Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees Part 3: Objective Assessment and Surgical Decision-Making.

Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the velopharyngeal (VP) port, affecting speech and swallowing. After an auditory-perceptual speech evaluation by a speech-language pathologist, objective assessment of the VP port is required to determine the need for surgical intervention. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism; (2) fundamental speech terminology and principles of perceptual speech assessment for VPD; and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 3, the authors focus on the modalities for objective VP port assessment, including both direct and indirect methods. Direct imaging techniques such as videofluoroscopy, nasoendoscopy, and MRI are detailed for their strengths and limitations in visualizing VP port function and preoperative planning. Indirect assessments, including nasometry and aerodynamic measurements, are also briefly discussed. The decision-making process for surgical intervention is explored, emphasizing factors such as the severity and etiology of VPD, VP closure patterns, palatal length, orientation of the levator veli palatini, and other patient-specific considerations. The authors review the surgical options for repair including palatoplasty procedures (Furlow palatoplasty, straight-line intravelar veloplasty, and palatal lengthening buccal myomucosal flaps) and pharyngoplasty procedures (posterior pharyngeal flaps and sphincter pharyngoplasty), highlighting their indications, techniques, and potential complications. This series serves as an accessible resource, providing the foundational knowledge required for surgical trainees new to this topic.