Soft Palate Resection

The speech and swallow disability experienced after resection of the soft palate is generally proportional to the amount of palate excised. Although important in the production of intelligible speech, the soft palate's main function is to close off the nasopharynx during the pharyngeal phase of swallowing. This obviously prevents the food bolus from entering the nasopharynx but also provides a pumping mechanism to propel the bolus over the epiglottis to enter the piriforms. The ability of the soft palate to seal off the nasopharynx actively is essential. Loss of up to half the soft palate is manageable with flaps or obturation because the remaining palate is dynamic and can provide for the natural valvular function of this structure. Complete loss of the soft palate portends a poor prognosis with respect to nasal and oral function. The valvular function of the soft palate is completely lost and only static obturation remains as a reconstructive option. In this case, there is a trade-off between nasal breathing and sealing the nasopharynx during swallowing. Flaps and obturators will perform the same function: providing for a subtotal static seal.

In cases of total or near-total removal of the soft palate or if the remaining soft palate is dysfunctional, mechanical obturation is preferred to obturation using flap tissue because adjusting the amount of leak is difficult with a soft tissue flap. However, if adequate dynamic soft palate remains then reconstruction with a flap is preferred. The amount of soft palate necessary to effect an adequate seal is usually about half. The palate must be dynamic and of adequate length to reach the posterior oropharyngeal wall and Passavant's ridge. Minor tissue loss at the lateral margin of the soft palate may be amenable to primary closure along the free edges of the palatal and pharyngeal defect margins. More extensive tissue loss will require reconstruction. With regard to flap reconstruction, two choices are available: recreate the form of the soft palate using thin folded tissue, or obliterate the portion of the oropharynx on the side of the defect with no attempt to recreate the form of the soft palate in the area of the defect. Recreating the form of the soft palate with a folded flap may seem logical but can lead to a poor functional outcome. The typical flap used for this purpose is the radial forearm free flap because it is thin and easily folded. Immediately postoperatively, the patient usually experiences minimal problems with nasopharyngeal leak or velopharyngeal incompetence (VPI) and is able to perform an adequate swallow. However, the VPI and swallow function inevitably worsen within weeks as tissue edema subsides and scar contracture occurs. The tissue edema helps to obliterate the space occupied by the flap, thereby reducing VPI. As the edema dissipates, VPI increases because the remaining dynamic soft palate cannot lift the adynamic flap tissue adequately to seal off the nasopharynx. In addition, scar contracture across the reconstructed portion of the soft palate will pull the dynamic portion of the palate forward (clothesline effect), significantly worsening

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Figure 19 Sensate lateral arm free flap used to obliterate a lateral soft palate defect and reconstruct the lateral oropharyngeal wall. Note the portion of the flap used to obliterate the space behind the palatal defect (star).

VPI. These factors make attempts at recreating the form of the soft palate futile and counterproductive.

In the absence of truly dynamic tissue able to replicate soft palate function exactly, it is best to obliterate the space. This can be accomplished with a variety of soft tissue flaps since their bulk is not an issue unless the excess bulk intrudes on the opposite normal side. The free lateral edge of the soft palate should be approximated to the posterior oropharyngeal wall as much as possible. In patients with significant palatal defects, this will leave deadspace lateral to this closure that can be filled with flap tissue (Fig. 19). Postoperatively, the remaining dynamic palate is able to seal the nasopharynx and this function is minimally affected by scarring within the soft palate or flap tissue.

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