- Email: [email protected]
Reconstruction of the palatal aponeurosis with autogenous fascia lata in secondary radical intravelar veloplasty: a new method
Int. J. Oral Maxillofac. Surg. 2008; 37: 756–760 doi:10.1016/j.ijom.2008.05.007, available online at http://www.sciencedirect.com
Technical Note Congenital Craniofacial Anomalies
Reconstruction of the palatal aponeurosis with autogenous fascia lata in secondary radical intravelar veloplasty: a new method
K. Smolka1, E. Seifert2, N. Eggensperger1, T. Iizuka1, W. Smolka1 1 Department of Cranio-Maxillofacial Surgery, University of Bern, Bern, Switzerland; 2 Division of Phoniatrics, Department of Otorhinolaryngology, Head and Neck Surgery, University of Bern, Bern, Switzerland
K. Smolka, E. Seifert, N. Eggensperger, T. Iizuka, W. Smolka: Reconstruction of the palatal aponeurosis with autogenous fascia lata in secondary radical intravelar veloplasty: a new method. Int. J. Oral Maxillofac. Surg. 2008; 37: 756–760. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Velopharyngeal insufficiency in cleft patients with muscular insufficiency detected by nasendoscopy is commonly treated by secondary radical intravelar veloplasty, in which the palatal muscles are reoriented and positioned backwards. The dead space between the retro-displaced musculature and the posterior borders of the palatal bone remains problematic. Postoperatively, the surgically achieved lengthening of the soft palate often diminishes due to scar tissue formation in the dead space, leading to reattachment of the reoriented muscles to the palatal bone and to decreased mobility of the soft palate. To avoid this, the dead space should be restored by a structure imitating the function of the missing palatal aponeurosis. The entire dead space was covered using a double layer of autogenous fascia lata harvested from the lateral thigh, which should allow sufficient and permanent sliding of the retropositioned musculature. A clinical case of a 9-year-old boy who underwent the operation is reported. Postoperatively, marked functional improvements were observable in speech assessment, nasendoscopy and nasometry. The case reported here suggests that the restoration of the dead space may be beneficial for effective secondary palatal repair. Fascia lata seems to be a suitable graft for this purpose.
Accepted for publication 1 May 2008 Available online 30 June 2008
Velopharyngeal insufficiency (VPI) remains a problem in patients with cleft palate after primary palatal repair. Insufficient length of the velum and decreased velar mobility are the most frequent deficiencies causing VPI4. Numerous differ-
when showing residual abnormality or inadequate function of the palatal muscles in nasendoscopic or videofluoroscopic assessment. In this secondary radical intravelar veloplasty (IVV), the sagittally oriented muscles are dissected from the
0901-5027/080756 + 05 $30.00/0
ent surgical procedures are applied for speech improvement in cleft patients with VPI2,5,6,8. Cleft patients with VPI after primary repair commonly undergo palatal re-repair for correction of the muscular deformity
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Palatal aponeurosis reconstruction
757
Fig. 1. Example of recurrence of muscular deformity after radical intravelar veloplasty without reconstruction of the dead space. Endoscopic view (a) before surgery, presenting a muscular deformity; (b) 6 months after repair of the deformity but with a slight notch; and (c) 18 months postoperatively, with a severe notch representing recurrence of muscular deformity.
oral and nasal mucosa, detached from the palatal bones, transversally reoriented, and positioned backwards2,7. Velar function is improved by this procedure and contributes to speech improvements8. Radical dissection and transversal reorientation with backward positioning of the palatal muscles creates a dead space between the retro-displaced musculature and the posterior borders of the palatal bones. Postoperatively, the surgically achieved lengthening of the soft palate often diminishes due to scar tissue formation in the dead space, leading to reattach-
ment of the reoriented muscles to the palatal bone, and to decreased mobility of the soft palate (Fig. 1). To avoid such a recurrence, the dead space should be restored. For this purpose, the authors covered the entire dead space using a double layer of autogenous fascia lata harvested from the lateral thigh. Surgical procedures
In cleft palate patients the tensor-aponeurosis is missing1. In residual muscular deformity after primary repair with mini-
mal or no muscle dissection, the sagittally oriented muscles are often attached to the palatal bones and do not create muscular slings (Fig. 2a and b). In secondary IVV, the muscles are detached from the palatal bones, dissected from the oral and nasal mucosa, and positioned backwards. The muscular slings of the soft palate are then reconstituted, in particular the slings of the levator, palatopharyngeus and palatoglossus muscle (Fig. 2c). This procedure creates a dead space between the retrodisplaced musculature and the posterior borders of the palatal bones (Fig. 2d).
Fig. 2. The palatal muscles and the surgical procedure: (a) residual muscular deformity in cleft patients (the sagittally oriented palatopharyngeal muscle is often attached to the palatal bone and does not create a muscular sling; the levator muscle is retracted); (b) physiological situation; (c) first step in intravelar velopalatoplasty (bold red lines represent the muscle detachment at the palatal bone; thin red lines show the tensor-tenotomy; arrows indicate the backward positioning of the muscles); (d) second step in surgery (red ellipsis shows the dead space anteriorly to the reorientated muscular slings).
758
Smolka et al.
Fig. 3. Drawings and intraoperative photographs: (a) oral view of the reconstruction of the dead space with fascia lata; a straight bar of fascia (b) is fixed with sutures through boreholes at the posterior palatal bone and a double layer of fascia (c) is sutured to the bar; (d) sagittal view; (e) the oral mucosa (white arrows) has been separated from the muscles. The palatal muscles (green arrows) have been reoriented and sutured in the midline. Anterior to the muscles, the dead space (yellow ellipse) appears; (f) reconstruction of the dead space with fascia lata; (g) the oral part of the double layer of fascia lata has been turned anteriorly to allow a view of the nasal part of the double layer; (h) closure of the oral mucosa (green circles indicate mattress sutures used to narrow oral and nasal mucosa).
For reconstruction of the entire dead space, the authors covered it using a double layer of autogenous fascia lata harvested from the lateral thigh (Fig. 3a–c). First, a straight bar of fascia is fixed with sutures through boreholes at the posterior palatal bone for reconstruction of the posterior aspect of the hard palate. Then, a double layer of fascia is sutured to the bar. This double layer consists of one piece of fascia folded at the anterior aspect to allow sliding of the two layers across each other in the posterior part of the layers. The double layer of fascia covers the whole dead space and is sutured to oral and nasal mucosa and to the anterior aspect of the retro-displaced musculature. The double layer should allow sufficient and permanent mobility of the retro-positioned musculature in relation to the posterior shelves of the palatal bones (Fig. 3d). After reconstruction of the dead space, the oral mucosa is closed and narrowed to the nasal mucosa by mattress suturing in between the retro-positioned muscles and the bar of fascia.
was treated by secondary radical IVV and reconstruction of the dead space with fascia lata. (Fig. 3e–h) Preoperatively, the nasendoscopic view indicates severe muscular deformity characterized by a large groove in the middle of the nasal surface of the velum. During phonation (/k/ in
‘‘Coca-Cola’’), velar movement was minimal and no velopharyngeal closure could be achieved. Eighteen months postoperatively, nasendoscopy showed marked anatomic and functional improvements: specifically, a convex upper surface of the velum in the midline, markedly
Table 1. Results of nasometry (Kay Elemetrics Nasometer II Model 6400). The normative nasalance score was determined by a sample of 40 Swiss German-speaking children Vocals
Pre-op
3 months post-op
18 months post-op
Norm
j j j j j
7 31 49 20 35
14 45 69 33 55
8 21 43 10 24
(8–24) (12–22) (23–46) (4–10) (7–19)
Words j p jPille j p jPoster j t jTulpe j k j Karte j f j Feder j f j Foto j sch j Schere j mp j Ampel j mp j Lampe
34 23 17 24 18 17 28 24 37
23 24 22 22 20 28 17 35 40
14 13 13 15 15 21 13 32 31
(5–15) (3–9) (5–16) (7–15) (8–18) (2–15) (14–25) (28–44) (25–37)
Case report
Sentences S1 S2
28 57
28 58
15 67
(9–15) (66–79)
Owing to severe VPI, a 9-year-old boy with unilateral cleft lip palate deformity
S1 (oral test sentence): Die Schokolade ist sehr lecker; S2 (nasal test sentence): Nenne meine Mama Mimi.
a: j e: j i: j o: j u: j
Palatal aponeurosis reconstruction
759
Fig. 4. Oral and nasendoscopic view preoperatively and 18 months postoperatively.
increased and good movement of the velum during phonation, and possible but incomplete velopharyngeal closure (Fig. 4). Nasometry also showed marked improvement in nasalance scores for the case reported here (Table 1). Preoperatively, almost all nasalance scores for vocals, words and oral and nasal test sentences were out of the range of normative reference scores. Postoperative nasometry at 3 months showed elevated scores in most of the nasalance measurements. However, 18 months postoperatively, nearly all nasalance scores reached the norm. Speech improved markedly. Speech assessment was performed by a speech pathologist according to the scoring system of the cleft audit protocol for speech (CAPS) (Table 2)7. There was marked improvement in nasal emission, nasal turbulence and hypernasality (Table 3). Regarding intelligibility, speech improved from the classification ‘only just intelligible to strangers’ preoperatively to the classification ‘slightly different from other children’s speech’ 18 months postoperatively. Marked functional improvements after aponeurosis reconstruction were observable in nasendoscopy, nasometry and speech assessment.
Discussion
Radical IVV with backward positioning of the palatal muscles results in a dead space between the retro-displaced musculature and the posterior borders of the palatal bones. There have been attempts to treat this dead space in order to occlude it and to keep the muscles in a posterior position. Mattress suturing has been proposed as a
treatment option9, but proper reconstruction of the tensor-aponeurosis is not possible with this procedure. The idea of reconstructing the tensoraponeurosis is not new. Its reconstruction in primary cleft patients was proposed by KOCH et al. in 19983. Postoperatively, they obtained good results for speech in 150 patients, with a better functioning anatomical palatal reconstruction. Unfolding
Table 2. Cleft Audit Protocol for Speech (CAPS) Scoring System Nasal emission, nasal turbulence, hypernasality
Intelligibility rating
0 0–1
Normal Inconsistent
0 1
1
Mild
2
2 3
Moderate Severe
3 4
Normal Different from other children’s speech but not enough to cause comment Different enough to provoke comment but possible to understand most speech Only just intelligible to strangers Impossible to understand
Table 3. Speech assessment Nasal emission Nasal turbulence Hypernasality Intelligibility
Pre-op
3 months post-op
18 months post-op
3 2 2–3 3
0–1 0–1 2 2
0 0 0–1 0–1
760
Smolka et al.
the tensor tendon, which is necessary for primary reconstruction of the aponeurosis, is often impossible, and the unfolded tendon is often not large enough to create a functioning aponeurosis. Fascia lata has a structure very similar to that of the tensor-aponeurosis, and therefore the authors think it is suitable for palate reconstruction. In their experience, reconstruction of the posterior border of the hard palate using fascia lata is easy to perform. To avoid scarring of the nasal floor and the oral mucosa they used a double layer of fascia for reconstruction of the aponeurosis. The idea is to prevent fixation of this part of the nasal floor to the oral mucosa in order to allow sufficient and permanent sliding of the retro-positioned musculature. The surgical procedure presented here also seems to be a promising method to avoid reattachment of the retracted muscles to the posterior border of the hard palate.
References 1. Dickson DR. Anatomy of the normal velopharyngeal mechanism. Clin Plast Surg 1975: 2: 235–248. 2. Edgerton MT, Dellon AL. Surgical retrodisplacement of the levator veli palatini muscle. Plast Reconstr Surg 1971: 47: 154–167. 3. Koch KHK, Grzonka MA, Koch J. Pathology of the palatal aponeurosis in cleft palate. Cleft Palate Craniofac J 1998: 35: 530–534. 4. Marsh JL. Management of velopharyngeal dysfunction: Differential diagnosis for differential management. J Craniomaxillofac Surg 2003: 14: 621–628. 5. Perkins JA, Lewis CW, Gruss JS, Eblen LE, Sie KCY. Furlow palatoplasty for management of velopharyngeal insufficiency: a prospective study of 148 consecutive patients. Plast Reconstr Surg 2005: 116: 72–84. 6. Sie KCY, Tampakopoulou DA, Sorem J, Gruss JS, Eblen LE. Results with furlow palatoplasty in management of velophar-
yngeal insufficiency. Plast Reconstr Surg 2001: 108: 17–25. 7. Sommerlad BC, Henley M, Birch M, Harland K, Moiemen N, Boorman JG. Cleft palate re-repair—a clinical and radiographic study of 32 consecutive cases. Br J Plast Surg 1994: 47: 406–410. 8. Sommerlad BC, Mehendale FV, Birch MJ, Sell D, Hattee C, Harland K. Palate re-repair revisited. Cleft Palate Craniofac J 2002: 39: 295–307. 9. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg 2003: 112: 1542–1548. Address: Wenko Smolka Department of Cranio-Maxillofacial Surgery University of Bern Inselspital CH-3010 Bern Switzerland Tel.: +41 31 632 3317 Fax: +41 31 382 0279. E-mail: [email protected]
Technical Note Congenital Craniofacial Anomalies
Reconstruction of the palatal aponeurosis with autogenous fascia lata in secondary radical intravelar veloplasty: a new method
K. Smolka1, E. Seifert2, N. Eggensperger1, T. Iizuka1, W. Smolka1 1 Department of Cranio-Maxillofacial Surgery, University of Bern, Bern, Switzerland; 2 Division of Phoniatrics, Department of Otorhinolaryngology, Head and Neck Surgery, University of Bern, Bern, Switzerland
K. Smolka, E. Seifert, N. Eggensperger, T. Iizuka, W. Smolka: Reconstruction of the palatal aponeurosis with autogenous fascia lata in secondary radical intravelar veloplasty: a new method. Int. J. Oral Maxillofac. Surg. 2008; 37: 756–760. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Velopharyngeal insufficiency in cleft patients with muscular insufficiency detected by nasendoscopy is commonly treated by secondary radical intravelar veloplasty, in which the palatal muscles are reoriented and positioned backwards. The dead space between the retro-displaced musculature and the posterior borders of the palatal bone remains problematic. Postoperatively, the surgically achieved lengthening of the soft palate often diminishes due to scar tissue formation in the dead space, leading to reattachment of the reoriented muscles to the palatal bone and to decreased mobility of the soft palate. To avoid this, the dead space should be restored by a structure imitating the function of the missing palatal aponeurosis. The entire dead space was covered using a double layer of autogenous fascia lata harvested from the lateral thigh, which should allow sufficient and permanent sliding of the retropositioned musculature. A clinical case of a 9-year-old boy who underwent the operation is reported. Postoperatively, marked functional improvements were observable in speech assessment, nasendoscopy and nasometry. The case reported here suggests that the restoration of the dead space may be beneficial for effective secondary palatal repair. Fascia lata seems to be a suitable graft for this purpose.
Accepted for publication 1 May 2008 Available online 30 June 2008
Velopharyngeal insufficiency (VPI) remains a problem in patients with cleft palate after primary palatal repair. Insufficient length of the velum and decreased velar mobility are the most frequent deficiencies causing VPI4. Numerous differ-
when showing residual abnormality or inadequate function of the palatal muscles in nasendoscopic or videofluoroscopic assessment. In this secondary radical intravelar veloplasty (IVV), the sagittally oriented muscles are dissected from the
0901-5027/080756 + 05 $30.00/0
ent surgical procedures are applied for speech improvement in cleft patients with VPI2,5,6,8. Cleft patients with VPI after primary repair commonly undergo palatal re-repair for correction of the muscular deformity
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Palatal aponeurosis reconstruction
757
Fig. 1. Example of recurrence of muscular deformity after radical intravelar veloplasty without reconstruction of the dead space. Endoscopic view (a) before surgery, presenting a muscular deformity; (b) 6 months after repair of the deformity but with a slight notch; and (c) 18 months postoperatively, with a severe notch representing recurrence of muscular deformity.
oral and nasal mucosa, detached from the palatal bones, transversally reoriented, and positioned backwards2,7. Velar function is improved by this procedure and contributes to speech improvements8. Radical dissection and transversal reorientation with backward positioning of the palatal muscles creates a dead space between the retro-displaced musculature and the posterior borders of the palatal bones. Postoperatively, the surgically achieved lengthening of the soft palate often diminishes due to scar tissue formation in the dead space, leading to reattach-
ment of the reoriented muscles to the palatal bone, and to decreased mobility of the soft palate (Fig. 1). To avoid such a recurrence, the dead space should be restored. For this purpose, the authors covered the entire dead space using a double layer of autogenous fascia lata harvested from the lateral thigh. Surgical procedures
In cleft palate patients the tensor-aponeurosis is missing1. In residual muscular deformity after primary repair with mini-
mal or no muscle dissection, the sagittally oriented muscles are often attached to the palatal bones and do not create muscular slings (Fig. 2a and b). In secondary IVV, the muscles are detached from the palatal bones, dissected from the oral and nasal mucosa, and positioned backwards. The muscular slings of the soft palate are then reconstituted, in particular the slings of the levator, palatopharyngeus and palatoglossus muscle (Fig. 2c). This procedure creates a dead space between the retrodisplaced musculature and the posterior borders of the palatal bones (Fig. 2d).
Fig. 2. The palatal muscles and the surgical procedure: (a) residual muscular deformity in cleft patients (the sagittally oriented palatopharyngeal muscle is often attached to the palatal bone and does not create a muscular sling; the levator muscle is retracted); (b) physiological situation; (c) first step in intravelar velopalatoplasty (bold red lines represent the muscle detachment at the palatal bone; thin red lines show the tensor-tenotomy; arrows indicate the backward positioning of the muscles); (d) second step in surgery (red ellipsis shows the dead space anteriorly to the reorientated muscular slings).
758
Smolka et al.
Fig. 3. Drawings and intraoperative photographs: (a) oral view of the reconstruction of the dead space with fascia lata; a straight bar of fascia (b) is fixed with sutures through boreholes at the posterior palatal bone and a double layer of fascia (c) is sutured to the bar; (d) sagittal view; (e) the oral mucosa (white arrows) has been separated from the muscles. The palatal muscles (green arrows) have been reoriented and sutured in the midline. Anterior to the muscles, the dead space (yellow ellipse) appears; (f) reconstruction of the dead space with fascia lata; (g) the oral part of the double layer of fascia lata has been turned anteriorly to allow a view of the nasal part of the double layer; (h) closure of the oral mucosa (green circles indicate mattress sutures used to narrow oral and nasal mucosa).
For reconstruction of the entire dead space, the authors covered it using a double layer of autogenous fascia lata harvested from the lateral thigh (Fig. 3a–c). First, a straight bar of fascia is fixed with sutures through boreholes at the posterior palatal bone for reconstruction of the posterior aspect of the hard palate. Then, a double layer of fascia is sutured to the bar. This double layer consists of one piece of fascia folded at the anterior aspect to allow sliding of the two layers across each other in the posterior part of the layers. The double layer of fascia covers the whole dead space and is sutured to oral and nasal mucosa and to the anterior aspect of the retro-displaced musculature. The double layer should allow sufficient and permanent mobility of the retro-positioned musculature in relation to the posterior shelves of the palatal bones (Fig. 3d). After reconstruction of the dead space, the oral mucosa is closed and narrowed to the nasal mucosa by mattress suturing in between the retro-positioned muscles and the bar of fascia.
was treated by secondary radical IVV and reconstruction of the dead space with fascia lata. (Fig. 3e–h) Preoperatively, the nasendoscopic view indicates severe muscular deformity characterized by a large groove in the middle of the nasal surface of the velum. During phonation (/k/ in
‘‘Coca-Cola’’), velar movement was minimal and no velopharyngeal closure could be achieved. Eighteen months postoperatively, nasendoscopy showed marked anatomic and functional improvements: specifically, a convex upper surface of the velum in the midline, markedly
Table 1. Results of nasometry (Kay Elemetrics Nasometer II Model 6400). The normative nasalance score was determined by a sample of 40 Swiss German-speaking children Vocals
Pre-op
3 months post-op
18 months post-op
Norm
j j j j j
7 31 49 20 35
14 45 69 33 55
8 21 43 10 24
(8–24) (12–22) (23–46) (4–10) (7–19)
Words j p jPille j p jPoster j t jTulpe j k j Karte j f j Feder j f j Foto j sch j Schere j mp j Ampel j mp j Lampe
34 23 17 24 18 17 28 24 37
23 24 22 22 20 28 17 35 40
14 13 13 15 15 21 13 32 31
(5–15) (3–9) (5–16) (7–15) (8–18) (2–15) (14–25) (28–44) (25–37)
Case report
Sentences S1 S2
28 57
28 58
15 67
(9–15) (66–79)
Owing to severe VPI, a 9-year-old boy with unilateral cleft lip palate deformity
S1 (oral test sentence): Die Schokolade ist sehr lecker; S2 (nasal test sentence): Nenne meine Mama Mimi.
a: j e: j i: j o: j u: j
Palatal aponeurosis reconstruction
759
Fig. 4. Oral and nasendoscopic view preoperatively and 18 months postoperatively.
increased and good movement of the velum during phonation, and possible but incomplete velopharyngeal closure (Fig. 4). Nasometry also showed marked improvement in nasalance scores for the case reported here (Table 1). Preoperatively, almost all nasalance scores for vocals, words and oral and nasal test sentences were out of the range of normative reference scores. Postoperative nasometry at 3 months showed elevated scores in most of the nasalance measurements. However, 18 months postoperatively, nearly all nasalance scores reached the norm. Speech improved markedly. Speech assessment was performed by a speech pathologist according to the scoring system of the cleft audit protocol for speech (CAPS) (Table 2)7. There was marked improvement in nasal emission, nasal turbulence and hypernasality (Table 3). Regarding intelligibility, speech improved from the classification ‘only just intelligible to strangers’ preoperatively to the classification ‘slightly different from other children’s speech’ 18 months postoperatively. Marked functional improvements after aponeurosis reconstruction were observable in nasendoscopy, nasometry and speech assessment.
Discussion
Radical IVV with backward positioning of the palatal muscles results in a dead space between the retro-displaced musculature and the posterior borders of the palatal bones. There have been attempts to treat this dead space in order to occlude it and to keep the muscles in a posterior position. Mattress suturing has been proposed as a
treatment option9, but proper reconstruction of the tensor-aponeurosis is not possible with this procedure. The idea of reconstructing the tensoraponeurosis is not new. Its reconstruction in primary cleft patients was proposed by KOCH et al. in 19983. Postoperatively, they obtained good results for speech in 150 patients, with a better functioning anatomical palatal reconstruction. Unfolding
Table 2. Cleft Audit Protocol for Speech (CAPS) Scoring System Nasal emission, nasal turbulence, hypernasality
Intelligibility rating
0 0–1
Normal Inconsistent
0 1
1
Mild
2
2 3
Moderate Severe
3 4
Normal Different from other children’s speech but not enough to cause comment Different enough to provoke comment but possible to understand most speech Only just intelligible to strangers Impossible to understand
Table 3. Speech assessment Nasal emission Nasal turbulence Hypernasality Intelligibility
Pre-op
3 months post-op
18 months post-op
3 2 2–3 3
0–1 0–1 2 2
0 0 0–1 0–1
760
Smolka et al.
the tensor tendon, which is necessary for primary reconstruction of the aponeurosis, is often impossible, and the unfolded tendon is often not large enough to create a functioning aponeurosis. Fascia lata has a structure very similar to that of the tensor-aponeurosis, and therefore the authors think it is suitable for palate reconstruction. In their experience, reconstruction of the posterior border of the hard palate using fascia lata is easy to perform. To avoid scarring of the nasal floor and the oral mucosa they used a double layer of fascia for reconstruction of the aponeurosis. The idea is to prevent fixation of this part of the nasal floor to the oral mucosa in order to allow sufficient and permanent sliding of the retro-positioned musculature. The surgical procedure presented here also seems to be a promising method to avoid reattachment of the retracted muscles to the posterior border of the hard palate.
References 1. Dickson DR. Anatomy of the normal velopharyngeal mechanism. Clin Plast Surg 1975: 2: 235–248. 2. Edgerton MT, Dellon AL. Surgical retrodisplacement of the levator veli palatini muscle. Plast Reconstr Surg 1971: 47: 154–167. 3. Koch KHK, Grzonka MA, Koch J. Pathology of the palatal aponeurosis in cleft palate. Cleft Palate Craniofac J 1998: 35: 530–534. 4. Marsh JL. Management of velopharyngeal dysfunction: Differential diagnosis for differential management. J Craniomaxillofac Surg 2003: 14: 621–628. 5. Perkins JA, Lewis CW, Gruss JS, Eblen LE, Sie KCY. Furlow palatoplasty for management of velopharyngeal insufficiency: a prospective study of 148 consecutive patients. Plast Reconstr Surg 2005: 116: 72–84. 6. Sie KCY, Tampakopoulou DA, Sorem J, Gruss JS, Eblen LE. Results with furlow palatoplasty in management of velophar-
yngeal insufficiency. Plast Reconstr Surg 2001: 108: 17–25. 7. Sommerlad BC, Henley M, Birch M, Harland K, Moiemen N, Boorman JG. Cleft palate re-repair—a clinical and radiographic study of 32 consecutive cases. Br J Plast Surg 1994: 47: 406–410. 8. Sommerlad BC, Mehendale FV, Birch MJ, Sell D, Hattee C, Harland K. Palate re-repair revisited. Cleft Palate Craniofac J 2002: 39: 295–307. 9. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg 2003: 112: 1542–1548. Address: Wenko Smolka Department of Cranio-Maxillofacial Surgery University of Bern Inselspital CH-3010 Bern Switzerland Tel.: +41 31 632 3317 Fax: +41 31 382 0279. E-mail: [email protected]