Velopharyngeal DysfunctionAlbert S. Woo, MD11Cleft Palate- Craniofacial Institute and Department of Surgery,Washington University in St. Louis, St. Louis, MissouriSemin Plast Surg 2012;26:170177.Address for correspondence and reprint requests Albert S. Woo, MD,Director, Cleft Palate- Craniofacial Institute, Assistant Professor, PlasticSurgery, Department of Surgery, Washington University in St. Louis,660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110(e-mail: WooA@wustl.edu).Velopharyngeal dysfunction(VPD)referstoanysituationinwhichanindividualisunabletocompletelyclosethenasalairway during speech. The velopharyngeal mechanismis com-prised of a complex group of structures that act in unison tocontrol airowthrough the nose and mouthby elevationof thesoft palate and constriction of both the lateral and posteriorpharyngeal walls (Fig. 1). Any disruption in this mechanismmayresultinabnormal, poorlyintelligiblespeech. VPDcanmanifest as hypernasality, nasal emission, decreasedvocalintensity, and/or facial grimacing.1Moreover, patientswhosuffer from VPD will frequently develop maladaptive articu-lations to compensate for their speech difculties.2Numerous etiologies can be responsible for this failure ofnormal speechproduction. Myoneurogenic problems canimpairmusclecontroloraffectmuscleprogramming.Ana-tomic irregularities can present as a tissue decit, structuralproblemsthataffectfunction, orevenmechanicalinterfer-encepreventingnormal closure. Mislearningcomprises ahost of etiologies whereby the patient has developed abnor-mal usageof thevelopharyngeal mechanismdespitetheabsence of other pathology.3Velopharyngeal dysfunction is a carefully chosen termthatsimplydenotesthepresenceofincomplete velopharyngealclosure without making suggestions as to its cause. Use of thisnomenclature has gained increasing favor by experts, replac-ingthepreviousdesignation, velopharyngeal insufciency(VPI). This helps to avoid confusion, as VPI has been differen-tially interpreted as denoting insufciency, incompetence, andinadequacyterms that may be similar, but are not synony-mous and potentially implicate the cause of the dysfunctionrather thandescribethe clinical nding. VPDis seeninroughly 20 to 30% ofindividuals who have undergone cleftpalate repair,4,5and 5 to 10% of patients with a submucouscleft palate (SMCP).6Velopharyngeal AssessmentThe assessment of velopharyngeal function is best performedinthe settingof a multispecialty teamevaluation composedofa speech-language pathologist (SLP), otolaryngologist, pros-thodontist, and plastic surgeon.Multiple modalities shouldbe utilized to perform a complete evaluation of the patient.After a thorough review of the patients history, the standardworkupinvolves perceptual speech evaluation, followedbyvideonasoendoscopy(VNE) andmultiviewspeechvideo-uoroscopy (SVF).7,8There is considerable variation in the utilization of imag-ing studies to guide treatment of VPD. Different institutionsKeywordsvelopharyngealdysfunctioninsufciencycleft palatehypernasal speechAbstract Velopharyngeal dysfunction (VPD) is a generic term which describes a set of disordersresulting in the leakage of air into the nasal passages during speech production. As aresult, speechsamples candemonstratehypernasality, nasal emissions, andpoorintelligibility. The nding of VPDcan be secondary to several causes: anatomic,musculoneuronal, or behavioral/mislearning. To identify the etiology of VPD, patientsmust undergo a thorough velopharyngeal assessment comprised of perceptual speechevaluationandfunctional imaging,includingvideonasendoscopyandspeechvideo-uoroscopy. These studies are then evaluated by a multidisciplinary team of specialists,whocandecideonanoptimal courseforpatientmanagement.Atreatmentplanisdeveloped and may include speech therapy, use of a prosthetic device, and/or surgicalintervention. Differentsurgical options are discussed, including posterior pharyngealap, sphincter pharyngoplasty, Furlowpalatoplasty, palatal re-repair, andposteriorpharyngeal wall augmentation.Issue ThemePediatric PlasticSurgeryClefts; Guest Editor, EdwardP. Buchanan, MDCopyright 2012 by Thieme MedicalPublishers, Inc., 333 Seventh Avenue,New York, NY 10001, USA.Tel: +1(212) 584-4662.DOI http://dx.doi.org/10.1055/s-0033-1333882.ISSN1535-2188.170will preferentially utilize VNE or SVF or other novel imagingmodalities;otherinstitutionsuse bothstudies for compre-hensive evaluation. Lipira et al9evaluatedthe relative benetsof videouoroscopyversus nasoendoscopyandconcludedthat bothstudieswerebest usedintandemtooptimallyevaluate patients with VPD.Perceptual Speech EvaluationTheinitial diagnosisofVPDismadeonperceptual speechevaluation (PSE) conducted by a specialized SLP. During thisexamination, the SLP will perform multiple tests to elicit theetiology of the VPD and determine whether further diagnos-tic imagingwould be benecial. The diagnosis of velophar-yngeal dysfunction (VPD) encompasses a range ofstigmatizing speech impairments characterized by inappro-priate nasal resonance, nasal air emission, nasal turbulence,grimacing, and nasalized plosives.1,2Abnormal closure of the nasal valve can result in abnormalresonance, whichis a descriptor of where soundmovesthroughout the vocal tract. Hypernasality is a resonancedisordercharacterizedbyabnormal soundescapeintothenasal cavity during speech, particularly withthe use ofvowels. Hyponasality, on the other hand, describes a situationwhere there is decreased resonance in the nasal cavity, whichcandevelop secondary to blockage of the upper airway duringupperrespiratoryinfectionorothermeansof obstruction(i.e., overly large pharyngeal ap).Nasal emissiondescribestheescapeofairinto thenoseduring speech. This is especially notable during the produc-tion of pressurized consonants, such as s/z and p/b. Emissionsmay be easily detected by placement of a mirror underneaththenostril duringthespeechsample. Nasal turbulence(ornasal rustle) is a phenomenon that occurs when air is leakingthrough a small residual velopharyngeal opening. The result-ingsoundcanbedistractingandismostnotablewiththeproduction of oral pressure consonants.Inadequate intraoral air pressure is a commonnding inpatients with VPD, who can lose pressure during the produc-tion of oral speech sounds secondary to leakage of air into thenasal cavity. Several compensatory mechanisms can developto make up for the loss of pressure. One such mechanism isnasal grimace, whichis anabnormal constrictionof thenostrils during speech production. This phenomenon occursas a subconscious attempt to block airow through the nosewhen nasal emissions occur.Compensatory ormaladaptive misarticulations describea host of speech production disorders that may havespontaneouslydevelopedtocompensatefor reducedin-traoral air pressure. One must always remember, however,that articulationdisorders mayresult froma myriadofdifferingetiologiesunassociatedwithVPD;itisthe jobofanSLPexperiencedincleftspeechabnormalitiestoparseout articulation disorders fromthose resulting fromastructural abnormality.Based on the perceptual speech examination, the SLP canestablish the presence of VPD and develop suspicions as to itsunderlyingcause. Nevertheless, thespecicetiologyoftheVPD and the degree of nasopharyngeal valve dysfunction canonly be determinedwith anatomic visualization. This isachievedvia the modalities of videonasoendoscopyandspeech videouoroscopy.Video Nasopharyngeal EndoscopyVideo nasopharyngeal endoscopy (VNE) is a technique thatallows direct visualization of the velopharyngeal mechanismduring speech production. In this procedure, an endoscopistinserts a small, exible nasopharyngoscope into an anesthe-tized nostril. The scope is passed through the middle meatusof the nose and rests in the posterior nasal passages. Optimalviewingof the soft palate, lateral pharyngeal walls, andposterior pharynxallows theendoscopist toestablishanoverall assessment of velopharyngeal function.Once appropriate positioning and visualization has beenobtained, an SLP guides the patientthrough repetition of astandardized speech sample tailored to the patients abilities.Eachstudy (composedof bothvideoandaudiodata) isrecorded for later review by the multispecialty group.VNE evaluation allows the direct visualization of thedegree of maximal velopharyngeal closure, the positionand function of the levator musculature, length and qualityof thesoftpalate, andthedegreeof motionof thelateralpharyngeal walls and the posterior pharynx. Moreover, VNEis the best study to establish assessment of an overall closurepatternbasedonthedirectional movements of differentcomponents of the velopharynx (Fig. 2). An understandingof thepatternof closureandthedegreeof movement ofdifferent musculature will play a critical role in the decision-making process for treatment.One limitation of this study is the inability to quantitative-lymeasurepertinent anatomicndings, suchasgapsize.Estimates, however, can bemade basedupon standardizedreporting techniques.10Younger patients may also havedifcultywithcooperatingwiththespeechsampleduringthe examination, as nasopharyngoscopy may be an awkwardand uncomfortable procedure even at the hands of anexperienced endoscopist.Fig. 1 Velopharyngeal anatomy in the sagittal plane.Seminars in Plastic Surgery Vol. 26 No. 4/2012Velopharyngeal Dysfunction Woo 171Speech VideouoroscopyMultiview speech videouoroscopy is another modality thatprovides visualization of the velopharyngeal apparatus dur-ingspeechproduction. This procedureis performedas acollaborative effort between a radiologist and an SLP. High-density contrast material is syringe-injected via both naresprior to examination. An SLP then guides the patient throughthe repetition of a standardized speech sample personalizedtothe patients abilities. This procedure is typically performedinboththelateral andanteroposterior (AP) viewsandisrecorded for subsequent review.Radiographic studies tend to be better tolerated than VNE,especially among younger patients, and are able to providesomequantitativedata regardingvelopharyngeal closure.However, patternsof closurearemoredifcult toassess.SVF also necessitates some exposure toradiationandislimited by the individuals ability to cooperate.Classication of Velopharyngeal DysfunctionThe management of VPDdiffers signicantly depending on itsetiology, which is a critical factor in decision making and canbe classied into several categories. Anatomic causes are mostcommon and are typically associated with a previouslyrepairedcleft palate. Oftenreferredtoas velopharyngealinsufciency, thesoftpalatemaybetooshort(orinsuf-cient) to permit adequate approximation of the velum to theposterior pharynx. The palate may also contain a signicantamount of scar tissue, whichcanshortenthepalateanddecrease the mobility of the velum. Further, aberrant inser-tion ofthe levatorveli palatini muscles can inhibit optimalpalatal movement. Fistulas anywhere within the palate canlead to abnormal intraoral air escape, and tonsillar hypertro-phy or scarring of the posterior tonsillar pillars can also serveas a barrier tonormal closure of the velumagainst theposterior pharyngeal wall.Neuromuscular etiologies can also result in VPD and areoccasionally referred to as velopharyngeal incompetence.Childhoodapraxia of speechis a motor speechdisorderthat hinders appropriate coordination of muscle movementsfor appropriate function. Hypernasality increases with con-nected speech and is associatedwith inconsistent articulationerrors. Neurologic impairment, congenital abnormalities, ortraumatic/iatrogenicinjuryareamongsomeof theothermyoneuronal etiologies that can render the velopharyngealapparatus incompetent, leading to VPD.Articulationdisorders due to mislearning are a frequentsource of VPD. Behavioral (rather than structural) etiologiestypically present withconsistent phoneme-specic nasalemissionsorhypernasalityratherthanthepervasivenon-specic hypernasality present when velopharyngeal closureis incomplete. Nevertheless, almost all patients withanatomicFig. 2 Velopharyngeal closure patterns are demonstrated. Note that the velum is anterior and the posterior pharyngeal wall is inferior.(A) Coronal: There is signicant movement of the velum with less movement of the lateral pharyngeal walls. (B) Sagittal: The lateral pharyngealwalls have excellent motion and provides the predominant source of closure. The velum demonstrates less movement. (C) Circular: Goodmovement is seen from the velum and lateral walls, resulting in a circular pattern of closure. A Passavant ridge may also contribute to thisphenomenon. (D) Bowtie: Closure is primarily due to the velum and possibly a Passavant ridge from the posterior pharynx. Lateral wall movement is poor.Seminars in Plastic Surgery Vol. 26 No. 4/2012Velopharyngeal Dysfunction Woo 172causes of VPDpresent with compensatory misarticulations tooptimize speech production. Differentiating between the twotypes of misarticulations (mislearning vs compensatory) canbe a challenging task for the SLP. Regardless of etiology, mostchildren with VPD will benet from an appropriate course ofspeech therapy to optimize their ability to communicate.Nonsurgical Treatment OptionsProsthetic options exist to aid in the treatment of VPD andmay be utilized temporarily or serve as a permanent solutionfor nonsurgical candidates. Prostheses typically are availableinthe formof apalatallift oranobdurator. Each deviceiscustom-made forthe individual by a maxillofacial prostho-dontist and is designed to anchor into the maxillary dentition,similar to a retainer. Palatal lifts contain posterior extensionsthat press upward along the soft palate, physically displacingit superiorlyinanattempt toaidvelopharyngeal closure(Fig. 3). Thesedevices arebest utilizedinsituations ofvelopharyngeal incompetence, where the palate suffersfromhypomobility, poormusclecoordinationorparalysis,but has adequate soft tissue length.Soft palate obdurators or speech aid prostheses are moreeffectiveinvelopharyngeal insufciency, wherethepalatehasinadequatetissuelength. Thesedevicesaresimilar inappearance to obdurators, but are designed with additionalmaterial that extends beyond the soft tissues to aid inachieving velopharyngeal closure.Surgical Treatment OptionsPatients with a history of previously repaired cleft palate andanatomic ndings of VPD are frequently candidates for surgi-cal intervention. Oncethedecisionfor surgeryhas beenestablished, a choice must be made as to which interventionwould best t the needs of the patient. The two mostcommonly discussed procedures for correctionof VPDremaintheposteriorpharyngeal apandthe sphincterpharyngo-plasty. Bothprocedures worktodecreasethesizeof theresidual velopharyngeal port.Morerecently, proceduresdesignedtoimprovepalatalclosure have gained increasing popularity. The Furlow pala-toplasty and palatal re-repair are two techniques performedto either lengthen the palate or otherwise tighten the levatorsling. Some authors have also reported a modicum of successwith posterior pharyngeal wall augmentation procedures.Due to the plethora of surgical and nonsurgical options, amultidisciplinary teamconsisting of a plastic surgeon, speechtherapist, otolaryngologist, and maxillofacial prosthodontistis thought to be best equipped for optimal decision making.Surgical procedures can be tailored to the patients specicanatomy, as visualized on VNE and SVF studies. Based uponthe imaging, a pattern of closure can be determined as well asthe size of the defect.Velopharyngeal closure patterns can be classied ascoronal, sagittal, circular, or bowtie (Fig. 2). Surgicalmanagement should differ based upon the type of deformitypresent. Pharyngealaps are designed to bringtissue intothe central portion of the velopharynx. Therefore, they arebest utilizedtocorrect central gaps (sagittal or circularpatterns of closure) where goodlateral pharyngeal wallmotion is visualized on VNE or SVF in the AP dimension.11Sphincter pharyngoplasty, on the other hand, brings intissue laterally toward the center and appears mostusefulfor lateral defects (coronal and bowtie patterns), especiallywhenlateralwallmotionispoor. Furlowpalatoplastyhasshown success primarily in smaller central gaps, especiallyincircumstanceswhereevidenceexistsofdiastasisofthelevatormuscle sling (i.e., midline notch on VNE).Posteriorpharyngeal augmentation procedures are similarly utilizedfor verysmall residual defects. Littleconsensusexistsinregardsto the treatment oflargeblackhole deformities,which tend to have the poorest results when reconstructionis attempted. Some have noted success with sphincterpharyngoplastyalone12or withwide, nearlyobstructingpharyngeal aps. Others havesuggestedthat results arebestwhenpalatal lengtheningproceduressuchasFurlowpalatoplasty are performed in conjunction with a sphincterpharyngoplasty.13Despitethetheoriesandpreferencesforreconstructionthat have been noted above, little evidence exists suggestingwhether pharyngeal ap or sphincter pharyngoplasty issuperior totheother. Rather, bothprocedures appear tohaveequivalent efcacywhenperformedbyexperiencedsurgeons.14In a prospective, randomized trial, the VPI Surgi-cal Trial Group15evaluated 97 patients atve internationalcenters who presented with VPD. Individuals were random-ized to either of the procedures, which were performed in astandardizedfashionbyeachof thesurgeonsinvolved. At3 months following surgery, pharyngeal appatientsweretwiceaslikelytodemonstrateresolutionofhypernasality.However, at 12 months, there was no statistically signicantdifference in outcomes.Fig. 3 Diagram of a palatal lift, which is stabilized on the dentition and isdesigned to elevate the soft palate tissues with its posterior extension.Seminars in Plastic Surgery Vol. 26 No. 4/2012Velopharyngeal Dysfunction Woo 173Pharyngeal FlapThe primary concept behind the pharyngeal ap is thecreation of a static wall of mucosa connecting the soft palateto the posterior pharynx, thereby decreasing airow throughthe velopharyngeal port. The nasal airway is preservedthrough two lateral openings on either side of the ap. Thesuccess of the operation depends on adequate mobility of thelateral pharyngeal walls, which should constrict inwardduring speech production to limit airow through the nosewhen producing pressure consonants.Therst pharyngeal approcedurewasintroducedbySchoenborn16in1875. Originallyinferiorlybased, hehadconverted his technique to a superiorly-based procedure afterperforming20operations by1886.17This procedurewasbrought to the United States by Padgett,18who used asuperiorly-basedap for correction of dehisced cleft palaterepairs. Variations of the procedure became widely adoptedinthe 1950s. In1973, the modernpharyngeal apwasintroduced by Hogan,19who popularized the idea oflateralport control and discussed coverage of the raw surface of theap to prevent postoperative contracture. This concept wastakenastepfurther byShprintzen,20whodescribedthecreation of aps that were tailored based on lateral pharyn-geal wall excursion. It is nowstandard dictumthat lateral wallmotionis critical for effective closure of the lateral pharyngealports following pharyngeal ap surgery.11Hence, this proce-dureisthoughttobemosteffective forsagittalorcircularclosure patterns, with adequate lateral wall motion.The standard technique for elevation of a superiorly-basedpharyngeal ap (Fig. 4) involves divisionof the soft palate inthe midline to aid in visualization of the posterior pharynx.Longitudinal incisions are made in the posterior pharyngealwall converging into a point along the inferior border. The apis then elevated at the prevertebral fascia to the level of therst cervical vertebrae. The nasal lining on either side of thesoft palate is then released to serve as lining for the under-surface of the pharyngealap. The pharyngealap is insetintothebaseoftheincisedsoftpalate. Lateralportsizeisoften controlled by placement of red rubber catheters (1012French) on either side to maintain adequate airow outlets.Control of port size is important because an overly obstruct-ingapwill result inhyponasalitywithexcessivemouthbreathing and even obstructive sleep apnea; incontrast, a apthat is too narrow will not adequately correct the VPD. Thenasal lining is then sutured to the raw surface of the pharyn-geal ap. Thesoftpalateisclosedatthemidlineasisthedonor site along the posterior pharynx.Sphincter PharyngoplastyThe sphincter pharyngoplasty technique serves conceptuallyas aspeed bump or extension of the lateral and posteriorpharyngeal walls, whichhelpstocloseupthesizeof thevelopharyngealgap, makingiteasierforthesoftpalatetoachieveclosureduringdynamicmovement. Althoughthenasalairway remainscentrally, itis signicantly decreasedin size. The success of this procedure hinges upon adequatefunction of the levator veli palatini muscles, which serve toclose the central port during speech production. Lateral wallmotion is less important, as the ap brings in tissue on eitherside.The procedure wasrstintroducedby Hynes in1950,21who originally described elevation of the salpingopharyngeusmusclesandmobilizationintoatransverseorientationforaugmentation of the posterior pharynx. Eventually, heFig. 4 Technique for pharyngeal ap surgery. (A) The soft palate is divided at the midline and retracted laterally. A superiorly-based ap is thendesigned along the posterior pharynx (dotted lines). (B) The posterior pharyngealap is elevated from inferior-to-superior at the level of theprevertebral fascia. (C) The ap is inset into the nasal mucosa of the soft palate. Laterally, nasal mucosa aps from the soft palate are elevated toserve as lining for the raw edge of the pharyngeal ap. (D) The nasal mucosaaps are inset onto the undersurface of the pharyngeal ap. Thedonor site of the pharyngeal ap has also been closed primarily. (E) The oral mucosa is closed. Note that the pharyngeal ap is not visible afterclosure is completed.Seminars in Plastic Surgery Vol. 26 No. 4/2012Velopharyngeal Dysfunction Woo 174advocated elevation of more robust aps, which included thepalatopharyngeus muscle, bringing them together in an end-to-endfashion.22Severalvariationsofthisprocedurehavesince been introduced, including notable techniques by Orti-cochea23and Jackson.24A modied version of Hynes originaltechnique remains one ofthe most popularvariants ofthesphincter pharyngoplasty utilized today.Given the mobilization of the laterally based palatophar-yngeus myomucosal aps intothemidline, thesphincterpharyngoplasty should be a favored procedure for correctionof coronal or bowtie patterns of closure where lateral pha-ryngeal wall motion may be poor. Suggestions have also beenmade that this may be a more physiologic procedure than thepharyngeal ap, and that the sphincter itself may have somedynamic function due to its incorporation of muscle. Howev-er, these claims remain largely unproven.The technique is performed with initial retraction of theuvula to obtain maximal visualization of the posterior phar-ynx, without division of the soft palate itself (Fig.5). Theposterior tonsillar pillars (incorporatingpalatopharyngeusmuscle and surrounding mucosa) are then incised and ele-vated superiorly. These superiorly-basedaps are raised ashigh as possible. A transverse incision is then made across themucosa of the posterior pharynx, allowing a raw surface forinset of the aps. Thepharyngoplasty aps canthenbesuturedend-to-endor overlappedsignicantlytofurthertightenthelateral walls andallowadditional soft tissuebulkover the posterior pharyngeal wall. Followinginsetand suture of the aps, the lateral donor sites are then closeddirectly.Furlow PalatoplastyThe Furlowdouble-opposing Z-plasty repair of the palate wasoriginally proposed as a means of primary cleft palaterepair.25Its elegant designhadthe additional benet ofaddressing several issues related to subideal speech outcomesafter cleft repair. Not only does it offer considerable palatallengthening,26it further corrects the abnormal anteriordirectionandinsertionof thelevatorveli palatini musclesby repositioning the bers into a transverse orientation. It isthoughtthatlengtheningthepalatemayallowittomoreeffectively span and occlude the velopharyngeal gap duringspeechproduction. Addressingthepositionof themusclefavorsenhancedpalatalmobility27andhasbeenshowntoyieldbetter velopharyngeal competence.28Several studieshave shown it to be efcacious as a secondary treatment forVPD resulting froma previously repairedcleft,2931orasaprimary treatment for VPDdue to a SMCP.32When utilized forthe correctionof VPD, the Furlowtechnique has showngreatestsuccessinthecorrectionof smallerpostoperativevelopharyngeal gaps,33,34whichwereestimatedtobelessthan 1 cmin depth29or demonstrating a small residual gap of20% or less.This technique has been compared with pharyngealapandsphincterpharyngoplasty,6,35,36andthereisevidencethattheFurlowtechniquemayoffersuperioroutcomesinmany situations. In general, the Furlowtechnique is preferredin palates that are kinetic, with evidence of anterior orienta-tionof thelevator musclebers. It offersalower riskofobstructivesleepapnea thaneitherthepharyngeal aporsphincter pharyngoplasty, andhas alowrateof oronasalstulas. Thisisnowthepreferredrst-lineinterventionatmany institutions, though individual practice varies andevidence for a comprehensive treatment algorithm continuesto accumulate.37ThesecondaryFurlowpalatoplasty(Fig. 6)isinitiallyperformedwithidenticationof thehamuli prior totheinjection oflocal anesthetic. The soft palate is then dividedat the midline, typically along a previous scar frominitial cleftrepair, up to the region of the hard/soft palate junction. OralZ-plasty incisions are then designed from the hamuli,withthe posteriorly-basedmusculomucosal apdrawntotheposterioredgeofthehardpalateandtheanteriorly-basedmucosal ap extending posteriorly toward the divided uvula.The levator muscle is then carefully released from the poste-rioredgeof thehardpalateandseparatedfromthenasalmucosa. During this process, the tensor veli palatini attach-ments areautomaticallydividedandseparatedfromtheFig. 5 Technique for sphincter pharyngoplasty. (A) Musculomucosalaps are elevated from the posterior tonsillar pillars on either side. Notshown: The uvula may be retracted for improved visualization. (B) Flaps are transposed into a horizontal direction to be inset into a transverseincision on the posterior pharyngeal wall. (C) The aps are inset in an end-to-end fashion and the donor sites are sutured closed. The airway issmaller, but remains patent centrally. Note: For greatertightening of the sphincter, the aps may be overlapped upon each other.Seminars in Plastic Surgery Vol. 26 No. 4/2012Velopharyngeal Dysfunction Woo 175levator. After myomucosal apelevation, the nasal mucosal apis then elevated on the ipsilateral side. This limb is incised fromthe base of the uvula to the lateral edge of the exposed levator.Attentionisturnedtotheoppositeside, whereanoralmucosal apiselevatedfromthebaseoftheuvulatothehamulus, using care to avoid any elevation of muscle. Follow-ingthis, thenalnasalmyomucosal apis developed. Themuscle is carefully released fromthe hard palate andthe nasalmucosa is divided, taking care to leave a small cuff of mucosaalong the hard palate edge to suture to during closure. Oncethe dissection has been completed, the nasal Z-plastyapsare transposedandsutured. The oral aps are similarlytransposed. In the process, the levator musculature is mobi-lized from an oblique orientation to a transverse dimension,with signicant overlap of the muscle on the oral and nasallayers occurring.Palatal Re-RepairThe concept of palatal re-repair has largely been advocated bySommerlad38,39forthe secondary correctionofVPD in pa-tients who demonstrated anterior insertion of the levator velipalatini. Utilizing an aggressive intravelar veloplasty ap-proach whereby the velar musculature is radically dissectedandretropositioned, there-repairprocedure hasbeensuc-cessful in avoiding additional surgical intervention in 80% ofcases. ThisprovidesanattractivealternativetotheFurlowpalatoplastytechnique andargues for the importanceofcorrection of the abnormal position of the levator. However,theideaofre-repairhas garneredless popularitythantheFurlow procedure and little conrmatory data are yet avail-able from other institutions documenting similar results.Posterior Pharyngeal Wall AugmentationCorrection of VPD by augmentation of the posterior pharyn-geal wall hasbeenattemptedintermittentlysincethelate1800s. Conceptually, augmentation of the posterior pharyn-geal wall shouldbringthisstructurecloser tothevelumduring maximal closure of the velum, therebyaiding inspeech, especially for smaller velopharyngeal defects. Passa-vant40described an unsuccessful attempt to do so utilizingadjacent softtissues in 1879.Since then,a myriad of otherproducts have been tried in an attempt to optimize speechfunction. This has included petroleumjelly,41parafn,42cartilage,4345fat and/or fascia,46,47silastic,48,49Teon,50andProplast.51Numerouscomplicationshavebeendocu-mented with such procedures, including infection, exposure,extrusion, migration, andembolism. Theresults havere-mainedlargelyunimpressiveandtheprocedurehasyettobe accepted as a mainstay of treatment.AcknowledgmentsThe author would like to acknowledge the work of Dr. JudyL. Jang who created the illustrations for this article.References1 Lewis JR, Andreassen ML, Leeper HA, Macrae DL, Thomas J. Vocalcharacteristics of childrenwithcleft lip/palateandassociatedvelopharyngeal incompetence. J Otolaryngol 1993;22(2):1131172 Paal S, Reulbach U, Strobel-Schwarthoff K, Nkenke E, Schuster M.Evaluation of speech disorders in children with cleft lip and palate.J Orofac Orthop 2005;66(4):2702783 Trost-CardamoneJE. ComingtotermswithVPI: aresponsetoLoney and Bloem. Cleft Palate J 1989;26(1):68704 Witt PD, Wahlen JC, Marsh JL, Grames LM, PilgramTK. 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Oral mucosal incisions (dark lines) and nasal mucosalincisions (dotted lines) are shown. On the right side, an oral musculomucosal ap will be elevated, whereas the left oral ap will contain mucosaonly. (B) The nasal Z-plasty has been transposed and this layer has been closed. Note that the left side contains the nasal myomucosal ap, which isnow transversely oriented. The oral mucosaaps remain elevated. (C) The oral mucosa is now closed. The palate has been lengthened by theZ-plasties and the levator musculature has been transposed and overlapped upon itself.Seminars in Plastic Surgery Vol. 26 No. 4/2012Velopharyngeal Dysfunction Woo 1769 LipiraAB, GramesLM, MolterD, GovierDP, KaneAA, WooAS.Videouoroscopic and nasendoscopic correlates of speech invelopharyngeal dysfunction. Cleft Palate Craniofac J 2011;48(5):55056010 Golding-Kushner KJ, Argamaso RV, Cotton RT, et al. 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