34.

2 Posterior Pharyngeal Flap

The posterior pharyngeal flap functions as a soft tissue
obturator of the velopharyngeal port. Closure of
the lateral openings beside the sagittally oriented flap
is primarily achieved by medial movement of the lateral
pharyngeal walls [4]. Thus, use of a pharyngeal
flap is best suited to those patients who demonstrate
good lateral pharyngeal wall motion, as in a sagittal or
circular velopharyngeal closure pattern. Passavant
first reported secondary management of VPD by simple
adhesion of the velum to the posterior pharynx in
1865 [47]. Elevation of an inferiorly based flap from
the posterior pharyngeal wall was described by
Schoenborn in 1875 [57]. In 1886, he reported on the
use of a superiorly based flap [58.]. The superiorly
based flap was described in the USA by Padgett in
1930 [46]. In 1973,Hogan [29] advocated the intraoperative
use of rubber catheters to allow for creation of
a wide pharyngeal flap with lateral port control. In
his technique, port size was based upon the pressureflow
studies ofWarren et al. [71, 72],wherein velopharyngeal
valve area of greater than 20mm2 was documented
to result in hypernasality and nasal air escape
during connected speech. Although Hogan reported
excellent results in his series, many have since abandoned
the use of lateral port control, citing a greater
potential for postoperative airway obstruction.
The selection of either an inferiorly or a superiorly
based flap remains the subject of some debate.While
technically easier to perform, the inferiorly based flap
has the disadvantages of limited flap length and an
obscured donor site. The inferiorly based flap also has
the theoretical disadvantage of tethering of the soft
palate inferiorly, although a poorly designed superiorly
based flap may also result in such tethering.
Several studies have failed to document a significant
difference in surgical outcome between patients who
have had superiorly based flaps and those who have
had flaps based inferiorly [24, 63, 74]. Nevertheless,
the superiorly based flap remains more commonly
used today.

Surgical Technique (Fig. 34.4)

The superiorly based pharyngeal flap, composed of
pharyngeal mucosa and the underlying superior pharyngeal
constrictor muscle, is elevated from the prevertebral
fascia and inset into the posterior velum. In
order to optimize surgical outcome, flap design
should be individualized, based upon anatomic and
functional information provided by preoperative imaging
studies. Ideally, the base of flap should correspond
to the level of velopharyngeal closure, high on
the posterior pharyngeal wall.When there is a marked
asymmetry in lateral pharyngeal wall motion, or
when there is significant displacement of a carotid artery,
the origin and inset of the flap may be skewed to
one side [3]. Flap width is determined by the size of
the gap to be obturated. Care should be taken to avoid
creation of side ports that are too small, however, as
such may lead to nasal airway obstruction and to

sleep apnea.
Inset of the pharyngeal flap into the nasal surface
of the velum may be accomplished either by dividing
the soft palate in the midline or by dissecting a submucosal
pocket through a posterior transverse, or
fishmouth, incision.Use of the latter allows for fairly
precise control of flap width, as described by Argamaso
[2]. Use of a broad, relatively short flap avoids
the tendency of unlined flaps to tube upon themselves
and to thereby produce a narrow flap with large

Fig. 34.4. Posterior pharyngeal flap. (From

[84] with permission)

side ports [69]. The raw oral surface of narrower flaps

should be lined by turnover flaps of soft palatal mucosa
to avoid this otherwise inevitable outcome. The
donor site of narrow flaps and those of moderate
width may be closed primarily. When use of a wide
flap precludes donor site closure, the posterior pharyngeal
wall may be left to heal secondarily within
23 weeks.

34.2.2 Outcome
Decades of successful use have established the posterior
pharyngeal flap as the gold standard for surgical
management of VPD. Accurate interpretation of
reported series is hindered by the use of different
surgical techniques, heterogeneous patient characteristics,
and nonstandardized measures of surgical outcome.
Argamaso [2] reported elimination of hypernasality

in 96.1% of 226 patients after pharyngeal flap

surgery. In a recent long-term outcomes study of pharyngeal
flap surgery at the University of Iowa [9], investigators
rated hypernasality on a scale from 1 to 6,
with a score of 1 indicating no hypernasality and that
of 6 denoting severe hypernasality.Mean scores were
1.94, 1.53, 1.71, and 1.75 after 2- to 5-year, 5- to 8-year,
8- to 11-year, and 11- to 14-year follow-up, respectively,
indicating that pharyngeal flap surgery most often
significantly improves or eliminates hypernasality
and that the surgical outcome is durable.
Complications of pharyngeal flap surgery include
bleeding, dehiscence, nasal airway obstruction, and
obstructive sleep apnea [28]. Rare cases of postoperative
death have been reported and are primarily the
result of upper airway obstruction [68]. Fraulin et al.
[17] reported that the surgeon involved, the presence
of associated medical conditions, concurrent surgical
procedures, and an open donor site may be predictive
factors for complications. Bleeding most often occurs
within the first 24 h and may be reduced by closure of
the donor site and by the use of electrocautery to elevate
the flap. Although many patients will demonstrate
some degree of upper airway obstruction in the
early postoperative period, this most often resolves as
edema subsides. Syndromic patients and those with a
history of Pierre Robin sequence may present with
structural narrowing of the upper airway or pharyngeal
hypotonia and may therefore be at greater risk for
postoperative obstructive sleep apnea [1, 73].Wells et
al. [73] reviewed their 17-year experience with 111 patients
who underwent posterior pharyngeal flap surgery
for management of VPD.Twelve patients demonstrated
clinical evidence of postoperative nocturnal
respiratory obstruction, and three required takedown
of the flap.Nine of 12 patients with obstructive symptoms
underwent polysomnographic evaluation, eight
of which were normal. Thus, although nocturnal respiratory
obstruction may occur commonly after pharyngeal
flap surgery, obstructive symptoms do not
necessarily imply the occurrence of obstructive sleep
apnea. In order to determine the incidence of obstructive
sleep apnea after pharyngeal flap surgery, Sirois et
al. [62] evaluated postoperative polysomnograms in
40 patients.Abnormal studies were obtained in 14 patients
(35%), of whom six demonstrated obstructive
apnea, six central apnea, and two mixed obstructive
and central apnea. Ten of the 14 patients were restudied
in the following months, eight of whom demonstrated
normal studies and two of whom demonstrated
central apnea. The remaining four patients were
noted to demonstrate no obstructive symptoms. Patients
with tonsillar hypertrophy may be at greater
risk for postoperative obstructive apnea and should
therefore undergo tonsillectomy either prior to or at
the time of pharyngeal flap surgery [82].
Postoperative monitoring of the upper airway, including
continuous oximetry, plays an important role
in the management of all patients undergoing pharyngeal
flap surgery. Use of a nasopharyngeal airway
and admission to an intensive care unit should be considered
for those patients at highest risk for postoperative

airway obstruction.Patients are discharged once

they demonstrate adequate airway stability and oral
intake of fluids.