Video Atlas Phẫu Thuật Khe Hở Môi Và Vòm Miệng

235
A
B
Figure 16–7.  Buccal rotational/finger flap.
C
D
E
F

236
Video Atlas of Cleft Lip and Palate Surgery
• The length should not exceed three times the
width of the base to assure adequate blood
supply to the tip (Figure 16–8). This rule is
often violated with larger defects extending
into the palate. The longer the finger flap,
the more likely perfusion and venous return
at the tip will be compromised resulting in
necrosis.
• The donor site in the vestibule is closed
primarily but this may shorten the buccal
vestibule.
• Does not provide keratinized tissue
(Figures 16–9 and 16–10).
Lateral Sliding Flap
• A broad-based, full-thickness mucoperiosteal
flap extending two or more teeth off the
defect to the mesial or distal side of the fistula.
It is made horizontally under the attached
gingiva with an anteriorly angled vertical
incision deep into the buccal vestibule. The
periosteum is liberally incised to allow for
medial and distal rotation of the flap into the
anterior hard palate.
• A cut back can be made (the “Herman” modi-
fication) to allow for further advancement
onto the palate.
Island Flap (Video of Revision Repair of Cleft Palate with
Advancing Island Flap) 
In the event that more palatal tissue is required for oral
layer closure as is the caswith large fistulae, a palatal
island flap can be mobilized (Figure 16–11). This flap is
basically a continuation of the laterally released palatal
flap but is extended posteriorly and medially into the
midline of the palate to completely mobilize the soft
tissue on all sides of the flap. The flap will thereby be
pedicled solely off the greater palatine artery (Figure
16–12). This flap is consequently dependent upon the
presence and health of an intact greater palatine artery.
The artery must therefore be adequately and thor-
oughly identified prior to mobilization. If the artery is
not present, do not complete the cutting of this flap;
such action would quickly devitalize the flap. The time
Figure 16–9.  Buccal advancement flap secured on the patient’s
right with the buccal finger flap on the left.
Figure 16–10.  A buccal finger flap has been rotated into the
anterior hard palate to cover a palatal fistula.
Figure 16–8.  Mobilization of the buccal finger flap.

Revision Cleft Palate Repair
237
to identify the artery and assess the vitality thereof is
when making the lateral incision. At this time the flap
can be elevated slightly and a search via this incision
made for the presence of the artery. If no viable artery
is identified, the island flap should not be completed.
Replace the flap into its bed and consider other options.
When creating the island flap, remember that the
posteromedial and medial portions are over areas where
no bony palate exists. It is therefore necessary to dissect
in a split-thickness plane in these areas. The tissue can
be superficially incised with a #15 blade and two layers
developed using sharp, curved scissors. More mobility
can be achieved by carefully “skeletonizing” circumfer-
entially around a well-visualized greater palatine artery.
Sharp scissors are most effectively utilized for this pur-
pose. With adequate mobilization, the island flap may
be advanced anteriorly more than 10 mm. This move-
ment can be most effective in covering large anterior
alveolar clefts or large anterior palatal fistulae. The flap
should then be seated and sutured as anteriorly as pos-
sible with 4-0 or 5-0 Vicryl™ sutures (Figure 16–13). Any
posterior defect created can be left to granulate. How-
ever, the laxity of tissue in the soft palate may allow for
closure of this defect with 4-0 Vicryl™ sutures.
Anteriorly Based Tongue Flaps. 
For extremely large palatal defects, an anteriorly
based tongue flap may be employed for closure of
the oral layer (Figure 16–14). The middle third of
the dorsal aspect of the tongue can be raised and
pedicled off the anterior third of the tongue (Figure
16–15). This provides a very robust and well-vascu-
larized source of tissue for covering large oral side
defects. A nasal intubation is best employed for bet-
ter access to the tongue and oral cavity. The nasal
side of the defect is first closed using local tissue as
described previously (Figure 16–16). The tongue flap is
raised and rotated onto the palatal defect (Figure 16–17).
After closure of the donor site, it is carefully sutured
into place with 4-0 Vicryl™ sutures (Figures 16–18 and
16–19). The patient is well instructed in the use of a
A
B
Figure 16–12.  Palatal island flap.
Figure 16–11.  A large defect in the mid-hard palate. An island
flap, tongue flap, or temporalis muscle flap will be required to
repair this defect.

238
Figure 16–14.  Anteriorly based tongue flap.
Figure 16–15.  Large anterior palatal fistula. One option for
oral-side coverage is the anteriorly based tongue flap.
Figure 16–16.  Nasal layer closure of palatal defect.
Figure 16–13.  The island flap based off the greater palatine
artery.

Revision Cleft Palate Repair
239
liquid diet and cautioned to avoid opening the mouth
during the 2-week healing period. Less frequently,
intermaxillary fixation is employed for the 14-day
duration of flap vascularization. After 14 days, the
pedicle is cut and the stump resutured in place on the
donor bed. Some minor trimming of the stump or flap
might be necessary at this time. This flap provides a
large source of distant tissue and functions nicely for
coverage of large oral-side defects. It will maintain the
papillary anatomy of the tongue and often requires
electrocautery to smooth out the surface anatomy at a
later date. Large anterior nasoalveolar fistulae can also
be closed with this flap (Figures 16–20 and 16–21).
Combination Flaps 
Frequently a combination of a buccal and palatal flap
will be necessary to close a large anterior defect/fis-
tula. Nasal-side closure is usually accomplished easily
with a continuous line of reflected mucosa. It is the oral
side of the defect that is the most challenging; this often
requires combining a number of buccal, palatal, or
tongue flaps for full closure. For completeness sake, it
should be mentioned that the temporalis muscle could
also be used for closure of difficult palatal fistulae. The
temporalis muscle is a good source of plentiful tissue
but requires a major surgical event to provide its access
into the oral cavity. This procedure requires fracturing
of the zygomatic arch with a large section of the tempo-
ralis muscle rotated into the oral cavity. This can leave
an unaesthetic divot in the scalp on the affected side.
It is, however, the only flap that can be used for a one-
layer closure of an oral–nasal defect. The muscle will
granulate on both sides and thereby allow for recon-
struction of varied surgical, traumatic, and pathologic
defects in the oral–nasal region.
Mid-Hard Palate Fistula with Extension to the
Junction of the Hard and Soft Palate
Defects in this area are most common (Figure 16–22).
They are the result of inadequate mobilization of the
Figure 16–17.  Anteriorly based tongue flap being raised.

Figure 16–18.  Anteriorly based tongue flap is raised and the
donor site closed with 3-0 Vicryl™ sutures. The base of the flap is
sutured into place first. A suture is being placed for this purpose.
Figure 16–19. Anteriorly based tongue flap in place at the
recipient site with pedicle noted.

240
Video Atlas of Cleft Lip and Palate Surgery
flaps used in primary repair of the cleft palate. This is
a defect that is most frequently the result of poor tech-
nique. An acceptable result can and should be achieved
with proper understanding of the steps required to
freely mobilize all flaps at the time of primary pala-
toplasty. Refer to the section on cleft palate repair to
review these steps.
Nasal-Side Closure
As with anterior palatal fistulae, a two-layer closure is
mandatory. Nasal-layer closure is again accomplished
by reflection of mucosa at the margins of the defect.
This is done in a similar fashion as described in the
foregoing (Figure 16–23).
Oral-Side Closure
This side is usually closed with lateral rotation of
palatal mucosal flaps, rotation of island flaps, or a
posteriorly based tongue flap (Figure 16–24). The pala-
tal–mucosal flap and the island rotation flap are done
in a similar manner as described in the foregoing. The
posteriorly based tongue flap is also done in a similar
Figure 16–21.  Nasoalveolar defect closed with anteriorly based
tongue flap.
Figure 16–22.  Large defect noted involving most of the hard
palate with extension into the soft palate.
Figure 16–23.  The nasal side of the fistula closed with local
tissue.
Figure 16–20.  Large necrotic fistula at site of breakdown of
a nasoalveolar cleft.

Revision Cleft Palate Repair
241
fashion with the exception that it will now be based off
the posterior third of the tongue. This will allow for
easier rotation up and into the posterior palate (Figures
16–25 and 16–26). The donor site must be closed pri-
marily (Figure 16–27). The temporalis muscle flap can
also be considered in this area.
Figure 16–24.  Posteriorly based tongue flap.
Figure 16–25.  Developing the posterior tongue flap.

Figure 16–26.  The posteriorly based tongue flap is mobilized
and rotated up into the palatal defect.
Isolated Soft Palate Fistula (Video of
Revision Repair of Soft Palate Fistula)
Secondary defects in this area are usually the result of
failure to adequately mobilize the soft tissue flaps at
the time of primary cleft palate repair (Figure 16–28).

242
Video Atlas of Cleft Lip and Palate Surgery
Failure to properly anastomose muscle when perform-
ing the intravelar veloplasty is also a contributing fac-
tor. Speech and swallowing should be assessed prior
to deciding on a secondary revision of these defects.
Without significant speech or swallowing disability,
one might consider not performing any surgical repair
of small defects in this region. Larger compromising
fistulae will require repair. Options for repair include
mobilization of local tissue, or in more severe cases
involving velopharyngeal insufficiency (VPI), a supe-
riorly based pharyngeal flap (see Chapters 11 and 20).
Mobilization of localized tissue would start with
nasal-side closure. This is achieved by making an inci-
sion circumferentially (split thickness) around the fis-
tula. The width of this incision will be dependent on
the overall width of the fistula. The larger the fistula the
more tissue will be required to close the nasal side. The
flap is cut, delicately mobilized, and rotated up into the
soft palate fistula. The epithelialized side is turned into
the nose and sutured in the midline with 5-0 Vicryl™
sutures. Lateral releasing incisions are then made distal
to the maxillary tuberosities and extended posteriorly
into the lateral aspect of the soft palate. The tissue is
then liberally undermined and mobilized medially to
close without tension over the nasal-side flap. The lat-
eral gaps (if present) will be left to granulate.
With larger defects that involve VPI, a superiorly
based pharyngeal flap will be required. The soft palate
is sectioned completely in the midline up to the junction
of the hard palate. The split edges of the soft palate are
then separated into two layers, a nasal and oral compo-
nent. A superiorly based pharyngeal flap is then raised
with its anterior limit up under the Dingman tongue
blade. It is dissected carefully up to Passavant’s pad
to ensure adequate length. It is then rotated superiorly
with the epithelialized side facing the nasopharynx.
The lateral margins of the flap are then sutured to the
nasal layer of the previously sectioned soft palate flaps.
The oral side of the soft palate flaps are then approxi-
mated and sutured over the raw side of the pharyngeal
flap. Care is taken to cover as much of the denuded
side of the pharyngeal flap as possible without restrict-
ing the lateral ports. The donor bed can be closed pri-
marily with 3-0 Vicryl™ sutures or left to granulate
secondarily. Large, obstructing tonsils may need to be
removed prior to completion of a pharyngeal flap.
Postoperative Considerations
• Oral antibiotics are used for the first 7 to
10 days.
• Meticulous oral hygiene is necessary.
Consider prescribing an oral rinse such as
chlorhexidine gluconate.
• Clear liquid diet for first postoperative week
advanced to full liquids the next week. Sharp
Figure 16–27.  The site is closed, and the pedicle is set into
position.


Figure 16–28.  The soft palate is the third anatomic area of
concern for the formation of palatal fistulae. Velopharyngeal
insufficiency (VPI) is commonly associated with defects in this
region.

Revision Cleft Palate Repair
243
foods of any type for the first few weeks
should be discouraged as these may cause
mechanical trauma to the healing flaps.
• If a tongue flap has been used, limited
opening of the mouth will be necessary.
Occasionally, intermaxillary fixation of the
teeth may be required. This is a pedicled flap
and must therefore be protected during the
vascularization period.
• With the pharyngeal flap, close monitoring
of the airway is required within the first
24 hours.
Complications
• Loss of blood supply to a flap.
• Decreased venous return of island and finger
flaps.
• Wound dehiscence.
• Recurrence of fistula.
• Infection, bleeding, or airway compromise.
Pearls and Pitfalls
• The salient points in this chapter are related
to technique and a full understanding of the
reasons for initial flap breakdown. It must be
emphasized that the best attempt at successful
palatal surgery will be the first attempt. All
secondary (revision) procedures are fraught
with challenges not seen at the initial attempt.
Secondary surgery is therefore considerably
more challenging than primary surgery.
• The principles of two-layer closure for all cleft
palate and cleft alveolus deformities must not
be violated. Any attempt at one-layer closure
(with the exception of a temporalis muscle
flap) will always result in failure. Free grafts
and alloplastic materials for oral-side closure
will also result in failure. Viable blood supply
is required for survival of all oral/nasal flaps.
• Understanding the anatomy of the palatal
fistula and appreciating the quality of the
surrounding soft tissues will be critical to
planning a successful revision surgery. It is
important to know what tissue is viable and
to what extent it can be mobilized. Understand
from where local flaps can be raised and how
far they can be rotated. These are important
questions that only the experienced surgeon
can answer. Do not attempt a primary or
secondary palatal surgery unless you under-
stand the challenges and can fully visualize
the end result. Palatal surgery is conceptually
simple but technically most difficult. This is
an extremely important point and must never
be overlooked.
• When the defect/fistula is severe and a
good surgical option not apparent, always
consider a prosthetic option. Frequently
a palatal obturator of some type can be
made to separate the oral and nasal cavities.
A qualified dentist or prosthodontist
would be required to take an impression
and fabricate the appliance. These can also
be considered with patients that are not
candidates for general anesthesia. Medically
compromised patients fall into this category.
Not all palatal/alveolar defects can be
treated in this manner but many can. It is an
inexpensive, nonsurgical option that should
be part of the cleft surgeon’s armamentarium.
References
Most of the didactic information contained in this
chapter is taken from notes based on 30 years of expe-
rience performing cleft palate surgery in developing
countries. Additional resources include:
1. Assael LA. Maxillary intraoral reconstruction with
regional flaps. Atlas Oral Maxillofac Surg Clin North Am.
1995;3(1):63–73.
2. Dufresne CR. Oronasal and nasolabial fistulas. In: Bar-
dach J, Morris HL, eds. Multidisciplinary Management of
Cleft Lip and Palate. Philadelphia, PA: Saunders; 1990:​
425–436.
3. Losee JE, Smith DM, Vecchione L, Afifi AM, Ford MD.
Post-palatoplasty fistulae: diagnosis, treatment, and
prevention. In: Losee JE, Kirschner RE, eds. Comprehen-
sive Cleft Care. New York, NY: McGraw-Hill Medical;
2008:525–554.
4. Kapetansky DI. Secondary repair of persistent hard pal-
ate fistula. In: Kapetansky DI, ed. Techniques in Cleft Lip,
Nose, and Palate Reconstruction. Philadelphia, PA: Lippin-
cott; 1987:122–124.
5. Millard RD Jr. Secondary fistulae. In: Millard RD, ed. Cleft
Craft. Boston, MA: Little Brown & Co; 1980:809–824.
6. Millard RD Jr. Development of the palatal island flap for
nasal lining. In: Millard RD, ed. Cleft Craft. Boston, MA:
Little Brown & Co; 1980:525–542.

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Section VIII
Velopharyngeal Insufficiency

(Trang không có chữ)

247
Chapter 17
Evaluation and Management of
Speech and Resonance Disorders
Jean E. Ashland and Marie J. Rozeboom
Abstract
Speech and resonance assessment protocols include nonin-
strumental and instrumental assessment, depending on the
age of the child. Noninstrumental assessment includes evalu-
ation of nasalance or resonance balance via perceptual listen-
ing and nasal mirror exam. In addition, there is assessment
of speech sound production abilities, oral motor function,
and language skills. Age of the child and degree of language
acquisition guide the testing process. Testing for children
under 3 years of age utilizes more informal approaches.
Instrumental assessment of soft palate function for speech
generally is initiated at 4 years of age when sufficient speech
and language skills have emerged. Instrumental procedures
include nasometry to assess nasal airflow, videofluoroscopy,
and nasoendoscopy. MRI is being used in research formats
to assess velopharyngeal function. Surgery is always pur-
sued first when an anatomic defect prevents velopharyngeal
(VP) closure. Therapy is generally pursued first when a child
achieves inconsistent velopharyngeal closure or has sound
specific velopharyngeal insufficiency (VPI), such as nasal air
emission with /s/. It is not uncommon for children to receive
a combination of surgical intervention and speech therapy
through the course of management of their cleft palate.
Approaches to resonance therapy for children under 4 years
of age include establishing accurate articulation placement
and achieving age-appropriate articulation skills. Accurate
placement and production is critical before pursuing surgi-
cal intervention to maximize VP closure. Visual and audi-
tory feedback for maximizing oral airflow and minimizing
compensatory speech patterns can be added to the treatment
protocol when children are 4 years of age or older.
The speech-language pathologist plays an essential
role in managing the care of children with craniofa-
cial anomalies and cleft palate. This role includes both
assessment and intervention for speech and resonance
concerns as well as feeding. In the first year of life,
feeding is the primary focus in the presence of a cleft
palate, with assessment of early speech and prelan-
guage development later in infancy. Assessment proto-
cols for speech and resonance include noninstrumental
and instrumental assessment, depending on the age of
the child. As language emerges in the toddler period,
noninstrumental assessment is initiated with percep-
tual assessment of resonance balance and testing of
speech sound production abilities, oral motor func-
tion, and language skills. Instrumental assessment of
soft palate function for speech is generally initiated
at 4 years of age when sufficient speech and language
skills have emerged. Instrumental procedures include
nasometry to assess nasal airflow, videofluoroscopy,
and nasoendoscopy. Selection of instrumental proce-
dures may vary across centers. The speech-language
pathologist and otolaryngologist work closely together
in this assessment process. There are resonance screen-
ing protocols available to the otolaryngologist to deter-
mine whether further testing is warranted with the
assistance of the speech language pathologist. Kum-
mer1 provides speech samples for informal assessment
of voice, resonance, and articulation to assist the otolar-
yngologist in treatment planning, including referrals to
speech language pathology.
Noninstrumental Assessment
Noninstrumental assessments are typically the sole
evaluation method until a child reaches at least 4 years
of age, when he or she has sufficient speech sound

248
Video Atlas of Cleft Lip and Palate Surgery
production capabilities and compliance levels to incor-
porate instrumental assessment methods. Noninstru-
mental evaluations include an oral motor exam and
perceptual assessment of vocal loudness, vocal quality,
intraoral air pressure, the presence of nasal air emis-
sions and/or turbulence, and the degree of hyperna-
sality perceived.2,3 Perceptual evaluation scales are
also used as a means of noninstrumental assessment to
quantify the degree of VPI. One of the most commonly
used is that of McWilliams and Phillips, which is some-
times referred to as the Pittsburgh Weighted Speech
Scale.4 Efforts to develop a universal rating scale of
perceptual measures of velopharyngeal function con-
tinue in order to provide professionals with a standard-
ized approach to report outcome measures on a global
level.5 The challenges are to develop measures that will
span all languages and to institute change from cur-
rent approaches. The proposed universal rating scale
by Henningsson and colleagues in 2008 continues to
be examined.5
The Following Elements Comprise the
Noninstrumental or Perceptual Exam
Oral Motor Exam
Assessment of oral and facial anatomy is completed,
including visualization of the hard/soft palate at rest
and during sustained phonation. Symmetry, coordi-
nation, and structure of the articulators (lips, palate,
tongue, and jaw) are examined. Also, dental occlusion
is documented in relation to speech production.
Vocal Loudness
Vocal loudness parameters are observed in conver-
sation as well as structured activities to observe the
range of loudness and ability to sustain loudness in
connected speech. Children with a history of cleft pal-
ate may present with reduced vocal loudness due to
incompetent valving of the velopharyngeal mechanism
and leakage of airflow via the nasopharynx. This may
manifest itself in reduced vocal volume and/or shorter
length of utterances to compensate for the degree of air
loss the child is experiencing.
Vocal Quality
It is important to note whether a child presents with
hoarseness and/or breathiness during the perceptual
evaluation. Children with repaired clefts may engage
in compensatory valving mechanisms, which may
result in pathologies such as vocal nodules.2,6
Intraoral Air Pressure
Use of standard phrases weighted with sibilant speech
sounds (eg, Suzy sees a horse) and plosive consonants
(eg, Pick up the puppy) assists the evaluating clinician
in identifying any intraoral pressure deficits. Children
with cleft palate may present with reduced intraoral
air pressure for speech sound production secondary
to leakage of airflow via the nasopharynx. Diagnostic
therapeutic approaches, such as nasal occlusion during
speech efforts (eg, cul-de-sac test7) are used to monitor
improvement in intraoral pressure and speech produc-
tion. Positive speech changes with use of nasal occlu-
sion may be used informally in the clinical setting to
support candidacy for secondary surgical intervention.
Nasal Air Emissions/Turbulence
A nasal mirror is used to identify the presence of inau-
dible nasal air emissions during production of nonna-
sal speech sounds. The presence of audible nasal air
emissions or nasal turbulence in spontaneous speech
and during speech evaluation tasks is also noted. Gen-
erally, nasal turbulence is indicative of a small defect,
whereas frank nasal air emission is representative of a
larger velopharyngeal gap.8,9
Instrumental Assessment
Nasometry
Nasometry offers a baseline instrumental assessment
to measure nasal air emissions that is noninvasive. It
is often used pre- and postoperatively for secondary
surgical procedures as well as in resonance therapy
to monitor for progress. Nasometry is a computer-
based measurement of nasal acoustic energy within
speech.10 A headset with two-directional microphones
(nasal and oral) is connected through a converter to a
computer. The child being evaluated wears the head-
set and voices standardized passages. A nasalance
score relating the nasal acoustic energy as related to
the total acoustic energy is displayed graphically on
the computer screen, and a nasalance score is gener-
ated. The score is then compared to normative data,
such as with the MacKay-Kummer Simplified Naso-
metric Assessment Procedures (SNAP) test.11 Addition-

Evaluation and Management of Speech and Resonance Disorders
249
ally, nasometry can be useful in therapy in the form of
biofeedback. It should be noted that Sweeny and Sell12
reported a weak correlation between nasalance scores
and resonance treatment outcomes for VPI. Kummer,10
however, supports use of nasometry scores when the
computer recordings match perceptual judgment of
nasal resonance.
Videofluoroscopy or Multiview Fluoroscopy
Videofluoroscopy or multiview fluoroscopy was for
many years the primary means of assessing velopha-
ryngeal closure. Three views are traditionally used after
instilling a small amount of high-density barium into
the child’s nose to coat the nasopharynx. The anterior–
posterior view allows assessment of lateral pharyngeal
wall motion. The lateral view allows visualization of
palatal motion and the posterior pharyngeal wall. The
closure pattern of the sphincter is viewed directly in
the base view. Videofluoroscopy provides excellent
visualization of the shape of the velum and angle of
elevation in lateral view, and may serve as a better
tolerated alternative for children who are noncompli-
ant with nasopharyngoscopy. The requirement of ion-
izing radiation, 2-D representation of VP mechanism,
and potential difficulties in standard positioning with
a noncompliant child are potential limitations of the
study. One should remember that videoflouroscopy
and nasopharyngoscopy often provide complementary
information.
Case Example (Video of Videofluoroscopy)
This is a videofluoroscopy exam of a 12-year-old female
with repaired unilateral cleft lip and palate. The video
displays reduced soft palate shaping and incomplete
velopharyngeal closure for plosive speech sounds
/p, b, g, k/ and sibilant sounds /s, z/. Lateral wall
motion closely approximates the midline. The coronal
view shows a circular pattern with reduced soft palate
motion in the superior quadrant.
Nasoendoscopy
Flexible nasoendoscopy permits excellent visualization
of the velopharyngeal mechanism in most children.
The flexible endoscope is passed transnasally to a posi-
tion in the posterior nasal cavity allowing a complete
view of the velum and nasopharynx. Children of all
ages can be evaluated anatomically; however, it is gen-
erally around 6 years of age that children can cooperate
and perform comprehensive volitional verbalization
tasks for a complete evaluation. Flexible nasoendos-
copy provides a three-dimensional view of the nasal
surface of the palate and may provide the only sign of a
submucous cleft palate as described previously. Addi-
tionally, flexible nasoendoscopy allows an examination
of the larynx, which may uncover additional patholo-
gies associated with compensatory measures, such as
vocal nodules, that may have developed in response
to the VPI.3
MRI (Video of Cine MRI)
The evaluation of velopharyngeal insufficiency contin-
ues to evolve. Of recent note, the utility of magnetic
resonance imaging (MRI) as an evaluation tool has
emerged as stronger magnets and imaging algorithms
have been developed. These new advancements have
provided high-resolution detailed pharyngeal move-
ment visualized without ionizing radiation.13–16 The
following video example of a cine MRI was collected
by Silver and colleagues17 using speech phrases and
simultaneous recording of the voice during the MRI.
The premise of cine MRI use with VPI is that the
dynamic visualization and measurements of the ana-
tomic defect during speech efforts will enable indi-
vidualized surgical planning to precisely target the
specific underlying muscular defect in each individ-
ual patient.18 Cine MRI has successfully been used to
assess the levator veli palatini muscle in individuals
with cleft palate in relation to velopharyngeal function
and to assist with diagnosing and surgical planning
of occult submucous cleft palate. 18,19,20 Defining the
muscle function and muscle distribution contributes to
better understanding of the biomechanics of velopha-
ryngeal mechanism and hopefully improved outcomes
for treating velopharyngeal dysfunction.21
Assessment:  Infancy
Through Childhood
Infancy (Birth to 12 Months)
Feeding
When does the infant or child with cleft palate first meet
the speech-language pathologist? The first encounter is

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Video Atlas of Cleft Lip and Palate Surgery
generally as a newborn in the acute care setting when
feeding concerns arise in the presence of a cleft palate
(unilateral or bilateral). The family and infant benefit
from guidance for feeding techniques and selection of
feeding devices or bottles that will be optimal for the
baby to meet his or her nutrition needs.22 This is an
excellent opportunity for the family to be introduced
to the concept of team care for their child with a cleft.
Follow-up after discharge home may be required pend-
ing feeding progress. 23 The next encounter often occurs
at 6 months when babies are transitioning to spoon-
feeding prior to cleft palate repair. In nonsyndromic
cases, parents benefit from early assistance with feed-
ing their infant to avoid frustration and to maximize
efficient feeding behaviors. When a syndrome or addi-
tional medical complications are present, the concern
for swallow coordination and aspiration may be a fac-
tor. The speech-language pathologist can assist with
assessment and management of dysphagia.22
Early Speech/Resonance Development
Following palatoplasty at 6 to 9 months, the speech lan-
guage pathologist may screen early babbling/jargon
development. Guidelines and strategies for monitor-
ing and intervening with compensatory voicing behav-
iors, such as glottal stops, can be offered to families to
develop good early speech habits prior to the palato-
plasty. 6,24 Often, at 1 year of age, children are first seen
by a multidisciplinary craniofacial/cleft palate team
for baseline assessment.
Toddler (13 to 24 Months)
Feeding
Feeding skills are generally established following pal-
atoplasty. However, if there are persistent difficulties
with feeding, the pediatric speech-language patholo-
gist can provide additional assessment and treatment
when indicated.
Speech
As the child approaches 18 months of age, frustrations
may arise with communication if there is impaired
competency of the velopharyngeal valve. Nasal air
emissions and reduced intraoral pressure can lead
to compensatory speech strategies (eg, glottal stops,
pharyngeal fricatives) and deviant articulation place-
ment.25 A pediatric speech-language pathologist with
background in resonance issues can assess early speech
development. Test outcomes will determine if interven-
tion is needed to establish accurate articulation place-
ment and maximize oral airflow.
Resonance
Generally, noninstrumental assessment methods as
described previously are used to evaluate resonance at
this age due to limited speech production capabilities.
Language
It is important to assess early language development
at 18 months and 2 years of age to ensure children are
functioning at age level. Lengthy or repeated hospital-
izations, psychosocial issues, frequent ear infections,
and cognitive deficits risk language delay in children
with cleft palate and/or craniofacial anomalies with
associated syndromes.26,27
Children (2 to 4 Years of Age)
Oral Motor Exam
Assessment of the oral and facial anatomy is com-
pleted, including visualization of the hard/soft palate
at rest and during sustained phonation. Structure and
movement of the articulators (lips, tongue, jaw, and
palate) are examined. Also, dental occlusion is evalu-
ated in relation to speech production.
Speech
Standardized testing may begin as early as 3 years of
age to assess speech development. If needed, informal
testing can be done via observation and parent report.
A speech sound inventory can be gathered, and speech
errors can be categorized as developmental or structur-
ally based related to the cleft. Delays in speech sound
development are frequently identified in preschool-
aged children with a history of cleft palate.28
Resonance
Generally, noninstrumental assessment methods de-
scribed previously are used at this age to assess reso-
nance unless a child demonstrates adequate speech

Evaluation and Management of Speech and Resonance Disorders
251
capabilities and compliance to participate in instru-
mental evaluation tasks.
Language
Receptive and expressive language skills should be
monitored to ensure a child is functioning at age level,
as research suggests children with a history of cleft pal-
ate are at risk for delayed expressive language devel-
opment.26 Vocabulary, direction following capabilities,
and emergence of early developing grammatical mark-
ers are a few skills that are assessed.
Assessment of Children
Older Than 4 Years of Age
Speech Standardized Articulation Assessments
Speech standardized articulation assessments are used
to identify the presence of developmental articulation
errors/phonological processes and distinguish these
patterns from deviant speech errors secondary to the
repaired cleft palate. Diagnostic therapy methods may
be trialed during the evaluation to see if the child is
stimulable for a reduction in hypernasality or air emis-
sion with changes in placement of the oral articula-
tors.25 If developmental errors or compensatory speech
errors are noted, speech therapy may be initiated to
promote proper articulation placement and oral air-
flow prior to pursuing secondary surgery.
Resonance
A combination of noninstrumental and instrumental
assessment methods described previously are used to
assess resonance at this age. The evaluating speech-
language pathologist assists the surgeon in deter-
mining if resonance therapy or secondary surgery is
indicated at this time. A pediatric speech-language
pathologist with a background in resonance may initi-
ate resonance therapy if appropriate to promote oral
airflow and improve resonance balance.
Language
Ongoing assessment of receptive and expressive lan-
guage skills should continue in order to ensure a child
is functioning at age level. As children enter the school
environment, language demands increase, and they
may become frustrated with communication chal-
lenges with their peers and/or teachers. Language
evaluations at this age should also include assessment
of early reading skills, as research suggests children
with cleft palate and speech deficits are at higher risk
for delays in development of early literacy skills.27
A timeline for noninstrumental and instrumental
assessment is outlined in Table 17–1.
Therapy Versus Surgery
One of the perpetual challenges in treatment of children
with cleft palate is deciding when to pursue therapy
and when to pursue surgical management. Typically,
secondary surgery is not pursued until 3 or 4 years of
age due to airway concerns and inability to participate
in instrumental assessment measures.3 Figure 17–1A
outlines therapeutic versus surgical intervention deci-
sion making, whereas Figure 17–1B details who is a
candidate for each respective type of intervention.
Figure 17–1A also delineates when speech and reso-
nance reassessment is indicated, including nasometry.
Surgery is always pursued first when an anatomical
defect prevents velopharyngeal closure.25 Therapy is
generally pursued first when a child achieves inconsis-
tent velopharyngeal closure or has sound-specific VPI,
such as nasal air emission with /s/.6,24 It is not uncom-
mon for children to receive a combination of surgical
intervention and speech therapy through the course of
management of their cleft palate.
Treatment:  Infancy Through Childhood
Toddler (18 Months to 3 Years)
Typically, speech therapy is initiated well before 3 years
of age in order to facilitate development of early speech
sounds and remediate developmental speech errors. It
is critical to develop appropriate speech sound place-
ment prior to pursuing secondary surgery.3 Compen-
satory speech errors may also be targeted during this
time through play-based therapy methods.
Early Childhood (3 to 5 Years of Age)
As children acquire a larger speech sound repertoire
and vocabulary, resonance balance becomes a more

252
Video Atlas of Cleft Lip and Palate Surgery
central focus of therapy in addition to continued reme-
diation of speech production and compensatory strate-
gies. If a child presents with deviant speech patterns
not amenable to diagnostic therapy techniques or due
to structure alone, secondary surgical intervention may
be pursued. 6,25,29 Speech and resonance therapy is gen-
erally resumed after recovery from secondary surgery
to maximize the benefits of surgical invention.
School-Aged Children
(5 Years of Age and Older)
Some children continue to have deviant speech errors
that require therapy beyond the early childhood years.
If a child plateaus or does not make progress in therapy
throughout the course of treatment, he or she should
be referred back to the surgeon or cleft palate team for
consideration of additional surgical intervention. 6,25
Therapy Aids with Biofeedback
The use of biofeedback in speech and resonance therapy
is highly beneficial when the child has the capability
to achieve complete velopharyngeal closure.25 Visual
feedback methods include use of nasometry and/or
See-Scape device, whereas auditory feedback methods
include use of a simple straw or listening tube. 6,29 Each
method provides a child feedback regarding changes in
hypernasality and/or resonance while reinforcing correct
production. Biofeedback is particularly effective when a
child is stimulable, but not consistent, in achieving accu-
rate productions with diagnostic therapy techniques.
Table 17–1.  Time Line for Noninstrumental and Instrumental Assessment
VPI and Feeding
ASSESSMENT
Infancy:
Birth–12 months
Toddler:
13 months–2 years
Children:
2–4 years
Older Children:
4 years and older
NONINSTRUMENTAL ASSESSMENT
Feeding
Birth
6 months
Acute postoperative
consult
N/A (unless problems)
N/A (unless
developmental feeding
issues)
N/A (unless developmental
feeding issues)
Speech and Resonance
6–9 months
1 year (babbling,
glottal stops)
1 year
18 months
2 years
Annually if not at age
level
After designated
resonance therapy trial
Annually if not at age level
After secondary palatal surgery
After designated resonance
therapy trial
Language
1 year
2 years
Annually as needed
Annually as needed
INSTRUMENTAL ASSESSMENT
Nasometry
N/A
N/A
N/A
4 years old minimum (obtain
baseline)
Repeat after secondary surgery
Repeat after designated period
of resonance therapy
Nasoendoscopy
N/A
N/A
N/A
4 years old minimum (center
dependent)
Videofluoroscopy
N/A
N/A
N/A
4 years old minimum (center
dependent)

253
A
B
Figure 17–1.  Algorithm for treatment of speech and resonance disorders.

254
Video Atlas of Cleft Lip and Palate Surgery
References
1. Kummer A. A screening assessment of voice, resonance,
and articulation: a guide for the otolaryngologist. Curr
Opin Otolaryngol Head Neck Surg. 2001;9:369–373.
2. Kuehn D, Moller K. Speech and language issues in the
cleft palate population: the state of the art. Cleft Palate
Craniofac J. 2000;37(4):​348-1–348-35.
3. Rudnick E, Sie K. Velopharyngeal insufficiency: current
concepts in diagnosis and management. Curr Opin Oto-
laryngol Head Neck Surg. 2008;16:530–535.
4. McWilliams B, Phillips B. Velopharyngeal incompetence.
In: Audio Seminars in Speech Pathology. Philadelphia, PA:
WB Saunders; 1979.
5. Henningsson G, Kuehn D, Sell D, Sweeney T, Trost-
Cardamone JE, Whitehill TL. Universal parameters for
reporting speech outcomes in individuals with cleft pal-
ate. Cleft Palate Craniofac J. 2008;45(1):1–17.
6. Peterson-Falzone S, Trost-Cardamone J, Karnell M. Artic-
ulation therapy for school-age children. In: The Clinician’s
Guide to Treating Cleft Palate Speech. St. Louis, MO: Mosby;
2005:124–160.
7. Bzoch K, ed. Measurement and Assessment of Categorical
Aspects of Cleft Palate Speech. Boston, MA: Little Brown
and Co.; 1979;No. 2.
8. Kummer A, Briggs M, Lee L. The relationship between
characteristics of speech and velopharyngeal gap size.
Cleft Palate Craniofac J. 2003;40:590–596.
9. Kummer A, Curtis C, Wiggs M, Lee L, Strife J. Compari-
son of velopharyngeal gap size in patients with hyper-
nasality, hypernasality and nasal emission, or nasal
turbulence (rustle) as the primary speech characteristic.
Cleft Palate Craniofac J. 1992;29(2):152–156.
10. Kummer A. Nasometry. Cleft Palate and Craniofacial
Anomalies: The Effects on Speech and Resonance. 2nd ed. San
Diego, CA: Singular; 2008:377–407.
11. MacKay I, Kummer A. Simplified Nasometric Assessment
Procedures, the MacKay-Kummer SNAP Test. 2nd ed. Lin-
coln, NJ:Kay Elemetrics; 1994.
12. Sweeny T, Sell D. Relationship between perceptual rat-
ings of nasality and nasometry in children/adolescents
with cleft palate and/or velopharyngeal dysfunction. Int
J Lang Commun Disord. 2007;3:1–18.
13. Bae Y, Kuehn D, Sutton B, Conway C, Perry J. Three-
dimensional magnetic resonance imaging of velopha-
ryngeal structures. J Speech Lang Hear Res. 2011;54(6):​
1538–1545.
14. Perry J, Kuehn D. Magnetic resonance imaging and com-
puter reconstruction of the velopharyngeal mechanism. J
Craniofac Surg. 2009;20:1739–1746.
15. Sato-Wakabayashi M, Inoue-Arai MS, Ono T, Honda E,
Kurabayashi T, Moriyama K. Combined fMRI and MRI
movie in the evaluation of articulation in subjects with
and without cleft lip and palate. Cleft Palate Craniofac J.
2008;45:309–314.
16. Sutton B, Conway C, Bae Y, Seethamraju R, Kuehn D.
Faster dynamic imaging of speech with field inhomoge-
neity corrected spiral fast low angle shot (FLASH) at 3 T.
J Mag Res Imag. 2010;32(5):1228–1237.
17. Silver A, MD, Nimkin K, MD, Ashland JPS. Cine mag-
netic resonance imaging with simultaneous audio to
evaluate pediatric velopharyngeal insufficiency. Arch
Otolaryngol Head Neck Surg. 2011;137(3):258–263.
18. Perry J, Kuehn D, Sutton B, Goldwasser M, Jerez A.
Craniometric and velopharyngeal assessment of infants
with and without cleft palate. J Craniofac Surg. 2011;​22(2):​
499–503.
19. Atik B, Bekerecioglu M, Tan O, Etlik O, Davran R, Arslan
H. Evaluation of dynamic magnetic resonance imaging
in assessing velopharyngeal insufficiency during phona-
tion. J Craniofac Surg. 2008;19(3):566–572.
20. Kuehn D, Ettema S, Goldwasser M, Barkmeier J, Watchel
J. Magnetic resonance imaging in the evaluation of occult
submucous cleft palate. Cleft Palate Craniofac J. 2001;​38(5):​
421–431.
21. Ettema S, Kuehn D, Perlman A, Alperin N. Magnetic
resonance imaging of the levator palatine muscle during
speech. Cleft Palate Craniofac J. 2002;39(2):130–144.
22. Miller C. Feeding issues and interventions in infants and
children with clefts and craniofacial syndromes. Semin
Speech Lang. 2011;32(2):115–126.
23. Reid J, Kilpatrick N, Reilly S. A prospective, longitudinal
study of feeding skills in a cohort of babies with cleft con-
ditions. Cleft Palate Craniofac J. 2006;43(6):702–709.
24. Golding-Kushner K. Therapy Techniques for Cleft Palate
Speech and Related Disorders. San Diego, CA: Singular; 2001.
25. Kummer A. Speech therapy for errors secondary to cleft
palate and velopharyngeal dysfunction. Semin Speech
Lang. 2011;32(2):191–198.
26. Neiman G, Savage H. Development of infants and tod-
dlers with clefts from birth to three years of age. Cleft
Palate Craniofac J. 1997;34(3):218–225.
27. Hardin-Jones M, PhD, Chapman K, PhD. Cognitive and
language issues associated with cleft lip and palate.
Semin Speech Lang. 2011;32(2):127–140.
28. Hardin-Jones M, Jones D. Speech production in pre-
schoolers with cleft palate. Cleft Palate Craniofac J. 2005;​
42(1):​7–13.
29. Kummer A. Cleft Palate and Craniofacial Anomalies: Effects
on Speech and Resonance. 2nd ed. San Diego, CA: Thomas
Learning; 2008.

255
Chapter 18
Prosthetic Rehabilitation for
Velopharyngeal Insufficiency
Matthew J. Jackson
Abstract
The coordination and improvement of therapies have evolved,
enhancing outcomes and quality of life for individuals with
velopharyngeal insufficiency (VPI). As a consequence, the
burden has lessened on the maxillofacial prosthodontist,
reducing the prosthetic complexities previously required.
Surgery, dental, and orthodontic/orthopedics coupled with
speech therapy ideally should be adequate. However, less
than ideal outcomes will occur resulting in persistent VPI
with hypernasal speech and/or nasal regurgitation of food
and liquids. Presented here are the various prostheses, such
as the obturator/speech aid prostheses, palatal lifting devices,
or combinations of these, necessary to resolve VPI. Various
problems uniquely found in the cleft palate patient are dis-
cussed as well as anatomical guides to maximize prosthetic
clinical success and fabrication techniques.
In our cosmetic culture, congenital facial deformities
such as cleft palate elicit negative responses. To prop-
erly habilitate such individuals into society, a multi-
disciplinary cleft palate team is required. A cascade of
treatments and therapies will be necessary from birth
to early adulthood. Our goal is to enhance communi-
cation, restore function, and improve facial aesthetics.
The prosthodontist’s role has evolved over the
years due to improvement in different surgical proce-
dures, orthodontics/orthopedics, and speech therapy.
These enhancements have lessened the burden on the
prosthodontist and the patient, reducing the prosthetic
complexities. Although many prosthetic advancements
have occurred, the objective is still to improve aesthet-
ics, speech, mastication, and swallowing.
Terminology
The terminology for the various prostheses employed
can be extensive. Terms such as obturator, palatal lift,
speech appliance, speech aid, or speech bulb are used
interchangeably and can be confusing to the lay per-
son or professional. By using several anatomic com-
ponents of the maxillary deformity, hard palate, soft
palate, pharynx, or any combination of these, the vari-
ous names of the prostheses can be established.1
The nomenclature recommended for the prosthe-
ses used to treat velopharyngeal insufficiency (VPI) or
“palatopharyngeal insufficiency” is2:
1. Obturator/speech aid prosthesis.
2. Palatal lift or combination of the above.
3. Nasal valve.
Obturator/Speech Aid
Prosthesis (Figure 18–1)
The obturator prosthesis involves restoration of the
hard palate and alveolar deformities, whereas the
speech aid appliance is used in soft palate deformities
to separate the oropharynx from the nasopharynx.3
This rehabilitates and restores the palatopharyngeal
sphincter function. Additional prosthetic aspects
can be placed contacting the functional pharyngeal
walls. Closure of these residual portals prevents nasal
regurgitation of food and/or liquids while improv-
ing speech intelligibility, mastication, and swallowing.

256
Video Atlas of Cleft Lip and Palate Surgery
When the velum is short and scarred and the ratio of
velar length to nasopharyngeal depth is excessive, the
obturator/speech aid prosthesis substitutes for this tis-
sue deficiency.4–7
By properly positioning the prosthetic in the
deficient anatomic location, one can stimulate the
neuro­musculature activity of the lateral and poste-
rior pharyngeal walls. Over time, strengthening of the
native pharyngeal tissue may allow one to downsize
the prosthetic bulb.
Another variant of prosthetic obturation is the
meatal obturator (Figure 18–2).2 This is a static pros-
thesis extending obliquely cephalad from the junction
of the hard and soft palate to occlude against the tur-
binates and the superior aspect of the nasal cavity. The
disadvantage of this type of obturation is that it tends
to make the patient’s speech hyponasal by impeding
nasal airflow. Hyponasal speech may be improved by
boring holes through the meatal extension, creating a
more balanced airflow and speech quality. This type
of prosthesis can also be used in conjunction with a
conventional functional obturator targeting the naso-
pharyngeal deficiency. Such a combination can be of
great help when the entire soft palate has been lost.
This design will reduce leverage factors on the pros-
thesis, but it will not permit function of the pharyngeal
musculature against it. If speech is the primary issue
as opposed to swallowing or nasal regurgitation, this
approach would be indicated.
Palatal Lifting Prosthesis
The palatal lifting prosthesis, with or without an obtu-
rator/speech aid prosthesis, is employed when there
is adequate length of the soft palate but the dynamic
motion of the soft palate is poor as a consequence of
neuromuscular etiologies and/or scarring. The objec-
tive of the lift is to reduce the distance the soft palate has
to traverse to produce adequate closure.5,6,8,9 A hybrid of
the two previously described prostheses is termed “lift-
obturator” and is useful when elevation of the velum
itself is insufficient to develop closure (Figure 18–3).
Nasal Valve
A nasal valve is a prosthesis custom fitted to each nos-
tril. This is a one-way valve allowing the patient to
breathe in through the nose or valve but it stops nasal
air escape with exhalation or speech. It is designed pri-
marily for speech, not nasal regurgitation issues. Dis-
lodgement due to excessive exhalation is often quite
troublesome.2,6
Figure 18–1.  Obturator/speech aid prosthesis extending into
the space between the soft palate and pharyngeal walls. Note
the forcible elevation of the velum distally.
Figure 18–2.  Diagram indicating the two different positions of
the meatal and conventional obturator/speech aid prosthesis.5

Prosthetic Rehabilitation for Velopharyngeal Insufficiency
257
All these prostheses can be used as a temporary
reversible trial providing diagnostic information for
surgical correction when it is unclear whether surgery
will significantly improve speech quality. However,
a prosthesis is the primary treatment when the indi-
vidual is medically compromised prohibiting surgery,
refuses surgery, or has any other surgical contraindi-
cation. In these cases, the various prostheses become
the permanent treatment for VPI.3 Today’s young cleft
palate patients require less complex prosthetics due to
surgical advances and an increased understanding of
growth, dentistry, and speech.10 The more challenging
prosthetic dilemmas are found in older patients, where
they did not benefit from newer techniques and have
less than ideal therapeutic results.
Prosthetic Deficiencies
Associated with Cleft Palate
Oral deficiencies of the treated cleft palate population
are often a result of posttreatment aberrations. They
can be categorized as follows5–6:
1. Vertical dimension:  The lateral and anterior seg-
ments of the maxilla are hampered from devel-
oping in their normal downward and forward
pattern. In the vertical plane, it will result in verti-
cal dimension of the jaws with overclosure of the
normal mandible (Figure 18–4).
2. Maxillary constriction:  This is due to the effects of
the surgical lip repair on tissue areas in the cleft
that impede normal lateral and anterior growth,
collapsing the maxilla in the horizontal plane (Fig-
ures 18–5 and 18–6).
3. Teeth:  Supernumerary, hypoplastic, or missing teeth
in the cleft region.
4. Speech:  The composite of teeth, hard and soft pal-
ate, and lip deficiencies produces distortion in
voice quality, intelligibility, and articulation.
Although a prosthesis can treat and resolve many
or all of these issues, ideally the therapy of choice
should still be surgery.4 Replacement of missing or
malformed teeth should be the only need for pros-
thetics. Repairing the lip is always indicated as soon
as possible. With orthodontics/orthopedics, one can
achieve a more normal growth pattern of the cleft
segment.10–13
Lateral growth of the maxilla is completed by 6
years of age. During this interval, prosthetic manage-
ment can achieve improved speech and swallowing.
It has been found that a prosthesis must be placed
prior to the development of meaningful speech if it
is to improve articulation sounds. In the long term to
improve speech, surgical repair and intervention are
preferred. When surgical intervention is less than opti-
mal, it can lead to problems that can be addressed by a
prosthesis and/or orthodontics.9,14
Concerning Vertical Dimension
When the provider attempts restoration in the horizon-
tal plane for facial contour, aesthetics, or occlusion, it
will often lead to compromise in the vertical plane. As
Figure 18–3.  Infant obturator combined with orthopedic palatal
expander.

258
Video Atlas of Cleft Lip and Palate Surgery
maturity continues, the mandible will grow normally
relative to the maxilla, and the discrepancy between the
two arches becomes more pronounced. As the discrep-
ancies become more evident, the lack of opposing tooth
stops as the mandible closes results in an upward and
forward movement of the lower jaw with the condyles
malpositioned anteriorly and forward to the glenoid
fossa until the patient finally obtains an occlusal stop.
Consequently, the patient becomes prognathic and may
develop temporomandibular joint dysfunction (TMD).
The maxillary anterior teeth now could be as much as
5 to 10 mm behind the mandibular incisors in labial
version. By reestablishing the vertical dimension to a
more superior position in the vertical plane, the two
jaw relationships markedly improve, minimizing the
problems associated with overclosure. The condyle is
then repositioned into the glenoid fossa. Often, when
missing teeth require restoration and there is a palatal
defect, restorative dentistry can be incorporated with
the obturator/speech aid prosthesis.
A
B
Figure 18–4.  A. Overclosure in the vertical plane resulting in the condyle anteriorly displaced out of the glenoid fossa with
overprominence of the chin. B. Increase in the vertical plane resulting in repositioning the condyles into the glenoid fossa and
reducing the overclosure of the dentition and mandible.
Figure 18–5.  Maxillary constriction with overclosure in the
vertical plane.
Figure 18–6.  Constricted maxilla and bilateral crossbite.

Prosthetic Rehabilitation for Velopharyngeal Insufficiency
259
Maxillary Constriction Prosthetic
Treatment Concepts
The resultant constricted maxilla is a consequence of
the limited success of the surgical/dental procedure.
This arises from the forces of the repaired restricted
cleft lip and type and size of the cleft palate. With the
bilateral cleft patient, the maxillomandibular relation-
ship will be a crossbite. For unilateral clefts, constriction
will only be on the cleft side. In such cases, the over-
lay denture is utilized. Here the constricted maxilla is
“overlayed” in the horizontal plane by a flange facially
to the patient’s own teeth and ridge and restored by
denture acrylic with or without denture teeth. Over-
laying the ridge and teeth or gum will improve the
tooth, labial, and facial contours with gingival acrylic
and denture teeth, improving the lip contour relative to
the opposing mandibular arch. Generally, the overlay
facial flange and artificial teeth should be extended far
posteriorly to create an acceptable aesthetic and facial
support. The primary objective of the overlay prosthe-
sis is to improve aesthetics, function, and articulation
of the teeth.
Surgical correction of the hard and/or soft palate
can be less than desired leading to varying degrees of
speech intelligibility (Figure 18–7). Unfortunately, in
routine general dental prosthetic and restorative pro-
cedures, speech does not play a major role for the gen-
eral dental practitioner. With the practitioner involved
in maxillofacial prosthetics, correction of speech issues
is paramount. When speech is altered due to the lack
of separation of the oropharynx and nasopharynx,
one must understand the nature of the oral, nasal, and
pharyngeal tissues immediately adjacent to or func-
tionally against the prosthesis. These prostheses can
be classified as either static, functional, or a combina-
tion of both. The static obturator touches tissues that
are immobile or static. Examples would be a residual
midline cleft of the hard palate or a floating premax-
illa. A functional obturator, by necessity, will function
against dynamic tissues such as the soft palate or pha-
ryngeal walls.
The functional obturator/speech aid prosthesis
is often needed to resolve VPI after surgical or orth-
odontic procedures (Figure 18–8). These prostheses are
much more technique-sensitive and more difficult in
comparison to the static prostheses. The objective in
VPI prosthetic therapy is for the obturator “bulb” to
function against the various muscle groups involved,
but not to interfere with their movements. Too much
contact will cause displacement, sore spots, and strain
on the retentive abutments of the prosthesis, tending
to dislodge the prosthesis. However, inadequate con-
tact results in abnormal speech and allows food and
liquid to reflux nasally. The complexity increases when
resolving both deficiencies.
Palatal Pharyngeal Landmarks
To fabricate the distal aspect of the prosthesis when cor-
recting VPI, several landmarks will improve the initial
positioning of the functional aspect of the obturator/
speech aid prosthesis. The three starting landmarks are
Figure 18–7.  Short velum unable to seal off the oropharynx
from the nasopharynx.
Figure 18–8.  Obturator and speech aid bulb with a complete
denture resolving VPI.

260
Video Atlas of Cleft Lip and Palate Surgery
the anterior tubercle C1 (Atlas), Passavant’s ridge or
pad, which is the greatest muscle activity of the lateral
and posterior pharyngeal musculature and the exten-
sion of a plane from superior height of the palatal vault
to the pharyngeal walls. These landmarks may not
exactly coincide, however, with the proper functional
waxes, and speech pathologist’s support captures
and records the best speech and swallowing for the
patient. Ultimately, the bulb will fall somewhere within
these parameters. One must remember each segment
of the tissue may exhibit nonsymmetrical movement
and different ranges in activity, especially in a split
soft palate.15
When dealing specifically with VPI, it is required
that the pharyngeal obturator and speech aid prosthe-
sis have less active displacement of tissue relative to
the palatal lift prosthesis, which actively and intention-
ally displaces the soft palate and its associated muscu-
lature. Although the obturator/speech aid prosthesis
does not displace the tissue actively working against
it, its stability results from gravity, weight of the pros-
thesis, and the long lever arm.
Construction and Fabrication
of the VPI Prosthesis
The two major sections when prosthetically restoring a
patient with VPI are the oral and the pharyngeal por-
tions. The oral component is constructed in a conven-
tional prosthetic manner utilizing complete, partial
removable, overlay, fixed partial denture, or various
combinations of these. One must remember in cleft pal-
ate or other congenital malformations of the maxilla
and palate we are dealing with a constricted anatomy
of the maxilla and dental arches that can only be par-
tially restored.16 With the bilateral cleft lip and palate,
this will lead to a bilateral crossbite of the dental arches
of the teeth, whereas the unilateral cleft constriction
will only involve arch misalignment on the cleft side.
The prosthesis has to meet the standard of any conven-
tional prosthetic restoration optimizing support, sta-
bility, and retention. Obviously, modifications must be
made aesthetically and prosthetically to accommodate
aberrations of the lip, maxilla, and teeth. Often mal-
positioned and malformed teeth necessitate removal
for proper anatomic form and prosthesis fit. Gener-
ally, the procedures required will include preliminary
impressions, diagnostic articulation, custom trays for
final impressions, establishment of centric and verti-
cal registrations for articulation, and tentative setup for
verification of centric and vertical measurements.
It is often recommended to insert the oral pros-
thesis first allowing the patient to adjust accordingly.
However, often one can simultaneously fabricate the
oral and pharyngeal sections. This accelerates the rees-
tablishment of speech and swallowing and can provide
instant gratification to the patient.
When fabricating the pharyngeal position, a
retentive loop extension is fastened from the oral sec-
tion posteriorly into the distal deficiency facilitating
retention of the impression materials into the pharyn-
geal defect. Modeling compound is usually employed,
which is a thermoplastic substance placed around the
retentive loop. When heated properly, it will mold to
the pharyngeal deficiency until contact is made. This
material can be added to or removed at the discretion
of the provider when determining the three landmarks
of palate vault, Passavant’s ridge, and the Atlas (C1).
When the modeling compound is warmed, the patient
is instructed to flex his or her neck forward tucking
the chin to the chest. This establishes the Atlas posi-
tion on the impression. The lateral aspect of the bulb is
defined by rotation and flexion of the neck and having
patients touch their left and right shoulder. When com-
pleted, the modeling compound should not permit air
and liquid to flow between the nasal and oral cavities.
The compound is removed and chilled. After establish-
ing the boundaries of the pharyngeal deficiency in the
modeling compound, approximately 1 mm circumfer-
entially is removed. To this cutback, mouth melting
functional temperature wax (ie, Adaptol™, Iowa Wax,
Korecta Wax) is applied. This type of wax will function-
ally mold to anatomical contours at the patient’s body
temperature. This is then reinserted into the patient’s
mouth. The maneuvers previously performed are
repeated. In addition, the patient is asked to speak and
swallow. The wax, with repetition of these exercises,
is left intraorally for at least 10 minutes. This allows
flow and recording of the anatomical function. Any
exposure of the underlying compound is cut back,
and additional wax is added to these areas. Then, the
impression is reinserted and the exercises are repeated.
On completion, nasal breathing should be comfort-
able and unrestrained as well as swallowing. If addi-
tional space is needed for nasal breathing, material
laterally can be removed. However, this might induce
some hypernasality.
Once the low-fusing wax is circumferentially
developed and there is comfortable breathing and swal-
lowing, the wax is removed and chilled. If the pharyn-

Prosthetic Rehabilitation for Velopharyngeal Insufficiency
261
geal extension is secured from the custom dental tray,
the impression is boxed and poured in dental stone in
the conventional way. If the oral portion has been made
prior to the pharyngeal extension, it is poured in dental
stone and joined by the “altered cast technique.” Either
way, the functional and dynamic palatal/pharyngeal
aspects have been captured and can be incorporated
into the prosthesis. The remaining procedures are the
standard dental laboratory procedures, which trans-
form this portion into acrylic resin.
In the case of the soft palate being intact but
inadequate in length to contact the posterior or lat-
eral pharyngeal walls, the soft palate and uvula must
be circumvented in order to obturate the necessary
region of the deficiency. Usually, the telltale presenting
symptom is hypernasal speech. This prosthesis can be
diagnostic or therapeutic often indicating the success
of a pharyngeal flap procedure. Once the pharyngeal
extension extends into the nasopharynx, the previously
mentioned techniques are employed.
The meatal obturator prosthesis is indicated when
the posterior pharyngeal elicits a gag reflex or results
in displacement of the prosthesis. The meatal prosthe-
sis extends or projects statically and vertically at the
posterior aspect of the prosthesis usually at the junc-
tion of the soft and hard palate and obturates the pos-
terior nasal turbinate and superior aspect of the nasal
cavity. This vertical projection tends to be closer to the
hard palate. There is less torque placed on the palatal/
oral portion, decreasing dislodgement. Unfortunately,
the speech tends to be somewhat hyponasal and may
prevent nasal breathing. The rest of the fabrication is
similar. The full extent of the defect is established in a
compound, cut-backed application of wax until entirely
covering the compound with proper adaptation to the
nasal choanae. Again, the prosthesis is completed in
the conventional way. Once placed into the mouth,
one hole is placed on either side of the meatal vertical
extension. This restores nasal breathing and reduces
some of the hyponasality. Also, boring small holes and
using proper angulations should limit nasal reflux.
Another consideration for resolving VPI is the use
of a palatal lift (Figure 18–9). Here the posterior distal
extension elevates the immobile soft palate to the level
of the palatal plane and the anterior tubercle of C1.
The ability and ease of elevation is a direct function of
the elasticity, fibrosis, and muscular activity of the soft
palate. The soft palate is elevated to a functional posi-
tion and this displacement superiorly must be resisted
by the retentive components of the oral part of the
prosthesis. When teeth are involved, adequate reten-
tive clasping will limit displacement. However, with
the edentulous patient, retention could be severely
compromised.5 Adjuncts for retention can be resolved
with dental adhesives or endosseous implants. Simi-
lar construction techniques as before are used. Breath-
ing comfortably can be an issue and is improved by
reducing the prosthetic laterally with the possibility of
some residual hypernasality. Usually, elevating a flac-
cid soft palate can be accomplished with little counter-
force, preventing dislodgement of the lift. However, the
fibrotic and taut palate resists lifting, making retention
by the oral aspect paramount for success.
In the final analysis, the effectiveness of any of
the various prosthetic obturations can only be deter-
mined by the “team.” Speech-language pathologists
are crucial for advising additions or removals of the
obturator/lift to maximize the speech and swallowing
while preventing nasal regurgitation of food and liq-
uid. The prosthodontist attempts to artificially restore
oropharyngeal function, but success is often a product
of the team approach and perhaps more importantly,
the ability of the patients to accept what they have and
adjust to their alternative environment. This applies to
anyone suffering from an acquired or congenital defect.
To summarize what is needed for cleft lip and pal-
ate rehabilitation, Dr. Herbert Cooper states:
A physical defect such as a cleft palate does not nec-
essarily constitute a social handicap. Although the
defect will always be present, the patient must learn
to accept things which cannot be changed, must be
encouraged to change the things that can be changed,
and must be taught to know the difference.11
Figure 18–9.  Design of the palatal lift noting the superior
aspect of the most distal end of the pharyngeal extension.

262
Video Atlas of Cleft Lip and Palate Surgery
References
1. The glossary of prosthodontic terms, 7th ed. J Pros Dent.
1999:81:39–110.
2. Schloegel I. Velopharyngeal dysfunction treatment
and management. Medscape Medline Reference. 2012 Jan.
Retrieved from
3. Yenisey M, Cengiz S, Sarikaya L. Prosthetic treatment of
congenital hard and soft palate defects. Cleft Palate Cra-
niofac J. 2012;49(5):618–621.
4. Moore D, McCordd JF. Prosthetic dentistry and the unilat-
eral cleft lip and palate patient. The last 30 years. A review
of the prosthodontics literature in respect of treatment
options. Eur J Prosthodont Restor Dent. 2004;12(2):70–74.
5. Beumer J, Curtis T, Marunick M. Maxillofacial rehabilita-
tion: prosthodontics and surgical considerations. Ishiyaku
EuroAmerica, Inc. St. Louis, MO; 1996.
6. Rahn A, Boucher, B. Maxillofacial Prosthetics: Principles and
Concepts. Philadelphia, PA: WB Saunders Co.; 1970.
7. Speech prosthesis. School of Dentistry, University of
Minnesota.
8. Shifman A, Finklestein Y, Nachmani A, Ophir D. Speech-
aid prostheses for neurogenic velopharyngeal incompe-
tence. J Prosthet Dent. 2000;83(1):99–106.
9. Reisberg DJ. Dental and prosthodontics care for patients
with cleft or craniofacial conditions. Cleft Palate Craniofac
J. 2000;37(6):534–537.
10. Zhang I, Husein M, Dworschak-Stokan A, Jung J, Matic
DB, Siu V, et al. Neurofibromatosis and velopharyngeal
insufficiency: is there an association? J Otolaryngol Head
Neck Surg. 2012;41(1):58–64.
11. Cooper H, Mazuheri M, Millard R. Psychological, orth-
odontic and prosthetic approaches in rehabilitation of the
cleft palate patient. Dent Clin North Am. 1960:383–393.
12. Mylin W, Hagerty R, Hess D. The pin-retained prosthesis in
cleft palate orthopedics. J South Carolina Med Assoc.; 1965.
13. Pham AV, Abaraca M, De May A, Malevez C. Reha-
bilitation of a patient with cleft lip and palate with an
extremely edentulous atrophied posterior maxilla using
zygomatic implants: case report. Cleft Palate Craniofac J.
2004;41(5):571–574.
14. Fen-Huey L, Tsung-Chin W. Prosthodontic rehabilitation
for edentulous patient with palatal defect. J Formos Med
Assoc. 2011;110(2):120–124.
15. Yoshida H, Michi K, Yasashita Y, Ohno K. A comparison
of surgical and prosthetic treatment for speech disorders
attributable to surgically acquired soft palate defects. J
Oral Maxillofac Surg. 1993;51(4):361–365
16. Pinto JH, Pegoraro-Krook MI. Evaluation of palatal pros-
thesis for the treatment of velopharyngeal dysfunction. J
Appl Oral Sci. 2003;11(3):192–197.

263
Chapter 19
Surgical Management of
Velopharyngeal Insufficiency
Derek J. Rogers and Christopher J. Hartnick
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Army, the
Department of Defense, or the U.S. government.
MAJ Rogers is a military service member. This work
was prepared as part of his official duties. Title 17
U.S.C. 105 provides that “Copyright protection under
this title is not available for any work of the United
States Government.” Title 17 U.S.C. 101 defines a
United States Government work as a work prepared
by a military service member or employee of the
United States Government as part of that person’s
official duties.
Abstract
The velopharynx is a three-dimensional structure that
functions to separate the nasopharynx from the orophar-
ynx during speech and deglutition. Dysfunction of the
velopharyngeal sphincter can therefore produce functional
deficits that may require surgical correction if not amenable
to resonant speech therapy. The most common reasons for
velopharyngeal insufficiency are cleft palate, submucous
cleft palate, neuromuscular disorders, and adenoidectomy
or tonsillectomy. The keys to defining whether surgery will
be required and to choosing between the various surgical
options are accurate evaluation and diagnosis. Such workup
for this condition involves nasendoscopy, possibly videofluo-
roscopy, and evaluation by a surgeon and speech pathologist
with expertise in velopharyngeal dysfunction. Nonsurgical
management may include speech bulb or palatal lift prosthe-
ses and speech therapy. Surgical management is comprised
of pharyngeal flap surgery, sphincter pharyngoplasty, Fur-
low palatoplasty, and posterior pharyngeal wall augmenta-
tion. Depending on the type of velopharyngeal closure or
size of the velopharyngeal gap, one procedure may be more
efficacious than another. Many patients still require speech
therapy to maximize the benefit from surgery. Persistent
velopharyngeal insufficiency, poor speech outcomes, and par-
tial or complete flap dehiscence represent common reasons for
revision velopharyngeal surgery.
Children born with cleft palate deformities commonly
suffer from velopharyngeal insufficiency. Other terms
frequently used to classify this problem include velo-
pharyngeal dysfunction or velopharyngeal incompe-
tence. The velopharynx, or velopharyngeal sphincter,
is a complex structure that forms roughly a rectangle
at rest (Figures 19–1 and 19–2). One must remember
that this valve is a three-dimensional structure, affected
by each of its sides.1 The anterior border is made up of
the hard and soft palate. The soft palate components
include the levator veli palatini, tensor veli palatini,
and musculus uvulae. The levator veli palatini muscu-
lar sling is believed to be the most important contribu-
tor to the velopharynx because it elevates the palate
to the posterior pharyngeal wall.2 The lateral borders
are comprised of the palatoglossus and palatopharyn-
geus tonsillar pillars, tonsils, hamulus, and superior
pharyngeal constrictor muscle. The adenoids and pos-
terior pharyngeal wall make up the posterior border.
The velopharynx serves as a valve between the naso-
pharynx and oropharynx, which is essential for both
deglutition and speech. A properly functioning velo-
pharyngeal sphincter prevents reflux of food up into
the nose. During speech, it closes to allow production
of oral consonants.3
Velopharyngeal insufficiency may arise when any
part of the sphincter malfunctions. The problem may
be lack of an intact levator veli palatini anteriorly. The
soft palate may be too short to bridge the gap to the

264
Figure 19–2.  Oblique view of the velopharyngeal sphincter.
Figure 19–1.  Anatomy of the velopharyngeal sphincter in (A) normal palate and (B) unilateral
cleft palate. Reproduced with permission from Costello BJ, Ruiz RL, Turvey TA. Velopharyngeal
insufficiency in patients with cleft palate. Oral Maxillofacial Surg Clin North Am. 2002;14:539–
551. Copyright 2002 Elsevier Science (USA).

Surgical Management of Velopharyngeal Insufficiency
265
posterior pharyngeal wall. The lateral walls may not
contract enough to close the sphincter. Many patients
have malfunction of more than one part of the velopha-
rynx. The velopharynx closes either coronally, sagitally,
circumferentially, or coronally with contribution from
Passavant’s ridge in the posterior pharyngeal wall.
Golding-Kushner et al devised criteria to describe the
velopharyngeal gap and closure pattern as a move-
ment ratio of one structure relative to the resting posi-
tion of the structure at the opposite side of the valve,
with the movement of each structure rated separately.4
Kummer et al showed that the perceptual characteris-
tics of hypernasality, nasal emission, and nasal rustle
are related to the velopharyngeal gap size, where large
velopharyngeal gap size causes more severe hyperna-
sality and smaller gap size causes only nasal rustle.5
The workup for velopharyngeal insufficiency
remains paramount in determining which treatment
should be used. A perceptual speech evaluation should
be performed by a speech pathologist who has exper-
tise in velopharyngeal dysfunction.6 Careful physical
examination by an otolaryngologist usually reveals
whether a patient is able to effectively close the velo-
pharynx. A mirror can be placed under the nares,
while a cooperative patient is asked to say a plosive
consonant, such as the word baseball. Fogging of the
mirror suggests significant nasal air escape. Although
this method identifies the presence of velopharyngeal
insufficiency, it does not determine the site of the gap or
deficit. Nasometry is also a means of quantifying this
nasal air escape and is excellent for tracking changes
from speech therapy and/or surgery.
The two most commonly used methods for fully
evaluating the velopharyngeal sphincter mechanism
remain nasendoscopy and video fluoroscopy. Lam et al
showed that although nasendoscopy and multiplanar
view video fluoroscopy provided complementary infor-
mation, nasendoscopy correlated more strongly with
velopharyngeal insufficiency severity.7 Havstam et al
found that lateral projection videofluoroscopy followed
by nasendoscopy if needed provided the best informa-
tion to decide which surgical procedure to use.8 The key
to a successful nasal endoscopy is a compliant child,
which requires patience and teamwork. Simply placing
a nasopharyngoscope and briefly viewing the velopha-
rynx fails to adequately assess this complex sphinc-
ter. A child with velopharyngeal insufficiency often
has remarkably good velopharyngeal closure with
swallowing and while crying. Velopharyngeal insuffi-
ciency is task specific, as the neuromuscular functions
are different for speech and swallowing. Some centers
have investigated the use of cine MRI in the assessment
of velopharyngeal insufficiency. Silver et al evaluated
the use of cine MRI in three adult and five school-aged
children and were able to acquire sufficient diagnostic
information in the children to determine their velopha-
ryngeal closure patterns.9 Using cine MRI is still exper-
imental and expensive but may have a role in select
patients. With the high cost of MRI and increasing con-
cern for radiation in children during videofluoroscopy,
nasendoscopy continues to be the most commonly used
method for evaluating velopharyngeal insufficiency.10
Nonsurgical Management
Once the diagnosis of velopharyngeal insufficiency
has been made, many patients benefit from a trial of
resonant speech therapy. Mild velopharyngeal insuf-
ficiency is more likely to respond to speech therapy
alone. A nonsurgical device, such as a speech bulb or
palatal lift prosthesis, should be considered in cases of
profound weakness of the palate where the only surgi-
cal cure would be to completely occlude the nasophar-
ynx or in children with velopharyngeal insufficiency
and significant comorbid obstructive sleep apnea
(OSA). A daytime palatal lift prosthesis can be removed
at night without fear of worsening the baseline OSA.
Pinto et al found that using palatopharyngeal obtura-
tors and pharyngeal bulbs improves speech intelligi-
bility after primary cleft palate repair by maintaining
intraoral air pressure.11 Speech therapy was still needed
to correct any compensatory articulations that had
developed prior to the prosthesis. Although palatal lift
prostheses work well, compliance remains a signifi-
cant problem as many children have an exuberant gag
reflex that precludes them from wearing the prosthesis.
Moreover, cost may be an issue because the prostheses
are not covered by insurance.
Surgical Management
Moderate to severe velopharyngeal insufficiency with
a consistently documented anatomic abnormality fre-
quently requires surgery.1 Regardless of the surgical
procedure that is chosen, the goal remains the same.
Local tissue must be either recruited or augmented
to allow better closure of the velopharyngeal valve.
Most patients undergo surgery for velopharyngeal
insufficiency as early as feasible to allow more rapid
or early normalization of speech. However, Becker et
al showed that the age of the patient at surgery did

266
Video Atlas of Cleft Lip and Palate Surgery
not impact the subsequent normalization of speech as
measured by the duration of speech therapy necessary
to normalize the speech impairments.12 Children with
velopharyngeal insufficiency rarely undergo surgery
before age 3 years because they must have developed
conversational speech to make the diagnosis. Excep-
tions are children with velocardiofacial syndrome and
pronounced nasal regurgitation of food who obviously
have profound velopharyngeal insufficiency. These
children would also require preoperative imaging to
ensure they do not have medialized carotid arteries.
Surgical options for the treatment of velopharyngeal
insufficiency include pharyngeal flap, sphincter pha-
ryngoplasty, Furlow palatoplasty, and posterior pha-
ryngeal wall augmentation. The goal of pharyngeal flap
surgery is to recruit tissue from the posterior pharyngeal
wall and attach it to the soft palate to bridge the cen-
tral portion of a large velopharyngeal gap. Two lateral
ports are created that remain patent during respiration
and nasal consonants but close during oral consonants.13
Sphincter pharyngoplasty involves recruiting tissue
from the lateral pharyngeal walls, including the ton-
sillar pillars, and rearranging it to help close the velo-
pharyngeal gap. The most common technique sutures
these superiorly based lateral flaps together and to the
posterior pharyngeal wall at the level of the palate to
decrease the distance from the posterior pharyngeal wall
to the soft palate.14 Where pharyngoplasties and poste-
rior pharyngeal wall augmentation procedures attempt
to alter the anatomy and dynamics of the posterior pha-
ryngeal wall, Furlow palatoplasty specifically targets
the soft palate to improve its form and function.15 Fur-
low palatoplasty involves a double opposing Z-plasty,
which both reorients the levator veli palatini muscular
sling and lengthens the soft palate. The goal of poste-
rior pharyngeal wall augmentation is to increase the
width of the posterior pharyngeal wall to allow con-
tact with the soft palate. Multiple techniques have been
used to accomplish this including a rolled superiorly
based pharyngeal flap or implantation with autolo-
gous or nonautologous materials. Injectable calcium
hydroxylapatite, polytetrafluoroethylene, silicone,
paraffin, acellular dermis, fascia, fat, and cartilage rep-
resent possible implant materials.16–22 One procedure
may be more advantageous than another depending
on the type of velopharyngeal closure and size of the
gap (Table 19–1). The specifics of these velopharyngeal
surgeries will be described in the following chapters.
Table 19–1.  Velopharyngeal Surgical Options
VPD Surgery
Gap Type
Deficit
Pros
Cons
Risks
Pharyngeal flap
• Large
anteroposterior
distance
• Best for
noncoronal closure
• Short, tethered
soft palate with
good lateral wall
motion
• Patients s/p cleft
palate repair
• Use potentially
for any closure
pattern
• May require
revision for flap
dehiscence or
nasal obstruction
• OSA
• Persistent VPI
Sphincter
pharyngoplasty
• Large, central gap
• Coronal closure
• Poor lateral wall
motion
• Diffusely
adynamic
• Postoperative
OSA rare
• Few postoperative
complications
• May require
revision for flap
dehiscence
• Persistent VPI
Furlow
palatoplasty
• Small gaps
• Short palate
• Sagitally oriented
levator veli
palatini
• Patients with
submucous cleft
palate
• Few postoperative
complications
• Not effective for
larger gaps
• Persistent VPI
• OSA
• Palatal fistula
Posterior
pharyngeal wall
augmentation
• Small, central gap
• Touch closure
• VPI with
conversant, but
not task-specific,
targeted speech
• Patients
with VPI s/p
adenoidectomy
• VPI during
conversational
speech
• Not effective for
larger gaps
• Less effective
in craniofacial
patients
• Persistent VPI
• Implant migration
• Flap dehiscence
OSA = obstructive sleep apnea; VPI = velopharyngeal insufficiency.

Surgical Management of Velopharyngeal Insufficiency
267
References
1. Costello BJ, Ruiz RL, Turvey TA. Velopharyngeal insuffi-
ciency in patients with cleft palate. Oral Maxillofacial Surg
Clin N Am. 2002;14:539–551.
2. Dickson DR. Normal and cleft palate anatomy. Cleft Palate
J. 1972;9:280–293.
3. Marsh JL. The evaluation and management of velopha-
ryngeal dysfunction. Clin Plastic Surg. 2004;31:261–269.
4. Golding-Kushner KJ, Argamaso RV, Cotton RT, Grames
LM, Henningson G, Jones DL, et al. Standardization for
the reporting of nasopharyngoscopy and multiview vid-
eofluoroscopy: a report from an international working
group. Cleft Palate J. 1990;27(4):337–348.
5. Kummer AW, Briggs M, Lee L. The relationship between
the characteristics of speech and velopharyngeal gap
size. Cleft Palate Craniofac J. 2003;40(6):590–596.
6. D’Antonio L. Evaluation and management of velopha-
ryngeal dysfunction: a speech pathologist’s viewpoint.
Probl Plastic Reconstr Surg. 1992;2:86–111.
7. Lam DJ, Starr JR, Perkins JA, Lewis CW. A comparison
of nasendoscopy and multiview videofluoroscopy in
assessing velopharyngeal insufficiency. Otolaryngol Head
Neck Surg. 2006;134(3):394–402.
8. Havstam C, Lohmander A, Persson C, Dotevall H, Lith A,
Lilja J. Evaluation of VPI-assessment with videofluoroscopy
and nasoendoscopy. Br J Plast Surg. 2005;58(7):​922–931.
9. Silver AL, Nimkin K, Ashland JE, Ghosh SS, van der
Kouwe AJW, Brigger MT, et al. Cine magnetic resonance
imaging with simultaneous audio to evaluate pediatric
velopharyngeal insufficiency. Arch Otolaryngol Head Neck
Surg. 2011;137(3):258–263.
10. Rowe MR, D’Antonio LL. Velopharyngeal dysfunction:
evolving developments in evaluation. Curr Opin Otolar-
yngol Head Neck Surg. 2005;13(6):366–370.
11. Pinto JHN, Dalben GS, Pegoraro-Krook MI. Speech
intelligibility of patients with cleft lip and palate after
placement of speech prosthesis. Cleft Palate Craniofac J.
2007;44(6):635–641.
12. Becker DB, Grames LM, Pilgram T, Kane AA, Marsh JL.
The effect of timing of surgery for velopharyngeal dys-
function on speech. J Craniofac Surg. 2004;15(5):804–809.
13. Sloan GM. Posterior pharyngeal flap and sphincter pha-
ryngoplasty: the state of the art. Cleft Palate Craniofac J.
2000;37(2):112–122.
14. Jackson I, Silverton JS. The sphincter pharyngoplasty as a
secondary procedure in cleft palates. Plast Reconstr Surg.
1977;59(4):518–524.
15. Perkins JA, Lewis CL, Gruss JS, Eblen LE, Sie KC. Furlow
palatoplasty for management of velopharyngeal insuffi-
ciency: a prospective study of 148 consecutive patients.
Plast Reconstr Surg. 2005;116(1):72–80.
16. Brigger MT, Ashland JE, Hartnick CJ. Injection pharyngo-
plasty with calcium hydroxylapatite for velopharyngeal
insufficiency: patient selection and technique. Arch Oto-
laryngol Head Neck Surg. 2010;136(7):666–670.
17. Lando RL. Transplant of cadaveric cartilage into the pos-
terior pharyngeal wall in treatment of cleft palate. Stoma-
tologiia (Mosk). 1950;4:38–39.
18. Willging JP, Cotton RT. Velopharyngeal insufficiency. In:
Bluestone CD, Stool SE, Alper CM, eds. Pediatric Otolaryn-
gology, Vol 2. 4th ed. Philadelphia, PA: WB Saunders Co;
2003:1789–1799.
19. Hagerty RF, Hill MJ. Cartilage pharyngoplasty in cleft
palate patients. Surg Gynecol Obstet. 1961;112:350–356.
20. Bluestone CD, Musgrave RH, McWilliams BJ, Crozier
PA. Teflon injection pharyngoplasty. Cleft Palate J. 1968;5:​
19–22.
21. Blocksma R. Correction of velopharyngeal insufficiency
by Silastic pharyngeal implant. Plast Reconstr Surg. 1963;​
31:268–274.
22. Sipp JA, Ashland J, Hartnick CJ. Injection pharyngoplasty
with calcium hydroxyapatite for treatment of velopala-
tal insufficiency. Arch Otolaryngol Head Neck Surg. 2008;​
134(3):268–271.

(Trang không có chữ)

269
Chapter 20
Superior Pharyngeal Flap
J. Paul Willging
Abstract
Velopharyngeal insufficiency (VPI) refers to the abnormal
sound resulting from the inability to separate the naso-
pharynx from the oropharynx during speech. The superior
pharyngeal flap is an operation designed to correct VPI,
creating an obturator against which the lateral walls of the
velopharyngeal sphincter mechanism can close. This is the
workhorse for velopharyngeal surgery. Central gaps are most
amenable to correction with a pharyngeal flap. The side walls
of the velopharynx need to buttress against the inset flap to
affect velopharyngeal closure. The procedure is effective in
correcting large or small gaps in the velopharyngeal sphinc-
ter mechanism. Stents are used to determine how far laterally
to place the flap.
For normal speech intelligibility and resonance, closure
of the velopharyngeal sphincter is essential. Incomplete
closure distracts the listener and interferes with com-
munication. Velopharyngeal insufficiency (VPI) refers
to the abnormal sound resulting from the inability to
separate the nasopharynx from the oropharynx during
speech. It may be caused by a structural abnormality
(cleft of the palate) or neurologic causes.1
Prior to surgical correction of VPI, nasopharyn-
goscopy should be performed. It allows the level of
velopharyngeal closure to be precisely determined.
It permits an assessment of the closure pattern dem-
onstrated by the patient and identifies the size and
location of the area of velopharyngeal escape. It also
allows an assessment of the posterior pharyngeal wall
for medialized carotid arteries. In patients with VPI
not associated with an overt cleft of the palate, velo-
cardiofacial syndrome is the most common syndrome
associated with VPI. This syndrome is associated with
a chromosomal microdeletion of 22q11.2. Phenotypic
expression of this syndrome includes: VPI, submucous
cleft palate, learning disabilities, cardiac anomalies,
retrognathia, malar flattening, pharyngeal hypotonia,
slender hands and fingers, small stature, and medial-
ized carotid arteries.2 Cardiac status should be investi-
gated in this patient population.
A speech pathologist skilled in the assessment of
velopharyngeal function is also necessary in the team
evaluation of patients with hypernasality. Phoneme-
specific VPI (a specific articulation error) presents
with hypernasality but will respond to speech therapy
techniques, where surgical intervention is reserved for
those with structural or neurologic deficits of velopha-
ryngeal function. Apraxia and other speech disorders
may have nasal emission as part of their disorder, and
the speech specialist is able to properly diagnose the
underlying condition and prevent inappropriate sur-
gical intervention. A geneticist is also a valuable team
member to identify patients with previously undiag-
nosed syndromes and associated medical problems.
Superiorly Based Pharyngeal Flap
The pharyngeal flap is an operation designed to cor-
rect VPI, creating an obturator against which the lateral
walls of the velopharyngeal sphincter mechanism can
close (Figure 20–1).
Surgical Indications
This is the workhorse for velopharyngeal surgery. Cen-
tral gaps are most amenable to correction with a pha-
ryngeal flap. The side walls of the velopharynx need to
buttress against the inset flap to affect velopharyngeal
closure. The procedure is effective in correcting large

270
Video Atlas of Cleft Lip and Palate Surgery
or small gaps in the velopharyngeal sphincter mecha-
nism. Lateral wall motion is not essential prior to flap
placement. Lateral wall motion will often improve
(develop) after flap placement with postoperative
speech therapy.
Surgical Equipment and Tools
• Shoulder roll
• Headlight
• Electrocautery
• Dingman mouth gag
• 3 mL of 1% lidocaine with 1:100,000 units
epinephrine
• Two 3.5 or 4.0 endotracheal tubes to be used
as stents
• 3-0 Vicryl™ sutures
• Beaver® blade scalpel
• Right-angled beaver blade scalpel
• Angled scissors
Anesthesia
• General endotracheal anesthesia with an oral
RAE® tube.
• Subacute bacterial endocarditis antibiotic
prophylaxis is often necessary.
• Dexamethasone is often given
intraoperatively to minimize airway
edema and reduce perioperative nausea
and vomiting, but in these cases it should
be avoided. There is little surface contact
Figure 20–1.  Diagram depicting the inset of a superiorly based pharyngeal flap.

Superior Pharyngeal Flap
271
between the pharyngeal flap and the soft
palate during this operation. Anything that
may inhibit normal postoperative wound
healing should be avoided.
Surgical Procedure
Preparation
• Adenotonsillar hypertrophy may require
a conventional adenotonsillectomy before
flap placement to prevent postoperative
obstructive apnea. A 6-week interval for
healing should elapse between procedures.
It is possible to perform an intracapsular
tonsillectomy at the time of the pharyngeal
flap procedure without increasing the risk of
oropharyngeal stenosis. This would negate
the need for an additional procedure under
general anesthesia.
• The recording of the nasopharyngoscopy
exam obtained preoperatively is reviewed
before the operation to determine the level of
attempted velopharyngeal closure. Anatomic
landmarks are identified on the video that can
be used to locate this level in the patient.
• The patient is positioned on a shoulder roll to
maintain hyperextension of the neck.
Procedure (Video of Superior Pharyngeal Flap)
1. Dingman mouth gag is inserted, and the patient is
placed into suspension.
2. The posterior pharyngeal wall is visualized and
palpated to identify any significant vessels in the
operative field. The internal carotid arteries may be
medialized in velocardiofacial syndrome patients.
These vessels will be deep to the prevertebral fas-
cia and will not interfere with the operation, but
increased care in raising the flap is necessary.
3. Proposed posterior pharyngeal wall incision lines
are infiltrated with 1% lidocaine with 1:100,000
units of epinephrine to promote vasoconstric-
tion and ease the raising of the flap. The posterior
aspect of the soft palate is similarly infiltrated at
the level of velopharyngeal closure. This will be
5 mm cephalad from the free edge of the soft palate
in children. Care should be taken to avoid distort-
ing the tissues with the injection.
4. The standard flap width generally runs from a
point approximating the posterior tonsillar pillars.
The inferior extent of the flap should be near the
midpoint of the tonsil. The length of the flap can be
checked by estimating the distance from the poste-
rior pharyngeal wall to the free margin of the soft
palate, and then measuring down from the level
of velopharyngeal closure. Care should be exer-
cised not to elevate a flap that is too long, as it may
adhere to the posterior pharyngeal wall in a posi-
tion below the level of velopharyngeal closure.
5. The superiorly based pharyngeal flap is elevated
by incising down to the prevertebral fascia (Fig-
ure 20–2). This fascial layer is bright white in color,
and the plane will be essentially avascular. It can
generally be elevated bluntly after the inferior inci-
sion is completed. The flap should be elevated high
into the nasopharynx. Hemostasis can be accom-
plished with monopolar cautery.
6. The lateral limbs of the superiorly based flap inci-
sions are curved slightly laterally near the base
of the flap to assist with creation of the lateral
ports and to ensure the broadest possible vascular
pedicle.
7. Flap elevation needs to be high into the nasophar-
ynx to the natural level of velopharyngeal closure.
Failure to raise the flap high enough will result in
an inferior tethering of the free edge of the soft pal-
ate, further compromising velopharyngeal func-
tion. If the flap is low, it will not be in a position to
participate in velopharyngeal closure.
8. Closure of the donor site with 3-0 Vicryl™ suture
(Figure 20–3). Undermining of the surrounding
Figure 20–2.  The flap is elevated above the level of the pre-
vertebral fascia.

272
Video Atlas of Cleft Lip and Palate Surgery
mucosa is rarely necessary. Suturing the mucosa
directly to the prevertebral fascia will prevent tent-
ing of the mucosa and the creation of dead space.
Superiorly the donor site is left to granulate. Over-
zealous closure of the donor site superiorly can
lead to nasopharyngeal stenosis. In most cases, two
thirds of the donor site can be closed (Figure 20–4).
9. A pocket is created on the posterior aspect of the
soft palate (Figure 20–5). The incision must be at
the level of velopharyngeal closure. The central
aspect of the incision is made with a right angle
Beaver® blade. The palate is everted anteriorly with
forceps. The incision is made into the substance of
the palate. Care must be taken not to extend the
incision inferiorly along the tonsillar pillars. The
lateral aspect of the incision is made with palate
scissors, again everting the palate for adequate
visualization (Figure 20–6). One tine of the scissors
is placed within the previously created pocket in
the midline, and the tine is slid laterally along the
plane of velopharyngeal closure. The scissors are
turned such that the blades are perpendicular to
the plane of the soft palate.
10. Nasal stents are placed transnasally into the hypo-
pharynx. These are used to size the lateral ports.
Size 3.5 endotracheal tubes are used for children
aged 6 years and below, whereas 4.0 endotracheal
tubes are used for children aged 8 years and above.
Figure 20–5.  Pocket created in the posterior velum high in the
nasopharynx with an angled blade.
Figure 20–6.  Enlargement of the soft palate pocket with
scissors.
Figure 20–3.  The donor site is closed.
Figure 20–4.  Examination of the nasopharyngeal inlet to
ensure no overclosure.

Superior Pharyngeal Flap
273
For children from 6 to 8 years of age, endotracheal
tube stent size is determined by the size and weight
of the child. The stents define the final size of the
lateral ports.
11. Starting with the lateral sutures, the pharyngeal
flap is positioned into the soft palate (Figure 20–7).
A 3-0 Vicryl™ suture is placed laterally, going
through the oral surface of the soft palate and exit-
ing the previously created fishmouth incision in
the soft palate.
12. The suture is placed in the pharyngeal flap at the
junction of the proximal and middle thirds of the
flap. The suture is placed in the muscle and submu-
cosa only; the squamous mucosa is not included in
this suture
13. The suture then passes through the fishmouth inci-
sion of the soft palate and exits into the oral cavity
within 2 mm of its initial pass, completing the hori-
zontal mattress suture.
14. The suture is pulled (not tied) to position the flap
into the palate. A mirror is used to check the size
of the lateral port created when the flap is inset into
the soft palate (Figure 20–8). The flap should touch
the endotracheal tube, leaving space anterior and
posterior to the endotracheal tube stent. The flap
should not wrap tightly around the stent, as naso-
pharyngeal obstruction will likely develop. The
suture is then loosened, and the opposite lateral
suture is placed in similar fashion and checked.
15. Two paramedian sutures are similarly placed to
finish the insetting of the flap.
16. The sutures are tied, starting with the lateral
sutures. Care must be taken to approximate the
flap into the pocket without strangulating the tis-
sue. Care also must be taken to ensure that the free
end of the flap is positioned such that the muscle
of the flap is in contact with the raw surface of the
soft palate. The squamous mucosa of the flap can-
not reside within the soft palate pocket.
17. A final check of the position of the flap and size
of the ports is undertaken (Figure 20–9). The flap
should not be visible from the oral cavity, as it
needs to be high in the nasopharynx (Figure 20–10).
18. The endotracheal tube stents are positioned in the
oropharynx, with the tips at the level of the mid-
tonsil (Figure 20–11).
19. The endotracheal tubes are secured to the upper lip
with tape and then trimmed.
20. A number 6 to 8 Fr suction catheter is measured to
direct the suctioning of the stents postoperatively.
The catheter should extend 5 mm beyond the tip of
the stent to ensure continued patency of the tube.
Postoperative Considerations
• The patient is admitted for postoperative
observation.
• The child is advanced to a regular diet as
tolerated. Intravenous fluids are continued
while in the hospital.
• Perioperative oral antibiotics are prescribed
for 1 week.
• Acetaminophen is used for pain control for
the first 24 hours, after which ibuprofen is
Figure 20–7.  Horizontal mattress suture incorporating sub-
mucosa and muscle of the flap.
Figure 20–8.  Examination of the lateral port to ensure the
flap is against the stent laterally.

274
Video Atlas of Cleft Lip and Palate Surgery
added. Narcotics are only administered for
children aged 6 years and older.
• The nasal stents are irrigated with normal
saline and suctioned as necessary.
• Elbow cuffs are used to protect the nasal
stents.
• Stents are removed the following morning.
The child is discharged after demonstrating
an adequate airway and adequate oral intake;
this usually occurs 48 hours postoperatively.
• Steroids should be avoided, as they may
increase the risk of dehiscence of the flap from
the soft palate pocket.
• Patients return for a postoperative check
at 3 weeks. Speech therapy should begin
3 weeks postoperatively to obtain maximal
functional use of the pharyngeal flap.
• A repeat office evaluation for objective
resonance testing occurs at 3 months. Repeat
nasopharyngoscopy is performed if continued
hypernasality or nasal emission is detected.
Complications
• Adenotonsillar hypertrophy must be
addressed prior to or at the time of
performing a pharyngeal flap to prevent
obstructive sleep apnea. Snoring is
expected following a pharyngeal flap in the
postoperative period. Obstructive events,
however, need treatment. Continuous positive
airway pressure (CPAP) can alleviate the
problem until postoperative edema subsides.
Persisting airway problems require surgical
revision of the ports.
• Stenosis of the lateral ports leading to
hyponasality and obstructive breathing.
Revision surgery may be necessary if
symptoms continue beyond 3 months.
• Continued velopharyngeal insufficiency
secondary to failure of the lateral ports
to close may be identified. Patients will
frequently require a short course of speech
therapy to learn how to use their flap. Failure
to show improvement by 3 months suggests
further surgery will be necessary.
Figure 20–9.  After four sutures secure the flap into position,
the flap is against the stents laterally, and the oral mucosa of
the flap is not visible on examination.
Figure 20–10.  Horizontal mattress sutures in the soft palate.
Figure 20–11.  Nasopharyngeal stents positioned in the oro-
pharynx at the midtonsil level.

Superior Pharyngeal Flap
275
• Dehiscence of the flap from the soft palate is
rare. It may be related to the use of steroids
postoperatively.
Pearls and Pitfalls
• Nasopharyngoscopy allows proper selection
of patients and determination of the size of
the flap to create. It also allows landmarks
to be identified to ensure the flap is elevated
sufficiently to contribute to velopharyngeal
closure.
• Excessive closure of the donor site can
create nasopharyngeal stenosis. Inspection
of the velopharyngeal inlet with a mirror
after the donor site is closed can ensure this
complication will not develop.
• The flap needs to be high in the nasopharynx.
If the flap is visible on examination of the
oropharynx, it is too low and will not function
properly.
• The stents are used to determine how far
laterally to place the flap. Care should be
taken not to “wrap” the flap around the stents
as stenosis of the ports will develop. Bring the
flap laterally until it touches the stent. Space
anterior to the stent will not create a problem
with velopharyngeal closure.
References
1. Kummer AW, Curtis C, Wiggs M, Lee L, Strife JL. Com-
parison of velopharyngeal gap size in patients with
hypernasality, hypernasality and nasal emission, or nasal
turbulence (rustle) as the primary speech characteristic.
Cleft Palate Craniofac J. 1992;29:152–156.
2. Shprintzen R, Goldberg R, Lewin M, Sidoti EJ, Berkman
MD, Argamaso RV, et al. A new syndrome involving
cleft palate, cardiac anomalies, typical facies, and learn-
ing disabilities: velo-cardio-facial syndrome. Cleft Palate
J. 1978;15:56–62.

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277
Chapter 21
Sphincter Pharyngoplasty
Scott E. Bevans and Kathleen C. Y. Sie
The views expressed in this article are those of the
authors and do not necessarily reflect the official pol-
icy or position of the Department of the Army, Depart-
ment of Defense, or the United States government.
CPT Bevans is a military service member. This work
was prepared as part of his official duties. Title 17
U.S.C. 105 provides that “Copyright protection under
this title is not available for any work of the United
States Government.” Title 17 U.S.C. defines a “United
States Government work” as a work prepared by a
military service member or employee of the United
States government as part of that person’s official
duties.
Abstract
Sphincter pharyngoplasty is one of several procedures used
to address velopharyngeal insufficiency. The technique was
initially described by Hynes, who transposed posterior ton-
sillar pillar flaps across the posterior wall of the velophar-
ynx to assist in velopharyngeal closure. Surgical outcomes
likely depend on patient selection, position of the transposed
flaps, and preparation of the recipient mucosal bed. The goal
of this tutorial is to present sphincter pharyngoplasty for
management of velopharyngeal insufficiency and to prepare
surgeons to perform the procedure, highlighting key points
and potential complications.
The sphincter pharyngoplasty is one of several proce-
dures used to treat velopharyngeal insufficiency (VPI).
Despite the similarities in nomenclature, appreciating
the differences in types of pharyngoplasties and their
indications is a critical first step to use these proce-
dures appropriately. As the name implies, “sphincter
pharyngoplasty” aims to augment the physiologic
velopharyngeal sphincter by rotating flaps of muscle
with overlying mucosa across the posterior aspect of
the velopharynx. A sphincter pharyngoplasty is there-
fore ideal for reducing deficits in anterior/posterior
closure. This differs from the “pharyngeal flap,” which
typically uses a superiorly based myomucosal flap to
span the central portion of the velopharynx and cre-
ates two lateral ports (see Chapter 20). At least theo-
retically, patients with good lateral pharyngeal wall
motion resulting in sagittal closure of the velopharynx
are more favorable candidates for pharyngeal flap.
Assessment of velopharyngeal function requires
nasal endoscopy, and may involve one of several other
imaging modalities (see Chapter 17). The selection of
pharyngeal flap versus sphincter pharyngoplasty is
commonly based on surgeon preference. At the most
basic level, velopharyngeal insufficiency is a failure to
effectively isolate the oral and nasal passages during
speech production. This inappropriate anatomic gap is
created by compromised structure or function of the
velopharyngeal mechanism. The function of the velo-
pharynx is predicated by the actions of several muscles
working in concert. The superior constrictor narrows
the posterior/lateral aspects of the velopharyngeal
inlet. The levator veli palatini functions to elevate the
soft palate. The salpingopharyngeus and tensor veli
palatini provide lateral contraction of the pharyngeal
walls and tense the soft palate (respectively). The pala-
topharyngeus and palatoglossus elevate and narrow
the oropharyngeal inlet by depressing the soft palate.
The musculus uvulae elevate and retract the uvula.
Together, these muscles narrow and close the velopha-
rynx during swallowing and speech production. The
presenting signs and symptoms of incomplete closure
of the velopharynx are inappropriate nasal air escape

278
Video Atlas of Cleft Lip and Palate Surgery
and hypernasal resonance during speech production.
Some patients may also complain of nasopharyngeal
reflux of fluid or food during swallowing. There are
several possible etiologies for velopharyngeal insuffi-
ciency, including anatomic defects (both syndromic and
nonsydromic), neurologic causes, or learned behaviors
(sometimes referred to as velopharyngeal mislearning).
In his initial description of a sphincter pharyngo-
plasty in 1950, Hynes rotated the salpingopharyngeus
and its overlying mucosa into a posterior pharyngeal
mucosal defect. He initially proposed that in many
cases the transposed muscles retained their contract-
ibility, adding to the dynamic function of the velopha-
rynx.1 Subsequent studies have shown that the rotated
flaps have minimal contractile activity when measured
by electromyography (EMG), suggesting that the effect
is secondary to the passive bulk added to the velophar-
ynx.2 Although not reliably present, clinically we have
seen active contraction of sphincter pharyngoplasties.
The specific techniques, size, and location of myomu-
cosal flaps have been modified by several authors with
good purported results.3,4 In fact, both pharyngeal flap
and sphincter pharyngoplasty procedures are safe and
have excellent result profiles.5 Overall success rates
for treating VPI with pharyngoplasty (all types) are
quoted as high as 84%.6 Still, authors report improv-
ing results by using a more tailored surgical approach,
with sphincter pharyngoplasty being more effec-
tive for managing patients with coronal-type closure
patterns.7
Surgical Indications
When evaluating patients with velopharyngeal insuf-
ficiency, it is important to work with a speech-lan-
guage pathologist who can identify velopharyngeal
mislearning and other speech disorders. Patients with
these issues will require speech therapy. Velopharyn-
geal insufficiency of anatomic or neurologic etiology
warrants intervention. Nonsurgical management with
a speech appliance and surgical options should be
presented. There are several factors that influence the
choice of surgical approach and timing of intervention:
1. Pattern of closure — Coronal gaps are most effec-
tively closed with a sphincter pharyngoplasty (Fig-
ure 21–1).
2. Presence of obstructive sleep apnea (OSA) — ​Because
any pharyngoplasty can increase the risk of OSA,
severe OSA should be treated prior to entertaining
surgical treatment of VPI. If surgical treatment of
OSA (adenotonsillectomy or tonsillectomy alone)
is indicated, most surgeons will wait 2 to 3 months
after sleep surgery before undertaking sphincter
pharyngoplasty.
3. Concomitant procedures — Patients with tonsil-
lar hyperplasia may not have symptoms of sleep
disordered breathing (SDB) or recurrent infections.
However, if the tonsils are enlarged, they may com-
promise surgical exposure during sphincter pha-
ryngoplasty and may also predispose the patient
to postoperative OSA. Adenoids that are signifi-
cantly enlarged can prevent adequate positioning
of the sphincter. If removal of tonsils or adenoids
is indicated to facilitate surgical exposure during
sphincter pharyngoplasty, the authors will per-
form the procedures at the same surgical setting.
We note that some surgeons prefer to perform any
oropharyngeal surgery 2 to 3 months in advance of
sphincter pharyngoplasty.8
4. Craniofacial syndromes — Syndromic diagnosis and
associated findings may have an impact on surgi-
cal recommendations and planning. For example,
patients with 22q11 deletion are more likely to have
medially displaced carotid arteries.
Surgical Equipment and Tools
• Dingman retractor
• Red rubber catheter
• Long-handled scissors (Metzenbaum and/or
angled)
• 2-0 silk and 4-0 chromic sutures
• Tonsil (Hurd) retractor
• Suction electrocautery
• Headlight
Anesthesia
• Oral Rae® or guarded endotracheal tube
secured in the midline.
• Intraoperative dexamethasone (0.5 mg/
kg up to 8 mg) is often requested unless
contraindicated.
• If tolerated, FiO2 below 40% reduces the
likelihood of airway fire during the use of
electrocautery.

Sphincter Pharyngoplasty
279
Surgical Procedure
(Video of Sphincter Pharyngoplasty)
1. The Dingman retractor is placed and suspended
from a mayo stand (Figure 21–2).
2. Both lateral walls and the posterior oropharynx are
carefully evaluated for the presence of medialized
(aberrant) carotid arteries (we dub this step the
“moment of silence” — an intentional pause of sur-
gical activity for careful inspection of the posterior
and lateral pharyngeal walls to identify aberrant
carotid pulsations prior to injection of local anes-
thesia and creation of incisions) (Figure 21–3A).
3. A red rubber catheter is placed through the nasal
passage into the oropharynx. A 2-0 silk suture is
then placed through the base of the uvula and tied
Figure 21–1.  Diagram of a coronal closure gap on nasopharyngoscopy.
Figure 21–2.  Dingman retractor on suspension.

280
Video Atlas of Cleft Lip and Palate Surgery
to the opening on the catheter. Gentle retraction on
the catheter retracts the uvula and soft palate into
the nasopharynx (Figure 21–3B).
4. 2-0 silk sutures through the tonsillar pillars may
provide retraction of the lateral walls and improve
visualization.
5. The proposed mucosal incisions are marked with a
marking pen, typically posterior and lateral to the
posterior tonsillar pillars (Figure 21–4).
6. Local anesthetic (1% lidocaine with 1:100,000 epi-
nephrine or equivalent) is infiltrated carefully into
a submucosal plane throughout the posterior and
lateral walls of the velopharynx.
7. The medial aspect of one of the flaps is incised with
a #15 blade.
8. Metzenbaum or angled scissors are used for blunt
and sharp dissection down to the alar fascia (note
the solid white sheen when this plane is achieved).
This dissection proceeds superiorly and inferiorly.
9. The lateral aspect of the same flap is incised.
10. The inferior aspect of the flap is transected, and
4-0 chromic suture is placed through the distal tip.
We leave the needle on and place this suture in the
Dingman retractor to retract the flap.
11. This retraction allows for easier dissection to the
superior extent of the flap.
12. Hemostasis is achieved with judicious use of suc-
tion electrocautery.
13. The inferior aspect of the donor site is closed with
interrupted 4-0 chromic sutures.
14. The contralateral flap is defined in a similar fashion.
Note the laterally retracted flaps and the alar fascia
visible in through the mucosal defect (Figure 21–5).
A
B
Figure 21–3.  Preoperative view of soft palate before (A) and after (B) retraction.
Figure 21–4.  Proposed incision lines.

Sphincter Pharyngoplasty
281
15. The #15 blade is then used to incise the superior
and inferior edges of the recipient mucosal bed. It is
critical to make the recipient bed as superior as pos-
sible at the caudal aspect of the adenoid pad so that
the rotated tissue will not be visible after the soft
palate is in anatomic position. Fine angled scissors
and pencil tipped suction are helpful for removing
the mucosa in this region entirely (Figure 21–6).
16. Two interrupted 4-0 chromic sutures are placed
through the superior edge of the mucosa adjacent
to the recipient bed (needle left on both sutures).
These will later be placed through the superior
edge of the rotated flap, but placement before the
flap is rotated makes visualization significantly
easier.
17. One flap is rotated and secured. The position of
the superior flap is determined by the amount of
augmentation required. The dimensions of the flap
are also considered. Typically, the distal tip of the
flap is secured to the contralateral corner.
18. The two superior mucosal sutures are then tied.
19. The opposite flap is then transposed and secured
inferior to the previously secured flap. Again, the
lateral securing suture is placed. Interrupted sutures
are placed through the inferior mucosal edge. The
position of the inferior flap is also determined by
the augmentation required. The degree of lateral
transposition will determine the amount of aug-
mentation achieved. One of the advantages of the
sphincter pharyngoplasty is the great flexibility it
affords the surgeon to tailor the procedure to the
patient’s velopharyngeal closure. In addition to the
positioning of the flaps, the surgeon can control
the dimensions and shape of the flaps.
20. The junction between the two flaps is closed also
using interrupted 4-0 chromic sutures.
21. Any remaining portions of the lateral incisions are
then reapproximated (Figure 21–7).
Figure 21–6.  Proposed demucosalization site of recipient bed.
Figure 21–7.  Final result (flaps rotated and secured).
Figure 21–5.  Flaps elevated (alar fascia visible).

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Video Atlas of Cleft Lip and Palate Surgery
Postoperative Considerations
• Overnight admission is warranted for airway
observation.
• We prefer to avoid the use of nasal
instrumentation in the immediate
postoperative period.
• Some surgeons use perioperative antibiotics.
Patients are kept on oral antibiotics for 7 days
following surgery.
• We do not restrict diet in our postoperative
patients. Some surgeons place patients on a
soft diet for 2 to 3 weeks following surgery to
prevent mechanical disruption of the rotated
flaps before they heal.
Complications
• Patients may develop OSA or sleep-
disordered breathing postoperatively. Some
patients may require supplemental oxygen
and steroids. Most patients can be monitored
clinically. Snoring or sleep-disordered
breathing can be expected to improve over
several months as the postoperative edema
resolves. If symptoms of sleep-disordered
breathing persist for more than 3 months
postoperatively, polysomnography should
be considered.
• Dehiscence of the flaps may result in recurrent
VPI.
• This procedure may not adequately close
velopharyngeal gap, requiring repeat
instrumental assessment and consideration
of obturator use or revision surgery. One
of the most common causes for failure
of sphincter pharyngoplasty is caudal
positioning of the sphincter. In his review
of 61 consecutive pharyngoplasties, Pryor
found 50% of the revisions he performed were
to address sphincters placed too low in the
nasopharynx.6
Pearls and Pitfalls
• Speech therapy is important for patients
with velopharyngeal mislearning or other
speech disorders such as childhood apraxia of
speech.
• Careful observation of the surgical field
before incision allows the surgeon to identify
aberrant carotid arteries (associated with
multiple craniofacial syndromes).
• Preoperative imaging is not necessary. Care
must be taken to avoid injury to the aberrant
carotid arteries.
• Visualization is assisted with retraction
sutures laterally and retraction of the uvula
with a red rubber catheter.
• Flaps should be dissected to the alar fascia to
provide adequate myomucosal bulk.
• Demucosalization of a superiorly placed
recipient bed is key to achieving appropriate
positioning of the sphincter.
• Careful mucosal approximation results in
reliable healing of the incisions.
• After surgery, the flaps should not be visible
with the soft palate in the anatomic position
(Figure 21–8).
References
1. Hynes W. Pharyngoplasty by muscle transplantation. Br
J Plast Surg. 1950;3:128–135.
Figure 21–8.  Final result with soft palate in anatomic position
(covering the pharyngoplasty).

Sphincter Pharyngoplasty
283
2. Ysunza A, Pamplona MC. Velopharyngeal function after
two different types of pharyngoplasty. Int J Pediatr Oto-
rhinolaryngol. 2006;70:1031–1037.
3. Orticochea M. A review of 236 cleft palate patients treated
with dynamic muscle sphincter. Plast Reconstr Surg. 1983;​
71:​180–188.
4. Orticochea M. Construction of a dynamic muscle
sphincter in cleft palates. Plast Reconstr Surg. 1968;41:
323–327.
5. Abyholm F, D’Antonio L, Davidson Ward SL, Kjoll L,
Saeed M, Shaw W, et al. Pharyngeal flap and sphincter-
plasty for velopharyngeal insufficiency have equal out-
come at 1 year postoperatively: results of a randomized
trial. Cleft Palate Craniofac J. 2005;42:501–511.
6. Pryor LS, Lehman J, Parker MG, Schmidt A, Fox L, Murthy
AS. Outcomes in pharyngoplasty: a 10-year experience.
Cleft Palate Craniofac J. 2006;43:222–225.
7. Armour A, Fischbach S, Klaiman P, Fisher DM. Does
velopharyngeal closure pattern affect the success of pha-
ryngeal flap pharyngoplasty? Plast Reconstr Surg. 2005;​
115:​45–52; discussion 53.
8. Ruda JM, Krakovitz P, Rose AS. A review of the evalua-
tion and management of velopharyngeal insufficiency in
children. Otolaryngol Clin North Am. 2012;45:653–669.