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

Jackson modification

• 
  sphincter is constructed from the posterior tonsillar pillars, which are elevated to include the palatopharyngeus muscles sutured together in the midline and were attached to the undersurface of a superiorly based posterior pharyngeal flap.
  

1. 
   dynamic sphincter closure as a result of retained neuromusc innervation
   
2. 
   ease of operation
   
3. 
   good results
   
4. 
   low complication rate
   
5. 
   nonobstruction of the nasal airway and no interference with the velum
   

Best for those with circular closure patterns with mild nasal resonance

Better results in children under the age of six
Palatal lengthening

• 
  Theoretical advantage of lengthening the palate without damaging the normal VP mechanism
  
• 
  The V-Y palatal push back was designed to create a retro displacement of the palatal mucoperiosteum and the velar musculature during initial palatoplasty
  
• 
  Double opposing Z plasty (Furlow) now commonly used
  
• 
  Best used in those with small defects only
  

• 
  a static augmentation of the posterior wall to allow a compromised palate to achieve contact. It is best with a small gap and with good palate movement, and it has been especially good with patients who get VPI after adenoidectomy.
  
• 
  The goal is to achieve Vp closure without altering the function of the velumor the lateral walls
  
• 
  Many materials have been used to augment the post pharyngeal wall
  
• 
  Materials used include paraffin, cartilage, sialastic, fat, Teflon and collagen
  
• 
  Mostly abandoned due to the unpredictable effect of migration and rejection
  
• 
  folded superior pharyngeal flap technique is an alternative
  

Large fistulae may be associated with hypernasality and nasal emission and thus may benefit from occlusion

1. 
   Obstructive sleep apnoea (90%)
   
   1. 
      One of the most common complication of pharyngeal flap surgery
      
   2. 
      Tonsillectomy recommended preop or intraop if enlarged
      
   3. 
      Affects most pts early post op - it is usually short lived and last for 1-2 days
      
   4. 
      other factors such as decreased airway size , presence of tonsils, alteration in resp pattern and syndromic contributions are more likely to contribute to OSA than the flap width)
      
2. 
   snoring
   
3. 
   bleeding(8%)
   
4. 
   airway obstruction in the first 24 hrs(9%)
   
5. 
   OSA(4%)
   
   1. 
      May require flaps to be taken down or revised
      
6. 
   Inadequate correction of the VPI
   
7. 
   Overcorrection
   
8. 
   flap dehiscence and loss
   
9. 
   Inhibition of facial growth due to the tethering effect of the velum that may restrict maxillary advancement
   
   1. 
      No significant change in facial form noted
      

Predictive factors of complications included the operating surgeon, presence of associated medical conditions, concurrent performance of another major procedure, and leaving the posterior pharyngeal donor site open.

• 
  A nasoendoscope- guided clinical examination by a speech pathologist familiar with cleft palate and jaw deformities can reliably predict current and expected velopharyngeal function
  
• 
  When significant postoperative velopharyngeal deterioration is anticipated, the patient and family are educated about the sequencing of treatment, and alternatives are discussed.
  
• 
  Unusual to need to transect an in-placed pharyngeal flap to achieve the desired advancement.