A case of a survivor to a through-and-through head gunshot wound following Russian roulette.

posteriorly. The oral flaps are then positioned over the unfurled, inset posterior pharyngeal and nasal flaps (Fig. 2). The combination of palatal lengthening and posterior pharyngeal flap, performed simultaneously, has not previously been described. However, managing velopharyngeal insufficiency secondary to a short, straight-line, immobile palate is challenging. For gaps of 5 to 10 mm, a Z-plasty alone may be sufficient for improvement and should be attempted first. However, in cases without levator elevation and/or gap sizes greater than 10 mm, a double-opposing Z-plasty alone is not corrective. Certainly, palatal lengthening alone can always be performed and, if there is no improvement, the posterior pharyngeal flap completed later. However, this necessitates an additional procedure with yet another incision through an already scarred palate. We therefore submit that simultaneous Z-plasty and posterior pharyngeal flap is ideal for addressing velopharyngeal insufficiency gaps greater than 10 mm with a previous straight-line repair. Why not perform posterior pharyngeal flap surgery only in these cases? The classic posterior pharyngeal flap splits the palate, possibly worsening the already reduced velar function, in exchange for a static, mechanical blockade of the velopharyngeal port. Our approach advocates maximizing intrinsic velar capabilities and muscular overlap, as a dynamic solution, in combination with structural narrowing of the velopharynx, as a static posterior pharyngeal flap. Insetting the posterior pharyngeal flap to relatively inflexible hard-palatal nasal mucosa holds the posterior pharyngeal flap taut and unfurled. The flattened posterior pharyngeal flap is interposed between nasal Zs and is lined with oral Zs. The proximal unlined posterior pharyngeal flap may curl near the base, though likely minimally because of tenting along both its origin and its insertion. The constrictor muscle also adds integrity on the posterior pharyngeal flap undersurface, to lessen distortion. Anteroposterior contraction of the raw flap base back toward the pharyngeal wall may also occur. However, this would serve only as a benefit, to pull the soft palate farther posteriorly and optimize velopharyngeal port closure. As with any newly described surgical strategy, the outcome and treatment benefits must be duly vetted. Preliminarily, these techniques in concert are safe and well-tolerated, and achieve significant speech improvement following a single-stage intervention. DOI: 10.1097/PRS.0000000000000200