Over the years, many pharyngeal flap modifications were attempted to optimize results and minimize complications in repairing velopharyngeal insufficiency. L flap was designed and used to add 1cm of superior constrictor muscle covered by mucosa to the palate adding length and width to the already short and tense palate and make its sutures more secured under direct vision. Then L flap could successfully close palatal fistula and correct VPI as single stage procedure with easy applicability and no registered complication without palatal dissection. Additionally, a cephalic de-mucosalized modified L flap allows to immediately cover the superior part of the donor site in the posterior pharyngeal wall with mucosa avoiding possible adhesion and downward PF migration Therefore, familiarity with the easily applicable safe and simple L PF is important Velopharyngeal (VP) valve that closes and opens VP port between the nasopharynx and oropharynx is formed by the velum and aided by lateral and may posterior pharyngeal walls Normal velopharyngeal (VP) function occurs when the nasal cavity is completely closed from oral cavity during speech. Such proper VP valve closure is necessary for production of normal oral pressure consonants, speech intelligibility, resonance and deglutition.

When VP valve fails to provide complete closure, both air and sound energy may escape from the nasal cavity and so such incompetent valve required surgical repair. The most common procedure to repair VPI is the superior based pharyngeal flap (PF) that is well established, with a long history [1] since it was originally described by Schoenborn and popularized by Shprintzen [2]. PF idea is to borrow tissues from the posterior pharyngeal wall to be attached to soft palate, creating a central closure of velopharynx and two lateral ports that remain open during respiration and nasal consonant and close during oral consonants [1]. Over the years, many modifications [2-4], were attempted to optimize results and minimize complications. At 2012, new flap inset into a transverse full  thickness palatal incision that was designed 1 cm posterior to hard soft junction but 8% flap dehiscence, 19% borderline sufficiency and 4% incomplete VP closure were reported [3]. Later, Elshiekh and El-Anwar used the same palatal incision but designed PF to be L flap adding 1cm of tissue (superior constrictor muscle covered by mucosa) to the palate adding length and width to the already short and tense palate. The L flap makes suturing of the palatal part of the flap into its central palatal inset is more secure, controlled, easier and under direct vision so avoid flap dehiscence and achieve perfect VP closure [4]. This central inset of the PF was proved to improve ET functions in patients with persistent VPI following palatoplasty. Therefore, there is no need for ventilation tube insertion to manage OME in these cases should not be performed except after see the results of such PF [5]. Then, Elshiekh and El-Anwar L flap could successfully close palatal fistula and correct VPI as single stage procedure with easy applicability and no registered complication without palatal dissection [6].  Moreover, Elshiekh and El-Anwar L flap was modified to be cephalic de-mucosalized L flap to immediately cover the superior part of the donor site in the posterior pharyngeal wall with mucosa enhancing primary donor site healing avoiding its negative sequels particularly of possible adhesion and downward PF migration [7]. Familiarity with the easily applicable safe and simple Elshiekh and El-Anwar L flap4 its modifications will help to popularize the technique in the way to reach the optimum way to repair VPI.

1. Sloan GM. Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art. Cleft Palate Craniofacial J. 2000; 37: 112-122.
2. Shprintzen RJ, Lewin ML, Croft CB, Daniller AI, Argamaso RV, Ship AG, et al. A comprehensive study of pharyngeal flap surgery: tailor made flaps. Cleft Palate J. 1979; 16: 46-55.
3. Emara TA, Quriba AS. Posterior pharyngeal flap for velopharyngeal insufficiency patients: a new technique for flap inset. Laryngoscope. 2012; 122: 260-265.
4. Elsheikh E, El-Anwar MW. Posterior pharyngeal flap for velopharyngeal insufficiency patients: a new L shaped flap. J Craniofacial Surg. 2016; 27: 204-208.
5. El-Anwar MW, Amer HS, Elnashar I, Khazbak AO, Khater A. Effect of central inset for velopharyngeal insufficiency on Eustachian tube function. Laryngoscope. 2015; 125: 1729-1732.
6. El-Anwar MW, Elsheikh E, Askar S. Single stage repair of palatal fistula and velopharyngeal incompetence by the new L flap. J Craniofacial Surg. 2018; 29: 70-73.
7. Askar SM, El-Anwar MW, Elaassara AS, Quribab AS, Anany A, Elmalta A, et al. Cephalic de-mucosalized superiorly-based pharyngeal flap: a modified mucosa-preserving technique for velopharyngeal insufficiency. Int J Pediat Otorhinolaryngol. 2018; 115: 65-70.