ORIGINAL ARTICLE
FUNCTIONAL SOFT PALATE RECONSTRUCTION: A COMPREHENSIVE SURGICAL APPROACH Hadi Seikaly, MD, FRCSC,1,2 Jana Rieger, PhD,2,3 Jana Zalmanowitz, BA,2 Judith Lam Tang, MSc,2 Khalid Alkahtani, MD,1 Khalid Ansari, MD, FRCSC,1 Daniel O’Connell, MD,1 Gerald Moysa, MD, FRCSC,4 Jeffrey Harris, MD, FRCSC1,2 1
Division of Otolaryngology–Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada. E-mail:
[email protected] 2 Craniofacial Osseointegration and Maxillofacial Prosthetic Rehabilitation Unit (COMPRU), Edmonton, Alberta, Canada 3 Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada 4 Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada Accepted 19 May 2008 Published online 16 September 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20919
Abstract: Background. Dysfunction of the soft palate is devastating to the patient’s quality of life, resulting in unintelligible speech and poor swallowing. Reconstruction of the soft palate is complex because the dynamic fibromuscular structure cannot be duplicated. The efficacy of soft palate reconstruction has therefore been called into question. The purpose of this article is: (1) to describe our comprehensive surgical paradigm for soft palate reconstruction, (2) to provide details of the surgical techniques used, and (3) to report on patient functional outcomes. Methods. Fifty-two patients spanning 3 different size-based categories of soft palate reconstruction were included in the final analysis. Using videofluoroscopic studies of swallowing, the presence of nasopharyngeal reflux and any instance of aspiration of a bolus into the airway was noted. In addition, a simple diet survey was completed, and the use of a g-tube was noted. Results. The results revealed that our protocol for soft palate reconstruction provided the majority of our patients with separation of the oropharynx and nasopharynx, while maintaining nasal
Correspondence to: H. Seikaly Contract grant sponsor: Alberta Heritage Foundation for Medical Research. C V
2008 Wiley Periodicals, Inc.
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patency. Restoration of swallowing function was timely, with 91% of the patients returning to an oral diet at the early postoperative visit and only 14% of patients demonstrating mild nasopharyngeal reflux. Conclusion. We have developed a comprehensive reconstructive protocol that provides patients with separation of the oropharynx and nasopharynx, while maintaining nasal patency. Restoration of function is timely, with reestablishment of normal intelligibility and resonance of speech as well as safe and effiC 2008 Wiley Periodicals, Inc. Head cient swallowing function. V Neck 30: 1615–1623, 2008 Keywords: microvascular reconstruction; soft palate; radial forearm free flap; speech; swallowing
The soft palate is the most important component of the velopharyngeal mechanism, which also includes the lateral and posterior pharyngeal walls. This organ is responsible for proper speech production, resonance, and is intimately associated with complex functions of swallowing and respiration. Dysfunction of the soft palate due to surgery or trauma is devastating to the patient’s
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quality of life, resulting in unintelligible speech and poor swallowing. Reconstruction of the soft palate is complex because the dynamic fibromuscular structure cannot be duplicated with our current capabilities, which are limited to restoration of integrity, bulk, and sensation.1–16 The efficacy of soft palate reconstruction has therefore been called into question, and the debate regarding reconstruction versus prosthetic obturation continues. Reconstruction of the soft palate has traditionally resulted in poor functional outcomes leading most centers to abandon reconstructive efforts and to continue with the use of prosthetic rehabilitation. Prosthetic soft palate rehabilitation can attain good results when the defects are small,17 movement of the residual velopharyngeal complex exists, and the patient has good supporting tissue to anchor the palatal device properly. Prosthetic treatment for defects involving more than half of the soft palate, however, has met with less success at restoring function to preoperative standards.18 The other disadvantages of prosthetic treatment protocols is the potential delay in function because definitive obturation cannot be performed until postoperative healing is complete or the radiation sequela resolve. Clinical experience also suggests that some patients may find the process of wearing a prosthesis inconvenient and annoying. Attempts at reconstruction of the soft palate were resurrected with the advent of free tissue transfer, and many methods of reconstruction have been described. These methods differ in the type of flaps1–10 used and in the inset manner. Some techniques have been noted to work well with smaller defects but have been inadequate in restoring function in defects involving more than half of the soft palate.11 The literature remains deficient in a comprehensive approach to reconstruction for all types of soft palate defects. There also is the need for more thorough, objective reporting of the functional outcomes of these techniques. Our experience has shown that standardized functional assessments play an integral role in evaluating the efficacy of a surgical technique. In a study completed at our institution in 2003,12 objective assessments of speech and swallowing function were used to evaluate radial forearm free flaps for soft palate reconstruction. Although speech intelligibility approached levels of preoperative function, nasality and velopharyngeal orifice area were unsatisfactory in patients with larger defects, resulting in abnormal resonance of
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speech. Thus, our strategy for reconstruction of the soft palate was in need of change and we needed to develop new and comprehensive techniques that met all our criteria for the ideal soft palate reconstruction listed as follows: (1) achieve separation of the oropharynx and nasopharynx; (2) maintain nasal patency; (3) provide timely restoration of function; (4) restore normal intelligibility and resonance of speech; (5) preserve safe and efficient swallowing function; (6) allow cancer surveillance; (7) be cost effective. We have developed a reconstructive paradigm based on the above criteria and objective functional outcomes that classifies defects into 3 different sizes and includes different surgical techniques for reconstruction of each. The purpose of this article is to describe these techniques in detail and report on swallowing outcomes associated with each type of reconstruction at 4 points in time (preoperative, and 1 month, 6 months, and 1 year postoperative). Comprehensive speech results are described in detail in a companion paper.19
PATIENTS AND METHODS Patients.
Seventy-eight consecutive patients treated for oropharyngeal cancer by primary resection and reconstructive surgery between May 2001 and June 2006 were followed in a prospective manner through our interdisciplinary Head and Neck Surgery Functional Assessment Clinic. All patients were enrolled in our functional assessment protocol. Patients received a standard protocol of postoperative radiation therapy (RT) at 1 institution and chemotherapy when indicated. No patients received speech therapy during the time of follow-up, but all patients had swallowing therapy before discharge from the hospital. No patient received prosthetic intervention during the time of follow-up. All patients had involvement of the soft palate, pharyngeal walls, base of tongue, or some combination thereof. Patients were excluded from the study if (1) the resection included any of the oral cavity structures including the oral tongue, or (2) the method of reconstruction was different than the ones described next.
Surgical Technique.
Access to the oropharynx for resection and reconstruction was gained through a lip split and presymphyseal mandibulotomy. All patients had at least 1 intact hypoglossal nerve,
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The method of reconstruction depended on the size of the soft palate defect, as described herein. First, defects less than ¼ of the soft palate were reconstructed with primary closure or simple approximation to the flap. Second, defects greater than ¼ but less than ½ of the soft palate were reconstructed with a pharyngeal flap and radial forearm free flap (PHAR). Figure 1A demonstrates such a soft palate defect. The superior constrictor and overlying mucosa were elevated (Figure 1B) and attached to the remaining posterior aspect of the soft palate in a tension-free closure, effectively reducing the size of the nasopharynx and surrounding the residual nasopharyngeal space with muscle and mucosa (Figure 1C). A radial forearm free flap was then draped over the exposed superior constrictor muscle and sutured to the surrounding mucosa as a patch (Figure 2). This provided a 3-layer closure of the nasopharynx with skin facing orally, posterior pharyngeal mucosa facing the nasopharynx, and superior constrictor muscle between the 2 epithelial surfaces. Third, defects equal to or greater than ½ of the soft palate were reconstructed with a radial forearm free flap and a 2-layer complete adhesion to the posterior pharyngeal wall which resulted in the soft palate insufficiency repair (SPIR). A complete soft palate defect is seen in Figure 3A. To begin, a folded radial forearm free flap (Figure 3B) was inset into the defect, re-creating the anatomic relations of the soft palate. This resulted in a large adynamic neopharyngeal isthmus, which is seen
FIGURE 1. (A) Defect greater than ¼ but less than ½ of the soft palate. (B, C) Elevation of the superior constrictor and overlying mucosa and attachment to the remaining posterior aspect of the soft palate in a tension-free closure. [Color figure can be viewed in the online issue, which is available at www. interscience.wiley.com.]
lingual nerve, and lingual vessels at the end of the resection. The patients had varying degrees of soft palate and base of tongue defects.
FIGURE 2. Draping of a radial forearm free flap over the exposed superior constrictor muscle and the flap is sutured to the surrounding mucosa as a patch. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley. com.]
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arm flap. The incision was continued around the left lateral pharyngeal wall and onto the posterior pharyngeal wall (Figure 4A). Small subdermal and submucosal flaps were elevated on either side of these incisions. The superior posterior pharyngeal flap was then sutured to the posterior free edge of the folded flap (Figure 4B). This effectively closed off the nasopharyngeal side of the defect on the left. The anterior subdermal flap was then approximated to the inferior posterior pharyngeal flap (Figure 4C). This resulted in a 2-layer closure of the nasopharyngeal defect, leaving only a small nasopharyngeal port on the right side, which was just large enough to accommodate a feeding tube (Figure 5). Functional Assessment.
Informed consent was obtained prior to treatment from each patient as part of a routine clinical procedure. A speech-language pathologist collected the data using a standard protocol. Swallowing function was assessed via modified barium swallows. For this study, the presence of nasopharyngeal reflux was noted during review of the videofluoroscopic swallowing study (VFSS). In addition, the Penetration-Aspiration Scale20 was used to assess the degree of airway compromise during swallowing observed on the VFSS. Finally, clinical notation of the type and consistency of foods typical in the patients’ diets was completed, and the presence or absence of the use of a g-tube was noted. This information was collected at the preoperative assessment and at 1 month, 6 months, and 1 year postoperatively.
RESULTS
FIGURE 3. (A) Complete soft palate defect. (B, C) A folded radial forearm free flap is inset into the defect and the anatomic relations of the soft palate are re-created. [Color figure can be viewed in the online issue, which is available at www.interscience. wiley.com.]
with a feeding tube passing through the oropharynx in Figure 3C. Velopharyngeal insufficiency and poor speech resonance is almost certain if no further modifications are instigated. The SPIR modification was performed by incising the dermis along the free edge of the folded radial fore-
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A total of 78 patients were reviewed, and 52 patients were included in the final analysis. Of the 78 patients, 16 were excluded due to involvement of the oral cavity structures and 10 were excluded because reconstruction was done using an adhesion. Patients with adhesions were not included in this article because we have determined that this type of surgical reconstruction does not result in optimal functional speech outcomes, and, therefore, it has been excluded from our protocol. Please see our companion paper for results that support this decision.19 The average age of our patients was 57 years, 41 (79%) were males and 50 (96%) had squamous cell carcinoma. Three patients had T1 disease, 15 had T2, 28 had T3, 4 had T4, and 2 were not TNM classified. The soft palate defect classification and reconstructive
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FIGURE 5. Two-layer closure of the nasopharyngeal defect leaving only a small nasopharyngeal port on the right side. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]
the soft palate and underwent the PHAR procedure detailed earlier. Ten patients received the radial forearm free flap with the SPIR modification for defects equal to or greater than ½ of the soft palate. Twenty of 22 patients in the primary closure group, 19 of 20 in the PHAR group, and 9 of 10 in the SPIR group underwent adjuvant RT. The associated base of tongue defects when present were reconstructed with the radial forearm free flaps and were classified as follows: 3 (6%) patients had 100% defects, 1 (2%) had a 75% defect, 13 (25%) had 50% defects, 26 (50%) had 25% defects, and 9 (17%) had no base of tongue defects. All the flaps survived and none required salvage. Three patients developed exposed tendons in the forearm site that healed with conservative measures. There was no other flap or donor site– related complications. The reconstructions proFIGURE 4. The SPIR modification. (A) Elevation of small subdermal and submucosal flaps. (B) The superior posterior pharyngeal flap is sutured to the posterior free edge of the folded flap. (C) The anterior subdermal flap is approximated to the inferior posterior pharyngeal flap. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]
methods are documented in Table 1. Twenty-two patients underwent the primary closure described for defects less than ¼ of the soft palate. Twenty patients had defects ranging between ¼ and ½ of
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Table 1. Soft palate defect classification and type of reconstruction.
Defect classification
No. of patients (N 5 52)
½
10
Type of reconstruction Primary closure Pharyngeal flap and RFFF (PHAR) SPIR modification of RFFF (SPIR)
Abbreviation: RFFF, radial forearm free flap.
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Table 2. G-tube placement and usage at each evaluation point.
Type of reconstruction Primary closure PHAR SPIR
Defect classification
Preoperative (N 5 48)
1 mo postoperative (N 5 43)
6 mo postoperative (N 5 44)
1y postoperative (N 5 38)
½
1S 0 0
1 NPO 1 NPO; 2 S 2 NPO
2 NPO; 1 S 4S 1 NPO; 2 S
1 NPO; 3 S 1 NPO; 2 S 1 NPO; 1 S
Abbreviations: S, supplemental oral feeding; NPO, nil per os; PHAR, pharyngeal flap and radial forearm free flap; SPIR, SPIR modification of radial forearm free flap; (N 5 ##), the number of patients out of the total sample (52) who were seen for a swallowing assessment at each evaluation time. Note: Numbers in cells represent the number of patients who were using a g-tube at each particular assessment.
vided a permanent separation between the oral and nasal cavities. None of the patients with reconstructed soft palate defects of less than ½ experienced reduced nasal patency. Two patients with the SPIR modification experienced reduced nasal patency which was easily corrected by increasing the nasopharyngeal opening using laser. Timely restoration of function is reflected in the early (1 month) postoperative speech and swallowing outcomes. With respect to speech function, normal perceptual, acoustic, and aeromechanical speech outcomes for patients across all 3 reconstruction groups that are described in this article were found not only at the early postoperative time, but also across a 1-year time period. Details of these speech assessments can be found in the companion paper.19 Data from swallowing assessments were available for 48 patients at the preoperative visit, 43 patients at the 1-month postoperative visit, 44 patients at the 6-month postoperative visit, and 38 patients at the 1-year postoperative visit. Missed appointments were due to a variety of reasons, including patient illness, loss to follow-up, and recurrence. The swallowing results reveal that timely restoration of swallowing function was achieved for the majority of patients at the early postoperative visit (1 month postoperative). At this appointment, only 9% of the assessed sample required a g-tube for primary nutrition (Table 2). This remained steady across the course of the year with only 8% of the sample requiring a g-tube for primary nutrition at the 1-year postoperative visit. A Pearson correlational analysis revealed that g-tube placement was associated neither with the degree of base of tongue or soft palate resected, nor with the type of surgical procedure. With respect to measures of aspiration of liquid boluses during the VFSS at the preopera-
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tive visit, 1 of 48 patients showed evidence of the bolus passing the level of the vocal folds, with or without residue. At the early postoperative visit, 9 of 40 patients assessed showed signs of the liquid bolus passing the level of the glottis. This number increased to 11 of 42 at the 6-month postoperative visit and reached 12 of 37 by the 1-year postoperative visit. A Wilcoxon signed ranks test revealed that while the preoperative rate of aspiration differed significantly from all postoperative assessment times, there were no significant differences in the rate of aspiration between any of the postoperative assessment times. An analysis of the factors that may be associated with the rate of aspiration at the final postoperative visit revealed that neither the degree of base of tongue or soft palate resected, nor the type of surgical reconstructive procedure were associated with aspiration score. With respect to pureed boluses, only very rarely did they pass the level of the glottis, with this outcome being consistent across all evaluation points. Nasopharyngeal reflux was assessed and included any vertical movement of either a liquid or pureed bolus vertically into the nasopharynx beyond the inferior border of the soft tissue of the reconstructed palate. Once again, at the early postoperative visit, and across the course of the year, the majority of patients did not show evidence of any retrograde flow into the nasopharynx (Table 3). Furthermore, although a proportion of patients had reflux beyond the inferior border of the reconstructed soft palate, no patient showed evidence of horizontal movement of the bolus into the nasal cavity and along the nasal floor of the hard palate. Finally, the majority of patients were able to consume a diet that was regular or minced/ soft (Table 4). Much of the change in diet consistency from a regular diet consistency to either a soft/minced or puree/liquid diet can be attributed
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Table 3. Nasal reflux at each evaluation point.
Type of reconstruction
Defect classification
Preoperative (N 5 48)
1 mo postoperative (N 5 43)
6 mo postoperative (N 5 44)
1y postoperative (N 5 38)
½
0 (0%) 0 (0%) 1 (2%)
0 (0%) 3 (7%) 3 (7%)
1 (2%) 4 (9%) 2 (5%)
1 (3%) 2 (5%) 0 (0%)
Primary closure PHAR SPIR
Abbreviations: PHAR, Pharyngeal flap and radial forearm free flap; SPIR, SPIR modification of radial forearm free flap; (N 5 ##), the number of patients out of the total sample (52) who were seen for a swallowing assessment at each evaluation time. Note: Numbers in cells represent the number of patients who showed evidence of nasal reflux of either liquid or puree consistency vertically into the nasopharynx (but not horizontally into the nasal cavity) during a videofluoroscopic swallowing study at each particular assessment.
to the inability to successfully wear conventional dentures for chewing in the postoperative period.
unsatisfactory results were found in our patients’ aeromechanical and acoustical results, which effectively translated into increased levels of hypernasality and distortion of the quality of the speech signal. The evolution of the SPIR technique was a result of such findings that were based on a comprehensive assessment of speech that took into account more than speech intelligibility. Although speech intelligibility is important, distorted resonance can result in negative social perceptions of individuals, such as being ‘‘less intelligent.’’21 Thus, comprehensive functional assessment should look at more than only speech intelligibility. Furthermore, assessment of swallowing outcomes over time is also necessary. Continual assessment of our patients’ swallowing function has also directed the evolution of our soft palate reconstruction protocol. This direction was specifically related to 1 of the primary aspects of swallowing that is affected by velopharyngeal dysfunction—nasopharyngeal reflux. We have effectively reduced nasopharyngeal reflux from affecting 39% of our patients (at 6 months postoperative)12 to affecting only 16% of the present sample of patients for the same evaluation period. With respect to diet consistency at the final evaluation time, a correlational analysis of the data revealed that none of the following were associated with
DISCUSSION
Previous literature has detailed various surgical techniques for soft palate reconstruction. A number of early reports exist that detail specific cases.4–6,14,15 More recently, focus has shifted to recognize that the flap inset technique may have to be adapted in order to repair defects of different sizes, and to attain acceptable functional outcomes. For example, Lacombe and Blackwell9 described 2 techniques for inset of a radial forearm free flap. The technique that they described was dependent on the size of the resection (less than 1/3 or greater than 1/3 of the soft palate resected). While providing important information on adapting surgical reconstruction technique, their account does not include functional outcomes to support the efficacy of their procedures. Brown et al11 reported on functional outcomes after radial forearm free flap in conjunction with a pharyngeal flap. They detailed their surgical technique and reported that they were satisfied with the speech intelligibility results they obtained. In our 2003 study,12 we also found that speech intelligibility outcomes were satisfactory; however,
Table 4. Patient diet classification.
Type of reconstruction Primary closure PHAR SPIR
1 mo postoperative (N 5 39)
Preoperative (N 5 48)
6 mo postoperative (N 5 41)
1y postoperative (N 5 35)
Defect classification
R
M/S
P/L
R
M/S
P/L
R
M/S
P/L
R
M/S
P/L
½
16 15 6
3 3 3
1 0 1
6 6 1
4 6 3
4 5 4
5 7 1
5 6 2
7 4 4
7 7 2
5 2 2
5 3 2
Abbreviations: R, regular diet; M/S, minced/soft diet; P/L, pureed/liquid diet; PHAR, pharyngeal flap and radial forearm free flap; SPIR, SPIR modification of radial forearm free flap; (N 5 ##), the number of patients out of the total sample (52) who had diet information recorded. Note: Numbers in cells represent the number of patients in each category based on current diet at each evaluation time.
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the type of diet that a patient consumed: the amount of base of tongue resected, the amount of soft palate resected, the type of surgical reconstruction, and the degree of aspiration recorded for either liquid or pudding boluses. We have suggested that alterations in diet consistency are related to a patient’s dental status at the time of examination. The relationship between dentition and diet has been described by others. In a study of patients between the ages of 44 and 100 who were in long-term care institutions, Tosello et al22 found that 21% of their sample was on a puree diet, with those who were edentulous with no prosthetic teeth being more likely to consume this type of diet than those with their own teeth, a full upper and lower denture, or a partial denture. Furthermore, the interplay between diet and dentition has recently been subject to a predictive test of swallowing function. In a recent study on dysphagic patients, Suiter and Leder23 recommend a puree diet for edentulous patients and a soft or regular consistency diet for dentate patients. Our team now feels that our surgical techniques have been modified to get results that are superior to what we achieved in the past. By revisiting the goals of soft palate reconstruction outlined in the introduction, we can see how our approach has covered all the necessary objectives. The SPIR modification provided timely restoration of function as is reflected in our early postoperative functional outcome measures. Functional separation of the oral and nasal cavities is reflected in normal resonance of speech and a reduction in the presence of nasal reflux during deglutition. Any decreases in normal nasal airway patency have been resolved through minor adjustments with a laser. One concern that has been raised regarding soft palate reconstruction is that it does not allow for cancer surveillance. It is our belief that, with the availability and sensitivity of modern imaging and endoscopic techniques for the detection of recurrence, this concern is no longer valid. Finally, issues of cost-effectiveness should be considered when implementing new medical interventions. We do not have data to reflect the cost-utility of soft palate reconstruction versus conventional techniques of rehabilitation with a pharyngeal obturator; however, we surmise that over the course of a patient’s life, the costs (both monetary and social) associated with maintaining a prosthesis, maintaining a patient’s oral structure and health with that prosthesis, and managing a patient’s acceptance of their prosthesis may be more costly
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than a single surgical reconstruction at the beginning of treatment.
CONCLUSIONS
In conclusion, we have developed a comprehensive reconstructive protocol that includes 3 different techniques for soft palate reconstruction that are deployed based on the size of the defect after resection. Our experience with soft palate reconstruction confirms that it provides our patients with separation of the oropharynx and nasopharynx, while maintaining nasal patency. Our functional assessment outcomes have revealed that restoration of function is timely, with reestablishment of normal intelligibility and resonance of speech as well as safe and efficient swallowing function. We complete cancer surveillance in our patients who have microvascular reconstruction of the soft palate with the use of imaging and endoscopic technology. Finally, cost-effectiveness and utility of microvascular reconstruction of the soft palate are issues that still remain to be explored. REFERENCES 1. Zohar Y, Buler N, Shvilli Y, Sabo R. Reconstruction of the soft palate by uvulopalatal flap. Laryngoscope 1998; 108:47–50. 2. Gillespie MB, Eisele DW. The uvulopalatal flap for reconstruction of the soft palate. Laryngoscope 2000; 110:612–615. 3. Gangloff P, Deganello A, Lacave ML, et al. Use of the infra hyoid musculocutaneous flap in soft palate reconstruction. Eur J Surg Oncol 2006;32:1165–1169. 4. Kavanagh KT, Hinkle WG. Reconstruction of the soft palate after jaw, tongue, neck dissection with subtotal palatectomy (velopharyngoplasty). Laryngoscope 1987; 97:1461–1463. 5. Birt BD, Gruss JS. Extended posterior wall pharyngoplasty for immediate reconstruction of the soft plate in commando excision of oropharyngeal neoplasms. J Otolaryngol 1982;11:116–118. 6. Shapiro BM, Komisar A, Silver C, Strauch B. Primary reconstruction of palatal defects. Otolaryngol Head Neck Surg 1986;95:581–585. 7. Zoller J, Maier H. Intraoral cheek transposition flap for primary reconstruction of the soft palate. Int J Oral Maxillofac Surg 1992;21:156–159. 8. McCombe D, Lyons B, Winkler R, Morrison W. Speech and swallowing following radial forearm flap reconstruction of major soft palate defects. Br J Plast Surg 2005;58:306–311. 9. Lacombe V, Blackwell KE. Radial forearm free flap for soft palate reconstruction. Arch Facial Plast Surg 1999; 1:130–132. 10. Michiwaki Y, Schmelzeisen R, Hacki T, Michi K. Functional effects of a free jejunum flap used for reconstruction in the oropharyngeal region. J Craniomaxillofac Surg 1993;21:153–156. 11. Brown JS, Zuydam AC, Jones DC, Rogers SN, Vaughan ED. Functional outcome in soft palate reconstruction
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using radial forearm free flap in conjunction with superiorly based pharyngeal flap. Head Neck 1997;19:524–533. Seikaly H, Rieger J, Wofaardt J, Moysa G, Harris J, Jha N. Functional outcomes after primary oropharyngeal resection and reconstruction with the radial forearm free flap. Laryngoscope 2003;113:897–904. Gullane PJ, Arena S. Extended palatal island mucoperiosteal flap. Arch Otolaryngol 1985;111:330–332. Maldonado AR, Baker BM, Judson WF. Palatal insufficiency: a surgical technique for reconstruction. South Med J 1985;78:945–957. Zeitels SM, Kim J. Soft-palate reconstruction with a ‘‘SCARF’’ superior-constrictor advancement-rotation flap. Laryngoscope 1998;108:1136–1140. Penfold CN, Brown AE, Lavery KM, Venn PJ. Combined radial forearm and pharyngeal flap for soft palate reconstruction. Br J Oral Maxillofac Surg 1996;34:322–324. Bohle G, Rieger J, Huryn J, et al. Efficacy of speech aid prostheses for acquired defects of the soft palate and velopharyngeal inadequacy. Clinical assessments and cephalometric analysis: a Memorial Sloan-Kettering Study. Head Neck 2005;27:195–207.
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18. Yoshida H, Michi K-I, Yamashita Y, Ohno K. A comparison of surgical and prosthetic treatment for speech disorders attributable to surgically acquired soft palate defects. J Oral Maxillofac Surg 1993;51:361– 365. 19. Rieger JM, Zalmanowitz JG, Li SYY, Sytsanko A, Williams D, Harris JR, Seikaly H. Functional outcomes after soft palate reconstruction—emerging evidence for efficacy of the SPIR procedure. Head Neck [in press]. 20. Robbins J, Coyle J, Rosenbek J, Roecker E, Wood J. Differentiation of normal and abnormal protection during swallowing using the Penetration-Aspiration Scale. Dysphagia 1999;14:228–232. 21. Rieger J, Dickson N, Lemire R, et al. Social perception of speech in individuals with oropharyngeal reconstruction. J Psychosoc Oncol 2006;24:33–51. 22. Tosello A, Foti B, Se´darat C, et al. Oral functional characteristics and gastrointestinal pathology: an epidemiological approach. J Oral Rehabil 2001;28:668–672. 23. Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia 2007 [Epub ahead of print].
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