الفهرس 
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Abstract
Velopharyngeal valve dysfunction is a common disorder after primary palate as primary palatal management is successful in only 70-80% in individuals with cleft palate. VPI affects language, voice and speech. Hypernasality, Nasal air emission and compensatory articulation are the main speech manifestations of VPI.
The study aims to assess speech outcome following with management of secondary velopharyngeal valve dysfunction through buccinator flap palatal lengthening with muscle retropostioning.
This study has been carried out on 24 patients (who are attending on the multidisciplinary cleft clinic Sohag university hospitals) with residual velopharyngeal insufficiency after primary repair of cleft palate. Their ages were above 3 years and with average mentality.
The treatment of velopharyngeal insufficiency patients in this study was done by close cooperation and teamwork between the surgeon and the phoniatrician for selection of proper line of management.
The procedure was selected for VPI treatment as a second choice when the re-repair procedure is not suitable.
Speech evaluation was carried out randomly and blindly by 3 different phoniatricians using the protocol of assessment that is applied in the Phoniatrics unit of Sohag University Hospital (Appendix 1) which included auditory perceptual assessment (APA), nasopharyngeal videofibroscopy and lateral videofluroscopy before operation and 6 month postoperatively.
This study showed that there is improvement in hypernasality, nasal air emission, consonants imprecision and overall intelligibility of speech. Also evaluation by nasoendoscopy shows significant improvement of VPV closure after the operation.
Lateral videofluroscopic assessment showed increasing in velar lengths and thickness with decrease in the velopharyngeal gap. Objective analysis of different parameters were done using computer software program for image analysis (Digimizer) and this provided the results with more accuracy.
Advantages of buccinator flap palatal lengthening with muscle retropostioning over other operations include: (1) a more sound anatomical basis, in that where the palate appears anatomically short in relation to the gap, the anatomical defect is addressed directly, (2) the absence of postoperative hyponasality, and especially (3) ease of technique in patients in whom access to the posterior pharyngeal wall is difficult.
Conclusion
Combining buccinator muscle flap with palatal rerepair gives the advantages of both operations at the same operation with least complications as:
1- Palatal rerepair is more physiological as it aims to retroposition the abnormally oriented velar muscles into a more normal posterior position.
2- More anatomical as the palate appears anatomically short in relation to the gap, the anatomical defect is addressed directly.
3- Both operations do not cause distortion of the anatomy of the pharynx and does not create a permanent obstruction in the pharynx to achieve velopharyngeal competence and no postoperative hyponasality.
Palatal lengthening with myomucosal buccinator flaps with palatal rerepair in patients with velopharyngeal insufficiency is effective and safe. The buccinator flap procedure is a relatively safe and easy procedure. It is an appropriate surgical option in patients in which short palate length is the primary factor in VPI
Multi approach assessment of velopharyngeal valve area and functions helps better selection of operation and gives better results.
Recommendation
1. We would recommend the use of the buccinator musculomucosal flap with palatal rerepair for the correction of velopharyngeal incompetence in case of short scarred palate. This is reflected by the speech results and low rate of complications achieved in our series.
2. Multi approach assessment of velopharyngeal valve area and function with applying both quasiobjective and objective measures.
3. Long term follow up for better knowledge of the results of the operation.