Sommerlad palatal sail lift ring reconstruction and soft palate lengthening for post-operative cleft palate VPI Cleft palate repair surgery is the most effective treatment for cleft palate deformities. According to data, approximately 20% of patients after initial cleft palate repair are affected by velopharyngeal incompetence (VPI) (1). Studies on the mechanism of VPI after cleft palate surgery have used the length of the hard and soft palate, the depth of the pharyngeal cavity, and the motility of the soft palate during articulation as indicators to observe the rate of velopharyngeal incompetence after cleft palate surgery, and also classified the characteristics of velopharyngeal incompetence in terms of soft palate and lateral pharyngeal wall movement patterns by means of observations such as nasopharyngeal fiberscopy and dynamic radiography, such as: good lateral pharyngeal wall movement and insufficient soft palate movement Inadequate movement of the lateral pharyngeal wall with good movement of the soft palate and inadequate movement of both the lateral pharyngeal wall and soft palate. The disproportion between the length of the soft palate and the depth of the pharyngeal cavity (3) is probably one of the most important factors contributing to VPI after cleft palate surgery, both morphologically and functionally. A perfect or near-perfect palatopharyngeal closure is necessary for normal speech function, and any cause of palatopharyngeal closure insufficiency (VPI) will result in a deficit in normal speech function. For VPI occurring after cleft palate surgery, we believe that repair surgery should mainly focus on restoring correct muscle movements and supplementing with effective soft palate length to achieve a coordinated palatopharyngeal scale ratio, and only after that can we achieve physiological palatopharyngeal closure function and then coordinate their articulation patterns from speech training, and finally it is possible to achieve truly good speech restoration results. To address this goal, we designed a targeted procedure for patients with incomplete palatopharyngeal closure, which is described below. Materials and methods. 2.1 Materials: 10 patients with postoperative cleft palate with slurred speech undergoing speech therapy from January 2010 to January 2011, with posterior anterior superior palatopharyngeal closure insufficiency confirmed by clinical examination and nasopharyngeal fiberscopy, and normal lateral pharyngeal wall motion. The ages ranged from 6 to 22 years. The mean age was 15.2 years. Eight of them were male and two were female. The time after cleft palate surgery ranged from 1 to 14 years. The average postoperative period was 7.1 years. Two cases had a combined hard palate fistula. The follow-up time ranged from 3 months to 1 year with a mean of 2.2 METHODS: After the patients were intubated with anesthesia, the distance L of the posterior edge of the soft palate from the posterior pharyngeal wall was measured at rest. If L <1cm, the soft palate could be effectively lengthened by simply using Sommerlad muscle dissection, reconstructing the palatal sail raphe muscle ring, while removing scar tissue in the midline area and closing the root tissue on both sides of the uvula. If the L is between 1 and 2 cm (common), in addition to the above mentioned methods, Z-plasty lengthening of the nasal side of the mucosa or/and the oral side of the mucosa is added. If the L is greater than 2 cm, two major flap retraction methods are used, combined with Sommerlad's muscle anatomy, to reconstruct the palatine fenestra muscular ring, which is mostly used in adult patients. The hard palate fistula is closed with a simultaneous repair. 2.3 For the method of Sommerlad muscle dissection and reconstruction of the palatine fenestra muscular ring during the repair, please refer to the relevant literature (3) Results After surgery, the extension of the soft palate ranged from 1 to 2.5 cm. Intraoperatively, four patients achieved voluntary palatopharyngeal closure and six patients achieved assisted palatopharyngeal closure using the Sommerlad negative pressure test. 3 out of 10 patients (3/10) completed treatment with normal speech sounds and disappearance of nasal sounds within 3 months after surgery. 4 out of 10 patients (4/10) are undergoing postoperative speech training with mild nasal sounds and increased proportion of normal speech sounds. Three were in the post-operative recovery period and were receiving rehabilitation guidance therapy. Discussion 4.1 The reasons for the occurrence of palatopharyngeal closure insufficiency after cleft palate repair surgery are multiple. The more common cause is the severe degree of congenital cleft palate deformity and poorly developed hard and soft palate tissues, resulting in poorer repair results. Other reasons such as insufficient length of the soft palate after repair, lack of proper anatomical treatment of the soft palate muscles, and excessive scar formation after surgery can lead to the possibility of VPI after cleft palate repair surgery. Statistically, 5 to 45% of cleft palate patients still experience palatopharyngeal closure insufficiency after cleft palate repair surgery (). In addition, postoperative tissue morphology around the soft palate, such as a shortened webbed pharyngopalatine arch and excessive tension after repair, as well as the occurrence of complications after repair surgery, can affect soft palate movement and physiological function as a cause of VPI. During development, the presence of an excessively wide pharyngeal cavity can cause a relative lack of soft palate length, as well as adenoid proliferators that gradually shrink with age, all of which can affect the normal closure of the palatopharynx. Therefore, the use of surgery to treat palatopharyngeal closure insufficiency should be based on the mechanism of occurrence of palatopharyngeal closure insufficiency, and a suitable surgical method should be selected to reconstruct physiological palatopharyngeal closure. 4.2 The main purpose of cleft palate repair is to close the cleft to restore the morphology of the palate and reconstruct palatopharyngeal closure to restore the physiological function of the mouth. Due to developmental and structural peculiarities, the occurrence of VPI after cleft palate surgery is mainly related to the incompatibility between the functional length of the soft palate and the relative scale of the pharyngeal cavity. Therefore, the goal of reoperation after cleft palate surgery should be focused on these two main issues, i.e., lengthening the length of the dynamic soft palate combined with reducing the size of the pharyngeal cavity. After primary cleft palate surgery, there is often a degree of scar contracture or even shortening of the nasal mucosal surface, resulting in a limited functional lengthening of the soft palate. In this group of cases, we designed the Sommerlad method of palatal sail ring reconstruction and soft palate lengthening in a targeted manner, that is, with a relatively normal pharyngeal cavity. In this group, we designed the Sommerlad palatal ring reconstruction and soft palate lengthening method, which is a combination of Sommerlad palatal ring reconstruction and purposeful soft palate lengthening with a relatively normal pharyngeal cavity. 4.3 For many marginal palatopharyngeal closure that occurs after surgery, it is possible to achieve a state of palatopharyngeal closure by means of speech training without surgical treatment. Speech therapy alone is characterized by a long course of treatment and often requires close cooperation between the parents and the child and the speech therapist to achieve good results. For patients who lack access to speech therapy, both posterior pharyngeal crest augmentation and limited soft palate lengthening can be performed to achieve good palatopharyngeal closure. This surgical concept is also applicable to mild VPI occurring after muscle reconstruction alone, regardless of the method used, the basic principle of adapting the physiological length of the soft palate to the pharyngeal cavity should be met, in addition to the correct reconstruction of the muscular ring of the palatofantoid muscle. Special cases should be treated separately. Conclusion In posteroanterior VPI, the use of Sommerlad's palatine fenestrated ring reconstruction combined with soft palate lengthening is effective when the pharyngeal cavity is relatively normal. It has a positive effect in the treatment of postoperative VPI after cleft palate surgery for the common postoperative shortening of the soft palate due to soft palate scarring or inappropriate palatal sail raphe anatomy.