Abstract
BACKGROUND: Velopharyngeal insufficiency (VPI) occurs in 5-36% of patients after primary palatorrhaphy for cleft palate, causing hypernasality and nasal emissions due to inadequate velopharyngeal closure. Although various surgical treatments are available, they may present limitations and potential risks, including obstructive sleep apnea. The buccinator myomucosal flap, with a reliable blood supply, provides a versatile option for VPI correction. In addition, it is associated with a low risk of complications, further supporting its safety and applicability in clinical practice. We report successful palatal lengthening using a modified bilateral buccinator myomucosal flap with a buccal fat flap in a 14-year-old patient with persistent VPI despite prior interventions. CASE PRESENTATION: A 14-year-old female with a bilateral complete cleft lip and palate underwent primary cheiloplasty at 3 months and palatorrhaphy at 9 months of age. Despite 10 years of speech therapy and 4 years of speech aid use, hypernasality persisted. To address this, palatal lengthening was performed using bilateral buccinator myomucosal flaps combined with buccal fat flaps. At 1 month postoperatively, partial necrosis of the buccal fat grafts was observed but healed without further complications. At 8 months postoperatively, soft palate elongation exceeding 1 cm was achieved, and nasometric assessments demonstrated nasality reductions of 25.5 percentage points for high vowels (/i/, /wi/) and 19.5 percentage points at the sentence level. In the consonant accuracy evaluation, the patient's word-level accuracy increased from 72.09% preoperatively to 88.37% at 6 months postoperatively. These objective improvements correlated with subjective reports of improved speech and reduced vocal effort. CONCLUSION: As seen in this case, the combined use of buccinator myomucosal and buccal fat flaps can be a viable surgical option for addressing VPI through soft palate lengthening. This approach can lead to improvement in hypernasality with minimal complications, and its efficacy may be further supported by future long-term follow-up studies involving larger patient populations.