The magnum procedure: surgical salvage of end-stage velopharyngeal incompetence.

One of the most difficult problems in cleft palate surgery is the patient who remains velopharyngeally incompetent after previous attempts at surgical correction. The magnum procedure was employed as a method of surgically salvaging these problem patients. The magnum flap is a procedure involving the use of a single or double hemipalatal flap based on the greater palatine vessels and inserted posterior to the hard palate to provide a maximum pushback in these patients. Eleven cases of severe and persistent velopharyngeal incompetence secondary to cleft palate after prior palatoplasty and secondary procedures are presented. All these patients had had at least two previous palatal procedures and were not considered good candidates for significant improvement by further speech therapy, based on evaluation in the Speech Pathology Department. All patients had preoperative and postoperative speech evaluations, including nasal airway studies and cineradiography. Postoperative follow-up was between 12 and 66 months. Speech evaluations and results and operative details and complications were investigated. All patients had mild to marked improvement in their velopharyngeal function, articulation, and resonant voice quality. There were two perioperative complications, one of which was a delayed bleeding episode requiring no treatment and the other of which was a case of cellulitis of the cheek requiring additional antibiotics. Based on this initial series of patients, we feel that the magnum procedure offers considerable promise in the salvage of those patients previously falling into the category of end-stage velopharyngeal incompetence.