closure during phonation. There are several other reasons surgery may fail the first time, including a poorly designed flap such as one that is too narrow, postoperative scar (contracture of the flap), or inappropriate patient selection. Also, the flap may be too wide and occlude the lateral ports. There are higher rates of surgical failure in children with a history of perinatal upper airway obstruction, such as those with Robin sequence (Witt et al., 1998). The type of cleft, as well as the type of flap used (superiorly or inferiorly-based) does not seem to make a difference in postoperative speech outcomes. It has been reported that different types of flaps give different speech configurations, however the results showed equally good outcomes for postoperative speech, regardless of the type of flap used. Therefore, it is imperative that the surgeon selects the right type of flap for each individual (Liedman-Boshki et al., 2005). Overall, speech should improve after pharyngeal flap surgery. It is important to remember that improvement is variable and individuals react to surgery differently. Changes in speech do not always occur immediately after surgery, but this does not mean improvements will not be made. Lastly, speech problems such as compensatory articulation strategies do not often extinguish on their own. A speech language pathologist is usually involved both before and after pharyngeal flap surgery to monitor and help improve speech difficulties. Alternatives Augmentation pharyngoplasty is a common alternative operation. External links Video example of posterior pharyngeal flap (example #6) References Palate surgery Pharyngoplasty