Inability of the velopharyngeal sphincter to close completely during production of the oral (nonnasal) sounds of speech

Superior based pharyngeal flap

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  Width and level of insertion are crucial
  
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  The flap must not be too wide that the lateral ports are occluded which will result in mouth breathing and sleep disturbances as sleep apnoea and snoring and hypo nasal speech
  
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  Lateral port control (introduced by Hogan) –aim for total port size of 10-20mm² cross sectional area (oropharyngeal air pressure decreases significantly when the orifice size exceeds 10 mm², with nasal escape of air obvious above 20 mm²)
  
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  Thus 10 mm² catheters are placed on each side to control the size of the port ( this does not however account for the effects of flap contraction)
  
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  Shprintzen et al. (1979 - Flaps are tailored according to the amount of lateral pharyngeal wall motion and gap size as based on the preoperative on videofluoroscopy and nasopharyngoscopy. Narrow, moderately wide, or very wide flap, depending on whether the preoperative lateral pharyngeal wall motion was rated as excellent, moderate, or poor, respectively
  

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  Flaps are raised from wide area and the post surface heals by second intention thus post op contraction is a problem with recurrence of the VPI
  
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  The position of the flap may also have effect on the overall post op state
  
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  Distal insertion of a wide short flap along the free margin of the soft palate may also lessen the problem of post op contraction
  

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  Superior based flaps may be better as the inferiorly based flaps have a
  

1. 
   severe length limitation
   
2. 
   disadvantage of tethering the flap in a inferior direction away from the palatal plane and in the opposite direction required for palatal closure
   

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  Most studies have not found a difference between the 2 methods in postoperative speech outcome, hearing, complications, or length of hospital stay.
  
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  Kapetansky (1973) introduced a third design, bilateral transverse flaps. He believed that basing the flaps laterally would preserve nerve supply, thus maintaining more flap mass, as well as preserving contractile function. Therefore, he made an S-shaped incision in the posterior pharyngeal wall and elevated two laterally based flaps, each 15 to 20 mm in width and 30 to 35 mm in length, using one to provide oral lining and one for nasal lining. However, this design has never become as popular as the superiorly or inferiorly based flaps.
  

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  speech improvement in 95% but up to 35% are overcorrected
  

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  Hynes(1950) described transposition of bylateral flaps from the lateral pharyngeal walls to join in the palatal midline anterior to Passavant’s ridge
  
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  Each flap is 3–4-cm long and consists of salpingopharyngeus muscle and its overlying mucosa.
  
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  67% of the flaps were noted to be contractile on postoperative examination, and 95% of patients achieved velopharyngeal competence.