Pharyngeal Flap Research Articles

Velopharyngeal insufficiency: diagnosis and management

Journal articles relevant to the diagnosis and treatment of velopharyngeal insufficiency were reviewed. All studies ascertained by PubMed search were included. Studies reported on the application of magnetic resonance scanning, reliability tests of the International Working Group diagnostic protocol, the use of nasometry, and techniques designed to assess the function of the velopharyngeal mechanism. Treatment studies focused on outcomes in small samples of cases and complication rates from pharyngeal flap. One study discussed ineffective speech therapy procedures. There were relatively few studies this past year. Those that were published were hindered by small and heterogeneous sample sizes and occasionally by inappropriate methods for assessing outcomes. None of the findings will have a major impact on the current state-of-the-art for diagnosis of velopharyngeal insufficiency. The speech therapy study has a very important message that should be taken to heart by all clinicians involved in the management of children with clefts and craniofacial disorders.

Revisional surgery following the superiorly based posterior pharyngeal wall flap. Historical perspectives and current considerations

The aim of this study was to describe the surgical and functional complications following superiorly based posterior pharyngeal wall (SBPP) flap surgery. Records of 130 patients with velopharyngeal insufficiency (VPI) who had undergone SBPP flap surgery as a secondary procedure to reduce nasal resonance in speech were reviewed. Complications were defined as the incidence of revisional surgery required to obtain a more satisfactory result. 20 patients (15%) required revisional surgery. In 4 patients (3%) early revisional surgery was indicated to treat surgical complications (1 postoperative bleeding, 3 flap dehiscences). In 16 patients (12%) late revisional surgery was indicated to achieve a better functional result with regard to nasal resonance in speech. The low incidence of surgical complications indicates that SBPP flap surgery is a safe procedure. After SBPP flap surgery, a satisfactory functional result with respect to nasal resonance was obtained in 88% of patients. This result was improved after revisional surgery. The hypothesis that the patients of an experienced surgeon have fewer complications and better functional results than those of a less experienced one was tested. The individual skill of the surgeon rather than their experience led to a better functional result.

Hemipalatal Hypoplasia

Asymmetric velopharyngeal incompetence (VPI) has a diverse etiology, but those without any underlying cleft, hemifacial microsomia (HFM), or facial asymmetry are rarely encountered. Such cases have been reported within the last few years, with unilateral velopharyngeal hypoplasia identified to be the underlying abnormality in these patients. However, there have been no reports to date on asymmetric VPI from idiopathic hemipalatal hypoplasia. A retrospective review of patients whose conditions were diagnosed with asymmetric VPI owing to hemipalatal hypoplasia and who do not have underlying cleft, HFM, or any significant facial asymmetry was performed. During a 10-year period, 5 patients with asymmetric VPI from idiopathic hemipalatal hypoplasia were treated at our center. Four of 5 of these patients presented with nasal regurgitation. Two were found to have tonsillar enlargement on the side of the hemipalatal hypoplasia, and another had an ipsilateral tongue mass that subsequently required wedge excision. Two were managed conservatively with speech therapy, whereas the other 3 developed speech problems that required surgery. The first patient underwent a skewed pharyngeal flap, but her speech problem improved only after a second surgery, which involved a centralized pharyngeal flap. The speech problems of the last 2 patients were corrected with a centralized pharyngeal flap. Hence, we conclude that patients with asymmetric VPI from idiopathic hemipalatal hypoplasia, compared with those of other etiology, particularly unilateral velopharyngeal hypoplasia, seem to present in a different manner. When surgical intervention is indicated for correction of the speech problem that eventually develops, centralized rather than skewed pharyngeal flap seems to be more reliable.

P2.75. Prospective functional study in patients with combined free tissue transfer and pharyngeal flap for soft palate reconstruction in tonsillar cancer

P2.75. Prospective functional study in patients with combined free tissue transfer and pharyngeal flap for soft palate reconstruction in tonsillar cancer

Velopharyngoplasty for Noncleft Velopharyngeal Insufficiency

To evaluate the results of velopharyngoplasty for velopharyngeal insufficiency (VPI) in relation to 22q11 deletion or nonsyndromic VPI. Retrospective study. Academic medical center. Eleven of 45 patients with 22q11 microdeletion (group 1) and 9 patients without 22q11 microdeletion (group 2) with noncleft VPI (hypoplastic velum or hypodynamic velopharynx and deep pharynx) underwent velopharyngoplasty (midline pharyngeal flap with superior pedicle). Exclusion criteria included cleft palate, submucous cleft palate, all syndromic cases, and all associated malformations (except those related to 22q11 microdeletion in patients with DiGeorge syndrome). Speech assessment before surgery using the Borel-Maisonny scale and at 9 months and 24 months after surgery. Velopharyngeal insufficiency was classified as normal, inconsistent, mild, moderate, and severe. Before surgery, in group 1, 3 patients had mild and 8 had severe VPI, and in group 2, 1 had mild and 8 had severe VPI. Postoperative outcomes at 9 months showed that in group 1, 2 patients had excellent results (normal and inconsistent) and 9 had mild VPI, while in group 2, 6 patients had excellent results and 3 had mild VPI (P = .03). Postoperative outcomes at 24 months showed that in group 1, 10 patients had excellent results and 1 had mild VPI, while in group 2, 8 patients had excellent results and 1 had mild VPI. Surgical treatment of noncleft VPI by pharyngoplasty was efficient in 10 of the 11 patients (91%) in the 22q11 group and in 8 of the 9 patients (89%) in the nonsyndromic group. Postoperative remission took longer for patients with the 22q11 microdeletion than for the control group. However, long-term results following surgical treatment were equally good in the 2 groups.

Revision of pharyngeal flaps causing obstructive airway symptoms: An analysis of treatment with three different techniques over 39 years

Pharyngeal flaps are used to treat velopharyngeal insufficiency. Occasionally the flap exceeds its intended function and results in an obstructive airway. In this article, the results of management of these cases are analysed. This is a 39-year retrospective review of patients who had revision of pharyngeal flaps causing obstructive airway symptoms. Three methods of relieving the airway obstruction were used, and the patients were thus separated into three groups, namely group 1 (release and Z-plasty of the lateral ports), group 2 (division of the pharyngeal flap) and group 3 (division of the pharyngeal flap combined with Furlow palatoplasty). The results obtained were based on four parameters: symptomatic improvement, velopharyngeal sufficiency, the presence of re-attachment of the pharyngeal flap and the necessity for re-operation. These results were then pooled into two groups: 'good result' and 'bad result'. The respiratory disturbance index (RDI) was also obtained and analysed separately. Statistical analysis was performed with the Fisher's exact test and the paired t-test in SPSS v.11. A total of 44 patients were included in the study. There were 20, 11 and 13 patients in groups 1, 2 and 3, respectively. The Pearson's chi-square test indicated that group 3 patients had a statistically significant proportion of 'good results' when compared to groups 1 (p=0.019) and 2 (p=0.004). There was a statistically significant reduction in RDI in group 3 (p=0.003). There was no statistically significant difference between the groups 1 and 2. Division of a pharyngeal flap for obstructive airway complications should be accompanied by a Furlow palatoplasty to reduce the myriad complications that arise from either a release+Z-plasty or a simple division of the pharyngeal flap.

Management of pharyngeal stenosis following tonsillectomy with local injection of steroids: Case report and literature review

Summary Objective: Tonsillectomy is a common surgical procedure in pediatric ENT. Pharyngeal stenosis is a late complication with an insidious onset and seems to occur largely in cases with suboptimal surgical technique or in a particular clinical scenario. We report the case of a 9-year-old child which presented a severe pharyngeal stenosis 4 months after a tonsillectomy for obstructive sleep apnea syndrome (OSAS). Method: Case report and literature review. Results: The boy presented with a severe recurrence of OSAS, dysphagia, and recent weight loss. The parents reported frequent vomiting after the initial procedure. Sleep monitoring showed numerous episodes of apnea and desaturation. Examination and endoscopy under general anesthesia confirmed the presence of a large, fibrous stenosis of the pharyngeal isthmus. Due to the pharyngeal stenosis, the control of the airway was difficult and required an uneasy fiberoptic intubation. The management of the lesions required several endoscopies and surgical procedures: LASER, stenting, pharyngeal flaps, use of mitomycine . Only repeated injections of corticosteroids in the fibrous area eventually allowed healing of the scarring. Pharyngeal stenosis is an unusual complication after tonsillectomy. We report a detailed review of the literature dealing with this complication and its management. There are only limited series and the exact incidence is unknown. Conclusion: Nasopharyngeal stenosis post-tonsillectomy is a rare but serious complication. Early detection of recurrence of the obstructive syndrome several weeks after the surgery is essential. A minimum follow-up of 10 months is required after surgery. Local triamcinolone acetonide injections can be used as first line therapy. Prevention of this complication can be achieved by surgical expertise and by preserving the anatomical structures, avoiding the use of a LASER and excessive electro coagulation. In cases with an associated significant gastro-esophageal reflux, systematic post-operative treatment with a proton pump inhibitor is recommended.

Influence of anesthetics on pharyngeal flap surgery: a 23-year study

This study assessed the influence of anesthetics on early complications after pharyngeal flap surgery. A 23-year retrospective chart review was carried out of all patients at the authors’ institution who underwent superiorly based pharyngeal flap surgery. Variables analyzed were gender, age at the time of surgery, cleft type, anesthesia procedure used and complications in the early postoperative period. 2299 patients (50% male; 50% female) who underwent pharyngeal flap surgery between 1980 and 2003 were reviewed. The highest number of surgeries was performed in patients aged 11–20 years. There were 1042 patients with at least one type of complication. Of these, 39 required reoperation to control complications such as bleeding and airway obstruction. There were no records of death. Vomiting and pain were the most frequent postoperative complications (16% and 14% of patients, respectively). Lower complication rates were observed when anesthesia protocols included sevoflurane, propofol and opioids.

Functional and aesthetic correction of secondary unilateral cleft lip nasal deformities

The treatment of patients with unilateral cleft lip has undergone significant development during the last decades. With better understanding of the anatomy of the unilateral cleft lip and nasal deformities, primary correction of the nasal deformity at the time of lip repair, critical evaluation of short and long-term results following various treatment protocols, and constant striving for perfection in both aesthetics and function, we have been able to design improved treatment strategies and more accurate surgical techniques so as to achieve overall superior and long-lasting results. In this review article, we present our protocols and experience for functional and aesthetic correction of secondary unilateral cleft lip nasal deformities and a retrospective review of 219 consecutive patients treated at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities. The protocols used in the treatment of 219 consecutive patients at our Craniofacial Centre for correction of secondary unilateral cleft lip nasal deformities were reviewed. In addition, analysis of the most recent 51 consecutive patients who underwent complete clinical and functional evaluation with rhinomanometry followed by correction of the cleft lip nasal deformity was performed. A variety of time-honoured techniques of rhinoplasty were applied in the correction of the residual deformities to achieve symmetry, aesthetic balance, and functional correction of the nose. Follow-up ranged from 5-11 years. Analysis of the data revealed that 39 patients (76.47%) had significant functional and aesthetic improvement; seven patients (13.07%) had significant aesthetic improvement but a modest functional improvement; and five patients (9.8%) required additional surgery to improve their appearance and had no functional improvement. Further analysis demonstrated that five out of seven patients in the second group had pharyngeal flaps in place that were primarily responsible for the airway obstruction. No attempt was made to revise the ports of these flaps because the speech was excellent. The surgical plan is based on the information gained from our extensive clinical evaluation and is tailored to the patient's specific functional and aesthetic needs.

Velopharyngeal Morphological Analysis after 5 Years of Pharyngeal Flap Surgery in Early School Year Children

Velopharyngeal Morphological Analysis after 5 Years of Pharyngeal Flap Surgery in Early School Year Children

Cleft palate repair and variations

Cleft palate affects almost every function of the face except vision. Today a child born with cleft palate with or without cleft lip should not be considered as unfortunate, because surgical repair of cleft palate has reached a highly satisfactory level. However for an average cleft surgeon palatoplasty remains an enigma. The surgery differs from centre to centre and surgeon to surgeon. However there is general agreement that palatoplasty (soft palate at least) should be performed between 6-12 months of age. Basically there are three groups of palatoplasty techniques. One is for hard palate repair, second for soft palate repair and the third based on the surgical schedule. Hard palate repair techniques are Veau-Wardill-Kilner V-Y, von Langenbeck, two-flap, Aleveolar extension palatoplasty, vomer flap, raw area free palatoplasty etc. The soft palate techniques are intravelar veloplasty, double opposing Z-plasty, radical muscle dissection, primary pharyngeal flap etc. And the protocol based techniques are Schweckendiek's, Malek's, whole in one, modified schedule with palatoplasty before lip repair etc. One should also know the effect of each technique on maxillofacial growth and speech. The ideal technique of palatoplasty is the one which gives perfect speech without affecting the maxillofacial growth and hearing. The techniques are still evolving because we are yet to design an ideal one. It is always good to know all the techniques and variations so that one can choose whichever gives the best result in one's hands. A large number of techniques are available in literature, and also every surgeon incorporates his own modification to make it a variation. However there are some basic techniques, which are described in details which are used in various centres. Some of the important variations are also described.

Velopharyngeal insufficiency: current concepts in diagnosis and management

To discuss principles of evaluation and treatment of children with velopharyngeal insufficiency, and to review recent reports of surgical outcomes. Velopharyngeal insufficiency significantly impacts both quality-of-life and speech intelligibility in children. Diagnosis is made through history and physical, perceptual speech assessment, and instrumental measures including nasendoscopy and radiographic multiplanar videofluoroscopy. Treatment options for velopharyngeal insufficiency consist of prosthetic management or surgery, supplemented with speech therapy when appropriate. Surgical interventions are palatal, palatopharyngeal or pharyngeal in nature. Despite some controversy, most recent reports identify no significant difference in outcomes following pharyngeal flap or sphincter pharyngoplasty. Complications of surgical therapy relate to postoperative obstructive breathing or persistent velopharyngeal insufficiency. Although there is no universally accepted measure to assess velopharyngeal insufficiency severity, nasendoscopy and multiplanar videofluoroscopy are most commonly used for clinical diagnosis. A speech pathologist is an integral member of the velopharyngeal insufficiency team, and momentum toward a standardized reporting system of perceptual speech measurements is increasing. Treatment of velopharyngeal insufficiency should be tailored to the specific needs of the child and family. Surgical therapy may improve velopharyngeal function but may negatively impact upper airway patency and respiration during sleep. The otolaryngologist should be familiar with strengths and limitations of different surgical options for velopharyngeal insufficiency.

Transoral Robotic Surgery Using a Carbon Dioxide Flexible Laser for Tumors of the Upper Aerodigestive Tract

To determine the safety, feasibility, and efficacy of coupling transoral robotic technology with the flexible carbon dioxide (CO2) laser for various tumors of the oropharynx and supraglottic larynx. Prospective, pilot trial. Eight patients were enrolled in an IRB-approved prospective trial for transoral robotic surgery with the aid of the flexible CO2 laser. Seven male patients with early carcinoma of the oropharynx or larynx successfully underwent tumor extirpation with the transoral robot and the flexible CO2 laser. We were unable to gain access to the supraglottic larynx in one female patient. The final pathology revealed seven patients with squamous cell carcinoma and one patient with adenoid cystic carcinoma. The flexible CO2 laser provided fine incisions with excellent hemostasis and minimal peripheral tissue injury. Additionally, the laser provided an excellent tool for raising pharyngeal flaps for reconstruction of the oropharynx. The flexible CO2 laser offers a unique advantage of precise incisions and may provide a valuable tool for both tumor extirpation and the creation of flaps for transoral robotic reconstruction.

Orthognathic Surgery in the Young Cleft Patient: Preliminary Study on Subsequent Facial Growth

This study evaluated the long-term effects of orthognathic surgery on subsequent growth of the maxillomandibular complex in the young cleft patient. We evaluated 12 young cleft patients (9 male and 3 female patients), with a mean age of 12 years 6 months (range, 9 years 8 months to 15 years 4 months), who underwent Le Fort I osteotomies, with maxillary advancement, expansion, and/or downgrafting, by use of autogenous bone or hydroxyapatite grafts, when indicated, for maxillary stabilization. Five patients had concomitant osteotomies of the mandibular ramus. All patients had presurgical and postsurgical orthodontic treatment to control the occlusion. Radiographs taken at initial evaluation (T1) and presurgery (T2) were compared to establish the facial growth vector before surgery, whereas radiographs taken immediately postsurgery (T3) and at longest follow-up (T4) were used to determine postsurgical growth. Each patient's lateral cephalograms were traced, and 16 landmarks were identified and used to compute 11 measurements describing presurgical and postsurgical growth. Before surgery, all patients had relatively normal growth. After surgery, cephalograms showed statistically significant growth changes from T3 to T4, with the maxillary depth decreasing by -3.3 degrees +/- 1.8 degrees , Sella-nasion-point A by -3.3 degrees +/- 1.8 degrees, and point A-nasion-point B by -3.6 degrees +/- 2.8 degrees. The angulation of the maxillary incisors increased by 9.2 degrees +/- 11.7 degrees. Of 12 patients, 11 showed disproportionate postsurgical jaw growth. Maxillary growth occurred predominantly in a vertical vector with no anteroposterior growth, even though most patients had shown anteroposterior growth before surgery. The distance increased in the linear measurement from nasion to gnathion by 10.3 +/- 7.9 mm. Four of 5 patients operated on during the mixed dentition phase had teeth that erupted through the cleft area. A variable impairment of postoperative growth was seen with the 2 types of grafting material used. No significant difference was noted in the effect on growth in patients with unilateral clefts versus those with bilateral clefts. The presence of a pharyngeal flap was noted to adversely affect growth, whereas simultaneous mandibular surgery did not. After surgery, 11 of 12 patients tended toward a Class III end-on occlusal relation. Orthognathic surgery may be performed on growing cleft patients when mandated by psychological and/or functional concerns. The surgeon must be cognizant of the adverse postsurgical growth outcomes when performing orthognathic surgery on growing cleft patients with the possibility for further surgery requirements. Performing maxillary osteotomies on cleft patients would be more predictable after completion of facial growth.

Comparison of Pharyngeal Flap and Sphincter Pharyngoplasty for Velopharyngeal Insufficiency-A Retrospective Study

Purpose: Velopharyngeal insufficiency (VPI) is incomplete closure of the velopharyngeal space causing hypernasal resonance during phonation. Both pharyngeal flap (PF) and sphincter pharyngoplasty (SP) had been used for the correction of VPI in the Craniofacial Center, Chang Gung Memorial Hospital. The purpose of this study is to compare the effectiveness and complication between the PF and SP. Material and Method: Eighty-seven patients underwent pharyngeal flap or sphincter pharyngoplasty for VPI between June of 1995 and August of 2001. Seventy-one patients of them who had complete preoperative and follow-up evaluations were included. The follow-up period ended at October of 2006. All operations were done by one surgeon. Standard speech evaluation was performed. Results: Overall speech outcome and success rate was 68%. No significant difference on the speech outcome was found between the PF group and SP groups (chi-square test, p=0.419). Overall nasal airway obstruction rate was 14%. However, a significant difference on airway obstruction was noted between the PF group and SP group (chi-square test, p=0.015). Lower incidence of airway obstruction occurred in PF group. A concomitant finding revealed that a better speech result was achieved in patients who received the VPI surgery at an age younger than 6 years. Conclusion: This study showed that, in the authors' center, the PF is a better choice than SP for the correction of VPI.

Through-and-Through Dissection of the Soft Palate for High Pharyngeal Flap Inset: A New Technique for the Treatment of Velopharyngeal Incompetence in Velocardiofacial Syndrome

Patients with velocardiofacial syndrome often present with refractory velopharyngeal incompetence. Whereas the high wide pharyngeal flap has been advocated for these patients, poor visualization makes high inset of the flap technically difficult. We present a consecutive series of patients with velocardiofacial syndrome and severe velopharyngeal incompetence treated with high inset pharyngeal flap achieved by through-and-through dissection of the soft palate. All patients with velocardiofacial syndrome in whom secondary surgical management was recommended for treatment of severe velopharyngeal incompetence over the last 7 years were treated with a high inset pharyngeal flap achieved by through-and-through dissection of the soft palate (to be described). All patients had nasendoscopy and videofluoroscopy preoperatively and underwent perceptual speech assessment preoperatively and at least 12 months postoperatively. Eight patients met the inclusion criteria with a mean age at presentation of 7 years, 3 months. No patient had a history of cleft palate. All patients had minimal lateral pharyngeal wall motion and a medium to large velopharyngeal gap (>6 mm). Velopharyngeal incompetence, as measured by perceptual speech score, improved from a mean of 10.3 (range, 9 to 12 on a maximum scale of 13) to a mean of 1.9 (range, 0 to 4), achieving velopharyngeal competence (p < 0.01) without nasal airway obstruction in any patient. The present report demonstrates restoration of velopharyngeal competence in a consecutive series of patients with velocardiofacial syndrome who presented with severe velopharyngeal incompetence. We attribute this outcome to the development of a reliable technique for high inset of the pharyngeal flap using through-and-through dissection of the soft palate, enabling direct visualization of flap placement.

O.084 The pharyngeal flap: analysis of post-op complications

O.084 The pharyngeal flap: analysis of post-op complications

Clinical Outcomes of the Furlow Z-Plasty for Primary Cleft Palate Repair

To review the clinical outcomes following the Furlow Z-plasty for primary cleft palate repair. The primary objective was to determine if the presence of an associated sequence or syndrome (i.e., Pierre Robin sequence), age at palate repair, cleft type, or surgeon experience influenced speech outcomes after a Furlow Z-plasty. The outcomes of 140 patients who underwent palate repair were analyzed retrospectively. Speech evaluations were performed to score the severity of hypernasality, nasal escape, articulation errors, and velopharyngeal insufficiency. The mean age at latest evaluation was 4 years 9 months (age range 2 years old to 12 years old and 4 months). Of the 140 patients, 83% had no evidence of hypernasality, 91% had no presence of nasal escape, and 69% had no articulation errors. Overall, 84% of patients had no evidence of velopharyngeal insufficiency. Secondary posterior pharyngeal flap to correct velopharyngeal insufficiency was required in only 2.1% of patients. The formation of an oronasal fistula occurred in only 3.6% of patients. Nonsyndromic patients with Pierre Robin sequence and syndromic patients did just as well as purely nonsyndromic patients in terms of velopharyngeal insufficiency, hypernasality, and nasal escape. Syndromic patients were more likely to make mild-to-moderate articulation errors. In addition, age at palate repair, cleft type, and surgeon experience had no statistically significant effect on speech results. The Furlow Z-plasty yielded excellent speech results in our patient population with minimal and acceptable rates of fistula formation, velopharyngeal insufficiency, and the need for additional corrective surgery.

Speech Outcome regarding Overall Intelligibility, Articulation, Resonance and Voice in Flemish Children a Year after Pharyngeal Flap Surgery

Objective: The main purpose of this study is to determine the treatment effectiveness of pharyngeal flap surgery by measuring speech outcome 1 year after surgery. The authors hypothesized that flap surgery is an effective technique for velopharyngeal inadequacy resulting in improved intelligibility, decreased hypernasality and nasalance scores and normal voice characteristics. Patients and Methods: Objective (Nasometer, Dysphonia Severity Index) as well as subjective (perceptual evaluations) assessment techniques were performed in 7 subjects. Speech evaluations were performed 1 year after flap surgery and comparison was made between the speech results of the preoperative condition (1 week before surgery) and the first postoperative condition (6 weeks after surgery). Results: After pharyngeal flap surgery there was improved though still slightly impaired intelligibility, with normal nasality, normal nasalance values for standard Flemish speech and normal voice characteristics. The normal nasality and nasalance values were not present in the preoperative condition. Persistence of the incorrect production of the thrill sound /r/ and the fricatives /s/ and /sch/ were observed. Conclusion: It is likely that the slightly impaired speech intelligibility is determined by the presence of persistent articulation disorders.

Magnetic Resonance Imaging as an Aid in the Dynamic Assessment of the Velopharyngeal Mechanism in Children

Velopharyngeal incompetence is a complication following cleft palate surgery, with an incidence ranging from 5 to 38 percent following palatoplasty.1 It occurs when the velopharyngeal valving mechanism is incapable of complete closure to isolate the oropharynx from the nasopharynx during speech production. The anatomical components of the velopharynx are the velum (soft palate) and the three pharyngeal walls: posterior, right lateral, and left lateral. Velopharyngeal closure depends on three basic factors: (1) superior and posterior movement of the soft palate produced by the contraction of the levator veli palatini muscle, (2) medial movement of the lateral pharyngeal walls, and (3) bulging forward of the posterior pharyngeal wall, creating a Passavant's ridge to facilitate velopharyngeal closure. Both the levator veli palatini muscle and the soft palate play a major role in the pathogenesis of velopharyngeal incompetence. Dysfunction of the levator veli palatini muscle or shortness of the soft palate may cause velopharyngeal incompetence, yet treatment options are quite different. Therefore, accurate diagnosis is crucial. Procedures that rely on restoration of a functional levator sling require the presence of adequate levator musculature for reconstruction of the levator sling. When the diagnosis of velopharyngeal incompetence is confirmed, speech therapy is initiated. Should the patient fail to demonstrate sufficient improvement in nasality despite speech therapy, secondary surgical management to restore a competent velopharyngeal valving mechanism may be indicated. If it is possible to do so by restoration of the levator muscular sling, this may obviate the need for surgical alteration of the posterior or lateral pharyngeal walls as occurs during a pharyngeal flap or sphincter pharyngoplasty. Dynamic reconstruction of the levator sling can be accomplished using either a Furlow palatoplasty in patients with submucous cleft palate or postpalatoplasty velopharyngeal incompetence,2 or by palate re-repair in patients with postpalatoplasty velopharyngeal incompetence as advocated by Sommerlad and colleagues.3 However, should the levator mechanism be negligible or replaced with scar following prior surgery, attempting dynamic levator reconstruction would not result in a competent velopharyngeal valving mechanism, and pharyngeal flap or sphincter pharyngoplasty should be considered. Therefore, the ability to visualize different soft-tissue planes of the velopharynx and to visualize the muscular anatomy preoperatively become crucial when planning secondary surgical management of velopharyngeal incompetence. Current methods for functional visualization of the velopharynx are either invasive (nasendoscopy) or impart ionizing radiation (speech videofluoroscopy), and do not provide anatomical definition of palatal soft-tissue planes. In addition to its invasiveness, nasendoscopy allows only a single viewpoint (from a ventral and cephalad observation point) of the velum. Furthermore, both the passage of the endoscope itself and the local anesthetic agent used during scoping may affect speech. In contrast, although speech videofluoroscopy allows visualization of dynamic interaction (i.e., functional evaluation) of velopharyngeal structures from different angles, interpretation is difficult because of shadows introduced by the overlying structures. Moreover, relative proportion distortion is inevitable in speech videofluoroscopy because three-dimensional structures are converted into two-dimensional images. An ideal test that is noninvasive and does not impart ionizing radiation is not in widespread use for preoperative assessment of the velopharyngeal mechanism in children. Magnetic resonance imaging is noninvasive and poses no ionizing radiation hazard, and allows imaging of the velopharyngeal mechanism during limited speech production. Magnetic resonance imaging also allows anatomical assessment of soft-tissue planes involved in the velopharyngeal valving mechanism, which is not possible with other techniques currently in use. The major hurdle that prevents the widespread application of magnetic resonance imaging for functional evaluation of the velopharyngeal mechanism is poor image quality. To examine the function of the velopharyngeal mechanism during active phonation using magnetic resonance imaging, patients are instructed to sustain phonation of a chosen vowel or consonant during the image-acquisition process. Because most patients, especially children, are only able to sustain phonation for 15 to 20 seconds comfortably, image-acquisition time is limited. This in turn limits the resolution of the acquired image. Fortunately, magnetic resonance image quality is dependent not only on the length of acquisition time but also on the magnetic field strength and head coil design. By using more powerful magnetic resonance imaging scanners and better head coil design, improvement in magnetic resonance images is possible without increasing image-acquisition time. Previous magnetic resonance imaging studies involving functional evaluation of the velopharyngeal valving mechanism in children used magnetic resonance imaging scanners with a strength up to only 1.5 T.4–7 By using a 3.0-T magnetic resonance imaging scanner with a multichannel head coil, we hypothesize that the quality of the images acquired will be sufficient to allow functional evaluation of the velopharyngeal valving mechanism in children. Moreover, resolution of the images will allow delineation of palatal soft-tissue planes for surgical planning.