(A) Lateral palatine processes and median palatine process
(B) Maxillary prominence and lateral palatine process
(C) Maxillary prominence and mandibular prominence
(D) Medial nasal prominence and nasal septum

The correct response is Option A.

During development, primary cleft palate occurs as a result of unsuccessful fusion of the median palatine process, which forms the primary palate, and the lateral palatine processes, which form the secondary palate. In contrast, secondary cleft palate occurs following unsuccessful fusion of the lateral palatine processes to each other and with the nasal septum.

Because the lateral palatine process is derived from the maxillary prominence, these two structures cannot fuse. Unsuccessful fusion of the maxillary and mandibular prominences results in macrostomia, while cleft lip results from fusion of the medial nasal prominence and maxillary prominence. Fusion of the medial nasal prominences leads to development of the nasal septum; therefore, these structures cannot fuse to each other. The premaxilla, nasal tip, and the philtrum and cupid's bow of the upper lip are also formed from fusion of the medial nasal prominences; the lateral portion of the upper lip is formed from the first branchial arch.

References
1. Gosain AK, Moore FO. Embryology of the head and neck. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:223-236.
2. Moore KL. The Developing Human. 4th ed. Philadelphia, Pa: WB Saunders Co; 1988:170-206.

A child who had a cleft palate repair in infancy is undergoing sphincter pharyngoplasty for management of velopharyngeal insufficiency. When performing this procedure, which of the following muscles is typically used to create the sphincter?

(A) Levator veli palatini
(B) Musculus uvulae
(C) Palatopharyngeus
(D) Salpingopharyngeus
(E) Tensor veli palatini

The correct response is Option C.

The success of sphincter pharyngoplasty, a secondary technique performed for correction of velopharyngeal insufficiency, is most dependent on elevation of myomucosal flaps of the palatopharyngeus muscle. These flaps can be used to construct a sphincter in the pharyngeal wall. This technique effectively obliterates the lateral ports of the velopharyngeal mechanism and decreases the diameter of the central port.

Because the levator veli palatini muscle is important for initial palatal closure and movement, it would not be available in this child who previously underwent cleft palate repair. The musculus uvulae is a small sagittal muscle of the uvula that is not useful in sphincter creation. The salpingopharyngeus muscle arises from the inferior portion of the auditory tube near its orifice. It passes downward and blends with the posterior fasciculus of the palatopharyngeus muscle. The tensor veli palatini follows close to the eustachian tube and is also affected in patients with cleft palate.

References
1. Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg. 1950;3:128.
2. Jackson IT. Sphincter pharyngoplasty. Clin Plast Surg. 1985;12:711.
3. Witt PD. Velopharyngeal insufficiency. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;2:819-833.

Which of the following muscles is/are NOT involved in normal velopharyngeal closure?

(A) Levator palatini
(B) Palatopharyngeus
(C) Superior pharyngeal constrictors
(D) Tensor veli palatini
(E) Uvulus

The correct response is Option D.

Muscles involved in velopharyngeal closure include each of those mentioned above except for the tensor veli palatini. Normal velopharyngeal closure is crucial for production of intelligible speech; any abnormalities in this mechanism can result in hypernasality, nasal emissions, imprecise production of consonants, decreased speech volume, and/or shortness of phrases.

The levator palatini muscles are of primary importance in pharyngeal closure. These muscles join in the midline to form a sling in the normal palate, inserting into the palatal aponeurosis. Their mechanism of action is to pull the middle third of the soft palate superiorly and posteriorly, resulting in contact with the pharyngeal walls.

In contrast, patients with cleft palate have abnormal insertion of the levator palatini on the posterior aspect of the hard palate. Cleft palate repair recreates the "normal" muscle sling by reorienting the muscles horizontally through a procedure known as intravelar veloplasty.
If normal pharyngeal closure is not achieved following cleft palate surgery, additional procedures may be considered to allow for a more complete velopharyngeal closure. Sphincter pharyngoplasty or reconstruction with pharyngeal flaps is most frequently performed.

The palatopharyngeus muscles pull the soft palate posteriorly, while the superior pharyngeal constrictors move the lateral and posterior pharyngeal walls. The uvulus muscle enhances velopharyngeal closure by thickening the uvula.

Although the tensor veli palatini attaches to the eustachian tubes, acts to tense the soft palate, and is important for eustachian tube function, it does not provide an important contribution to velopharyngeal closure.

References
1. Fara M. The musculature of cleft lip and palate. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;4:2612.
2. Hobar PC, Johns DF, Flood J, et al. Cleft palate repair and velopharyngeal insufficiency. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:263.