Reoperative Aesthetic & Reconstructive Plastic Surgery

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These two diagnostic procedures, performed by speech-language pathologists, ra-
diologists, otolaryngologists, and plastic surgeons, provide the information that bears
most strongly on the choice of physical management method selected. I believe
that it is extremely important that the operating surgeon be involved in the tests,
preferably at the time they are performed, but at the least by reviewing the tapes
with the speech-language pathologist.The surgeon gains general information about
VPI as well as information speci c to the case and brings an anatomic viewpoint
to the discussion that the nonsurgeon is unlikely to have.The patient is best served only
if the decision regarding surgical treatment is made by both the speech-language
pathologist and the surgeon.
Although at the time of this writing the “exposure time” needed for CT and MRI
“movie frames” is too long to be useful in studying the rapid motions of the velopha-
ryngeal mechanism, it will probably not be long before we will be looking at the
moving mechanism on three-dimensional images and, more exciting, in stereo.116
An International Working Group117 has advocated a standardized method for re-
porting both video uoroscopy and nasendoscopy results based on a ratio, the per-
centage of the open port that the velum can close, and the percentage of the open
port that the side walls can close (closing ratio98 or closure ratio118-120). However,
studies using video uoroscopy historically108,121,122 were and are often still54,116,122,123
recorded in millimeters of residual gap, making comparisons between studies dif -
cult.98,117 A study that compared video nasendoscopic and video uoroscopic velar
closing ratios that included the video uoroscopic resting gap and residual gap data
in millimeters would permit interinstitutional comparison of results between
nasendoscopic studies that use closing ratios and the many uoroscopic studies that
provide only residual gap data in millimeters. At present one can only estimate the
relationship.98
Long a goal, selecting a method for physical management most suited to the pa-
tient’s anatomic problems is being increasingly pursued.98,117,123-126,219 The most com-
monly used techniques for physical management today are the obturating pharyn-
geal ap, sphincter pharyngoplasty, and re-repair with intravelar veloplasty (usually
by double opposing Z-plasty). Pushback with pharyngeal ap for nasal lining, pos-
terior pharyngeal wall augmentation, and prosthetic management are less frequently
employed. Criteria for selection of the procedure most likely to provide velopha-
ryngeal valving and least likely to produce complications for individual patients are
still works in progress.
PHARYNGEAL FLAP
Although concern over a high incidence of nasal airway compromise and obstruc-
tive sleep apnea has been the main factor in a reduction in the use of the obturat-
ing pharyngeal ap procedure, the superiorly based pharyngeal ap has been and
may still be the most commonly used procedure for correction of VPI. With the

possible exception of Kapetansky’s bilateral transverse ap operation,127,128 the var-
ious versions of the operation depend on active lateral pharyngeal wall motion for
closure. Preoperatively, patients using glottals are unlikely to demonstrate their full
lateral wall motion potential,38,129 indicating the importance of preoperative speech
therapy to overcome the glottal pattern.
The broad ap procedure in which the velum is opened sagittally and nasal mucosal
turnover aps are used for lining has been described as the “high attached ap” by
Owsley et al130 and the “lateral port control” ap by Hogan,12 and has been dis-
cussed in detail by Trier.131,132 IVV added to the procedure reduced the velopharyn-
geal competency rate from 60% without IVV to 24% with IVV, and increased the
hypernasality rate from 26% to 46% and the hyponasality rate from 16% to 30%.132
Criteria for selecting the pharyngeal ap procedure have included reduced velar
mobility, lateral wall motion greater than velar motion, and scarring of the
palatopharyngeus muscles133;poor velar motion, long velum, moderate to good lat-
eral wall motion,134 and residual velopharyngeal gap greater than 6 mm.135 These
factors indicate that a pharyngeal ap is used for more dif cult cases.136 Owsley et
al130 found that palatal and pharyngeal wall mobility predicted success. Armour et
al137 discovered that the pharyngeal flap procedure had a higher velopharyngeal
competency rate and a lower rate of hyponasality in patients with a circular or
sagittal closure pattern than a coronal closure pattern. The Monte ore group use
lateral pharyngeal wall motion as determined by videofluoroscopy and video
nasendoscopy to select the position of ap inset.138 At the University of Florida
this type of ap has been reserved for patients with poor palatal motion and/or a
residual gap greater than 10 mm, even in the presence of compensatory articulation,
but only when there is good lateral wall motion.
1077
Chapter 30
Secondary Cleft Palate Surgery
Pharyngeal flap
donor site
Pharyngeal flap
Incisions on
nasal side for
nasal turnover
lining flaps
In this technique a broad superiorly
based pharyngeal ap is elevated. The
velum is incised sagittally.

1078
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Port suture
through
ends of flap
incisions
Nasal
turnover
lining flaps
Pharyngeal
flap
On each side the nasal lining flaps
are elevated.The lining ap incision
and the pharyngeal ap incision end
1.5 to 2 cm apart. As Hogan12 de-
scribes, on each side a 14 Fr catheter
is placed through the port area to
determine its size, and the pharyn-
geal ap is then positioned and inset
around the catheter.The lining aps
are sutured to line the raw surface
of the pharyngeal flap. The donor
site may be left open or it may be
sutured.
Pharyngeal flap
donor site
Pharyngeal
flap
Pharyngeal flap
donor site
Nasal turnover
lining flaps
In constructing the ports, I maintain a distance of 15 to 20 mm between the ends of
the turnover ap and pharyngeal ap incisions. Rather than closing the port over a
14 Fr catheter, I join the ends of the two incisions by a suture.The intervening mu-
cosa completely lines the circumference of the 5 to 6 mm diameter (about 24 mm2)
port that is formed. This lines the ports entirely with mucosa, which should mini-
mize port contracture by scar.

1079
Chapter 30
Secondary Cleft Palate Surgery
Pharyngeal flap
Nasal turnover
lining flaps
Pharyngeal flap
donor site
On sagittal section, the ap positions and the catheter through the port can be seen.
The Monte ore group has come to depend entirely on a pharyngeal ap inset into
a transverse “ shmouth” incision in the velum.138-140 When lateral wall motion is
minimal to nil, the transverse incision into which the ap is inset is placed along the
posterior margin of the velum and even carried onto the posterior pillars. With
better lateral wall motion, the incision is moved farther anteriorly onto the dorsum
of the velum, leaving a longer portion of the ap unlined to narrow by tubing,
thus matching the ultimate breadth of the ap to the mobility of the lateral walls.
The velopharyngeal competency rate was 99% (75 of 76) in patients with excellent
sidewall motion who received high aps;88% (164 of 186) velopharyngeal compe-
tent, 4% (7 of 186) hypernasal, and 8% (15 of 186) hyponasal in patients with mod-
erate sidewall motion;and in patients with minimal to no lateral wall motion, who
received the widest “obstructing” aps inset into the posterior velar margin, 80%
(75 of 94) developed velopharyngeal incompetence and 20% (19 of 94) were pur-
posely made hyponasal. In a study of 71 patients with VPI after pharyngeal ap, it
was found that in 54%, although the ap was at the correct level, it was too narrow
or the walls did not move enough, in 38% the ap was too low, and in only one pa-
tient was the ap too high.140
Smith et al141 found that after pharyngeal ap surgery, only half of 31 patients had
optimal (8 of 31) or adequate (8 of 31) results by pressure- ow criteria. However,
a speech-language pathologist graded two of eight of the “optimal” patients and six
of eight of the “adequate”patients as hyponasal, identifying 4 of the 31 as hyper-
nasal, 19 of the 31 as hyponasal, and only 8 of the 31 as having normal nasal reso-
nance. It seems clear that many patients have some degree of hyponasality after
pharyngeal ap surgery.

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In 1973, Graham et al2 addressed the majority of complications related to pharyn-
geal ap surgery in their study of 222 patients. One child died, seven (3%) required
transfusions, and 17 (7%) suffered total or partial ap separation. Many of the com-
plications were related to airway obstruction. Seven patients (6 with Pierre Robin
sequence) required tracheostomies, and one needed an emergency tonsillectomy.
Twelve patients (5%) had chronic nasal airway obstruction, for which seven under-
went ap revision. A tongue stitch and a nasopharyngeal airway placed into one
port and sutured to the alar base were and still are advocated for the immediate
postoperative period.
Missing from this list of complications was obstructive sleep apnea (OSA),which was
not a recognized entity at that time. From 1976 to 1980, Jackson et al,142 Robson et
al,143 and Thurston et al144 described symptoms and sequelae of OSA in multiple
patients, which they related to perioperative infection or Pierre Robin sequence.
Kravath et al,145 later in 1980, seem to be the rst to label the problem as OSA af-
ter pharyngeal ap transfer. Since then, other reports have followed.146,147 Orr et al148
showed by means of polysomnographic sleep studies that OSA was present in 9 of
10 consecutively operated children 2 to 3 days after lateral port control pharyngeal
ap surgery. OSA resolved in all but two patients by 3 months. Sirois et al149 found
a much lower incidence (35%) in 40 patients undergoing polysomnography 5 days
after pharyngeal ap operation. On long-term follow-up, of the two patients who
still had abnormal polysomnographic studies, only one was symptomatic.
Liao et al119 con rmed with sleep studies a signi cantly higher rate of OSA in post-
palatoplasty patients treated for VPI with pharyngeal ap (of 28 patients, moderate-
to-severe OSA in 15,mild in 11) than with double opposing Z-plasty (mild in 4 of 20).
Of 585 patients who had undergone pharyngeal ap surgery for VPI,Ysunza et al150
con rmed by means of sleep studies and video nasendoscopy that 14 had OSA.
Thirteen patients had large tonsils and one had a very wide ap. In all but one, ton-
sillectomy and uvulopalatopharyngoplasty relieved the OSA. The authors recom-
mend tonsillectomy before pharyngeal ap surgery if the tonsils are at all enlarged.
Infants with Pierre Robin sequence are at higher risk for OSA after pharyngeal
ap; for them another procedure should be selected for VPI correction.151
Valnicek et al152 reported that in 219 children undergoing pharyngeal aps for VPI,
the most common perioperative complications were bleeding (13 patients), airway
obstruction (15 patients), and a combination of both (5 patients). Late complications
included OSA in nine, four of whom required ap takedown.VPI caused by ap
dehiscence or a too-narrow ap required reoperation in seven patients. Sixteen pa-
tients had chronic nasal obstruction or hyponasality.
It should be clearly understood that although chronic nasal airway obstruction is of-
ten present postoperatively in pharyngeal ap patients with OSA, it is not necessary

for the development of OSA: the vast majority of persons with OSA are middle-
aged, overweight men with intact, competent palates and patent nasal airways.The
entire airway must become obstructed, an event that, unless the mouth remains
closed, involves the tongue and pharynx below the palatal plane. Because OSA is a
debilitating, life-threatening condition, all patients must be monitored for it after
pharyngeal ap surgery, not just those patients who are hyponasal while awake.
Two prospective studies comparing sphincter pharyngoplasty and pharyngeal ap
in randomly assigned patients found no signi cant difference in speech outcomes
at 1 year. In one study153 the velopharyngeal competency rate in the 50 patients was
approximately 85%; there were no signi cant surgical complications and no clini-
cal evidence of OSA reported by parents.The other, a multicenter study,154 found
in 97 patients no statistically signi cant difference in resonance, nasalance scores,
surgical complications, or outcomes based on endoscopy. Sleep studies revealed no
patients who developed OSA.There were two signi cant differences between the
group with sphincter pharyngoplasty and the group with pharyngeal ap: (1) At 3
months the VPI rate was higher in the sphincter group, but it had equalized at ap-
proximately 85% velopharyngeal competence by the 1-year examination;and (2) at
12 months, four of the seven patients with slight or no velar movement preopera-
tively who underwent sphincter pharyngoplasty had inadequate function versus
only 2 of the 25 who received pharyngeal aps; it was concluded that active velar
motion should be present in patients selected for sphincter pharyngoplasty. At the
end of the trial, three pharyngoplasty patients were reoperated for VPI, and one ap
and two sphincter patients for obstruction.
When VPI remains or hyponasality occurs after pharyngeal ap surgery, the ports
can be modi ed. Barot et al146 described various maneuvers based on the Z-plasty
for increasing or decreasing port size and raising the base of a ap. Twelve of 14
with VPI achieved or nearly achieved velopharyngeal competence. All six who
were hyponasal remained so to some degree. Pharyngeal aps that were too narrow
have been augmented with aps,155-157 divided and redone,158 and individually tai-
lored depending on need.134 In 21 patients with VPI after pharyngeal ap surgery,
Barone et al159 reelevated a second pharyngeal ap, carrying the old too-narrow or
too-low ap up with the new ap when both ports were incompetent.When only
one port was incompetent, they used a unilateral patch ap to narrow the leaking
port. Eighteen of the 21 patients achieved velopharyngeal competence. Flaps made
restrictive by scar retraction of the bases inferiorly have been re-elevated and
Skoog’s lateral aps placed beneath for mucosal resurfacing.160
Relief of OSA or nasal airway obstruction has been achieved by ap takedown,134,161
but with recurrence of VPI in some patients.2,146,162 Suture closure of any raw ar-
eas after ap takedown has been recommended because reattachment and reob-
struction may occur if raw areas remain in contact.144,147 In eight patients who were
hyponasal and in 16 who were hypernasal after pharyngeal ap surgery, Jackson163
divided the ap and performed a sphincter pharyngoplasty with excellent results.
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Chapter 30
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1082
PART III
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PALATAL PUSHBACK W ITH PHARYNGEAL FLAP LINING
Because this procedure,164,165 also called a Honig pharyngoplasty,134 adds length and
motion to the velum, it can restore a coronal pattern of closure without requiring
lateral wall motion.The hard palate mucoperiosteum is elevated as a ap across the
posterior margin of the hard palate, giving access for transverse incision of the nasal
mucosa and pushback of the velum, which is not opened sagittally.The ap, which
is inset anterior to the velum, is used only to provide mucosal lining for the nasal
defect resulting from the pushback and is left unlined so that the pedicle will tube
itself and occupy a minimum of nasopharyngeal space above the velum.165,166 For this
reason, there seem to be fewer nasal obstructive problems after the procedure than
after reconstruction with a broad, lined pharyngeal ap. Although the pushback
maneuver should achieve some degree of palatal muscle retropositioning, more for-
mal palatal muscle repositioning may be performed as part of the procedure.134,139
Criteria for pushback with pharyngeal ap lining vary. Jobe166 used the procedure
for patients with VPI but good palate motion after palate repair. Others have re-
served this procedure for the most dif cult patients. In 1962, Williams and Wool-
house167 described their results with this surgery in 12 patients selected because of
scarred, immobile palates; 4 of the 12 achieved velopharyngeal competence. Based
on simultaneous video uoroscopy and nasendoscopy,115 Piggott,160 Peat et al,126 and
Alberry et al134 have selected pushback with pharyngeal ap lining for their pa-
tients with a scarred, short, immobile velum and minimal lateral wall motion. In a
1982 report,134 of 56 patients with this most dif cult palatal condition, 14 developed
velopharyngeal competence, 7 were hypernasal, 29 were mildly hyponasal, and 6
were moderately hyponasal. In 1994, they reported on a subsequent series of 132
patients with VPI studied by video uoroscopy and nasendoscopy.126 The 53 with
poor palatal and lateral wall motion were treated with palatal pushback and pharyn-
geal ap lining. A total of 43 (81%) achieved acceptable nasal resonance balance,
two (4%) remained hypernasal, and eight (15%) became hyponasal, for which six
underwent revision. Twenty-two patients (42%) were able to eliminate nasal es-
cape, 24 (45%) had mild residual nasal escape, and seven (13%) had moderate resid-
ual nasal escape. These results are essentially the same as those achieved in their
group of 63 patients with a good range of velar motion, residual gaps of less than
5 mm, and minimal lateral wall motion who underwent a modi ed Hynes (sphinc-
ter) pharyngoplasty.

1083
Chapter 30
Secondary Cleft Palate Surgery
The design of the mucoperiosteal ap to be elevated after pharyngeal ap elevation
is outlined. A Dorrance-type hard palate incision is shown but the incision design
may be modi ed. On sagittal view, the posterior repositioning of the velum and
mucoperiosteal ap and the transfer of the pharyngeal ap to ll the resulting nasal
defect are shown.
When the clinical trials of posterior wall augmentation by Te on injection were
discontinued in 1974, at the University of Florida pushback with pharyngeal ap
lining was selected as the substitute procedure most likely to preserve the normal
velopharyngeal closure mechanism. Patients were selected who had good palatal
motion and a gap of 10 mm or less, preferably with good lateral wall motion. In one
study, 24 of 24 achieved velopharyngeal competence,168 in another study four of ve
operated on for VPI after palate repair became velopharyngeal competent,169 and in
their most recent review,123 41 of 45 were initially successful, two achieved velopha-
ryngeal competence after a secondary sphincter pharyngoplasty, and in one case
that was initially unsuccessfully treated by sphincter pharyngoplasty, pushback with
ap lining resulted in hyponasality, which resolved with ap division resulting in
velopharyngeal competence. In only one of the 45, a child with velocardiofacial
syndrome who was continuing with speech therapy, was velopharyngeal compe-
tence not achieved. No cases of OSA resulted.These excellent results suggest that
the criteria for pushback with pharyngeal ap lining could have been extended.

1084
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Greater
palatine vessels
Pharyngeal flap
Pharyngeal flap
donor site
Pharyngeal flap
The mucoperiosteal ap is elevated posteriorly just into the soft palate, a transverse
incision is made through the nasal mucosa, and the pushback is accomplished.The
pharyngeal ap is brought across the intact velum into the nasal mucosal pushback
defect. As Jobe166,170 has suggested, attaching the ap tip suture to a nasal catheter
passed into the posterior pharynx simpli es the ap transfer. When the pushback
and pharyngeal ap inset are completed, posterior sutures hold the pharyngeal ap
in place and lateral sutures hold the mucoperiosteal ap in its retroposed position.
Because the purpose of the pharyngeal ap is to provide nasal lining, not obtura-
tion, it is not lined.

Because the pushback mucosal scar inside the alveolus may be one factor that lim-
its maxillary growth, in young patients with cleft lip and palate I place the hard
palate portion of the pushback incisions more medially on the hard palate, medial
to the greater palatine foramina, and extended laterally behind the maxillary
tuberosities to end just medial to the hamuli. After making the transverse incision
through the nasal mucosa, the velar muscles are pushed back by bluntly separating
them from the superior constrictor with a Freer elevator.The levator becomes vis-
ible as a distinct muscle bundle.
1085
Chapter 30
Secondary Cleft Palate Surgery
Levator veli
palatini muscle
Superior
constrictor muscle
Hamulus
Greater palatine
vessels
Hamulus
Hamulus
Superior
constrictor muscle
Levator veli
palatini muscle
The pharyngeal ap is then brought superior to the velum and inset into the nasal
mucosal defect. Once the pushback is completed, three small oral mucosal defects
remain; however, they are not near the alveolus and quickly epithelialize.
Palatopharyngeus
muscle
Palatoglossus
muscle
Levator veli
palatini muscle
Superior
constrictor
muscle
Hamulus
Pharyngeal
flap
Greater
palatine
vessels
Hamulus
Palatopharyngeus
muscle
Palatoglossus
muscle
Levator veli
palatini muscle
Superior
constrictor
muscle
Hamulus
Greater
palatine
vessels
Hamulus

1086
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
A variation of the procedure, a repeat pushback in which a formal intravelar velo-
plasty was carried out and nasal-side mucosal closure obtained with a buccal mu-
cosal graft rather than a pharyngeal ap, achieved velopharyngeal competence in
53.3% of 15 patients.171
In the article by Dibell et al164 that popularized this method in the United States,
the cine uoroscopy tracings con rmed velar closure under and posterior to the ap,
but Shprintzen et al139 described, on nasendoscopy, closure by lateral wall movement
against the narrow flap, even though the flap may be “dragged upward by the
velum.” Although this procedure was initially used with superb results by the Mon-
tefiore group for patients with excellent lateral wall motion (17 of 17 achieved
velopharyngeal competence) and with intravelar veloplasty added for those with
moderate lateral wall motion (19 of 24 velopharyngeal competent, 1 hypernasal, 4
hyponasal),140 it was replaced by the transverse inset of a pharyngeal ap at the mid-
portion or the anterior end of the nasal side of the velum as described earlier in the
section on pharyngeal aps.138
Very few complications have been noted in reports on this procedure. Some reports
do not mention complications.139,167-169 Buchholz et al165 denied serious complica-
tions, including bleeding or ap detachment, in their rst 47 patients. Piggott160
and his group reported losing two aps in their patients undergoing multiple op-
erations, requiring three transfusions in 56 patients and removal of the pedicle of the
ap in eight of those patients who were hyponasal and in whom a coronal closure
pattern could be demonstrated.134 In their latest series,126 6 (11%) of 53 patients
had the procedure reversed because of hyponasality.This lack of problems is partic-
ularly gratifying when one considers how often the operation is reserved for those
patients with short, scarred, immobile palates and little or no lateral wall motion.
SPHINCTER PHARYNGOPLASTY
Sphincter pharyngoplasty is being selected more frequently for correction of VPI,
with the expectation that it will result in fewer of the obstructive problems related
to the obturating pharyngeal ap.
The sphincter pharyngoplasty that Hynes172 introduced more than 40 years ago
initially consisted of salpingopharyngeus aps from behind the posterior pillars that
were crisscrossed high on the posterior pharyngeal wall. He soon modi ed his pro-
cedure to use posterior tonsillar pillar aps containing the palatopharyngeus and
underlying superior constrictor bers.121,173 The procedure was used in the United
States167 but did not become popular at that time.

1087
Chapter 30
Secondary Cleft Palate Surgery
In 1968, Orticochea110 described his method of sphincter pharyngoplasty in which
the posterior pillars containing the palatopharyngeus muscles were inset into a short
turndown pharyngeal ap below the palatal plane the ori ce of which was visible
through the open mouth. Although his rationale seemed reasonable, his results were
not good in secondary cases.111,174 However, his work stimulated interest in and
modi cations of his operation by Jackson and Silverton,163,175,176 Kawamoto,177 Riski
et al,133,178,179 Roberts and Brown,180 and Stratoudakis and Bambace,122 all of whom
immediately or eventually raised the level of the sphincter178,189 near or to the palatal
plane by insetting the aps into a transverse incision from ap base to ap base
across the posterior pharyngeal wall to arrive at an operation that was essentially the
same as Piggott’s version of the Hynes procedure.121,134 The comparison studies by
Riski et al133,178,179 of their Orticochea (earlier) and Hynes (later) variations showed
that the low ap inset was the main operative cause of failure.178,179 Determination
of the level of ap inset by intraoperative review of lateral video uoroscopy to see
the relationship of the attempted level of velar closure to the easily palpated atlas120,181
and resection of adenoid tissue to make possible higher inset of the posterior pil-
lar aps have been advised recently.182,183 The main remaining difference in the pro-
cedures is the method of insetting the posterior pillar aps:overlapping120,177,178,182,183
as Hynes originally described or by an end-to-end butt joint.121,122,163 It seems un-
wise to appose a repaired velum, which may have a dorsal sagittal groove, to a sagit-
tal butt joint, where the sphincter’s ridge will be least prominent.
Criteria for selecting sphincter pharyngoplasty have generally included good velar
movement and a gap of less than 10 mm. Moss et al121 selected 5 mm because they
found the mean protrusion of the posterior wall ridge to be 6.2 mm. Although
Flaps overlapped
Flaps abutted end to end

1088
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Riski et al133 described somewhat better results when lateral wall motion was good,
only Stratoudakis and Bambace122 used good lateral wall motion as a criterion for
selection. Sie et al184 selected patients with no velar sagittal groove on nasendoscopy.
Although Moss et al121 and Kawamoto177 each demonstrated active sphinctering on
video uoroscopy in two thirds of their patients, and Witt et al185,186 measured active
reductions from 37% to 80% in their patients’ sphincter areas (and found that
sphincter closure of 64% or more correlated with velopharyngeal competence),
Mehendale et al120 described the Hynes pharyngoplasty as “a posterior pharyngeal
wall augmentation pharyngoplasty rather than a sphincter pharyngoplasty.”
In 1994, a major cautionary note was sounded by Witt et al186 in their report on 20
patients who were studied by speech evaluation and video nasendoscopy both be-
fore and after sphincter pharyngoplasty performed by six experienced surgeons.
The procedure was selected without regard for severity of VPI, gap size, closure
pattern, or age. Although 75% to 80% of the patients showed some improvement,
only 18% had complete resolution of nasal escape and hypernasality. Sixty- ve per-
cent were judged postoperatively to have residual VPI severe enough to be candi-
dates for another procedure.Thirty percent were judged to be hyponasal after sur-
gery (none were preoperatively).The authors discussed the problem of criteria for
success, noting that if the criteria for success are control of nasal escape and hyper-
nasality, the procedure could be considered successful in only 18% of their patients.
The poor results in this study, in which one procedure was used in all patients, re-
inforces the concept of basing the selection of a procedure on speci c criteria af-
ter careful preoperative evaluation and study of each patient.
In contrast, Kawamoto178 abandoned the pharyngeal ap for sphincter pharyngo-
plasty, which he modi ed from Jackson103,175,176 to inset the aps into a transverse in-
cision at the level of the atlas and used as his only VPI operation. Excluding three
patients who suffered ap disruptions, velopharyngeal competence was achieved
in 41 of 48. One of the seven failures was because of hyponasality. The two left
with moderate VPI had a port tightening. Eighteen of the patients underwent
nasendoscopy, which revealed an active sphincter in two thirds and a high correla-
tion of observed closure with perceptual speech rating.
Most authors report velopharyngeal competency rates in the 50% to 80% range,
with both hypernasality and hyponasality (severe in at least one case)134 causing fail-
ures. In 1994, Peat et al126 reported that among 63 patients,“acceptable” nasal res-
onance balance was achieved in 51 (81%) and in 31 (49%) there was no nasal es-
cape. Eleven (17%) became hyponasal, of whom ve (8%) required a reversal of the
pharyngoplasty.These results are not signi cantly different from the results in their
53 more severely affected patients selected for pushback with pharyngeal ap lining.
Sie et al,184 among 24 patients selected because they had no velar sagittal groove,
had 15 that developed velopharyngeal competence. Three became hyponasal, and
three of the six with residual VPI were reoperated successfully.

Losken et al187 selected 250 patients on the basis of “limited” lateral wall movement
and “large” velopharyngeal gaps, 142 with repaired clefts or submucous cleft palate,
32 with velocardiofacial syndrome, and 63 with noncleft VPI. Using as the criterion
of success improvement such that the sphincter pharyngoplasty did not need revi-
sion, 32 (13%) of the 250 needed revision (25 for VPI, 7 for hyponasality), which
was successful in 30. Predictors of failure were velocardiofacial syndrome, high
nasometry score, and large residual gap area on pressure- ow calculation.
From their excellent study of the 30 patients who still had VPI after sphincter
pharyngoplasty, Riski et al179 concluded that a large velopharyngeal gap, poor velar
movement, ingrained compensatory articulation, and scarred palatopharyngeus
muscles were conditions that predicted poor results with sphincter pharyngoplasty,
although Graivier et al,188 in one case of scarring of the posterior pillars, successfully
used palatoglossus aps.
Witt et al181 reported that a positive suction test predicted success after sphincter
pharyngoplasty but no signi cant difference in results among patients with active
palates, velopharyngeal hypotonia (“black hole”), Pierre Robin sequence, or sphinc-
ter pharyngoplasty revisions.
The sphincter pharyngoplasty complication rate has been low, consisting of hypo-
nasality (in one series181 an expected outcome of revision), occasionally ap dehis-
cence,122,175,177,178,181 and two cases of bleeding.163,180 Revisions have been performed for
nasal obstruction and hyponasality,122,126,175,187 as well as for hypernasality,133,177,188 and
have included reinsetting dehisced aps and re-elevating aps to adjust port size. The
ease of adjustment is considered to be an advantage of sphincter pharyngoplasty.
Velocardiofacial syndrome (VCFS) is said to be the most common congenital
anomaly associated with cleft palate.189 Patients with VCFS are likely to have an
unsuccessful outcome with cleft repair or surgery for VPI. Sphincter pharyngo-
plasty is proving to be an effective part of their treatment. For 42 patients with
VCFS and VPI without an open cleft, Mehendale et al120 followed an algorithm in
which those with transverse levators underwent Hynes pharyngoplasty.The 25 pa-
tients with anteriorly inserted palatal muscles underwent a radical dissection and
retropositioning of the palatal muscles,190 with the recognition that some would
need further surgery for VPI. After 6 months, 11 who had inadequate improve-
ment in velopharyngeal function had a Hynes pharyngoplasty and showed “signif-
icant improvement” in nasal escape and hypernasality (not stated was how many
achieved velopharyngeal competence).Three developed mild hyponasality.
For their patients with VCFS, Witt et al183 changed their criteria for sphincter
pharyngoplasty to active velar elevation and poor lateral wall motion, or any history
suggesting problems associated with Pierre Robin sequence. Although they re-
ported “success” in 18 of 19 patients with VCFS, they considered hyponasality to
be an expected consequence when VP competence was achieved, and an unstated
number of their successes were hyponasal, including one patient who developed
OSA requiring treatment with CPAP.
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Using operative revision as the criterion for failure, Losken et al191 found that
sphincter pharyngoplasty was effective for patients with VCFS (7 [22%] of 32
needed revision, six for hypernasality and one for hyponasality), although it was
not as effective as for the non-VCFS patients in the group (25 [11%] of 218;19 for
hypernasality and 6 for hyponasality). After one revision, 31 of the 32 VCFS patients
were felt to have a “satisfactory” speech outcome.
The anatomic nding of medially positioned internal carotid arteries in VCFS192 is
a concern. Palpation of the posterior pharyngeal wall for pulsations is considered to
be necessary, reliable, and adequate by some,191,193,194 whereas others depend on the
nding of pulsations on preoperative nasendoscopy to identify patients who need
MRI.195 Even though the anatomic correlation among MRI, nasendoscopy, and in-
traoperative palpation is not strong, some advocate a preoperative MRI of all VCFS
patients to identify the position of the carotid arteries prior to pharyngeal ap or
sphincter pharyngoplasty.196 It has to be reassuring that in this most common of
congenital anomalies associated with cleft palate and VPI, rst identi ed as a syn-
drome in the 1970s, reports of carotid artery injury are not, and in the nearly 200
years since the first successful cleft palate repair, have never become, familiar to
plastic surgeons.194
POSTERIOR PHARYNGEAL WALL AUGMENTATION
Because posterior pharyngeal wall augmentation disturbs the existing velar-lateral
wall closure mechanism the least, and if accomplished by injection would warrant
the expense and risk of surgical correction to the many patients with lesser de-
grees of VPI, it is unfortunate that no standard technique has become popular.
Hagerty et al197 abandoned the placement of allograft cartilage when resorption
became apparent. Injectable collagen can be expected to suffer the same fate. Denny
et al198 and Jobe199 described posterior pharyngeal wall placement of a segment of
autologous rib cartilage for VPI. Denny et al achieved velopharyngeal competence
in 5 of 20 patients and improvement in 11. No extrusions occurred.This procedure
is not often done, probably because of the inconvenient donor and scar site.
Synthetic blocks and pillows have been plagued by extrusion.200-202 In a century
span, Passavant (reported by Piggott160), Piggott,160 and Witt et al203 found that a
pharyngeal ap “caterpillared” or rolled up to form a transverse ridge was imper-
manent and ineffective for posterior wall augmentation.
Te on injection into the posterior pharyngeal wall showed considerable promise
because of its ease, precision, and repeatability, but the clinical trials were discontin-
ued in 1974 before FDA approval was obtained for use of the material for this pur-
pose.We participated in the clinical trials at the University of Florida from 1967 to
1974.108 Our criteria for selection, based on cine uorographic ndings and speech

evaluation, were active velar motion appropriate to the speech sounds, a residual gap
of no more than 10 mm, and minimal compensatory articulatory errors. Lateral
pharyngeal wall motion was not a prerequisite. Twenty-one of 27 patients with
VPI, including 9 of the 12 with repaired clefts, achieved velopharyngeal compe-
tence after one (in 15 patients) or two (in 6 patients) Teflon injections and re-
mained so 3 to 10 years after treatment. Treatment success was not related to gap
size;patients with 6 to 10 mm gaps did slightly better (6 of 7) than those with gaps
of 0 to 5 mm (15 of 20). Five of eight patients who had VPI after pharyngeal ap
surgery developed velopharyngeal competence after injection into the walls of the
enlarged ports. Pharyngeal ap surgery was performed in three of the failed pa-
tients without a problem, including the single patient whose Te on bolus extruded.
The only major complication was development of OSA in one patient, whose
symptoms cleared, with retention of velopharyngeal competence, after two resec-
tions, which removed all but the upper rim of the Te on pad.204
It seems unfortunate that no injectable material is in clinical use today to be com-
bined with recently described methods of marking the level of closure and local-
izing residual gaps in the line of closure.205,206 The precise posterior-wall Teflon
augmentation performed under nasopharyngoscopic guidance by the team of
Daniller et al207 would be a powerful tool in the treatment of VPI, especially for
those patients with “sometimes but not always” and “almost but not quite” condi-
tions who go untreated today. Experimental studies of injectable materials208 in-
cluding autogenous fat,209,210 and early clinical trials of collagen211 have been re-
ported, but neither of these materials has been reliably permanent. Despite the
plethora of materials being injected for cosmetic improvements, none has come
into clinical use for this un lled need.
R E-R EPAIR
In 1969, Dellon and Edgerton212 reported performing intravelar veloplasty as a sec-
ondary procedure for VPI in two patients. Jackson163,176 advocated re-repair of the
palate when the velum moves well but its muscles were not repositioned in the
initial repair;when on video uoroscopy and intraoral examination the velar eleva-
tion point is too far forward; and as Piggott160 described on nasendoscopy, there is
a characteristic midline groove in the velum where the uvular mound should be.
Sommerlad et al213 recently reported results using the operating microscope for re-
repair with “radical” muscle retropositioning for VPI. Based on their results and
comparison studies, they state that re-repair should be considered as the rst-line
operation for VPI.
Double opposing Z-plasty is a method for primary repair of cleft palate10,11,214,215
that has also been used as a re-repair procedure. In addition to overlapping and
repositioning the palatal muscles transversely, it adds velar length without requiring
tissue from the hard palate. Because it constructs a functioning palatal muscle sling,
sidewall motion should not be critical to success.Vistnes and Jobe216 note that they
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have used this method as a secondary procedure. In a small group of patients
studied preoperatively and postoperatively with video nasendoscopy, Witt and
D’Antonio217 described obliteration of the sagittal groove and complete closure in
a coronal pattern after secondary double opposing Z-plasty.
D’Antonio et al31 demonstrated that the operation could produce velar length or
thickness greater than matched norms. In their 12 carefully studied patients with
VPI, eight after palate repair and four with submucous cleft palate, velopharyngeal
competence was associated with marked increases in length or thickness, or mod-
erate increases in both, but when the increases in both length and thickness were
minimal,VPI persisted. Postoperative closure measurements were not given, but six
(75%) of the eight operated for VPI after palatoplasty demonstrated velopharyngeal
competence.
In 13 consecutive patients with VPI after cleft palate repair, Hudson et al218 achieved
velopharyngeal competence in 11 (85%). The patients were studied by video-
uoroscopy, but the measurements were apparently not used for patient selection
and were not reported;we do not know the size of the residual gaps that were suc-
cessfully corrected. In these two series31,218 without preoperative closure measure-
ments, 17 (81%) of the 21 patients who had repaired clefts achieved velopharyngeal
competence.
Two studies provided residual gap measurements in millimeters. Chen et al219 re-
ported the use of the double opposing Z-plasty technique in 18 patients with VPI
after palate repair.The patients were selected on the basis of video uoroscopy and/or
nasendoscopy ndings.All 15 patients with residual velopharyngeal gaps of 5 mm or
less achieved velopharyngeal competence.There were no patients in the study with
residual gaps of 6 to 10 mm.Three patients with residual gaps greater than 10 mm
were selected because of obviously anteriorly directed unrepaired levator muscles.
One of the three achieved velopharyngeal competence and the other two improved
to marginal VPI. Both patients over 20 years of age achieved velopharyngeal com-
petence. In the overall group, velopharyngeal competence was attained in 16 (89%)
of 18.The authors stated that there were no surgical complications.
Lindsey and Davis220 achieved velopharyngeal competence by means of double op-
posing Z-plasty in seven (88%) of eight patients whose preoperative velopharyngeal
gap was estimated on nasendoscopy to be 6 to 8 mm.
In private practice I used double opposing Z-plasty for two patients who had VPI
after primary palate repair; both developed velopharyngeal competence postoper-
atively.11 The strict criteria for selection were a residual gap of 5 mm or less, good
palatal motion, Jackson’s indications that the muscles were still ununited, and ab-
sence of compensatory articulation; good sidewall motion was not a requirement.
The overall rate of velopharyngeal competence achieved by double opposing Z-
plasty in these reports with gap measurements in millimeters was 89% (25 of 28).
The rate for residual gaps greater than 10 mm was 33% (1 of 3), for 5 to 10 mm

gaps, 87% (7 of 8), and for 0 to 5 mm gaps, 100% (17 of 17). Thus when palatal
function was measured in millimeters, the procedure seemed to be effective (96%)
for residual gaps from 0 mm up to 8 to 10 mm.
Two studies125,221 have provided pre- and postoperative data in the format of the In-
ternational Working Group116 in which palatal function is reported as a closing ra-
tio, the percentage of the open port that can be closed by the elevated velum.This
eliminates the two problems of inability to measure through the nasendoscope and
the considerable variation in velopharyngeal size among patients of different ages
and sizes. In both studies, closing ratios were determined on video nasendoscopy
and reported in one of three categories: less than 50% (large gap), 50% to 80%
(moderate gap), and 80% to 100% (small gap).
Perkins et al125 reported on 148 patients selected because they had VPI and a dor-
sal sagittal velar groove indicating velar muscles still in the cleft orientation. Ninety-
eight had VPI after cleft palatoplasty, 50 had VPI and submucous cleft palate; the
two categories were not distinguished in the data. Sixty-four had a syndrome or as-
sociated condition, including 16 with VCFS and eight with Pierre Robin sequence.
VPI ratings were based on perceptual evaluation of hypernasality and nasal escape.
Postoperatively 83 (56%) of 148 “had no VPI.” However, only 73 (49.3%) had nor-
mal resonance and only 47 (31.8%) had no nasal emission. How many had neither
hypernasality nor nasal emission is not reported. Thirty-eight (73%) of 52 with
preoperative closing ratios of 80% to 100%, 26 (51%) of 51with 50% to 80% ratios,
and 4 (13%) of 31 with closing ratios less than 50% had no or minimal VPI post-
operatively. Outcomes also were signi cantly related to degree of preoperative VPI.
Except for the 16 patients with VCFS, nine of whose velopharyngeal status did not
change from preoperative ndings, syndromic patients did as well as nonsyndromic
patients. Postoperatively eight patients developed snoring and ve had persistent
obstructive sleep apnea, but in ve patients preoperative obstructive sleep symp-
toms did not persist postoperatively.
On the basis of these results, the treatment protocol was changed to a sphincter
pharyngoplasty with double opposing Z-plasty for patients with closing ratios less
than 50%.
In a prospective study of 27 nonsyndromic children with VPI after pushback
palatoplasty done after age 3 years, Deren et al13,221 categorized nasal emission, nasal-
ity, articulation, and intelligibility into 4 degrees (none/normal, mild, moderate,
and severe), and performed video nasendoscopy before and 1 year after double op-
posing Z-plasty for correction of VPI. They classi ed closing ratios into four cat-
egories:less than 50% (large gap), 50% to 80% (moderate gap), 80% to almost com-
plete closure (small gap), and complete closure (no gap). Preoperatively all 27 had
moderate or severe grades of nasal escape, hypernasality, articulation, and intelligi-
bility, and closing ratios of less than 80% (large or moderate gaps).
Comparisons of the three measures of velopharyngeal valve function (nasal escape,
nasal resonance, and nasendoscopy) reveal a high correlation among the 1-year
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postoperative valve tests. For six patients (22%) all three tests were normal, eight pa-
tients (30%) had two normal and one mild, ve patients (19%) had one normal
and two mild, and all three were mild in one patient. Four patients (15%) were
graded moderate or severe on all three valve tests.There was disagreement of more
than one grade or across the mild-moderate line in only three patients.
Preoperative closing ratios correlated with postoperative velopharyngeal function.
Of the nine patients with preoperative closing ratios of 50% to 80% (moderate),post-
operatively 100% had at least one test indicating valve closure. Six showed closure
and three had closing ratios over 80% on video nasendoscopy; ve had normal reso-
nance, four had mild hypernasality; one had mild nasal escape, and eight had none.
Of the 18 with preoperative closing ratios less than 50% (large), postoperatively, only
67% had at least one test indicating closure. On video nasendoscopy, nine showed
closure, four had closing ratios over 80%, and ve had closing ratios of 50% to 80%;
ve had normal resonance,seven had mild,four had moderate,and two had severe hy-
pernasality; ve had mild nasal escape, ve had moderate escape,and eight had none.
Comparison between scores on the valve tests and the articulation/ intelligibility
tests showed that improvement in speech function depended on valve closure ca-
pability but not on patient age.The seven patients with a normal articulation and/or
intelligibility score had 20 normal and one mild valve scores. Of the ve patients
with mild articulation and intelligibility scores, three had two normal value scores
and two had one normal valve score.When valve scores agreed on incomplete clo-
sure, articulation and intelligibility scores were moderate or severe.
These data indicate the following:(1) Intelligibility and articulation improved to nor-
mal or mild only when there was evidence of capability for valve closure. (2) How-
ever, evidence of capability for valve closure did not ensure speech improvement.
(3) Speech function did not improve when valve closure remained inadequate.
Normal speech depends on, but is not ensured by, normal valve function.
For patients with VCFS there is ample evidence that double opposing
Z-plasty is ineffective for correction of VPI after repair of their cleft
palate.123,125 Sphincter pharyngoplasty is a far better choice.184,191 This is
doubly true for VCFS patients with VPI in the absence of a cleft palate,
because double opposing Z-plasty performed on a noncleft palate will
move the velar muscles into an abnormal alignment.
I have used double opposing Z-plasty as a secondary procedure for VPI after palate
repair in several dozen cases performed without bene t of preoperative video uo-
roscopy or follow-up. From this surgical experience I know that although scar from
the initial repair makes dissection more dif cult along the line of the cleft, the op-
eration (in particular, closure of the aps) is easier in secondary cases than in most
primary cases because one begins without the tissue de cit of a cleft to close and
because the hard palate does not require closure.

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Superior
constrictor muscle
Hamulus
Palatal aponeurosis
(divided by incision)
Palatal muscles
Levator veli
palatini muscle
Superior constrictor
muscle
Hamulus
Palatopharyngeus
muscle
Palatoglossus
muscle
The central limb of the incision is made full thickness through the old velar scar.
The lateral limb incisions end just posteromedial to the hamuli, automatically divid-
ing the palatal aponeurosis. A backcut from the end of the right lateral limb (dotted
line) is used if necessary to increase the mobility of the anteriorly based ap.
The oral posteriorly based ap is elevated with palatal muscles from nasal mucosa.
Medially the dissection may be dif cult because of the scar.There is rarely scarring
laterally, and to avoid injury the muscle should be separated bluntly from the supe-
rior constrictor with a Freer elevator. The levator can be identi ed as a separate
muscle bundle. The anteriorly based flap is then elevated, leaving the palatal
muscles in place beneath.This mucosal ap can be made quite thick anteriorly and
anterolaterally.

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Levator veli
palatini muscle
Superior constrictor
muscle
Palatoglossus and
palatopharyngeus
muscle
The anteriorly based nasal mucosal ap is cut so the lateral limb ends at the leva-
tor muscle at the posterior margin of the Eustachian tube. (The Eustachian tube is
easy to locate with a Freer elevator dropped through the cleft.) This incision should
not be shortened;to do so would decrease the lateral extent of the muscle transpo-
sition and the muscle overlap. The muscle of the posteriorly based nasal ap can
usually be separated a little from its nasal mucosa laterally to shorten the lateral
limb incision somewhat so that the nasal mucosal ap does not have to reach as far.
Levator veli
palatini muscle
Superior constrictor
muscle
Palatoglossus and
palatopharyngeus
muscle
Levator veli
palatini muscle
Superior constrictor
muscle
Palatoglossus
muscle
Palatopharyngeus
muscle
The nasal aps are transposed, retropositioning one set of palatal muscles.

Transposing the oral aps overlaps the palatal muscles.
Double opposing Z-plasty should be considered for surgical treatment for VPI when:
1. It is as likely to succeed as other methods (airway obstruction and OSA are
not as likely)
2. Residual velopharyngeal gap is less than 8 to 10 mm on video uoroscopy
3. The velar closing ratio is 80% to 99% on video nasendoscopy or video uo-
roscopy
4. The patient has a history suggestive of Pierre Robin sequence or Stickler syn-
drome, which carry a higher risk of airway obstruction and OSA
5. The surgeon is experienced and successful with double opposing Z-plasty as
a primary repair for cleft palate
6. In circumstances such as third-world sites, where nasendoscopy or video-
fluoroscopy is not available and follow-up is unlikely (to avoid OSA), or
when repairing a stula and the palate appears to function poorly, and nasal
escape and hypernasality have persisted when speech was tested with the
stula plugged with gum or tissue
Double opposing Z-plasty should not be used when:
1. The residual gap on video uoroscopy is greater than 10 mm
2. The closing ratio on video nasendoscopy is less than 80%
3. The palate is anatomically normal, or the velar muscles have been well over-
lapped in previous surgery,such as a double opposing Z-plasty.The Z-plasties
will disorient the properly aligned levator sling
4. The patient has velocardiofacial syndrome
5. Previous experience with the procedure has given less than a 75% rate of
velopharyngeal competence
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If VPI persists after double opposing Z-plasty is done, speech therapy should be
tried, limited to three to six months. If VPI persists, video uoroscopy and/or video-
nasendoscopy should be repeated to assist in selection of the surgical procedure
most likely to provide velopharyngeal competence with the least likelihood of air-
way problems.
1. Avoid dividing the velum sagittally; the overlapped levators will be cut
2. First choice, sphincter pharyngoplasty
3. Pushback with pharyngeal ap for nasal lining
4. If the residual gap is 2 mm or smaller,consider re-elevating and advancing the
oral side posteriorly based myomucosal ap as Philip K.Chen has described223
5. Pharyngeal ap with transverse ( shmouth) velar inset
TONSILLECTOMY
Tonsils and adenoids are usually considered as a single entity and removed together.
Because adenoidectomy may for obvious reasons cause VPI, there has been a ten-
dency to also avoid tonsillectomy in the child with a repaired cleft for fear of pro-
ducing VPI. However, the tonsils, which normally reside below the level of palatal
closure, may causeVPI when they are enlarged. Shprintzen et al224 reported 20 cases
of tonsillar hypertrophy causing VPI; one patient had a repaired cleft and one had
a submucous cleft.The tonsils inhibited motion of the sidewalls in three, the velum
in ve, and both structures in 12. Such characteristics as coexisting hypernasality
and hyponasality, dif culty swallowing, “potato in the mouth” speech, and OSA
should make one suspect the diagnosis, but the tonsils may not always look large on
intraoral examination. The diagnosis was made in these cases based on nasendos-
copy.The tonsils, normally not visible from above, had enlarged upward to become
visible in the plane of closure. There was usually a gap just medial to the tonsil
where it blocked closure. All 20 patients became velopharyngeal competent after
tonsillectomy. MacKenzie-Stepner et al225 reported two cases (noncleft) of VPI
caused by enlarged tonsils diagnosed by videofluoroscopy, and Kummer et al226
reported one such case. All three became velopharyngeal competent after tonsillec-
tomy. Moss et al121 also have stated that tonsillectomy may help VPI in some cases.
Whether to remove tonsils at the time of or before other surgery for VPI has been
controversial. Reath et al162 reported on 20 cases in which they had removed en-
larged tonsils at the time of pharyngeal ap surgery to avoid postoperative airway
obstruction caused by the tonsils and to obviate the increased risks of two opera-
tions. Two patients were returned to the operating room for bleeding and a third
needed a transfusion. OSA developed in one patient as a result of peculiar nasopha-
ryngeal scarring unrelated to the tonsil areas and required ap takedown. A letter
with signers from three countries condemning simultaneous tonsillectomy and
pharyngeal ap surgery227 and the rebuttal by the authors228 suggested that there
may be selected cases in which the dual procedure is warranted, such as the very
young patient with severe VPI and a scarred short palate, compensatory articulation,
and hypertrophied tonsils.Ysunza et al150 found enlarged tonsils in 13 of 14 patients
who developed OSA after pharyngeal ap surgery and recommended removal of
large tonsils before such surgery.

Similarly, the issue as to whether to remove hypertrophied tonsils at the time of
sphincter pharyngoplasty is not clear. Orticochea174 does so but says “this leaves too
much raw surface exposed.”229 Riski et al179 retract large tonsils but excise huge
tonsils at the same time because preliminary tonsillectomy may imbricate the pos-
terior pillar in scar. Jackson176 and Stratoudakis and Bambace122 remove large ton-
sils with pharyngoplasty. Moss et al121 recommend preliminary tonsillectomy be-
cause after healing the pharyngoplasty will be easier to perform, and in those few
cases in which the tonsils are causing VPI, tonsillectomy will eliminate the need for
pharyngoplasty.
SPEECH PROSTHESIS
The prospective randomized study of Marsh and Wray230 comparing prosthetic
versus lateral port control pharyngeal ap treatment of 39 patients with moderate-
to-severe VPI showed that although the two methods were equally effective (mar-
ginal or no incompetence in 11 of 12 prosthesis patients and 20 of 22 ap patients),
the nonacceptance rate for prosthetic management was high. Five of the 17 pa-
tients randomized for a prosthesis did not receive it or would not tolerate it, and 4
of the 11 patients treated successfully by obturator subsequently elected to have a
pharyngeal ap, which suggests that only those patients who will not do well with
surgery should be directed to prosthetic management.
Three categories of patients seem to be candidates for permanent prosthetic man-
agement: (1) Patients with poor or no motor control around the oronasal sphinc-
ter, such as those with nothing but scarred, immobile tissues, (2) those with VPI of
central origin who could bene t from the repetitively and nely adjustable and
removable features of a prosthesis, and (3) patients who are not operative candi-
dates, who have no other option.
A temporary prosthesis or obturator reduction program for patients who retain
glottal articulation despite concerted preoperative speech therapy may help to break
their glottal patterns and improve the speech results of subsequent surgery;some pa-
tients on an obturator reduction program have achieved velopharyngeal compe-
tence without surgery.231
CONCLUSION
For each patient in whom VPI is con rmed by clinical examination to be a struc-
tural problem, intraoral examination, evaluation of speech, video uoroscopy, and
video nasendoscopy should provide data on the presence of stulas, palatal motion,
residual velopharyngeal gap, lateral wall motion (pattern and degree of closure),
and compensatory articulation. Ideally these data should be used to select the pro-
cedure most likely to provide a functioning velopharyngeal mechanism with the
lowest risk of problems. The selection criteria shown in the table on p. 1100 are
based on the criteria and results discussed in the text and on personal experience.
These criteria are tentative and should be bolstered or changed by future data.
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If a stula is present, all examinations of function (clinical, uoroscopic, nasendo-
scopic, and any others) should be performed with the stula both open and oc-
cluded (with Kleenex, chewing gum, etc.) to determine if the stula is causing VPI
either directly or by its damping effect on the velopharyngeal mechanism. If obtu-
ration during the examinations is at all helpful, it is probably best to close the s-
tula either surgically or prosthetically before operating on the velopharyngeal port.
To activate the velopharyngeal musculature, compensatory articulations, particu-
larly glottals, should be eliminated or made controllable by the patient through
speech therapy. A speech appliance may be helpful in recalcitrant cases.
If the tonsils are large enough to endanger the airway postoperatively, and particu-
larly if video uoroscopy and/or nasendoscopy suggest that VPI may be caused by
enlarged tonsils, a preliminary tonsillectomy should be performed.
Selection Criteria for Treatment of Velopharyngeal Incompetence
Maximum
Velopharyngeal Gap
Lateral Wall
Compensatory
or Closing Ratio
Velar Motion
Motion
Articulations
Re-repair by double
8-10 mm
Good but anterior.
Not critical
Minimal, controllable
opposing Z-plasty
80%-99%
Dorsal velar groove
Posterior pharyngeal
10 mm
Good
Not critical
Minimal, controllable
wall augmentation
Sphincter
5 mm
Some to good
Not critical
Minimal, controllable
pharyngoplasty
Pushback with
Not critical
Some
Not critical
Glottals can be controlled
pharyngeal ap lining
Obturating
Not critical
Not critical
Needs to be
Glottals can be controlled
pharyngeal ap
good

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Additional Criteria
Improves anatomy by constructing retroposed overlapping velar muscle sling
Do not use if velar muscles were well overlapped at initial surgery or if palate is anatomically normal; Z-plasty will
cause malpositioned muscles
Do not use in patients with velocardiofacial syndrome; very high failure rate
Probably most effective for patients with relatively small gap and muscles still in cleft orientation
Velopharyngeal anatomy and function are unchanged except for Passavant’s pad
No good easy FDA-approved permanent method available today.
Some change in anatomy and closure mechanism occurs
Avoid this technique if posterior pillars or tonsillar beds are scarred
Has worked well in patients with velocardiofacial syndrome
Modi cation for postoperative hypernasality or hyponasality not dif cult
Anatomy is changed by presence of pharyngeal ap
Works well when velar motion good; sidewall motion not critical
Tubing and narrowing of an unlined ap seems to lead to fewer airway problems than a lined obturating ap
May be the best procedure when there is a scarred velum with some motion, a large gap, minimal sidewall motion
Pushback incisions may affect maxillary growth in young patients with cleft lip and palate
Avoid when possible in patients with Pierre Robin sequence
Examine for aberrant carotid arteries in patients with velocardiofacial syndrome
Closure mechanism is changed maximally and is dependent on lateral wall motion
With broad aps there is risk of hyponasality and OSA
Use other methods if feasible because of possible resultant airway problems
Likely to be effective regardless of velar movement when sidewall motion is good
Avoid in patients with Pierre Robin sequence
Avoid broad aps in patients with velocardiofacial and Stickler syndromes.
Examine for aberrant carotid arteries in patients with velocardiofacial syndrome
If preliminary procedures have been performed, the basic examinations (physical,
speech, video nasendoscopy, and/or video uoroscopy) will probably need to be re-
peated;if the ndings have changed, plans for physical management may need to be
revised.
It seems logical that the procedure to be used to control VPI should be selected for
each patient on a risk-bene t basis. The procedure selected should ideally be the
one most likely to produce velopharyngeal competence while reconstructing a
mechanism most like the normal one, with the least likelihood of immediate or
long-term side effects for the patient.The order in which the procedures are listed
in the table below re ects the degree to which they alter the normal velopharyn-
geal mechanism to achieve velopharyngeal competence, beginning with velar re-
construction and ending with obturation and dependence on sidewall motion. It is
true that the most favorable cases—those with minimal gaps, good velar and side-

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wall motion, good articulation, and youth—should have a very high rate of success
with any of the procedures but with a greater risk of hyponasality and/or OSA
with the procedures involving pharyngeal aps.This increased risk is the justi ca-
tion for arranging the options for treatment of VPI in a procedure ladder, starting
at the top and proceeding downward as necessary to t the criteria.
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98. Perkins JA, Lewis CW, Gruss JS, et al. Furlow palatoplasty for management of velopharyngeal
insuf ciency:A prospective study of 148 consecutive patients.Plast Reconstr Surg 116:72;dis-
cussion 81, 2005.
The objectives of this study were to describe speech outcomes in a large series of patients undergoing Fur-
low palatoplasty for management of velopharyngeal insuf ciency and to test whether preoperative
velopharyngeal gap size and other patient characteristics signi cantly affect those outcomes. Data col-
lected included age at the time of surgery, surgeon, type of cleft, syndrome diagnosis, preoperative velopha-
ryngeal gap size as determined by videonasendoscopy, and preoperative and postoperative perceptual
speech assessments. Descriptive statistics were generated and ordinal logistic regression on the outcome
variable, postoperative velopharyngeal insuf ciency severity score, was performed. In this series of 154
patients, 148 had complete perceptual speech data. Of these 148 patients, 72% had improvement in
velopharyngeal insuf ciency severity after the procedure and 56% had complete resolution of velopha-
ryngeal insuf ciency. Postoperative insuf ciency was scored as none or minimal (i.e., resolution) in 38
of 52 patients (73%) with a small preoperative velopharyngeal gap, 26 of 51 patients (51%) with a
moderate preoperative gap, and 4 of 21 patients (19%) with a large preoperative gap. Preoperative
velopharyngeal gap size was signi cantly associated (p 0.0001) with postoperative insuf ciency on
ordinal multivariate logistic regression after controlling for preoperative insuf ciency and other covariates.
There was not a significant association between syndrome diagnosis, age at Furlow palatoplasty (younger
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outcome, in either the unadjusted or adjusted analyses.The authors concluded that preoperative velopha-
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velopharyngeal insuf ciency severity after Furlow palatoplasty. Small gap size is associated with a
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surgery for velopharyngeal insuf ciency. Cleft Palate Craniofac J 30:387, 1993.
151. Abramson DL, Marrinan EM, Mulliken JB. Robin sequence: Obstructive sleep apnea fol-
lowing pharyngeal ap. Cleft Palate Craniofac J 34:256, 1997.
152. Valnicek SM, Zuker RM, Halpern LM, et al. Perioperative complications of superior pharyn-
geal ap surgery in children. Plast Reconstr Surg 93:954, 1994.
153. Ysunza A, Pamplona C, Ramirez E, et al. Velopharyngeal surgery: Prospective randomized
study of pharyngeal aps and sphincter pharyngoplasties Plast Reconstr Surg 110:1401, 2002.
154. VPI Surgical Group: Abyholn F, D’Antonio L, Davidson Ward SL, et al. Pharyngeal ap and
sphincterplasty for velopharyngeal insuf ciency have equal outcome at 1 year postopera-
tively: Results of a randomized trial. Cleft Palate Craniofac J 42:501, 2005.
155. Friedman HI, Gaines PC, Coston GN, et al. Augmentation of the failed pharyngeal ap. Plast
Reconstr Surg 90:314, 1992.
156. Cosman B, Falk AS. Pharyngeal ap augmentation. Plast Reconstr Surg 55:149, 1975.
157. Hirshowitz B, Bar-David D. Repeated superiorly based pharyngeal ap operation for per-
sistent velopharyngeal incompetence. Cleft Palate Craniofac J 13:45, 1976.
158. Owsley JQ, Lawson LI, Chierici GJ.The re-do pharyngeal ap. Plast Reconstr Surg 57:180,
1976.
159. Barone CM, Shprintzen RJ, Strauch B, et al. Pharyngeal ap revisions: Flap elevation from a
scarred posterior pharynx. Plast Reconstr Surg 93:279, 1994.
160. Piggott RW. The results of nasopharyngoscopic assessment of pharyngoplasty. Scand J Plast
Reconstr Surg 8:148, 1974.
161. Agarwal T, Sloan GM, Zajac D, et al. Speech bene ts of posterior pharyngeal ap are pre-
served after surgical ap division for obstructive sleep apnea: Experience with division of 12
aps. J Craniofac Surg 14:630, 2003.

162. Reath DB, LaRossa D, Randall P. Simultaneous posterior pharyngeal ap and tonsillectomy.
Cleft Palate Craniofac J 24:250, 1987.
163. Jackson IT. Pharyngoplasty: Jackson technique. In Bardach J, Morris HL, eds. Multidiscipli-
nary Management of Cleft Lip and Palate. Philadelphia:WB Saunders, 1990, p 386.
164. Dibell DG, Laub DR, Jobe RP, et al. A modi cation of the combined pushback and pharyn-
geal ap operation. Plast Reconstr Surg 36:165, 1965
165. Buchholz RB, Chase RA, Jobe RB, et al.The use of the combined palatal pushback and pha-
ryngeal ap operation: A progress report. Plast Reconstr Surg 39:554, 1967.
166. Jobe R.The pharyngeal ap-pushback procedure. Operative Techniques Plast Reconstr Surg
2:245, 1995.
167. Williams HB,Woolhouse FM. Comparison of speech improvement in cases of cleft palate af-
ter two methods of pharyngoplasty. Plast Reconstr Surg 30:36, 1962.
168. Dixon-Wood VL,Williams WN, Seagle MB.Team acceptance of speci c recommendations
for the treatment of velopharyngeal insuf ciency as provided by speech pathologists. Cleft
Palate Craniofac J 28:285, 1991.
169. Dixon VL, Bzoch KR, Habal MB. Evaluation of speech after correction of rhinolalia with
pushback palatoplasty combined with pharyngeal ap. Plast Reconstr Surg 64:77, 1979.
170. Jobe R. The combined pharyngeal ap and palate pushback procedure: Improvements in
technique. Br J Plast Surg 26:384, 1973.
171. Nakamura N, Ogata Y, Sasaguri M, et al. Aerodynamic and cephalometric analyses of
velopharyngeal structure and function following re-pushback surgery for secondary correc-
tion in cleft palate. Cleft Palate Craniofacial J 40:46, 2003.
172. Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg 3:128, 1950.
173. Hynes W. Results of pharyngoplasty by muscle transplantation in “failed cleft palate” cases.
Ann R Coll Surg Engl 13:17, 1953.
174. Orticochea M. A review of 236 cleft palate patients treated with dynamic muscle sphincter.
Plast Reconstr Surg 71:180, 1983.
175. Jackson IT, Silverton JS. The sphincter pharyngoplasty as a secondary procedure in cleft
palates. Plast Reconstr Surg 59:519, 1977.
176. Jackson IT Sphincter pharyngoplasty. Clin Plast Surg 12:711, 1985.
177. Kawamoto HK. Pharyngoplasty revisited and revised. Operative Techniques Plast Reconstr
Surg 2:239, 1995.
178. Riski JE, Sera n D, Riefkohl R, et al. NG. Rationale for insertion site for pharyngoplasty
aps. Plast Reconstr Surg 73:882, 1984.
179. Riski JE, Ruff GL, Georgiade GS, et al. Evaluation of failed sphincter pharyngoplasties. Ann
Plast Surg 28:545, 1992.
180. Roberts TM, Brown BS. Evaluation of a modi ed sphincter pharyngoplasty in the treatment
of speech problems due to palatal insuf ciency. Ann Plast Surg 10:209, 1983.
181. Witt PD, Marsh JL, Marty-Grames L, et al. Revision of the failed sphincter pharyngoplasty:
An outcome assessment. Plast Reconstr Surg 96:129, 1995.
182. Prior LS, Lehman J, Parker MG, et al. Outcomes in pharyngoplasty: A 10-year experience.
Cleft palate Craniofac J 43:222, 2006.
183. Witt P, Cohen D, Grames LM, et al. Sphincter pharyngoplasty for the surgical management
of speech dysfunction associated with velocardiofacial syndrome. Brit J Plast Surg 52:613,
1999.
184. Sie KC, Tampakopoulous DA, de Serres LM, et al. sphincter pharyngoplasty: Speech out-
come and complications. Laryngoscope 108:1211, 1998.
185. Witt PD, Marsh JL, Arlis H, et al. Quanti cation of dynamic velopharyngeal port excursion
following sphincter pharyngoplasty. Plast Reconstr Surg 101:1205, 998.
186. Witt PD, D’Antonio LL, Zimmerman GJ, et al. Sphincter pharyngoplasty: A preoperative
and postoperative analysis of perceptual speech characteristics and endoscopic studies of
velopharyngeal function. Plast Reconstr Surg 93:1154, 1994.
187. Losken A,Williams JK, Burstein FD, et al. An outcome evaluation of sphincter pharyngoplasty
for the management of velopharyngeal insuf ciency. Plast Reconstr Surg 112:1755, 2003.
1109
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Secondary Cleft Palate Surgery

1110
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
188. Graivier MH, Cohen SR, Kawamoto HK, et al. A new operation for velopharyngeal insuf-
ciency:The palatoglossus myomucosal pharyngoplasty. Plast Reconstr Surg 90:707, 1992.
189. Shprintzen RJ, Goldberg RB, Lewin ML, et al. A new syndrome involving cleft palate, car-
diac anomalies, typical facies, and learning disabilities: Velo-cardio-facial syndrome. Cleft
Palate Craniofac J 15:56, 1978.
190. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg 112:1542, 2003.
191. Losken A,Williams JK, Burstein FD, et al. Surgical correction of velopharyngeal insuf ciency
in children with velocardiofacial syndrome. Plast Reconstr Surg 117:1493, 2006.
192. MacKenzie-Stepner K, Witzel MA, Stringer DA, et al. Abnormal carotid arteries in the ve-
locardiofacial syndrome: A report of three cases. Plast Reconstr Surg 80:347, 1987.
193. Mehendale FV, Sommerlad BC. Surgical signi cance of abnormal internal carotid arteries in
velocardiofacial syndrome in 43 consecutive Hynes pharyngoplasties.Cleft Palate-Craniofacial
J 41:368, 2004.
194. Witt PD, Miller DC, Marsh JL, et al. Limited value of preoperative cervical vascular imaging
in patients with velocardiofacial syndrome. Plast Reconstr Surg 101:1184, 1998.
195. Ross DA,Witzel MA, Armstrong DC, et al. Is pharyngoplasty a risk in velocardiofacial syn-
drome? An assessment of medially displaced carotid arteries. Plast Reconstr Surg 98:1182,
1996.
196. Shprintzen RJ. Discussion of Witt PD, Miller DC, Marsh JL, et al. Limited value of preop-
erative cervical vascular imaging in patients with velocardiofacial syndrome. Plast Reconstr
Surg 101:1184; discussion 1196, 1998.
197. Hagerty RF, Mylin WK, Hess DA. Augmentation pharyngoplasty. Plast Reconstr Surg 44:353,
1969.
198. Denny AD, Marks SM, Oliff-Carneol S. Correction of velopharyngeal insuf ciency by pha-
ryngeal augmentation using autologous cartilage: A preliminary report. Cleft Palate Cranio-
fac J 30:46, 1993.
199. Jobe R. Retropharyngeal implants for velopharyngeal incompetence. Operative Techniques
in Plast and Reconstr Surg. 2:251, 1995.
200. Brauer RO, Fox DR, Humphreys D. Augmentation of the posterior pharyngeal wall. In
Bardach J, Morris HL, eds. Multidisciplinary Management of Cleft Lip and Palate. Philadel-
phia:WB Saunders, 1990, p 408.
201. Blocksma R, Braley S. Present status of retropharyngeal implantation for velopharyngeal in-
suf ciency. Plast Reconstr Surg 44:242, 1969.
202. Wolford LM, Oelschlaeger M, Deal R. Proplast as a pharyngeal wall implant to correct
velopharyngeal insuf ciency. Cleft Palate Craniofac J 26:119, 1989.
203. Witt PD, O’Daniel TG, Marsh JL, et al. Surgical management of velopharyngeal dysfunc-
tion:Outcome analysis of autogenous posterior pharyngeal wall augmentation. Plast Recon-
str Surg 99:1287, 1997.
204. Furlow LT Jr, Block AJ, Williams WN. Obstructive sleep apnea following treatment of
velopharyngeal incompetence by Te on injection. Cleft Palate Craniofac J 23:153, 1986.
205. Harries RHC, Moore MH, Bognall AD, et al. Posterior pharyngeal tattooing: Localizing the
implant in velopharyngeal incompetence. Br J Plast Surg 45:324, 1992.
206. Trigos T,Ysunza A, Gonzalea A, et al. Surgical treatment of borderline velopharyngeal insuf-
ciency using homologous cartilage implantation with video nasopharyngoscopic monitor-
ing. Cleft Palate Craniofac J 25:167, 1988.
207. Millard DR Jr. Cleft Craft III. Boston: Little Brown, 1980, p 872.
208. Hallen L, Dahlqvist A. Cross-linked hyaluronan for augmentation of the posterior pharyngeal
wall: An experimental study in rats. Scand J Plast Reconstr Surg Hand Surg 36:197, 2002.
209. Canaday JW,Thompson SA, Moon JB, et al. Augmentation of oral tissues in rabbit using au-
togenous fat. Cleft Palate Craniofac J 32:1, 1995.
210. Dejonckere PH, van Wijngaarden HA. Retropharyngeal autologous fat transplantation for
congenital short palate: A nasometric assessment of functional results. Ann Otol Rhinol
Laryngol 110:168, 2001.

211. Remacle M, Bertrand B, Eloy P, et al. The use of injectable collagen to correct velopharyn-
geal insuf ciency. Laryngoscope 100:269, 1990.
212. Dellon AL, Edgerton MT. Correction of velopharyngeal incompetence by retrodisplacement
of the levator veli palatini muscle insertion. Surg Forum 20:510, 1969.
213. Sommerlad BC, Mehendale FV, Birch M, et al. Palate re-repair revisited. Cleft Palate Cran-
iofac J 39:295, 2002.
214. Furlow LT Jr.The double opposing Z-plasty for palate closure—Part I. In Jackson IT, Som-
merlad BC, eds. Recent Advances in Plastic Surgery 4. Edinburgh: Churchill Livingstone,
1992, p 29.
215. Randall P, LaRossa D, Cohen SR, et al.The double opposing Z-plasty for palate closure—Part
II. In Jackson IT, Sommerlad BC, eds. Recent Advances in Plastic Surgery 4. Edinburgh:
Churchill Livingston, 1992, p 41.
216. Vistnes LM, Jobe RP. Experiences with the Furlow palatoplasty. In Kernahan DA, Rosen-
stein SW, eds. Cleft Lip and Palate:A System of Management. Baltimore:Williams & Wilkins,
1990, p 199.
217. Witt PB, D’Antonio LL. Velopharyngeal insuf ciency and secondary palatal management.
Clin Plast Surg 20:707, 1993.
218. Hudson DA, Grobbelaar AO, Fernandes DB, et al.Treatment of velopharyngeal incompetence
by Furlow Z-plasty. Ann Plast Surg 34:23, 1995.
219. Chen KT,Wu J,Chen YR, et al.Correction of secondary velopharyngeal insuf ciency in cleft
palate patients with Furlow palatoplasty. Plast Reconstr Surg 94:933, 1994.
220. Lindsey WH, Davis PT. Correction of velopharyngeal insuf ciency with Furlow palatoplasty.
Arch Otolaryngol Head Neck Surg 122:881, 1996.
221. Deren O, Ayhan M,Tuncel A, et al.The correction of velopharyngeal insuf ciency by Fur-
low palatoplasty in patients older than 3 years undergoing Veau-Wardill-Kilner palatoplasty:
A prospective clinical study. Plast Reconstr Surg 116:85, 2005.
222. D’Antonio LL, Davio M, Zoller K, et al. Results of Furlow Z-plasty in patients with velocar-
diofacial syndrome. Plast Reconstr Surg 107:1077, 2001.
223. Chen PKT. Re-repair for salvaging unsatis ed Furlow palatoplasty in managing secondary
velopharyngeal insuf ciency in cleft patients. Presented at the Annual Meeting of the Amer-
ican Cleft Plate-Craniofacial Association, Minneapolis, MN, April 2001.
224. Shprintzen RJ, Sher AE, Croft CB. Hypernasal speech caused by tonsillar hypertrophy. Int J
Pediatr Otorhinolaryngol 14:45, 1987.
225. MacKenzie-Stepner K, Witzel MA, Stringer DA, et al. Velopharyngeal insuf ciency due to
hypertrophic tonsils. A report of 2 cases. Int J Pediatr Otorhinolaryngol 14:57,1987.
226. Kummer AW, Billmire DA, Myer CM III. Hypertrophic tonsils:The effect on resonance and
velopharyngeal closure. Plast Reconstr Surg 91:608, 1993.
227. Argamaso RV, Bassila M, Bratcher GO, et al. Tonsillectomy and pharyngeal ap operation
should not be performed simultaneously. Cleft Palate Craniofac J 25:176, 1988.
228. Reath DB, LaRossa D, Randall P. Reply to letter by Ravelo Argamaso et al. Cleft Palate Cran-
iofac J 25:177, 1988.
229. Orticochea M.The dynamic muscle sphincter of the pharynx. In Bardach J, Morris HL, eds.
Multidisciplinary Management of Cleft Lip and Palate. Philadelphia: WB Saunders, 1990,
p 378.
230. Marsh JL,Wray RC. Speech prosthesis versus pharyngeal ap:A randomized evaluation of the
management of velopharyngeal incompetency. Plast Reconstr Surg 65:592, 1980.
231. Weiss CE. Success of an obturator reduction program. Cleft Palate Craniofac J 8:291, 1971.
1111
Chapter 30
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1112
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
1. Which of the following are usually compensatory articulations?
a. Glottal stop
b. Nasal grimace (“rabbiting”)
c. Nasal escape
d. Nasal “snort”
e. Hypernasality
2. Mark the following statements that are true.
a. After cleft palate repair more than 75% of children have no nasal escape
and no hypernasality
b. One who learns a second language after an operation to correct VPI is
more likely to have VPI when speaking the second language than the na-
tive language
c. After an operation for VPI, nasal escape on sibilants but not on plosives
means that the operation has failed
d. A closing ratio of 90% corresponds to a residual gap of greater than 10 mm
e. Measurements made on videonasendoscopy are accurate to
2 mm
3. Mark all the true statements.
a. Fistulas have been less common after stula repair than after cleft palate repair
b. Interposition of dermis between oral and nasal layers has improved stula
repair success rates
c. Nasal escape will not occur through a 3
8 mm hard palate stula on the
word “Kegel”
d. Palatal expansion may cause a palatal stula
e. A hard palate stula may reduce velar motion
4. Which one of the following procedures has been shown to be least likely to
correct VPI in a patient with velocardiofacial syndrome?
a. Sphincter pharyngoplasty
b. Double opposing Z-plasty
c. Pushback with pharyngeal ap for nasal lining
d. Broad pharyngeal ap
e. Posterior pharyngeal wall augmentation by injection of Te on paste
5. Which of the following is/are true?
a. Obstructive sleep apnea can occur in the absence of nasal airway obstruction
b. One must line the pharyngeal ap used for nasal lining with a pushback
operation
c. Velar mobility is unnecessary in sphincter pharyngoplasty because the pos-
terior pillar aps are contractile
d. It is fortunate that posterior pharyngeal wall augmentation for correction
of lesser degrees of VPI is so easily and widely available
e. Double opposing Z-plasty has been ineffective for correction of VPI for
residual gaps over 3 mm
R EVIEW QUESTIONS

1113
Craniofacial surgery is the treatment of congenital facial deformities, acquired or
traumatic facial deformities, defects resulting from cancer resections, and surgery of
the facial skeleton for purely aesthetic reasons. A basic tenet of craniofacial surgery
is that the etiology of the deformity resides in the craniofacial skeleton and is not
separable from issues that affect the bones of the cranium, orbit, and face (for ex-
ample, growth and development in children, brain growth, occlusion, vision, airway,
breathing).1,2 As a practical matter, the craniofacial surgeon must master soft tissue
surgery as well as the surgical principles of skeletal reconstruction.3,4 Rigid os-
teosynthesis and sophistication in bone-grafting techniques are unique in the arma-
mentarium of the craniofacial surgeon.5
Reoperative Craniomaxillofacial Surgery
W ith Emphasis on Alloplastic Failure
S. Anthony Wolfe, Paul S. Howard, Silvio Podda,
and Jeffrey M. Hartog
C ha pter 3 1
Reoperative Problems
Scarring
Foreign body reaction
Extrusion
Infection
Distortion of contour
Malposition
Some faces are, in their brightness, a prophecy;
and some, in their sadness, a history.
Charles Dickens

1114
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
There are now a large number of plastic surgeons who are residency trained in the
basic techniques of craniofacial surgery but who lack skills and experience in per-
forming osteotomies and the autogenous bone grafting needed to achieve skeletal
improvement. As an alternative, many of these surgeons choose to simulate osseous
improvement with alloplastic materials. In some instances, alloplastic material is ad-
equate, and in a few circumstances it may even be the preferred method of en-
hancement (for example, small chin or malar de ciencies). Regardless, the apparent
simplicity of using alloplastic material rather than autogenous grafts has led to over-
use of these materials and has thus created one of the most common reasons for re-
operative surgery on the facial skeleton.6,7 This inappropriate application of alloplas-
tic materials is particularly true in posttraumatic acquired craniofacial deformities
and craniofacial surgery performed for aesthetic reasons.
We strongly believe that autogenous material is always preferred.
However, if alloplastic material is to be used, principles apropos of the
placement of foreign bodies on the craniofacial skeleton must be un-
derstood and adhered to.8
The popularity of alloplastic material has bene ted from widespread use over the
years, especially for soft tissue augmentation, when in actuality an osseous problem
is known to exist.9,10 To date, the perfect alloplastic bone substitute does not exist,
although an enormous amount of energy and research dollars have been spent in
an attempt to provide a simple, off-the-shelf alloplast for simulation of a proper or
aesthetically pleasing osseous platform. Alloplastic implants for facial contouring
offer the surgeon several advantages that are particularly important for the aesthetic
surgery patient.11 First, the placement of alloplastic implants is certainly much sim-
pler and quicker than osteotomies or onlay bone grafts. Second, these implants are
generally much less expensive in terms of reduced operative time and the lack of a
need for expensive rigid xation, which is important in those operations that are
purely aesthetic in nature such as chin enhancement and malar enhancement. In ad-
dition, the training and expertise necessary to perform autogenous enhancement
may not be available in most aesthetic surgery centers.
The ideal properties of any soft tissue substitute are identi ed by the following scale:
1. Not physically modi ed within the body
2. Not capable of inciting a signi cant in ammatory reaction
3. Not capable of producing an allergic reaction
4. Chemically inert
5. Noncarcinogenic
6. Capable of resisting intrinsic and extrinsic forces
7. Capable of fabrication
8. Capable of sterilization

Silicone products, silicone rubber in particular, satisfy most of these requirements
and remain the most readily available, inexpensive, and most widely used alloplas-
tic materials for facial skeleton augmentation.
If strictly adhered to, certain implantation principles may reduce the risk of com-
plications.12,13 In general, alloplastic implants should be placed as deeply as possible
(subperiosteal positioning is not necessary), under normal tension or no tension,
and in an adequately dissected pocket via a skin incision located at a site distant
from the implant.
Alloplastic material placed in contact with an infected or potentially
infected area is a time bomb waiting to explode (or extrude).14
Reoperation for complications involving alloplastic material in the craniofacial
skeleton can be required for at least three possible problems: (1) implant infection,
(2) implant malposition, and (3) failure of the implant to achieve the desired recon-
structive or aesthetic result. Clearly, these problems may result from either recon-
structive procedures or aesthetic procedures, but the ultimate treatment of most al-
loplastic failures requires reconstruction with autogenous material.
PATIENT EXAMPLES
1115
Chapter 31
Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure
This young woman had had 25 operations after a right orbitozygomatic fracture.
Methylmethacrylate implants had been inserted and removed on three occasions,
and she presented with a 2.5 cm exposure of the implant at the superolateral orbital
rim.

1116
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
A large semilunar segment of methylmethacrylate was removed, and the temporalis
muscle was advanced into the resultant defect. The skin defect was closed with
temporal and cheek aps.
Seven months postoperatively, the lateral canthus is still pulled outward and slightly
downward.4 This problem could be easily corrected at this point with a small full-
thickness skin graft, but the patient had become very phobic about surgery and
has refused any additional surgery.

Ten years earlier, a methylmethacrylate implant had been used by an ophthalmol-
ogist to repair a right orbital oor defect in this woman. The patient did well for
8 years until a sinus infection developed and the implant fell into the maxillary si-
nus. An otolaryngologist removed the implant and replaced it with a silicone im-
plant.10 This implant also fell into the sinus;the otolaryngologist removed it and re-
placed it with another silicone implant, which this time eroded through the lower
eyelid, causing a substantial deformity.
Correction of the deformity required a temporalis muscle ap, iliac bone graft, and
at a second operation a chondromucosal graft and a full-thickness skin graft. None
of these problems would have occurred if an autogenous bone graft had been used
at the rst operation. All surgeons treating orbital fractures, including plastic sur-
geons, should be able to harvest the small amount of bone required to repair an or-
bital oor defect. If a surgeon insists on using alloplastic materials because he or she
cannot perform a bone graft, then he or she probably should forego treating orbital
fractures.
1117
Chapter 31
Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure

1118
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This 30-year-old woman had sustained a left orbitozygomatic fracture at age 15.
This was treated with rigid xation. She did well for 12 years until she developed
a “sinus infection.” She then underwent a series of operations that included re-
moval of a maxillary sinus mucocele, replacement of the orbital oor ( rst with ti-
tanium mesh, then with other types of foreign materials), a cadaveric bone graft, and
nally Medpor (Porex Technologies, Newnan, GA). At no point was her malposi-
tioned zygoma replaced, and at no point over her 12-year series of operations was
an autogenous bone graft used. She is shown preoperatively and 4 months after re-
moval of large amounts of Medpor from the orbital floor and anterior maxilla,
repositioning of the left zygoma, and an iliac bone graft for the orbital oor and an-
terior maxilla.

After a compound right frontoorbital fracture, this man was treated with a large
right frontal methylmethacrylate implant. We were loathe to do any reconstruc-
tive surgery with the foreign material in place, so the rst procedure involved re-
moval of the implant, cranioplasty with split cranial bone, malar osteotomy, and
bone grafts to the orbital oor and roof.8
1119
Chapter 31
Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure
After the rst operation, the enophthalmos was corrected, but a vertical malposition
of the globe was still present. It was explained to the patient that we could correct
the vertical malposition of the globe but it would require another intracranial pro-
cedure.The patient accepted this situation with aplomb.

1120
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The second operation consisted of exposure of the orbital roof transcranially via a
right frontal craniotomy and complete orbital dissection with intraorbital and ex-
traorbital osteotomies, which allowed for superior transposition of the entire orbit.
Cranial bone grafts were used to graft the infraorbital donor area; rigid osteosyn-
thesis was achieved with miniplates and wire. After the second operation, the pa-
tient has a normal vertical position of the globe and no enophthalmos;however, the
vision in his right eye remains diminished.

This 41-year-old man was in a bicycle accident and sustained nasoorbital ethmoid
fractures as well as a LeFort I fracture. He was treated appropriately for the LeFort
I fracture by intermaxillary xation. He was also treated with rigid xation of the
fractures and placement of a Medpor orbital oor implant. This is a classic exam-
ple of what Gruss has called an open internal xation without reduction (OIF). This
patient is shown before and after removal of all of the foreign material, refracture
and repositioning of the zygoma, iliac bone grafting of the orbital oor and nose,
a transmedial canthopexy, and a lateral canthopexy. He underwent eye muscle sur-
gery for persistent diplopia with a good outcome.
1121
Chapter 31
Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure

1122
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This man had a right orbitozygomatic fracture, and an attempt was made to cam-
ou age the resultant deformity rather than properly align the displaced bones. Sil-
icone implants had been placed in the right frontal region over the zygomatic arch
(causing an injury to the facial nerve branch to the forehead) and over the right
malar region.
Treatment consisted of removal of the silicone implants, right malar osteotomy and
repositioning, bone grafting of the orbital oor (which also corrected the enoph-
thalmos), and a right-sided forehead and brow lift.Trying to camou age displaced
bone segments rather than putting them into proper position is the wrong tactic
and was done here because the original surgeon did not know how to do anything
other than insert silicone rubber.

While serving in the military in a South American country, this man was shot
through the left upper orbit and frontal bone.When he presented for treatment, he
had a draining stula through the superomedial portion of the left orbit, canthal
dystopia, enophthalmos, and diminished vision in the left eye.The sinus tract com-
municated with the frontal sinus, which was found to be lled with a large amount
of bone wax.
The sinus was cleared of bone wax and mucosa, and packed with cancellous iliac
bone, a transnasal medial canthopexy was performed, and a malar osteotomy with
repositioning and bone grafting of the orbital oor were performed to correct the
enophthalmos.
1123
Chapter 31
Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure

1124
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This woman had undergone multiple nasal operations by an untrained and un-
principled individual who presented himself to the public as a plastic surgeon. She
had lost the nasal tip and believed that at one of the operations some silicone had
been inserted,15 which proved to be true.6 Segments of silicone were removed, and
then a midline forehead ap was used to reconstruct the aesthetic unit of the nasal
dorsum and tip. A thin cranial bone graft and conchal cartilage grafts were used as
well.4