Velopharyngeal incompetency in the absence of overt cleft palate: anatomic and surgical considerations.

Fifty-two patients with velopharyngeal incompetency without overt cleft palate underwent pharyngeal flap surgery. Surgery included exploration of the soft palate and reconstruction of the levator muscles. Four patients had a completely normal hard and soft palate. In two patients, the palatal musculature was normal but a U-shaped defect of the posterior hard palate was palpable. Seventeen patients had a diagnosis of submucous cleft palate made preoperatively and of these thirteen presented with the classic triad of a bifid uvula, a palpable abnormality of the hard palate and diastasis of the soft palate musculature. In thirteen patients a notch was found in the hard palate and in one patient a U-shaped defect was palpable at the posterior edge of the hard palate. Three patients presented no abnormality of the hard palate. One patient's uvula was normal. In the remaining twenty-nine patients, all demonstrated abnormal insertion of the palate muscles into the hard palate. In fifteen of these patients the hard palate was normal. In nine of the patients a U-shaped defect was palpable at the posterior hard palate and in three patients a notch was palpable. Thus, forty-eight of fifty-two patients (92%) demonstrated abnormal anatomy of the palate responsible for their velopharyngeal incompetency.