The Buccinator Mucomuscular Flap: An In-Depth Analysis and Evaluation of Its Role in the Management of Velopharyngeal Dysfunction

Abstract

Background A significant proportion of patients with cleft palate experience persisting velopharyngeal dysfunction (VPD) after primary surgery. Pharyngoplasty is the most common procedure to correct inadequate velopharyngeal closure. Although it is often effective, it poses a risk for postoperative airway obstruction. The mucomuscular buccinator flap is a more recent alternative: In the largest case series to date, we outline its use and evaluate its effectiveness in managing persistent VPD. Methods Over 9 years, 103 buccinator flap procedures were performed by the Cambridge group to improve velar function. Clinical records were retrospectively assessed: 60 patients were analyzed by two expert speech and language therapists external to the group using the Cleft Audit Protocol for Speech—Augmented. In a subset of patients, the buccinator flap was interpolated between the limbs of a large mucosal Z-plasty. Consensus listening was undertaken, and interrater reliability was calculated for 24.17% of the cohort. The remaining samples were assessed by a single listener following calibrated consensus listening. Results There was a significant reduction in VPD ( P < .001). Preoperatively, 68.5% of patients demonstrated marked VPD, falling to 24.1% postoperatively. The buccinator procedure demonstrated significant improvement for three of four individual speech parameters: hypernasality, passive cleft speech characteristics, and audible nasal emission. Overall, 13.5% of patients required further corrective speech surgery. Conclusions The buccinator mucomuscular flap reliably and effectively improves velar function in the management of VPD and has low complication rates. We therefore recommend the use of the buccinator flap in primary surgical management of persisting VPD.