgery
■ Halitosis
■ Not a true complication but a frequent concern/question raised by family
while wounds are healing
REFERENCES
1. Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr
Surg. 1986;78:724-736.
2. Jackson O, Low D, LaRossa D. The Children’s Hospital of Philadelphia
modification of the Furlow double-opposing Z-palatoplasty: 30-year
experience and long-term speech outcomes. Plast Reconstr Surg.
2013;132:613-622.
3. Mann RJ, Fisher DM. Bilateral buccal flaps with double opposing Z-plasty for
wider palatal clefts. Plast Reconstr Surg. 1997;100:1139-1143.
4. Smith DM, Vecchione L, Jiang S, et al. The Pittsburgh Fistula Classification
System: a standardized scheme for the description of palatal fistulas. Cleft
Palate Craniofac J. 2007;44:590-594.
5. LaRossa D. “The state of the art in cleft palate surgery.” Cleft Palate
Craniofac J. 2000;37(3):225-228.
6. Kirschner RE, Cabiling DS, Slemp AE, et al. Repair of oronasal fistulae with
acellular dermal matrices. Plast Reconstr Surg. 2006;118:1431-1440.
7. Chen PK, Wu JT, Chen YR, Noordhoff MS. Correction of secondary
velopharyngeal insufficiency in cleft palate patients with the Furlow
palatoplasty. Plast Reconstr Surg. 1994;94:933-941.
8. Owsley JQ Jr, Blackfield HM, Owsley JQ Jr. The technique and complications
of pharyngeal flap surgery: a continuing report. Plast Reconstr Surg.
1965;35:531-539.
9. Argamaso RV. The tongue flap: placement and fixation for closure of
postpalatoplasty fistulae. Cleft Palate Craniofac J. 1990;27:402-410.
10. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial artery
musculomucosal (FAMM) flap. Plast Reconstr Surg. 1992;90:421-429.
11. Pigott RW, Rieger FW, Moodie AF. Tongue flap repair of cleft palate fistulae.
Br J Plast Surg. 1984;37:285-293.
12. Coe HE. The use of the premaxillary flap in the repair of bilateral cleft palate.
Plast Reconstr Surg. 1953;123:194-197.
13. Schwabegger AH, Hubli E, Rieger M, et al. Role of free-tissue transfer in the
treatment of recalcitrant palatal fistulae among patients with cleft palates. Plast

Reconstr Surg. 2004;113:1131-1139.
14. Schultz RC. Management and timing of cleft palate fistula repair. Plast
Reconstr Surg. 1986;78:739-745.
15. Pigott RW, Albery EH, Hathorn IS, et al. A comparison of three methods of
repairing the hard palate. Cleft Palate Craniofac J. 2002;39:383-391.
16. Sohail M, Bashir MM, Khan FA, Ashraf N. Comparison of clinical outcome
of facial artery myomucosal flap and tongue flap for closure of large anterior
palatal fistulas. J Craniofac Surg. 2016;27:
1465-1468.

14
CHAPTERVelopharyngeal Insufficiency
Jennifer L. McGrath and Arun K. Gosain
DEFINITION
■ Velopharyngeal insufficiency (VPI) refers to a structural inadequacy of the
velopharyngeal apparatus, resulting in inadequate closure of the
velopharyngeal port during speech.
■ VPI may be congenital or acquired.
■ It is characterized by nasal air emission and hypernasality of speech,
articulation errors, decreased speech intelligibility, and nasal reflux of food and
liquids.
ANATOMY
■ The velopharyngeal sphincter is a complex, 3D arrangement of muscles that
serves to separate the nasal cavity from the oral cavity during speech and
swallowing.
■ Muscles of the soft palate: levator veli palatini, tensor veli palatini,
palatoglossus, palatopharyngeus, and musculus uvulae.
■ Paired levators are primarily responsible for velum closure by moving the
velum posteriorly and superiorly.
■ Superior pharyngeal constrictor moves the posterior and lateral pharyngeal
walls centrally.
■ Innervation:
■ Predominantly CN IX and X: levator veli palatini and pharyngeal constrictors
■ CN V3: Tensor veli palatini
■ Three patterns of closure have been described:
■ Coronal: majority of closure from posterior movement of the velum
■ Sagittal: majority of closure from medial movement of the lateral pharyngeal

walls to meet the velum
■ Circular: contributions of both movement of the velum posteriorly and
movement of the lateral pharyngeal walls medially. Passavant ridge may
contribute to closure.
PATHOGENESIS
■ The cause of VPI may be structural, functional, or dynamic.
■ Four main categories of VPI are frequently encountered. They include
■ Postpalatoplasty: after primary cleft palate repair
■ Inappropriate levator veli palatini positioning
■ Palatal scarring preventing functional contraction of repaired levator sling
■ Length discrepancy preventing contact with the posterior pharynx
■ Submucous cleft palate (SMCP)
■ May be classic (bifid uvula, palatal muscle diastasis) or occult
■ Often present later than cleft lip and palate
■ Not always associated with VPI (see section Natural History below)
■ Palatopharyngeal disproportion
■ No anatomic abnormality to reconstruct
■ Disproportion may result from a short palate and/or a deep nasopharynx.
■ May be seen after tonsillectomy and adenoidectomy
■ Neurogenic
■ More common in adults than children
■ Etiology may be upper motor neuron, nuclear, or lower motor neuron or
generalized hypotonia.
■ Examples: muscular dystrophy, neurofibromatosis, cerebral palsy, apraxia,
dysarthria
■ This subset tends to do more poorly with surgery.
NATURAL HISTORY
■ Transient VPI is common after primary palatoplasty.
■ Patients are referred to speech-language pathologist (SLP) as early as 2
weeks postoperatively.
■ Perceptual speech assessment (PSA) by a SLP is obtained when the patient is
of a cooperative age, often age 3 or above.
■ The incidence of lasting VPI after primary palatoplasty is about 10% to
20%.1,2
■ Submucous cleft palate (SMCP)

■ Not all patients with SMCP will develop VPI. Studies suggest roughly 5% to
10% of patients with SMCP will develop VPI warranting intervention.3,4
■ The incidence of VPI in the pediatric plastic surgery population is higher due
to referral bias.
■ Children with SMCP should undergo PSA by a SLP. Intervention should be
delayed until reliable PSA can be performed by a trained SLP, which is
usually after age 3 years.
■ Some children with SMCP may improve with speech therapy. Surgery is
indicated for SMCP only when VPI is present and cannot be corrected with
speech therapy.
■ VPI caused by palatopharyngeal disproportion tends to worsen as the tonsils
and adenoids regress or are surgically removed.
■ In general, if VPI is diagnosed on PSA by an SLP and is secondary to previous
palatoplasty, submucous cleft palate, or palatopharyngeal disproportion, VPI
will persist indefinitely.
■ Speech outcomes are better when surgery is performed at a younger age, but
there is not a specific age cutoff for surgical treatment. However,
misarticulations are harder to correct as a child ages.
PATIENT HISTORY AND FINDINGS
■ Patients are frequently identified by parents, teachers, and/or SLPs.
■ Patients with a history of cleft palate are frequently followed by SLP as part of
a multidisciplinary approach to cleft care.
■ Patients and parents may report nasal regurgitation, liquids worse than solids.
■ Hypernasal speech and nasal air emission are the classic findings. Nasal air
emission is normally only observed in /m/ and /n/ sounds.
■ Compensatory articulations occur when patients are unable to seal off the
nasopharynx.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ PSA by an SLP. Note that PSA is a subjective assessment of speech, one
component of which is nasal air emission.
■ Nasometry: objective test of nasal air emission, which can correlate subjective
assessment of nasal air emission on PSA
■ Imaging is indicated when VPI is documented on PSA.2,4
■ Multiview videofluoroscopy
■ Quantify lateral wall motion on AP view

■ Quantify velopharyngeal gap on lateral view
■ Requires reference landmarks for quantification
■ Nasendoscopy
■ Qualitatively assesses closure pattern
■ Helpful in identifying stigmata of SMCP in patients without overt clefting
■ Roughly quantifies closure ratio: fraction of the diameter of the
velopharyngeal port that is closed off during attempted sphincter closure
■ Nasendoscopy does not provide reference landmarks, so it cannot quantify
motion and gap as in videofluoroscopy. It does allow visualization of
nasopharyngeal and oropharyngeal structures, such as the adenoids.
DIFFERENTIAL DIAGNOSIS
■ Although the vast majority of patients will present with a history of previous
palatoplasty or submucous cleft palate, it is important to recognize other
mechanisms of velopharyngeal dysfunction that are less adequately treated
with surgery.
■ Velopharyngeal mislearning
■ Articulation errors with no anatomic disturbance; treat with speech therapy
■ Velopharyngeal incompetence: neurologic or neuromuscular origin
■ Globalized hypotonia with no structural abnormalities
■ Poor muscular competence of the lip and tongue may predict poor surgical
outcomes. However, many patients will benefit from traditional surgical
approaches.
NONOPERATIVE MANAGEMENT
■ Speech therapy: all patients should be evaluated and treated by an SLP prior to
intervention to minimize articulation errors.
■ Prosthetics
■ Speech bulb
■ Palatal lift
■ Disadvantages: compliance, fit, growth
■ Prosthetics may be a helpful training tool in conjunction with surgery to
improve oromuscular coordination and articulation placement.
■ If a true mechanical insufficiency exists, nonoperative management is not
recommended if a patient can tolerate surgery.
SURGICAL MANAGEMENT

■ The overall goal of surgical management is to recapitulate a velopharyngeal
port that can be closed during speech.
■ Surgical approach typically depends on deficiencies seen on videofluoroscopy
and/or nasendoscopy. Common approaches include
■ Intravelar veloplasty
• In cases of SMCP only, primary palatoplasty with intravelar veloplasty
repositions the aberrant insertion of the levator veli palatine muscles to
create a functional sling.
• This approach does not increase palatal length and is often passed over for
Furlow palatoplasty.
■ Furlow palatoplasty or double-opposing Z-plasty (DOZ)
• Initially described by Leonard Furlow as a technique for primary repair of
cleft palate, this technique has gained favor as an approach to the
management of VPI due to its ability to lengthen the palate via Z-plasty
while also opposing the levator veli palatini muscles to recreate an anatomic
muscular sling.
• The major benefits of this technique are as follows:
• It does not mechanically alter the closure mechanism of the velopharyngeal
port, leaving open the option of other surgical techniques for refractory
cases.
• It is not associated with airway obstruction as are other techniques.
■ Dynamic sphincter pharyngoplasty
• Dynamic sphincter pharyngoplasty (DSP) uses myomucosal flaps
transposed to the posterior pharynx to create a smaller, circular
velopharyngeal port.
• This procedure is typically selected for patients with a coronal or circular
closure pattern. When lateral wall movement is poor, DSP narrows the
velopharyngeal port and adds bulk to the posterior pharyngeal point of
velum contact.
• The senior author has advocated use of the DSP in conjunction with the
DOZ in cases of large velopharyngeal gaps.5
■ Pharyngeal flap pharyngoplasty
• Based on the palatopharyngeal adhesion described by Passavant in the
1800s, pharyngeal flaps have been described as a surgical treatment for VPI
for over a century.
• Superiorly based pharyngeal flaps are widely utilized as a preferred

treatment for VPI.
• We describe a high inset pharyngeal flap, which is used as a last resort
procedure due to its association with airway obstruction.
■ Posterior pharyngeal wall augmentation
• In cases of small gaps, implants and injectables have been used to augment
the posterior wall of the pharynx to reduce the velopharyngeal gap.
• Like many other applications of implants, implants in the posterior pharynx
have been associated with failure due to migration, extrusion, and infection.
• Silicone, Teflon, Gore-Tex, and polyethylene implants and calcium
hydroxyapatite injections have been used. Despite successful reports, these
techniques have not enjoyed widespread acceptance.
• Autologous fat grafting has gained popularity recently but is in need of
standardized protocols and prospective studies to evaluate retention of the
augmentation and its utility over time. Still, it is most likely only useful in
small velopharyngeal gaps.6–8
Preoperative Planning
■ Surgical procedures are usually selected based on the preoperative closure
pattern and velopharyngeal closure gap.9–11
■ For sagittal closure, velum may be too short and/or not move well, but lateral
wall movement is preserved; therefore:
• For small gaps less than 9 mm, we recommend double-opposing Z-plasty
(DOZ) to lengthen the palate.
• For gaps larger than 9 mm, we recommend a superiorly based pharyngeal
flap.
■ For coronal closure patterns in which lateral movement is poor, we
recommend dynamic sphincter pharyngoplasty (DSP).
• For gaps less than 9 mm, we recommend DSP alone.
• For gaps greater than 9 mm, we recommend DSP in conjunction with DOZ.
■ For circular closure patterns, many approaches have been used. DOZ may be
used in smaller gaps. Narrow pharyngeal flaps or sphincter pharyngoplasty is
recommended for larger gaps.2
■ Pharyngeal flaps may have better outcomes in noncoronal closure patterns.9
■ DSP may be most appropriate in coronal and circular closure patterns.10
■ Combined DOZ and DSP can be used in very large velopharyngeal gaps.2,5,12

■ Nasendoscopy can identify the point of maximal constriction and evaluate
adenoid tissues for flap inset planning.
Positioning
■ The patient is placed in the supine position on the operating table.
■ A shoulder roll can be used to gently extend the neck.
■ The head of the operating table can be extended to aid in visualization.
■ The face and neck are prepped and draped such that the infraorbital face and
submandibular region are adequately exposed.
■ Intraoral prep with chlorhexidine or Betadine swabs
■ Eyelids are taped closed to prevent corneal abrasions.
■ A nasal RAE tube should be used for intubation.
■ A Dingman retractor exposes the posterior pharynx and retracts the tongue
inferiorly.
T E C H N I Q U E S
■ Furlow Palatoplasty or Double-Opposing Z-Plasty
Markings
■ Z-plasty flaps are designed in two layers, oral and nasal, with one mucosal
and one myomucosal flap in each layer.
■ Oral flaps: posteriorly based myomucosal flap and anteriorly based
mucosa-only flap. By convention, the muscle-mucosa flap is on the
patient’s left side for the right-handed surgeon.
■ Nasal flaps: designed in opposite orientation to the oral flaps with a
posteriorly based myomucosal flap (right side) and anteriorly based nasal
mucosa flap
■ The anterior limbs are designed near the junction of the hard and soft palate.
Rather than the traditional 60-degree Z-plasty, we recommend a more obtuse
angle, roughly 80 to 90 degrees.
■ Cheating the placement of the anterior limb to the more elastic soft palate
tissue facilitates flap transposition (TECH FIG 1).
Dissection

■ Oral flaps are incised and elevated. The surgeon should be conservative with
the lateral extent of the mucosal incision as this dictates the inset location of
the tip of the contralateral flap (TECH FIG 2A,B).
■ It is critical to carefully identify the levator musculature within the
myomucosal flaps to ensure recapitulation of the levator sling.
■ A muscle stimulator can aid in identification of functional muscle and
facilitate complete release of muscle from scar in secondary palatoplasty. If
a muscle stimulator is used, it is important to let the anesthesiologist know
to avoid muscle relaxants or allow the relaxants to wear off prior to use of
the muscle stimulator.
■ The muscle dissection often extends submucosally laterally to fully release
the levator (TECH FIG 2C).
■ Nasal flaps are transposed in the standard Z-plasty fashion, with the
posteriorly based left-sided myomucosal flap rotated right and posterior and
the mucosal flap left and anterior (TECH FIG 2D). The limbs of the nasal
mucosa are closed with simple interrupted dissolvable sutures.
■ Oral flaps are transposed in a similar manner. Transposition of the oral
myomucosal flap completes reconstruction of a competent levator sling. The
oral mucosal limbs are then closed (TECH FIG 2E).
TECH FIG 1 • Markings for double-opposing Z-plasty.
Z-plasty marked on the oral mucosa. The posteriorly
based oromuscular flap is marked on the patient’s left

side for a right-handed surgeon (the end of the
oromuscular incision is designated by the pointer).
Note the curved arm of the anteriorly based Z-plasty
(arrow) as well as its obtuse angle to the midline
incision.
TECH FIG 2 • Double-opposing Z-plasty. A.
Posteriorly based oromuscular flap, held in forceps, is
being elevated. B. Marking of anteriorly based nasal
mucosa Z-plasty (black arrow) after dissection of the
posteriorly based oromuscular flap, retracted
posteriorly and laterally with forceps. Incisions have
been made to elevate the anteriorly based oral
mucosal Z-plasty (white arrow). C. Using a sweeping
motion from anterior to posterior, the posteriorly based
nasomuscular flap (arrow) is elevated and transposed
posteriorly and toward inset on the patient’s left side.
D. Transposing the nasomuscular flap. Right-sided
nasomuscular flap (forceps) is rotated posteriorly and
to the left, bringing the levator muscle into anatomic
position. E. Final closure of the double-opposing Z-
plasty.
■ Dynamic Sphincter Pharyngoplasty
Markings
■ The uvula can be reflected into the nasopharynx by suturing the tip to a red
rubber catheter passed through the naris.
■ The level of inset is based on the position of the adenoids (TECH FIG 3A).
■ Adenoids that extend inferiorly may hinder the ability to inset the flaps as
adenoid tissue does not hold sutures well. Low-lying adenoid tissue should
be identified preoperatively on nasendoscopy.

■ If the caudal extent of the adenoids is thought to compromise cephalic inset
of the sphincter pharyngoplasty, then an inferior adenoidectomy should be
considered prior to sphincter pharyngoplasty. In this case, we recommend
delaying sphincter pharyngoplasty for at least 3 months following
adenoidectomy.
■ Superiorly based myomucosal palatopharyngeus flaps are designed on the
posterior tonsillar pillars.
■ The base of the flaps should be designed at the level of inset (TECH FIG
3B).
■ A high inset should be anticipated, as the inset should be designed at the
anticipated level of velopharyngeal contact during phonation.
Dissection
■ Palatopharyngeus flaps are elevated to the height of the desired new
nasopharyngeal port, typically the level of velum opposition from
preoperative videofluoroscopy (TECH FIG 4A).
■ Flaps are transposed to the posterior pharyngeal wall and inset in a
transverse arrangement directly posterior to the desired nasopharyngeal port
location. Flaps may be inset in a stacked or end-to-end manner (TECH FIG
4B).
■ The size of the new sphincter should be roughly one fingerbreadth.
■ Donor sites in the posterior tonsillar pillars are closed primarily with
dissolvable sutures (TECH FIG 4C).
TECH FIG 3 • A. Horizontal marking at the level of
inset of the sphincter pharyngoplasty. The position of
the adenoids (arrow) may limit the superior extent of

inset of the sphincter. B. Incision along the left
posterior tonsillar pillar (arrow). Myomucosal flaps
based on the palatopharyngeus are marked bilaterally.
TECH FIG 4 • A. Elevating the left posterior tonsillar
pillar, held in forceps, to the level of desired inset at
the base of the adenoids. B. Setting the tension of the
bilateral myomucosal flaps (tonsillar pillars). Flaps can
be inset end to end or overlapping, depending on the
desired tension. In this illustration, the tonsillar pillars
are held in forceps in an overlapping configuration. C.
Final inset of dynamic sphincter pharyngoplasty.
Myomucosal flaps are inset (arrow) and donor sites
are closed primarily (not shown).

■ Posterior Pharyngeal Flap
Markings
■ Superiorly based myomucosal flap is marked on the central posterior
pharyngeal wall. The base of the flap must be designed with awareness of the
three-dimensional relationship of the flap to the velum. The width of the flap
may vary depending on the velopharyngeal gap (TECH FIG 5).
■ A transverse incision for flap inset is designed on the nasal side mucosa
anterior to the uvula.
■ A counterincision on the oral side creates a tunnel to pass and secure the
flap. This transverse incision is located near the hard-soft palate junction.
Incisions must be wide enough to accommodate flap width.
Dissection
■ The pharyngeal flap is elevated deep to the pharyngobasilar fascia and
superficial to the prevertebral fascia (TECH FIG 6A). This is crucial to safe
use of this technique in cases of velocardiofacial syndrome (VCFS) in which
the carotid arteries can be medially displaced.
■ The carotid vessels lie deep to the prevertebral fascia and therefore will not
be damaged irrespective of possible medial transposition, as long as the
dissection remains superficial to the prevertebral fascia.
■ A tunnel is created through the nasal and oral palate transverse incisions.
This then allows the pharyngeal flap to be passed through using a clamp or
forceps (TECH FIG 6B–E).
■ Flap is inset into the oral mucosal incision. The tip of the flap is anchored to
the periosteum at the posterior aspect of the hard palate to provide resistance
to constriction and descent during healing.
■ The donor site is closed with dissolvable sutures if possible. If too large to
close primarily, it can be left raw to mucosalize. The posterior soft palate
incision is also left to heal secondarily (TECH FIG 6F).
■ Port size is checked by manual palpation using a finger. The new ports are
typically stented in some manner. We choose 3-Fr endotracheal tubes
trimmed short and passed through the nares into the ports.

TECH FIG 5 • Marking of the superiorly based
posterior pharyngeal flap. The location of the base of
the flap can be determined by preoperative imaging.

TECH FIG 6 • A. Flap elevation. The pharyngeal flap
is elevated in a plane immediately superficial to the
pharyngobasilar fascia. B–E. Flap inset into the
velum. Incisions are made on the nasal (B) and oral
(C) mucosa of the posterior soft palate to allow flap
inset. A tunnel (D) is created between these incisions,
and the flap is passed through and inset into the oral
incision (E). F. Final appearance after pharyngeal flap
inset. The posterior pharynx donor site is closed
primarily.
PEARLS AND PITFALLS

Tongue edema
■ Release of the Dingman retractor every 90 minutes for 2
minutes reduces tongue edema and eliminates the need for a
tongue stitch postoperatively.
Velocardiofacial
syndrome
(VCFS)
■ VCFS disrupts the algorithm because outcomes are usually
poorer.
■ Assessment is the same, and selection of operation is not
necessarily different. However, care must be taken during
dissection to ensure surgical plane is deep to the pharyngobasilar
fascia and superficial to the prevertebral fascia
DOUBLE-OPPOSING Z-PLASTY
Flap design
■ Design mucosal flaps more obtusely (80–90 degree) and arch to
the desired end point.
■ The oral myomucosal flap back cut should be posterior enough
from the hard palate junction to lie within elastic soft palate
tissue to facilitate closure. Placing the back cut too close to the
hard palate will make it more difficult to achieve closure of the
oral mucosa
■ Limit the back cut of the anterior limbs of the mucosal flaps
again to reduce difficulty closing. Muscular incision and
dissection can extend beyond the mucosal incision.
Flap handling
■ Careful flap handling, particularly of flap corners, is key to a
satisfactory result.
DYNAMIC SPHINCTER PHARYNGOPLASTY
Low adenoids
■ Adenoid position should be assessed preoperatively.
■ Attempts to inset the flaps into the adenoids will be
unsuccessful and the adenoid tissue does not structurally hold
sutures well.
■ If adenoids are particularly inferior, consider preoperative
inferior adenoidectomy.
■ Inferior adenoidectomy should be at least 3 months prior to
pharyngoplasty.
Flap inset
■ Inset the flaps as high as possible, often immediately below the
adenoids (2 mm inferior).
■ Flaps should be inset at the point of maximum constriction,
Passavant ridge, if developed.
Flap tension on
inset
■ Flaps can be inset overlapping or tip to tip.
■ They should be placed on slight resting tension with residual
elastic tone.
■ Too tight at inset can cause airway obstruction.

■ Too loose at inset can cause persistent VPI.
PHARYNGEAL FLAP PHARYNGOPLASTY
Flap design
■ Width of the flap should be tailored to the patient’s needs.
Flap lining
■ Line as much of the pharyngeal flap as possible. The raw
surfaces will contract and the flap will narrow, creating a larger
distance for the lateral pharyngeal walls to move for closure.
Flap descent
■ Flaps tend to narrow and pull inferiorly over time.
■ High inset allows more lining of the raw surface as well as a
better anchor to the hard palate, resisting contraction and
descent.
■ High inset also shortens the exposed raw surface.
POSTOPERATIVE CARE
■ Patients are observed in the hospital overnight for signs of airway obstruction.
■ Some surgeons place a tongue stitch at the conclusion of the procedure to
assist in clearing tongue-base obstruction in the postoperative period.
■ Similarly, IV dexamethasone can be useful to reduce airway and tongue
edema in immediate postoperative period.
■ Although preoperative antibiotics are frequently given, postoperative
prophylactic antibiotics are not routinely used, as there is no evidence to
support their efficacy.
■ Stenting of the reconstructed ports:
■ Pharyngeal flap: Nasopharyngeal stents are left in place for 1 week
postoperatively to prevent synechiae, while the raw surfaces of the pharyngeal
flap are remucosalizing to maintain the newly constructed nasopharyngeal
ports. We opt to use two small endotracheal tubes cut short that are passed
through each naris into the pharynx. These are sutured to the caudal septum
for stability. Tube size depends on the size of the ports, but a size 3 is often
adequate.
■ DSP: A larger caliber truncated endotracheal tube may be passed from the
naris into the new port, but this is usually not necessary unless the
reconstructed port is very tight. DSP is less prone to synechiae as there are
fewer raw surfaces at the completion of the reconstruction.
■ Oral rinses, especially after feeding, can help maintain oral hygiene. Older
children may be prescribed chlorhexidine rinses if they are likely to be
compliant with swishing and spitting. Alternatively, plain water rinses can aid

in clearance of food and liquids from the oropharynx and flaps. We recommend
that all patients drink clear liquids after eating to assist in clearance of food
debris.
■ Patients are placed on a soft diet for 6 weeks postoperatively. They are also
instructed to drink from a cup only—no straws or suction.
■ Patients return for follow-up 1 to 2 weeks postoperatively for an early incision
check and at 6 weeks for a final assessment. At 6 weeks, all restrictions are
lifted. If a fistula were to develop, this would most likely be visible at the 6-
week appointment.
■ Nasal resonance and articulation speech therapy are resumed after 6 weeks.
■ PSAs are delayed until a minimum of 3 months postoperatively to allow for
complete resolution of edema.
OUTCOMES
■ Correction of VPI occurs in 80% or more of surgical patients, with slight
variation across techniques. Head-to-head comparisons of techniques are
difficult because most studies are based on treatment algorithms with groups
differing in both preoperative VPI characteristics and surgical approach.
■ Randomized trials of DSP and pharyngeal flaps have shown no difference in
residual VPI.1,13
■ DSP: 80% to 85% of patients demonstrated resolution of hypernasality.14
■ Pharyngeal flap: 85% to 95% improvement or resolution of VPI1,11,15
■ DOZ: 75% to 85% improvement or resolution of VPI11,16,17
• DOZ may be slightly less effective in resolving VPI, but this is dependent
on velopharyngeal gap size, supporting the use of an algorithmic approach
to procedure selection.18
COMPLICATIONS
■ Bleeding
■ Velocardiofacial syndrome: It is important to identify medial displacement of
the carotids as this may alter surgical plan. Preoperative imaging with CTA or
MRA is often obtained.
■ Airway obstruction
■ Obstruction may occur acutely postoperatively or chronically.
• Acutely, related to airway or tongue edema
• Chronically, related to inadequate size of pharyngeal port

■ Pharyngeal flap has the highest incidence of obstruction.
• Incidence of acute airway obstruction is as high as 38%,19 but most resolve
within the first few months postoperatively.
• Chronic obstruction/obstructive sleep apnea incidence is roughly 10%.
Pierre Robin sequence patients may be more susceptible.20,21
■ Sleep studies are useful in evaluating and quantifying obstruction.
■ Obstruction can be treated with CPAP or flap takedown in severe cases.
■ Dehiscence or fistula: may be assessed at the 6-week visit, but we recommend
waiting at least 6 months to intervene surgically.
■ Scarring: particularly in the DOZ, scarring can limit functionality of the repair.
We again emphasize dissection of functional muscle free from scar. Use of
intraoperative muscle stimulation can serve as a guide to the distinction of
functional muscle from scar.
REFERENCES
1. Ysunza A, Pamplona C, Ramirez E, et al. Velopharyngeal surgery: a
prospective randomized study of pharyngeal flaps and sphincter
pharyngoplasties. Plast Reconstr Surg. 2002;110(6):1401-1407.
2. Gart MS, Gosain AK. Surgical management of velopharyngeal insufficiency.
Clin Plast Surg. 2014;41(2):253-270.
3. Weatherley-White RC, Sakura CY Jr, Brenner LD, et al. Submucous cleft
palate. Its incidence, natural history, and indications for treatment. Plast
Reconstr Surg. 1972;49(3):297-304.
4. Gosain AK, Conley SF, Marks S, Larson DL. Submucous cleft palate:
diagnostic methods and outcomes of surgical treatment. Plast Reconstr Surg.
1996;97(7):1497-1509.
5. Gosain AK, Arneja JS. Management of the black hole in velopharyngeal
incompetence: combined use of a Furlow palatoplasty and sphincter
pharyngoplasty. Plast Reconstr Surg. 2007;119(5):1538-1545.
6. Bishop A, Hong P, Bezuhly M. Autologous fat grafting for the treatment of
velopharyngeal insufficiency: state of the art. J Plast Reconstr Aesthet Surg.
2014;67(1):1-8.
7. Cantarella G, Mazzola RF, Mantovani M, et al. Fat injections for the treatment
of velopharyngeal insufficiency. J Craniofac Surg. 2012;23(3):634-637.
8. Lau D, Oppenheimer AJ, Buchman SR, et al. Posterior pharyngeal fat grafting
for velopharyngeal insufficiency. Cleft Palate Craniofac J. 2013;50(1):51-58.
9. Armour A, Fischbach S, Klaiman P, Fisher DM. Does velopharyngeal closure

pattern affect the success of pharyngeal flap pharyngoplasty? Plast Reconstr
Surg. 2005;115(1):45-52.
10. Abdel-Aziz M, El-Hoshy H, Ghandour H. Treatment of velopharyngeal
insufficiency after cleft palate repair depending on the velopharyngeal closure
pattern. J Craniofac Surg. 2011;22(3):813-817.
11. Yamaguchi K, Lonic D, Lee CH, et al. A treatment protocol for
velopharyngeal insufficiency and the outcome. Plast Reconstr Surg.
2016;138(2):290e-299e.
12. Bohm LA, Padgitt N, Tibesar RJ, et al. Outcomes of combined Furlow
palatoplasty and sphincter pharyngoplasty for velopharyngeal insufficiency.
Otolaryngol Head Neck Surg. 2014;150(2):216-221.
13. Abyholm F, D’Antonio L, Davidson Ward SL, et al. Pharyngeal flap and
sphincterplasty for velopharyngeal insufficiency have equal outcome at 1 year
postoperatively: results of a randomized trial. Cleft Palate Craniofac J.
2005;42(5):501-511.
14. Riski JE, Ruff GL, Georgiade GS, et al. Evaluation of the sphincter
pharyngoplasty. Cleft Palate Craniofac J. 1992;29(3):254-261.
15. Sullivan SR, Marrinan EM, Mulliken JB. Pharyngeal flap outcomes in
nonsyndromic children with repaired cleft palate and velopharyngeal
insufficiency. Plast Reconstr Surg. 2010;125(1):290-298.
16. Hudson DA, Grobbelaar AO, Fernandes DB, Lentin R. Treatment of
velopharyngeal incompetence by the Furlow Z-plasty. Ann Plast Surg.
1995;34(1):23-26.
17. Chim H, Eshraghi Y, Iamphongsai S, Gosain AK. Double-opposing Z-
palatoplasty for secondary surgical management of velopharyngeal
incompetence in the absence of a primary furlow palatoplasty. Cleft Palate
Craniofac J. 2015;52(5):517-524.
18. Chen PK, Wu JT, Chen YR, Noordhoff MS. Correction of secondary
velopharyngeal insufficiency in cleft palate patients with the Furlow
palatoplasty. Plast Reconstr Surg. 1994;94(7):933-941.
19. Lesavoy MA, Borud LJ, Thorson T, et al. Upper airway obstruction after
pharyngeal flap surgery. Ann Plast Surg. 1996;36(1):26-30.
20. Wells MD, Vu TA, Luce EA. Incidence and sequelae of nocturnal respiratory
obstruction following posterior pharyngeal flap operation. Ann Plast Surg.
1999;43(3):252-257.
21. Jackson P, Whitaker LA, Randall P. Airway hazards associated with
pharyngeal flaps in patients who have the Pierre Robin syndrome. Plast

Reconstr Surg. 1976;58(2):184-186.

15
CHAPTER
Section III: Cleft
Rhinoplasty
Secondary Cleft Rhinoplasty
Ali Totonchi and Ji H. Son
DEFINITION
■ Rhinoplasty remains one of the most challenging plastic surgery procedures
for cleft patients. These patients present years after the initial cleft repair to
correct residual nasal deformities.
■ The nature of the procedure varies from patient to patient depending on the
nasal deformities. Systematic reorientation of distorted nasal architecture and
creation of a balanced platform for the lower lateral cartilages constitute some
of the cardinal principles for correcting the cleft lip nose deformities.
ANATOMY
■ Radix is the depth of the nasal root at the nasofrontal angle. This angle
connects the brow and the dorsum through a soft concave curve. Although this
angle can vary from 128 to 140 degrees, it is ideally 134 degrees in females
and 130 degrees in males.
■ Nasal dorsum is assessed using the curvilinear dorsal aesthetic lines traced
from the supraorbital ridge to the tip-defining points. Ideally, the width of the
dorsal aesthetic lines should match the width of either the tip-defining points or
the interphiltral distance.
■ Nasal deviation is evaluated by drawing a line from the mid-glabellar area to
the menton, bisecting the nasal ridge, upper lip, and Cupid bow. Deviation of
the nose from this line would most likely require septal surgery for correction.
■ The upper lateral cartilage (ULC) overlaps the nasal bones, septum, and the
lower lateral cartilages (LLCs). The internal valve is the angle formed by

intersection of the nasal septum and the caudal margin of the ULC.
■ LLCs comprise medial, middle, and lateral crura, which are connected to each
other, the ULCs, and the septum by fibrous tissue and ligaments. Modification
in any of these structures alters tip projection.
■ The nasolabial angle is used to determine the degree of tip rotation. This angle
is obtained by measuring the angle between a line coursing through the most
anterior and posterior edges of the nostril and a line dropped perpendicular to
the natural horizontal facial plane. This angle should be between 103 to 105
degrees in women and 95 to 100 degrees in men.
■ The septum, turbinates, and nasal valves (internal and external) serve as the
anatomic functional foundation for the nose, by contributing to respiration,
filtration, humidification, temperature regulation, and protection.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Although nasal deformities are partially corrected during cleft lip surgery,
patients often present years after the initial cleft repair to correct residual nasal
deformities.
■ Efforts to correct nasal deformity in patients between the ages of 4 and 14
years may have a significant chance of supratip deformity and loss of tip
definition, with widening and thickening of the skin.
■ Many patients with bilateral and complete cleft lip deformities have other
craniofacial abnormalities, particularly deformities of the maxilla. Correction
of the skeletal deformity sets the stage for a more successful correction of the
nasal deformity.
■ Approximately 60% of patients with cleft lip nasal deformity have difficulty
breathing through the nose. Correction of physiologic function of the nose
should be addressed at the time of correction of the nasal deformity.
■ Many of the patients may have asymmetry involving parts other than the nose
and the lip. Therefore, it is important to assess the entire face and note
asymmetry before analyzing the nose in detail (Table 1).1
Table 1 Detailed Nasal Analysis
Structure
Assessment
Skin
• Thickness
• Quality of the tissue for reconstruction
Nasal bone
• Symmetry

• Length
• Distance from the midline
• Depth of radix
• Presence or absence of a dorsal hump
Midvault
• Upper lateral cartilage collapse
• Vertical symmetry
Nasal tip
• Shape—bulbous, boxy, narrow, or parenthesis
deformity?
• Symmetry
• Fullness
• Projection
• Infratip lobule size
• Nasolabial angle
• Direction of the columella
Alar base
• Comparison of thickness of the ala
• Vertical position
• Configuration of nasal sill
Nostrils
• Symmetry
Internal nose
• Stenosis of the internal and external valve
• Presence or absence of a deviated septum
• Size and shape of the turbinates
• Synechiae
• Septal perforation
Table 2 Features of Unilateral Cleft Lip Nasal Deformity
• The columella is shorter on the cleft side.
• The base of the columella is deviated to the noncleft side.
• The lateral crus of the lower lateral cartilage is longer on the cleft side.
• The nasal tip is displaced in both the frontal and the horizontal planes.
• The nasal tip is asymmetric.
• The ala is flattened, resulting in horizontal orientation of the nostril.
• The nostrils are asymmetric.
• The entire nostril is retropositioned because of the deficiency in the underlying
frame.
• The base of the ala is displaced laterally and/or posteriorly and sometimes
inferiorly.
• The nasal floor is caudal on the cleft side.

• A nasolabial fistula could be present.
• The septum and anterior nasal spine are shifted toward the noncleft vestibule.
• The nasal septum is deviated, resulting in a varying degree of nasal
obstruction.
• The inferior turbinate on the cleft side is hypertrophic.
• The maxilla is hypoplastic on the cleft side.
• The premaxilla and the maxillary segments are displaced.
From Guyuron B. MOC-PS(SME) CME article: late cleft lip nasal deformity. Plast Reconstr Surg.
2008:121(4):1-11, with permission.
■ It is crucial to recognize common features of unilateral cleft lip nasal
deformity (Table 2) and bilateral cleft lip nasal deformity (Table 3).1
Table 3 Features of Bilateral Cleft Lip Nasal Deformity
• The columella is relatively short and the prolabium seems attached to the
nasal tip.
• The nasal tip is flat and broad.
• The nasal alae are flat and sometimes drawn in an S-shaped fashion.
• The base of the ala is displaced laterally and sometimes inferiorly on both
sides.
• Both nostrils are oriented horizontally.
• The lower lateral cartilages are severely deformed.
• The nasal floor is absent.
• The caudal cartilaginous septum and the nasal spine are displaced inferiorly
relative to the level of the alar bases.
• The nasal tip and the nostril are commonly asymmetric.
From Guyuron B. MOC-PS(SME) CME article: late cleft lip nasal deformity. Plast Reconstr Surg.
2008:121(4):1-11, with permission.
IMAGING
■ Imaging is not indicated for all of the patients undergoing secondary cleft
rhinoplasty unless there is airway obstruction from sinus or cephalic septal
pathology necessitating further imaging to aid in surgical planning.
SURGICAL MANAGEMENT
■ One of the most important aspects of cleft lip rhinoplasty is the creation of
symmetric nose.

■ Patients commonly have maxillary deficiency and may need orthognathic
surgery and maxillary bone grafting. Ideally, if maxillary surgery is
contemplated, it should precede repair of the cleft lip rhinoplasty deformity.
■ Maxillary advancement is not advised before the age of 14 to 15 years for a
female patient and 17 to 18 years for a male patient, unless serial
cephalograms or hand radiographs demonstrate completion of bone growth
before this age.
■ Otherwise, the patient may need another maxillary advancement if the
maxilla is advanced and the mandible continues growing, which can alter the
outcome of the initial cleft lip rhinoplasty.
■ The operation may be performed through an endonasal or an open technique.
Because of common asymmetry in the nasal frame, cleft lip–related nasal
deformities are usually more successfully corrected through an open technique.
■ The advantages of an open technique are excellent exposure, good
hemostasis, and flexibility in corrective procedures.
■ The main objectives of the operation are to restore symmetry and harmony to
the face as well as improve functional outcome.
■ The nature of the operation varies tremendously from patient to patient.
Preoperative Planning
■ Discuss risks, benefits, and expectations with parents and patients on the day
of surgery. Specifically outline the risks including asymmetry, incomplete
resolution or suboptimal correction of nasal deformities, and additional
operations.
■ It is paramount to do a detailed facial and midface analysis to address each
component of the nasal deformity before the operation.
Positioning and Approach
■ The patient is positioned supine.
■ Depending on the choice of cartilage graft, either the ear or the chest wall is
prepped in addition to the face.
■ Previous incisions are used to minimize creating new scars when possible.
T E C H N I Q U E S

■ Open Cleft Lip Rhinoplasty
Incision and Dissection
■ Incise the columella at the mid-columella, a stair-step incision helps to
realign the columella at the end of the procedure (TECH FIG 1A). When
possible, use an old scar in the nasal vestibule and avoid making a new
incision.
■ Extend the incision behind the columella and upward, continue as an
infracartilaginous incision on the noncleft side.
■ On the cleft side, the incision is made to match the noncleft side, which
may not coincide with an infracartilaginous incision.
■ Dissect the columella. Find the loose areolar space between the medial crura
and follow this upward in the lower lateral cartilage (LLC) to separate the
LLCs from the fibrofatty tissue.
■ The dissection extends to the pyriform rim laterally and nasal bone
superiorly and should be symmetrical on both sides to allow for symmetric
contracture after the operation (TECH FIG 1B).
■ The course of the operation varies from patient to patient depending on the
nasal deformities.
■ In our example, we present a patient with short medial crus, low dome, and
excessive soft triangle soft tissue (TECH FIG 1C).
Shape Correction1,2
■ After complete dissection and repositioning of the lower lateral cartilage on
the cleft side, double hooks are placed to lift the alar domes symmetrically.
■ A 30-gauge needle is used to facilitate alignment of the medial crura when
the columellar strut is placed (TECH FIG 2A).

TECH FIG 1 • A. A columellar incision. B. In an open
technique, the malformed lower lateral cartilage is
exposed. The cleft lower lateral cartilage (arrow) has
less projection relative to the noncleft side. C.
Comparing the cleft side (patient’s left) to the noncleft
side (patient’s right) with the skin retracted, the medial
crus (black arrow) is shorter and the nasal dome
(white arrow) is lower. From Guyuron B. MOC-
PS(SME) CME article: late cleft lip nasal deformity.
Plast Reconstr Surg. 2008:121(4):1-11, with
permission.
TECH FIG 2 • A. Medial crus is tattooed to facilitate
alignment when columellar strut is placed. B.
Columellar strut is placed. C. Columellar strut is

secured using sutures. There is excessive soft triangle
lining that will be trimmed (arrow). D. A shield graft is
placed. E. Alar graft is placed for better shape and
support. F. Internal and external splints are placed.
From Guyuron B. MOC-PS(SME) CME article: late
cleft lip nasal deformity. Plast Reconstr Surg.
2008:121(4):1-11, with permission.
■ Tattoo marks can be made with methylene blue on either medial crus to
mark the alignment.
■ The columellar strut is fixed in position and 6-0 clear nylon sutures are
placed in at least two or three sites guided by the previous tattoo marks
(TECH FIG 2B).
■ The final suture close to the domes will better align the medial crura. There
is still excessive soft triangle lining that will be trimmed (TECH FIG 2C).
■ A shield graft is placed in position to facilitate additional support and
maintain central alignment of the nasal tripod (TECH FIG 2D).
■ An alar rim graft is placed to support the ala in a better position, which will
be further supported using external and internal stents (TECH FIG 2E).
■ Upon completion of surgery, there is restoration of proper height and shape
to the nostrils and the nasal tip; an external nasal silicone stent is positioned
on the ipsilateral side to the cleft lip on the soft triangle (TECH FIG 2F).
■ The columellar incision is closed using 6-0 fast-absorbing catgut.
■ Turbinates are reduced to improve nasal airway passage, if needed.
■ Dorsal Correction
■ Many patients require removal of a dorsal hump and reduction of the radix.
Less frequently, there are patients with nasal deformities who may require
augmentation of the radix and dorsum.
■ Nasal bone deviation is corrected by nasal osteotomies when surgery is
performed on skeletally mature patients. These techniques are discussed in
the chapter on secondary rhinoplasty.
■ If augmenting the radix and dorsum, diced cartilage graft can be utilized.
■ Nasal bone asymmetry may require wedge osteotomy between the nasal

bone and the midline structures for medial repositioning of the nasal wall.
■ Nasal Framework Correction
■ The upper lateral cartilage (ULC) usually needs correction through
separation, trimming, and repositioning.
■ Most cleft lip noses benefit from spreader grafts.
■ If required due to septal deviation, septoplasty should include resection of
the posterior portion of the quadrangle cartilage, vomer bone, and
perpendicular plate of the ethmoid bone, leaving a strong and straight L-
shaped frame to support the nose.
■ This frame is straightened with or without scoring by application of
bilateral spreader grafts anteriorly.
■ The septum is then splinted using either a pair of Doyle stents or custom-
fabricated stents.
■ These stents are sutured in position using transseptal nonabsorbable
sutures.
■ The ULC is then fixed to the spreader grafts and the septum using 5-0 PDS
suture (Ethicon Inc., Somerville, NJ).
■ Reshaping the Tip and Ala
■ The dome on the affected side is posterior; the lateral crus extends laterally;
and almost always, the medial crus is shorter than ideal, causing length
deficiency in the columella.
■ A columellar strut is the most efficacious means of supporting the tip. Use
of a columellar strut will:
• Increase tip projection
• Elongate the columella on the cleft side
• Augment the subnasale, which is often deficient
• Increase the nasolabial angle
• Prevent the tip from shifting caudally
■ Free up the lower lateral cartilage on the cleft side completely or bilaterally
or advance in V-to-Y fashion to restore adequate projection on the cleft side.
■ Reduce the thickness of the ala by removing some of the fibrofatty tissue,
especially at the alar base and along the alar rim.

■ Interdomal, transdomal, and lateral crural sutures may be required.
■ A tip graft will only be used if the infratip lobule volume is inadequate,
which is seldom the case.
■ Placement of an alar rim graft and application of two stents externally and
internally that are fixed with a through-and-through suture reduces the
potential for recurrent alar thickening.
■ Nostril Correction
■ Augmentation of the floor of the nostril and elevation of the nostril sill on
the cleft side is achieved by placement of a cartilage graft.
■ The alar bases are then narrowed as needed and repaired using 6-0 fast-
absorbing catgut.
PEARLS AND PITFALLS
Physical
findings
■ Careful selection of patients at a suitable age is required along with a
cooperative patient and a caregiver.
■ Skeletal correction of the bony base must be performed before soft
tissue correction.
Technique
■ Use old scars and avoid new scars if possible.
■ If length of the surgery lasts more than 1.5 hours, consider reinjecting
vasoconstrictive agents to minimize bleeding intraoperatively and
postoperatively.
■ Restoration of the distorted structures should be based on normal
anatomy.
■ Careful tissue handling with meticulous alignment of landmarks is
required.
■ Forcing the cartilage anteriorly to achieve symmetry is doomed to
failure, as the cartilage will gradually shift the tip to the cleft side of
the nose.
POSTOPERATIVE CARE
■ A nasal splint is applied for 7 to 8 days.
■ Patients are asked to refrain from heavy exercise for 2 to 3 weeks and use of

eyeglasses for 4 to 5 weeks.
OUTCOMES
■ Cleft lip rhinoplasty addresses both functional and aesthetic nasal disturbance
following initial cleft lip repair.
■ Patients are usually very satisfied following cleft lip rhinoplasty due to the
resultant functional and aesthetic improvement.
COMPLICATIONS
■ The most common complication of secondary cleft lip rhinoplasty is
asymmetry. Patients should be informed that they might need additional
surgery. Most common sites of asymmetry are the alar base and nostril.1-3
■ Owing to the underlying condition, these patients have a higher chance of
nasal obstruction preoperatively and sometimes postoperatively.3
■ Septal deviation may recur, or there may be residual septal deviation due to
primary deformity. This may require additional procedures.
REFERENCES
1. Guyuron B. Late cleft lip nasal deformity. Plast Reconstr Surg. 2008;121:1-
11.
2. Broadbent TR, Woolf RM. Cleft lip nasal deformity. Ann Plast Surg.
1984;12:216.
3. Rifley W, Thaller SR. The residual cleft lip nasal deformity: an anatomic
approach. Clin Plast Surg. 1996;23:81.

16
CHAPTER
Section IV: Atypical Clefts-
Soft Tissue Component
Tessier 3 and 4 Clefts
(Nasal-Cheek Region)
Philip Kuo-Ting Chen and Vikram S. Pandit
DEFINITION
■ The Tessier no. 3 facial cleft occurs at the junction of the frontonasal and
maxillary process.
■ It involves the position of an ordinary cleft lip extending upward and passing
through the alar base towards the medial canthal region.
■ The medial part of the eye is displaced laterally and inferiorly (FIG 1A).
■ The Tessier no. 4 facial cleft is located lateral to the no. 3 facial cleft.
■ This cleft starts lateral to the philtral ridge and travels lateral to the alar base
toward the medial canthal region.
■ The medial part of the eye is displaced laterally and inferiorly (FIG 1B).
ANATOMY
■ The Tessier no. 3 and no. 4 facial clefts have similar soft tissue abnormalities
resulting in shortened oculo-alar and oculo-oral distances.
■ In the lip region, the cleft line is the same as ordinary cleft lip in no. 3 (FIG
2A) and is lateral to the philtral column in no. 4 (FIG 2B).
■ Both clefts are accompanied by distortion or disruption of the orbicularis oris
muscle. The cleft extends upward into the cheek with alar involvement in no. 3
and without alar involvement in no. 4.
■ In both clefts, orbital dystopia is coupled with globe abnormalities and
underlying skeletal deficiencies.