Management of velopharyngeal insufficiency: development of a protocol and modifications of sphincter pharyngoplasty

Velopharyngeal closure is required for normal speech production. Incomplete velopharyngeal closure manifests as resonance disorders and nasal air escape. Management of velopharyngeal insufficiency requires a general knowledge of speech production as well as a more detailed understanding of the velopharyngeal mechanism. Comprehensive evaluation by a velopharyngeal insufficiency team includes medical assessment focusing on airway obstructive symptoms, perceptual speech analysis, and instrumental assessment, which is utilized to characterize the velopharyngeal gap. Options for intervention include speech therapy, intraoral prosthetic devices, and surgery. Surgical interventions can be categorized as palatal, palatopharyngeal, or pharyngeal procedures. The therapeutic challenge lies in achieving velopharyngeal closure during speech production while maintaining patency of the upper airway. We present our protocol for evaluation of velopharyngeal function with a focus on indications for palatoplasty and pharyngoplasty. We also discuss surgical modifications of sphincter pharyngoplasty.

Application of a specially designed palatal lift prosthesis to a patient with velopharyngeal incompetence due to severe brain injury

This article reports the evaluation of the therapeutic effect of a palatal lift prosthesis with a specially designed connection between the anterior denture base and the palatal lifting plate in a patient with velopharyngeal incompetence due to severe brain injury.

Wundheilungsstörung nach Tonsillektomie

Tonsillectomy is one of the most commonly performed surgical procedures in the field of otorhinolaryngology. The first tonsillectomy was done about 600 B.C. [3]. This operation is indicated for patients with recurrent tonsillitis, peritonsillar abscess, hypertrophy or asymmetry of the tonsils. Even though a routine procedure, it has a relatively high risk of complications such as post operative hemorrhage, infection or impaired wound healing. The reported case involves a 20 year old female patient who developed velopharyngeal insufficiency as a result of impaired wound healing after tonsillectomy. The patient was treated conservatively and is free of discomfort after 2 months.

Influence of treatment concept, velopharyngoplasty, gender and age on hypernasality in patients with cleft lip, alveolus and palate

OBJECTIVES

The aim of this study was to analyse cleft patients for hypernasality following velopharyngoplasty.

PATIENTS AND METHODS

95 subjects (43 females, 52 males) with cleft lip, alveolus and palate (4 - 25 years old) were analysed. Forty-three patients were treated according to the current protocol of the Cleft Palate/Craniofacial Malformations Centre of the Department of Cranio-Maxillofacial Surgery in Muenster ('MS+' group) and 52 patients were treated elsewhere according to different protocols. In 19 of the 95 patients a velopharyngoplasty had been performed. Hypernasality was judged perceptually and nasalance data was measured objectively using the NasalView system.

RESULTS

Patients of the 'MS+' group showed significantly better results concerning hypernasality and nasalance data. Assessment of hypernasality and nasalance measurement showed no significant differences between subjects following velopharyngoplasty and those who had not had this operation. Gender and age did not correlate with hypernasality either.

CONCLUSION

A functionally orientated treatment with early closure of lip and palate ensures optimal velopharyngeal function, optimal oro-nasal balance of resonance, low hypernasality and excellent nasalance data.

Process and outcome study of multidisciplinary prosthetic treatment for velopharyngeal dysfunction

BACKGROUND

A prosthetic approach to velopharyngeal dysfunction (VPD) is not new. However, a collaborative interdisciplinary team approach by a speech-and-language therapist, dental specialist and maxillofacial technician, including accurate fitting using nasendoscopy, has provided an opportunity to define the clinical care pathway, and audit the outcomes of this intervention. Systematic outcome studies of the effectiveness of prosthetic appliances are few and largely anecdotal.

AIMS

The aim is twofold: first, to provide a description of the process including diagnosis, clinical and technical fabrication; and second, to determine the effectiveness of this intervention with nasendoscopy, objective blind perceptual analysis of speech data and nasometry.

METHODS & PROCEDURES

The selection criteria, age, aetiology and process of fabrication are described. Thirty-one patients embarked on the programme, but seven patients after initial failure or refusal were re-entered into the programme for a second time resulting in 38 interventions. At the time of audit, 20 patients had completed the treatment, but four of these were inadequately documented. This study reports on the 16 patients who successfully completed the programme and who had comprehensive records.

OUTCOMES & RESULTS

Significant differences were found between the pre- and post-treatment evaluations on the speech parameters of hypernasality, audible nasal emission and nasometry.

CONCLUSIONS

In our centre surgery is the first choice of treatment for VPD, but prosthetic management can be a useful alternative when this is contraindicated, can be a useful temporary solution and can be used to evaluate the potential benefits of surgical intervention in some cases. This treatment requires the combined expertise of an interdisciplinary team involving the speech-and-language therapist, orthodontist/prosthodontist, maxillofacial technician and endoscopist.

Analysis of Velopharyngeal Morphology in Adults With Velopharyngeal Incompetence After Surgery of a Cleft Palate

This study analyzed the relationship of velopharyngeal morphology and velopharyngeal function among 13 adults with velopharyngeal incompetence (VPI), 14 adults with velopharyngeal competence (VPC) after primary surgical treatment of cleft palate, and 20 noncleft adults. The measurements included velar length, pharyngeal depth, pharyngeal height, and the need ratio of pharyngeal depth to velar length. In addition, the cranial base, cervical vertebrae, posterior nasal spine, and also the position of the posterior pharyngeal wall (PPW) in the pharyngeal triangle were analyzed. All data were subjected to the Student t test of statistical significance. The results showed that the VPI group had normal pharyngeal depth and a significantly shorter velar length, resulting in a greater depth/length ratio than those of the VPC group and normal control subjects. The position of PPW in the pharyngeal triangle was located significantly more superior in the VPI group compared with the VPC group and normal control subjects. Measurements of the anteroposterior and the vertical dimensions in the regions of the cranial base and cervical vertebrae revealed no significant difference among the 3 groups. According to this study, the velopharyngeal morphology of adults with VPI is characterized by a shorter palate, greater need ratio, slightly counterclockwise-rotated pharyngeal triangle, and superiorly positioned PPW.

Fabrication of a meatus obturator on a titanium framework with a 1-step impression

The fabrication of meatal obturator prosthesis with titanium framework using a 1-step final impression procedure is described in the case of a 44-year-old woman with congenital absence of the soft palate. The meatus obturator results in a more stable maxillary prosthesis and permits acceptable speech for a patient with total absence of the soft palate. The fabrication technique is relatively easy and saves time by eliminating some laboratory procedures.

Velopharyngeal anatomy in 22q11.2 deletion syndrome: a three-dimensional cephalometric analysis

OBJECTIVE

22q11.2 deletion syndrome is the most common genetic cause of velopharyngeal dysfunction (VPD). Magnetic resonance imaging (MRI) is a promising method for noninvasive, three-dimensional (3D) assessment of velopharyngeal (VP) anatomy. The purpose of this study was to assess VP structure in patients with 22q11.2 deletion syndrome by using 3D MRI analysis.

DESIGN

This was a retrospective analysis of magnetic resonance images obtained in patients with VPD associated with a 22q11.2 deletion compared with a normal control group.

SETTING

This study was conducted at The Children's Hospital of Philadelphia, a pediatric tertiary care center.

PATIENTS, PARTICIPANTS

The study group consisted of 5 children between the ages of 2.9 and 7.9 years, with 22q11.2 deletion syndrome confirmed by fluorescence in situ hybridization analysis. All had VPD confirmed by nasendoscopy or videofluoroscopy. The control population consisted of 123 unaffected patients who underwent MRI for reasons other than VP assessment.

INTERVENTIONS

Axial and sagittal T1- and T2-weighted magnetic resonance images with 3-mm slice thickness were obtained from the orbit to the larynx in all patients by using a 1.5T Siemens Visions system.

OUTCOME MEASURES

Linear, angular, and volumetric measurements of VP structures were obtained from the magnetic resonance images with VIDA image-processing software.

RESULTS

The study group demonstrated greater anterior and posterior cranial base and atlanto-dental angles. They also demonstrated greater pharyngeal cavity volume and width and lesser tonsillar and adenoid volumes.

CONCLUSION

Patients with a 22q11.2 deletion demonstrate significant alterations in VP anatomy that may contribute to VPD.

Two-Flap Palatoplasty: 20-Year Experience and Evolution of Surgical Technique

BACKGROUND

The two-flap palatoplasty was described more than 30 years ago, but there are few reports of long-term results using this technique. There are also very few long-term series of a single method of palatoplasty from a single surgeon.

METHODS

The authors reviewed the technique of the two-flap palatoplasty, with emphasis on the senior author's (K.E.S.) modifications. The authors also retrospectively reviewed 382 two-flap palatoplasties performed by the senior author in nonsyndromic patients over a 20-year period. The incidence of secondary velopharyngeal surgery was established. Detailed speech analysis was performed in a subset of 150 patients.

RESULTS

The proportion of patients with velopharyngeal insufficiency over 20 years was 8.92 percent, falling from 10.95 percent in the first decade to 6.43 percent in the second decade. There was no significant difference in velopharyngeal insufficiency between the cleft subtypes. Age at palatoplasty did not affect the development of velopharyngeal insufficiency, but it should be noted that most of the patients underwent palate repair before 12 months of age. Speech results were consistently good across the two decades. In the second decade, 91.14 percent had normal to mildly impaired resonance, 79.75 percent had no or inaudible nasal air emission, and 97.47 percent demonstrated no compensatory articulation errors.

CONCLUSIONS

The two-flap palatoplasty is a reliable technique that has yielded excellent surgical and speech outcomes. Early and regular speech assessments and appropriate treatment when indicated are an integral part of the multidisciplinary approach to achieve good speech outcome.

Postsurgical use of prosthetic palatal appliances. Two case reports

Patients with cleft lip or palate encounter a myriad of difficulties in their early years of life, some of which begin at birth. The defect often impairs suckling and deglutition in the neonate. It can hinder appropriate speech development and may impose undue social and psychological stresses. Surgical and orthodontic interventions are essential and prosthetic palatal appliances play an important role not only throughout the patient's treatment course, but also in the treatment of unfavorable surgical sequelae.

Improved Outcomes in Cleft Patients with Severe Maxillary Deficiency after Le Fort I Internal Distraction

BACKGROUND

Correction of severe maxillary deficiency in cleft lip-cleft palate patients often results in undercorrection, relapse, and need for secondary corrective procedures. Le Fort I internal distraction osteogenesis offers an alternative to one-step orthognathic advancement, with advantages of gradual lengthening through scar and earlier treatment in growing patients.

METHODS

Patients with cleft lip-cleft palate deformities and maxillary deficiency were divided into three groups treated by Le Fort I advancement: group 1, mild to moderate deficiency (< 10 mm) with conventional orthognathic procedure; group 2, severe deficiency (> or = 10 mm) with conventional orthognathic procedure; and group 3, distraction procedure for severe deficiency (> or = 10 mm) (n = 51). Preoperative, postoperative, and follow-up (> 1 year) lateral cephalogram measurements were compared including angular (SNA and SNB) and linear (Deltax = horizontal and Deltay = vertical) changes. The Pittsburgh Speech Score was used to assess for velopharyngeal insufficiency (score > 3).

RESULTS

Results demonstrated that group 1 patients had a mean SNA change from preoperatively (78.7) to postoperatively (83.8), and a horizontal change of 5.0 mm, with no relapse. Group 2 patients had a mean SNA change from preoperatively (76.3) to postoperatively (82.0) and a horizontal change of 7.2 mm, with 63 percent relapse. Group 3 patients had a mean SNA change from preoperatively (74.1) to postoperatively (84.9) and a horizontal change of 16.5 mm, with 15 percent relapse. Thus, for severe maxillary deficiency, the distraction group had 48 percent less relapse than the conventional Le Fort I group. Postoperative speech evaluation showed velopharyngeal insufficiency in the following: group 1, four of 20 patients (20 percent); group 2, nine of 11 patients (82 percent); and group 3, nine of 20 patients (45 percent).

CONCLUSION

These data suggest that Le Fort I internal distraction for severe cleft maxillary deficiency leads to better dental occlusion, less relapse, and better speech results.

From Birth to Maturity: A Group of Patients Who Have Completed Their Protocol Management. Part II. Isolated Cleft Palate

BACKGROUND

The optimal management of the cleft palate patient from birth to completion of treatment continues to present a formidable challenge to the plastic surgeon. The management by multidisciplinary teams is well established, but long-term outcome data of cases managed by protocol remain sparse. This study continues to present the results of the Australian Craniofacial Unit of patients with isolated cleft palate who completed protocol management at the unit under the care of the senior author (D.J.D.) during the 29-year period from 1974 to 2003.

METHODS

A retrospective study of the outcomes in relation to facial growth, speech, hearing, and occlusion is presented of patients with an isolated cleft palate.

RESULTS

Thirty-two cases were identified from the departmental database, involving 17 female patients and 15 male patients. Cephalometric analysis at skeletal maturity revealed a range of facial growth, and maxillary advancement surgery was deemed necessary in just two cases. Speech results were evaluated using speech therapy assessments during development and at maturity. At maturity, 18 of 32 patients were assessed as being within normal limits. The hearing was within -20 dB, with just two exceptions.

CONCLUSION

Overall, these is a range of outcomes, but the results confirm that facial growth does not appear to be adversely affected by use of the pushback technique to reconstruct the palate.

Cleft palate speech and velopharyngeal insufficiency: surgical approach

Velopharyngeal insufficiency is the main morbidity associated with clefting of the secondary palate. Therefore, it is important to monitor speech production in all children with a history of cleft palate. Diagnosis and management of velopharyngeal insufficiency is an important function of the cleft palate team. The surgical approach used in the Craniofacial Center at Children's Hospital and Regional Medical Center, Seattle, Washington, USA is presented. Assessment of velopharyngeal function, as it relates to surgical intervention and measurement of outcome, is reviewed. Surgical management using Furlow palatoplasty and sphincter pharyngoplasty is discussed.

[The management of velopharyngeal insufficiency after pharyngeal augmentations and furlow surgery]

INTRODUCTION

The term insuffisance velopalatine was first used by Larmoyez in 1892 r. Nowadays the term is used to denote the failure of the palate to produce velopharyngeal closure that would completely block the nasopharynx from the lower pharynx during physiological processes of swallowing, blowing, speaking, breathing and ventilation of the internal auditory canal. Numerous surgical techniques used in the treatment of VPI were described in the past 100 years. Several techniques have been used to decrease the velopharyngeal space, like operations aiming at bulging of the posterior pharyngeal wall and alternating "Z-plasty" of the soft palate aiming at prolongation and improvement of the mobile function of the palate.

MATERIAL AND METHOD

The prospective studies were carried on from May 2003 to October 2004. Patients with severe forms of VPI were qualified for surgical treatment by a phoniatrist, speech therapist and plastic surgeon. All the surgical procedures were performed by the same surgeon. Bulging of the posterior pharyngeal wall by means of corionic graft was performed in 8 patients as the first stage treatment followed by prolongation of the palate by means of Furlow's technique 6 months later. The anatomical conditions as well as speech quality prior to, after the first and the second procedure were evaluated on the basis of direct examination, speech assessment, nasofibroscopic examinations and nasometric measurements.

RESULTS

Examinations performed 6 months after termination of surgical treatment revealed improvement or significant improvement in speech quality, especially concerning reduced nasality, speech intelligibility and decreased nasal airflow (on an average from 48% to 33%). Five patients rated in questionnaires the outcome of treatment as "significant improvement".

CONCLUSION

Complex staged management consisting in bulging of the posterior pharyngeal wall and Furlow's operation appeared to be a successful modality of treatment in patients with severe forms of velo-pharyngeal insufficiency in about 75% of cases.

SISL (ScreeningsInstrument Schisis Leuven): assessment of cleft palate speech, resonance and myofunction

This paper presents an assessment protocol for the evaluation and description of speech, resonance and myofunctional characteristics commonly associated with cleft palate and/or velopharyngeal dysfunction. The protocol is partly based on the GOS.SP.ASS'98 and adapted to Flemish. It focuses on the relevant aspects of cleft type speech necessary to facilitate assessment, adequate diagnosis and management planning in a multi-disciplinary setting of cleft team care.

Cleft palate speech and velopharyngeal dysfunction: the approach of the speech therapist

Cleft palate and velopharyngeal dysfunction cause communication disorders in many different ways (articulation, resonance, voice and language). These problems are mainly present in childhood but remain a matter of concern for many years. Speech and language pathologists are involved in speech and language assessment and speech therapy procedures. This article gives an overview of the standard procedures of the speech pathologist in a cleft palate team and discusses the relationship between the team and private practices or school teams, as well as the practical aspects relating to reimbursement by the National Institute of Health and Invalidity (RIZIV).

Evaluation of VPI-assessment with videofluoroscopy and nasoendoscopy

The purpose of this study was to investigate how different amounts of visual assessment information influence the recommended treatment for velopharyngeal insufficiency (VPI). Is a patient presented with videofluoroscopy (VF) in lateral projection recommended the same treatment as when frontal projection, nasoendoscopy, or both, are added? Retrospective material with video recorded assessment of VPI was blinded and copied in random order. Each patient was then presented in four separate combinations: VF in lateral projection; VF in lateral and frontal projection; VF in lateral projection and nasoendoscopy; and VF in lateral and frontal projection and nasoendoscopy (all of the available assessment material). The cleft palate team of Göteborg, Sweden, mutually rated velopharyngeal function and recommended action based on the presented material.

SUBJECTS

Nineteen consecutive patients (median age 7:5 years, range 4:4-19:7) investigated with VF in lateral and frontal projection and nasoendoscopy during 1997-99 at the cleft palate centre in Göteborg, Sweden. Post operative assessments were excluded. Percent agreement and Kappa calculations were used to compare the different combinations of parts of information to all of the available information.

RESULTS

Thirteen of the 19 patients (68%) were recommended the same action regardless of the amount of presented information. Percent agreement (Kappa) between parts and all of the available information: VF in lateral projection 84% (0.75), VF in lateral and frontal projection 79% (0.74), and VF in lateral projection and nasoendoscopy 84% (0.72).

CONCLUSIONS

VF in lateral projection is recommended to be the first step in visualising velopharyngeal function, and nasoendoscopy the next when further investigation is required.

Hearing and speech assessment of cleft palate patients after palatal closure. Long-term results

OBJECTIVE

The goal of this study was the development of a clinical methodology to assess speech and hearing impairment 5 years after the primary surgical repair of the cleft and, further, to determine the relative importance and long-term consequences of each cleft type and age to the velopharyngeal and eustachian tube function in patients who did not undergo pharyngeal flap surgery following primary palatoplasty.

MATERIALS AND METHODS

We evaluated with a certain assessment protocol hearing and speech abilities of 42 patients between 5 and 15 years of age: 9 with CP (cleft of the soft and hard palate), 19 with unilateral cleft lip and palate (UCLP), 14 with bilateral cleft lip and palate (BCLP), surgically treated by a team of surgeons using two different surgical techniques between 18 and 24 months of age. ACCORDING TO OUR RESULTS WE WERE ABLE TO EVALUATE: (a) the impact of hearing impairment to the development of speech in these patients. (b) The relation of hypernasality with compansatory articulation. (c) The influence of cleft type, by means of extent of the cleft palatal musculature, to speech integrity.

RESULTS

Sixty-nine percent of our patients presented with mild and moderate hearing loss. Hypernasality was observed in 40.5%, compensatory articulation in 28.5% of our patients.

CONCLUSIONS

Our findings indicated: (a) a simultaneous appearance of speech and hearing impairment at the same age for each cleft type post-surgically in our patients; (b) that the muscular and vomer complex rather than the anatomic extent of the cleft is a significant factor for speech outcome after surgical repair; and (c) that hypernasality is exacerbated by compensatory articulation.

Oro-nasal fistula development and velopharyngeal insufficiency following primary cleft palate surgery--an audit of 148 children born between 1985 and 1997

We present an audit of primary cleft palate surgery in our unit including rates of two important post-operative complications. Multidisciplinary audit clinics ran from March 1998 to April 2002 to follow up all local patients with a cleft lip or palate who had undergone primary palatal surgery in our unit. One hundred and forty eight patients were studied. Patient ages at follow-up ranged from 3 years and 10 months to 17 years and 4 months. Two surgeons performed the primary surgery. One hundred and twenty eight Wardill-Kilner and 20 Von Langenbeck repairs were performed. We found a 4.7% rate of oro-nasal fistula development requiring surgical closure, and a 26.4% rate of velopharyngeal insufficiency (VPI) requiring subsequent pharyngoplasty. We noted that the type of cleft involved affected the rate of VPI, 16% of patients with unilateral cleft lip and palate versus 29.2% of patients with a solitary cleft palate requiring secondary surgery. Outcome of surgery was determined by a 'Cleft Audit Protocol for Speech' (CAPS) speech therapy assessment at follow-up clinics. Only 14.9% of all patients assessed demonstrated any degree of hypernasality. Our results compare favourably with other recent studies including the Clinical Standards Advisory Group (CSAG) report into treatment of children with cleft lip and palate.

Efficacy of speech aid prostheses for acquired defects of the soft palate and velopharyngeal inadequacy--clinical assessments and cephalometric analysis: a Memorial Sloan-Kettering Study

BACKGROUND

Restoration of speech after surgical resection for oropharyngeal cancer traditionally includes maxillofacial prosthetic intervention. Relatively few publications with objective speech outcomes exist. The purpose of this study was to evaluate speech outcome relative to the size of the surgical defect, the type of speech prosthesis, and the height and position of the speech bulb in relation to the posterior pharyngeal wall in the nasopharynx.

METHODS

Fifty-five patients treated at the Memorial Sloan-Kettering Cancer Center Dental Service who underwent ablative cancer therapy were evaluated. All patients were 4 months or longer after surgery and were using a speech aid or obturator prosthesis at the time of the study. Speech samples for percent intelligibility and perceptual evaluation were collected and analyzed, in addition to aeromechanical measurements of palatopharyngeal function. Lateral cephalograms were taken while wearing the prosthesis using a radiopaque marker placed on the posterior aspect of the prosthesis for evaluating the height and position of the prosthesis obturator-speech bulb component.

RESULTS

After adjustment for the differences between listeners, findings revealed that as the percentage of resection of palate or tongue increased, the intelligibility of speech decreased. Aeromechanical assessment of speech was the only outcome measure sensitive to the type of speech prosthesis. The position of the speech bulb component, as well as the angle measured, was correlated with the percent intelligibility. The amount of the prosthesis physically contacting the posterior pharyngeal wall was not significantly associated with any of the functional outcome measures.

CONCLUSIONS

Speech aid and obturator prostheses contribute to a higher percentage of intelligible speech. A difference in intelligibility exists in relationship to the position of the prosthesis and the anterior tubercle of the atlas vertebrae (C1), both statistically and clinically. The position for optimal speech could not be specifically located mathematically (ie, 3 mm or 3 degrees inferior to the anterior tubercle of the atlas vertebrae) from the analysis. Subjective ratings of the efficacy of the obturator-speech bulbs by the clinicians did not correspond to the percent intelligibility. A strong statistical and clinical correlation exists supporting the efficacy of speech bulb-obturator intervention after velopharyngeal insufficiency for improved intelligibility of both words and sentences.

Collaboration of a dentist and speech-language pathologist in the rehabilitation of a stroke patient with dysarthria: a case study

OBJECTIVE

To elucidate the effectiveness of the collaboration of a dentist and speech-language pathologist (SLP) in the rehabilitation of a stroke patient with dysarthria.

DESIGN

A clinical case report treated in the rehabilitation hospital and dental surgery.

SUBJECT

A 71-year-old Japanese man who was admitted to the rehabilitation hospital for speech rehabilitation 2 years and 5 months after a stroke.

METHODS

Provision of prosthesis (palatal lift prosthesis + palatal augmentation prosthesis) for improving velopharyngeal incompetence (VPI) and articulation by dentist, and speech behavioural management by SLP including self-monitoring and bio-feedback training using the See-Scape.

RESULTS

Speech behavioural management proved useful for promoting improvement in speech intelligibility to a functionally sufficient level after improving VPI by prosthesis.

CONCLUSION

The collaborative efforts of the dentist and SLP in the rehabilitation of post-stroke patients with velopharyngeal incompetence should be encouraged.

Speech and swallowing following radial forearm flap reconstruction of major soft palate defects

Velopharyngeal function is often compromised by the resection and reconstruction of oropharyngeal and palatal tumours. While free tissue transfer has improved the outcomes of head and neck reconstruction. In general, palatal reconstruction remains a challenge. Velopharyngeal function was analysed in eight patients following microsurgical reconstruction of defects of between 50 and 100% of the soft palate. The radial forearm fasciocutaneous free flap was used in all cases. The outcome of reconstruction was analysed by patient questionnaire and with standardised tests of speech and swallowing function. Velopharyngeal function post-operatively ranged from poor to near normal. Poor function appeared due to the loss of active elevation and contracture of the reconstructed palate producing failure of velopharyngeal closure during swallowing and speech. The results emphasise the limitations of reconstruction of a dynamic structure such as the soft palate with the static fold of skin and soft tissue produced by a fasciocutaneous flap. The relatively poor results obtained suggest that an anatomical approach to soft palate reconstruction is inadequate and reduction of the calibre of the velopharyngeal aperture is required to compensate for the lack of mobility in the reconstructed palate.