CINERADIOGRAPHIC ASSESSMENT OF COMBINED ISLAND FLAP PUSHBACK AND PHARYNGEAL FLAP IN THE SURGICAL MANAGEMENT OF SUBMUCOUS CLEFT PALATE 1 By JOHN E. HOOPES,M.D., z A. LEE DELLON, 3 JACOB I. FABRIKANT, M.D., and ANN H. SOLIMAN From the Division of Plastic Surgery, the Department of Radiology, and the Division of Otolaryngology, The Johns Hopkins Hospital and The Johns Hopkins University School of Medicine, Baltimore, Maryland. OBJECTIVE methods of pre- and post-operative evaluation are essential for assessment of the numerous surgical procedures available for correction of velopharyngeal incompetence and cineradiographic investigation of the velopharynx has proved of clinical value for this purpose. It allows : I. Elucidation of the functional anatomy and pathophysiology of the velopharynx. 2. Precise diagnosis of the discrete anatomical factors responsible for velopharyngeal incompetence. 3. Accurate measurement of the anatomical modifications achieved surgically. 4. Estimation of prognosis. ANTERIOR POSTERIOR NASAL SPINE NASAL SPINE "~o ~ ~ POSTERIOR PHARYNGEAL LEVATOR WALL EMINENCE UVULA-...~ FIG. I Tracing obtained on the basis of frame-by-frame analysis demonstrating the anatomical reference points and the arc traversed by the levator eminence. Material and Method.--Four patients with hypernasal speech secondary to submucous cleft palate provided the basis for this investigation. A combined island flap pushback and pharyngeal flap was performed in each patient by the same surgeon using the same technique. Two additional patients were studied cineradiographically and received the operative procedure but subsequently were lost to follow-up evaluation. The technique and instrumentation for cineradiographic evaluation of the vocal tract with synchronous sound recording has been described in detail (Hoopes and Fabrikant, 1968), and a method of frame-by-frame analysis correlating objectively measur- able anatomical parameters with subjective evaluation of speech has been presented i This work is supported in part by the United States Public Health Service Grant No. 5 ToI GM o1328-o4 and by a gift from the Robert Garrett Foundation. Plastic Surgeon-in-Chief, The Barnes and Allied Hospitals and The St Louis Children's Hospital, The Washington University School of Medicine, St Louis, Missouri 631 IO. 3 Henry Strong Denison Scholar for 1968-1969. 39