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The Endoscopically Assisted Pharyngeal Flap

The aim of pharyngeal-flap procedures is to reduce the nasopharyngeal opening in patients with velopharyngeal insufficiency in order to limit abnormal nasal air escape. This dimension strikes a balance between the need for a patent nasopharynx and nasal airway to achieve nasal resonance and the need for dynamic closure of the nasopharyngeal sphincter to achieve normal speech and swallowing. Lateral port control techniques emphasize this goal and have been prevalent in the literature since their introduction by Hogan (1973). These techniques stress the creation of precisely controlled ports and adjunct procedures that attempt to maintain these ports by minimizing postoperative wound contracture and cicatrix formation. Hogan’s initially described procedure remains popular today and offers two significant changes from the classic superiorly based pharyngeal flap. First, the width of the pharyngeal flap is created to accommodate 3.5-mm diameter catheters at its lateral borders. These catheters then guide the extent of the lateral closure from the flap to the soft palate. Second, the raw surface of the pharyngeal flap is lined with two flaps taken from the posterior aspect of the soft palate’s nasal mucosa. These lining flaps minimize postoperative pharyngeal flap contracture and subsequent widening of the lateral ports (Bardach, 1991). The Hogan modification of the pharyngeal flap has been the procedure of choice for pharyngoplasty at our institution since 1990. Although we have found the procedure to be highly satisfactory, one challenge that has remained is the intraoperative estimation of the final port size and configuration. This had been classically achieved by observation transorally and