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The Pushback Pharyngeal Flap: An 18-Year Experience

Rochlin, Danielle H. M.D.; Mittermiller, Paul A. M.D.; Sheckter, Clifford C. M.D.; Menard, Robert M. M.D.

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1246e-1254e
doi: 10.1097/PRS.0000000000005645
Pediatric/Craniofacial: Original Articles

Background: The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism.

Methods: A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa.

Results: There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm2. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001).

Conclusions: The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening.


Stanford and Santa Clara, Calif.

From the Division of Plastic Surgery, Stanford University School of Medicine; and the Northern California Kaiser Permanente Regional Craniofacial Clinic, Department of Plastic Surgery, Kaiser Permanente Santa Clara.

Received for publication April 30, 2018; accepted September 27, 2018.

Presented at the 17th Biennial Congress of the International Society of Craniofacial Surgery, in Cancun, Mexico, October 24 through 28, 2017.

Disclosure: There are no commercial associations or financial disclosures for any author. No funding was received for this work.

Robert M. Menard, M.D., Northern California Kaiser Permanente Regional Craniofacial Clinic, Department of Plastic Surgery, Kaiser Permanente Santa Clara, Department 290, Second Floor, 710 Lawrence Expressway, Santa Clara, Calif. 95051,

Copyright © 2019 by the American Society of Plastic Surgeons