Pharyngoplasty

Relevant structures

• Soft palate (velum), particularly levator veli palatini, which elevates and retracts the palate.
• Lateral pharyngeal walls, containing superior constrictor-related musculature.
• Posterior pharyngeal wall, sometimes forming a Passavant ridge.
• Palatopharyngeus muscles, in the posterior tonsillar pillars, used to create flaps in sphincter pharyngoplasty.
• Nasopharyngeal airway, which must remain sufficiently patent during quiet breathing and sleep.

Assessment before surgery

1. Perceptual speech assessment by a speech-language therapist.
2. Flexible nasoendoscopy during speech to define:
   • gap size and site
   • palatal movement
   • lateral wall movement
   • closure pattern: sagittal, coronal, circular, or bow-tie
3. Multiview speech videofluoroscopy if needed.
4. Airway assessment, including history of snoring, witnessed apnea, obesity, tonsillar hypertrophy, syndromic craniofacial anatomy, and polysomnography when OSA is suspected.

Types of pharyngoplasty

1. Posterior pharyngeal flap

Principle

Indications

• Moderate to large central VP gap.
• Good lateral pharyngeal wall movement.
• Sagittal closure pattern, where lateral walls are the major source of closure.
• Selected circular closure patterns.
• VPI with relatively poor palatal movement but adequate lateral wall excursion.
• Some neurogenic VPI cases, depending on airway risk and endoscopic anatomy.

Relative contraindications

• Poor or absent lateral pharyngeal wall movement, because lateral ports may not close effectively.
• Significant untreated OSA, severe snoring, major airway narrowing, or high-risk craniofacial anatomy.
• Marked tonsillar hypertrophy, until considered or treated.
• Acute upper respiratory infection.
• Uncorrected coagulopathy or inability to tolerate general anesthesia.
• Pure compensatory articulation disorder without structural VPI.

Procedure: superiorly based pharyngeal flap

1. Exposure and planning
   • The palate and posterior pharyngeal wall are exposed.
   • Preoperative endoscopy guides flap width and level of inset.
   • A tailored flap is planned to suit the VP gap and lateral-wall motion.
2. Palatal incision
   • The soft palate is split in the midline or its nasal lining is elevated to make a recipient bed on the nasal surface.
3. Elevation of flap
   • A vertically oriented, superiorly based flap containing posterior pharyngeal mucosa and a thin layer of superior constrictor muscle is raised from the posterior pharyngeal wall.
   • Dissection must remain superficial to the prevertebral fascia.
4. Transfer and inset
   • The flap is rotated upward and sutured to the nasal surface of the soft palate.
   • Lateral nasal mucosal flaps are commonly used to line the flap margins and maintain two controlled lateral ports.
5. Donor-site closure
   • The posterior pharyngeal donor site is closed primarily where possible.
6. Final aim
   • A central bridge joins palate and posterior wall.
   • Two lateral ports remain for nasal breathing and close during speech through medial lateral-wall motion.

Complications

• Immediate airway obstruction from edema, blood clot, or excessive obturation.
• Postoperative OSA or worsening sleep-disordered breathing.
• Hyponasality due to over-obturation.
• Persistent hypernasality from inadequate flap width, inappropriate height, dehiscence, or poor lateral-wall motion.
• Lateral port stenosis.
• Snoring, mouth breathing, nasal obstruction.
• Hemorrhage, infection, aspiration, dehydration, pain.
• Flap dehiscence or need for revision.
• Rarely, severe airway compromise requiring reintubation or tracheostomy.

2. Sphincter pharyngoplasty

Principle

Indications

• Coronal closure pattern, where palatal motion is relatively good but lateral-wall movement is inadequate.
• Lateral or bow-tie VP gaps.
• VPI with a reasonably mobile palate but poor lateral pharyngeal wall contribution.
• Some circular patterns with lateral residual gaps.
• Can be combined with Furlow double-opposing Z-plasty when palate shortening and levator malposition coexist.

Relative contraindications

• Significant pre-existing OSA or severe airway compromise.
• Very poor palatal movement with a large central gap, where a posterior flap may be more suitable.
• Marked tonsillar hypertrophy or active pharyngeal infection.
• Purely learned articulation errors without structural VPI.
• Poor surgical/anesthetic fitness.

Procedure

1. Exposure
   • Under general anesthesia, the posterior tonsillar pillars and posterior pharyngeal wall are exposed.
2. Harvest bilateral flaps
   • Superiorly based myomucosal flaps containing palatopharyngeus muscle are elevated from both posterior tonsillar pillars.
3. Create recipient bed
   • A horizontal recipient bed is created on the posterior pharyngeal wall at the intended level of VP closure.
4. Rotation
   • Each flap is rotated approximately 90 degrees superomedially toward the posterior wall.
5. Inset
   • The distal ends are sutured to the contralateral posterior pharyngeal wall or overlapped in the midline.
   • This produces a dynamic sphincter-like posterior and lateral narrowing, preserving a central opening.
6. Mucosal closure
   • Raw surfaces are covered and haemostasis secured.

Complications

• Airway edema and early obstruction.
• OSA, snoring, and nasal obstruction.
• Hyponasality if the central port is too small.
• Persistent hypernasality if narrowing is inadequate or the sling migrates/involutes.
• Flap dehiscence, scar contracture, asymmetry, or need for revision.
• Bleeding, infection, pain, dysphagia, aspiration.
• Rarely, velopharyngeal overcorrection or undercorrection.

3. Hynes pharyngoplasty and other posterior wall flap variants

• Superiorly based flap
• Inferiorly based flap
• Lateral pharyngeal flaps
• Combined or tailored flaps

Procedures often grouped with VPI surgery but not true pharyngoplasties

A. Furlow double-opposing Z-plasty

• Small central gap.
• Short palate with good pharyngeal-wall movement.
• Submucous cleft palate.
• Abnormally anterior or longitudinal levator orientation.
• Palatal re-repair.

B. Intravelar veloplasty or radical intravelar veloplasty

C. Posterior pharyngeal wall augmentation

Choice of operation by closure pattern

General complications of all VPI operations

Functional/speech complications

• Persistent hypernasality and nasal emission.
• Hyponasality from excessive obstruction.
• Persistent compensatory articulation errors, requiring postoperative speech therapy.
• Dysphagia or nasal regurgitation.
• Unsatisfactory speech outcome or recurrent VPI as the child grows.

Airway complications

• Immediate edema-related obstruction.
• Snoring, chronic nasal obstruction, mouth breathing.
• New or worsened OSA.
• Need for CPAP, flap revision, port enlargement, takedown, or rarely tracheostomy.

Surgical complications

• Bleeding and hematoma.
• Infection.
• Wound dehiscence or fistula.
• Flap necrosis, contracture, displacement, or stenosis.
• Pain, poor oral intake, dehydration.
• Anesthetic and aspiration risks.

Key contraindications and cautions

1. No proven structural VPI
   Do not operate for isolated phoneme-specific articulation errors or compensatory misarticulation alone.
2. Untreated or severe OSA / high airway risk
   This requires careful sleep and airway assessment before any port-narrowing operation.
3. Anatomy unsuitable for the selected procedure
   Example: posterior pharyngeal flap in a child with very poor lateral-wall motion.
4. Active infection
   Acute pharyngitis, tonsillitis, or respiratory infection should be treated first.
5. Uncorrected bleeding disorder or serious anesthetic risk.
6. Unresolved palatal cause that should be repaired first
   A short palate, occult/submucous cleft, or abnormal levator insertion may be better treated with Furlow palatoplasty or intravelar veloplasty.
7. Major tonsillar hypertrophy
   It may affect VP assessment and increase postoperative obstruction risk.

Practical summary

• Posterior pharyngeal flap: closes the central gap, leaves two lateral ports, best when lateral-wall motion is good, particularly sagittal-pattern VPI.
• Sphincter pharyngoplasty: uses bilateral palatopharyngeus flaps to narrow the port around a central opening, commonly selected for coronal or lateral/bow-tie gaps.
• Furlow/intravelar veloplasty: corrects palatal length and levator-muscle problems and is preferred for smaller gaps or submucous cleft-related VPI.
• Posterior wall augmentation: reserved for selected small central defects.
• Most important complication: postoperative airway obstruction and OSA. Every patient needs airway-focused follow-up and postoperative speech therapy.

Six sources

1. Cummings Otolaryngology: Head and Neck Surgery, chapter on velopharyngeal dysfunction, especially the sections on surgical intervention, pharyngeal flap operation, and sphincter pharyngoplasty.
2. Scott-Brown’s Otorhinolaryngology and Head and Neck Surgery, section “Speech and Velopharyngeal Insufficiency.”
3. K. J. Lee’s Essential Otolaryngology, cleft palate and VPI surgical management section.
4. StatPearls VPI review
5. Shah et al., 2026 systematic review and meta-analysis
6. Secondary VPI surgery and OSA systematic review