title: The double-opposing buccal flap procedure for palatal lengthening.
abstract: BACKGROUND
  Velopharyngeal dysfunction has been treated with either a pharyngeal flap or sphincteroplasty with varying degrees of success. Both of these entities have their own series of problems, with sleep apnea and nasal mucous flow disruptions at the forefront. The purpose of this study was to review the senior author's (R.J.M.) experience performing the double-opposing buccal flap for palatal lengthening.
  
  
  METHODS
  All patients who were treated with double-opposing buccal flaps between October of 1994 and July of 2007 were reviewed. These patients presented with varying degrees of velopharyngeal dysfunction showing some degree of velar movement at the time of surgery. Preoperative and postoperative speech results were reviewed for comparison.
  
  
  RESULTS
  Twenty-seven patients underwent palatal lengthening, with an average length of follow-up of 58 months. Distal flap necrosis occurred in two patients. The level of intelligibility (65.4 percent versus 95.5 percent) and resonance (moderately hypernasal versus normal resonance) improved significantly postoperatively (p < 0.0001). Only one patient required the addition of a pharyngeal flap for persistent velopharyngeal dysfunction, and there were no postoperative issues with sleep apnea.
  
  
  CONCLUSIONS
  The double-opposing buccal flap is an effective technique for lengthening the palate, improving speech, and decreasing the risks of postoperative sleep apnea. All patients experienced a dramatic improvement in their resonance and intelligibility. This technique appears most effective in patients with intact velar movement who demonstrate a small to moderate posterior velar gap. The double-opposing buccal flap is a useful means of treating velopharyngeal dysfunction, thus serving as an adjunct when improving pharyngeal closure.
authors: Grand Rapids, Mich. From Grand Rapids Medical Education Partners/Michigan State University Plastic Surgery Residency; the Division of Plastic Surgery, Helen DeVos Children's Hospital; and Michigan State University College of Human Medicine.
authors: Robert J
authors: RJ
authors: Mann
authors: Keith C
authors: KC
authors: Neaman
authors: Shannon D
authors: SD
authors: Armstrong
authors: Ben
authors: B
authors: Ebner
authors: Robert
authors: R
authors: Bajnrauh
authors: Steven
authors: S
authors: Naum
references: Ysunza A, Pamplona C, Ramírez E, Molina F, Mendoza M, Silva A. Velopharyngeal surgery: A prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg. 2002;110:1401–1505.
references: Lang BR, Kipfmueller LJ. Pharyngeal inadequacy with the palatal lift concept. Plast Reconstr Surg. 1969;43:467–477.
references: Sherling ML. Correction of postoperative velopharyngeal inadequacy in a cleft palate patient utilizing a prosthetic obturator: A case report. Penn Dent J (Phila.) 1971;74:21–23.
references: Birnbach S. Physiologic recording of the soft palate for fabrication of obturator speech prostheses. J Prosthet Dent. 1978;39:539–545.
references: Weiss CE, Edwards MF. Selection and management of young obturator patients. J Pedod. 1979;3:335–349.
references: Lewy R, Cole R, Wepman J. Teflon injection in the correction of velopharyngeal insufficiency. Ann Otol Rhinol Laryngol. 1965;74:874–879.
references: Gray SD, Pinborough-Zimmerman J, Catten M. Posterior wall augmentation for treatment of velopharyngeal insufficiency. Otolaryngol Head Neck Surg. 1999;121:107–112.
references: Stellmach R. Biographical sketch and commentary by Dr. Rudolph Stellmach. Plast Reconstr Surg. 1972;49:561–562.
references: Trier WC. The pharyngeal flap operation. Clin Plast Surg. 1985;12:697–710.
references: Hynes W. Pharyngoplasty by muscle transplantation. Br J Plast Surg. 1950;3:128–135.
references: Orticochea M. Construction of a dynamic muscle sphincter in cleft palates. Plast Reconstr Surg. 1968;41:323–327.
references: Sphrintzen RJ. Pharyngeal flap surgery and the pediatric upper airway. Int Anesthesiol Clin. 1998;26:79–88.
references: Orr WC, Levine NS, Buchanan RT. Effect of cleft palate repair and pharyngeal flap surgery on upper airway obstruction during sleep. Plast Reconstr Surg. 1987;80:226–232.
references: Kravath RE, Pollak CP, Borowiecki B, Weitzman ED. Obstructive sleep apnea and death associated with surgical correction of velopharyngeal incompetence. J Pediatr. 1980;96:645–648.
references: Hill C, Hayden C, Riaz M, Leonard AG. Buccinator sandwich pushback: A new technique for treatment of secondary velopharyngeal incompetence. Cleft Palate Craniofac J. 2004;41:230–237.