Buccinator Flaps Palatal Lengthening and Posterior Positioning of the Velar Muscles as a Combined Procedure for VPI Management.

This letter is about a recent publication in the Cleft Palate Craniofacial Journal titled: "Posterior Positioning of Levator Veli Palatini with Intact Nasal Layer and Side-by-Side Bilateral Buccinator Flaps: Modified Approach for Palatal Lengthening" in which the authors present a 'modified' technique combining both palatal lengthening with buccinator flaps and velar muscles posterior positioning. However, earlier publications including two peer-reviewed articles and a book chapter had already introduced the same conceptual combination, yet these were not cited.We discuss the technical differences among these procedures, as well as the potential advantages and disadvantages of each. These differences include whether buccinator flaps are used to lengthen only the oral mucosa or both the oral and nasal layers, and whether the velar muscle is dissected in isolation or maintained attached to either the nasal or oral mucosa during retropositioning. Current evidence remains insufficient to determine whether oral-only or dual-layer lengthening provides superior outcomes, or which muscle dissection technique achieves more reliable velopharyngeal competence, as existing studies are limited by relatively small and heterogeneous cohorts, variations in assessment methods, and inconsistent follow-up durations. Further comparative studies are needed to clarify the optimal technique for combining buccinator palatal lengthening with muscle repositioning.