Buccinator flap operation

A buccinator flap operation aims to lengthen the soft palate. The surgeon moves some of the lining of the inside of the cheek on its blood supply to make the soft palate longer. This information sheet explains about the buccinator flap operation and what to expect when your child comes to the North Thames Cleft Service for the operation.

Some children whose cleft involves the palate develop a ‘nasal’ tone to their voice because the soft palate is too short and air escapes through their nose when speaking. Sometimes, food and drink can also go up into the nose. A buccinator flap operation effectively lengthens the palate so that less air, food or drink can go into the nose. This hopefully makes the speech less nasal.

Other children with nasal speech, not caused by a cleft palate, can also benefit from the buccinator flap operation.

Where possible, we advise you to keep your child away from children or adults who have colds, ‘flu’ or other infections in the weeks running up to the operation. This will reduce the chance that your child’s operation will have to be postponed because they are not well.

You will need to bring your child to Magpie Ward for a pre-admission appointment in the month leading up to the operation. The purpose of this appointment is to discuss the planned surgery and answer any questions. Your child will need to have a medical check-up and maybe a blood test. Some photos may be taken for medical records.

A doctor may also come to see you to explain the operation in more detail, discuss any worries you may have and ask you to give your permission for the operation by signing a consent form. If your child has any medical problems, such as allergies, please tell us. If your child is taking any medicines, please bring these with you.

Another doctor (an anaesthetist) will visit you on the day of the operation to explain about the general anaesthetic.

The operation is carried out by one of the specialist surgeons in the team. The soft palate is first separated from the hard palate and pushed back. Flaps of tissue are then taken from the lining of the inside of the cheeks (buccal mucosa) and placed into the gap between the soft and hard palates.

There are no cuts on the outside of the cheeks or face. The flap remains attached to the cheek, so that the blood supply is maintained. Sometimes the base of the flap (called the pedicle) passes between the back teeth so it could be damaged when chewing and biting. To prevent this, we may use a ‘bite block’, which stops the jaws closing completely. Some bite blocks are removed for washing after meals but others are fixed to the back teeth temporarily.

The operation usually takes about two hours, but expect your child to be away from the ward for two to three hours. Most children stay in hospital for one to two nights after this operation.

Once the flap has a new blood supply, usually two to three weeks after the operation, the pedicle may be cut in a second shorter operation and the bite block removed. This operation is usually carried out as a day case.

Your child is given a general anaesthetic by an anaesthetist who specialises in giving anaesthetics to babies and children. One parent or carer may be able to go with your child to the anaesthetic room and stay until they are asleep. This usually involves your child breathing some anaesthetic gas.

Later, a tube is passed into the airway (trachea) to safeguard breathing. A cannula (thin, plastic tube) is put in a vein and usually left in place for a short time after the operation. Fluids are given through this tube during the operation and afterwards.

There is a small risk of infection following this or any operation, but your child will be given an antibiotic during the operation. Every anaesthetic carries a risk of complications, but this is very small.

Your child’s cheek will be very swollen after the operation for about 10 days. The bite block also takes some getting used to, particularly for the first few days. They will be uncomfortable for the first few days but regular pain relief is usually enough to deal with this.

If your child’s mouth swells a lot after the operation, they may have difficulty breathing for a while. This complication is rare. If this happens, the doctors will put a tube in your child’s nostril to make breathing easier while the swelling goes down.

Your child will go to the recovery room after the operation and one parent or carer will be able to go there with a nurse as your child is waking up. During the operation, local anaesthetic is put into the wound and the anaesthetist gives intravenous pain relief to reduce post-operative discomfort.

Nonetheless, your child may be distressed and hungry. We expect there to be some blood around the face, from the nose or mouth but this is entirely normal and nothing to be concerned about. Occasionally a tube will have been placed into one nostril to help with breathing.

We are happy for your child to have something to eat and drink as soon as they are awake after the anaesthetic. The first few times may be difficult, partly because the lip is numb from the operation and also because of the bite block.

At first there may be some bleeding from the mouth or nose but this usually stops quickly. Only very rarely will any further measures be necessary to stop the bleeding. The corners of your child’s mouth may become sore after the operation but this will improve within a few days.

When your child has returned to the ward, fluid and puree food may be offered as soon as they are awake. If your child is reluctant to drink it may be necessary to give extra fluid through the drip. The drip will be removed once they are drinking well again. It is important to give your child water after eating and drinking to keep the wound clean.

Your child will have a sore mouth after the operation and so may not feel like eating or drinking much. Various medicines can be given at regular intervals to help ease the pain and make feeding more comfortable.

By the time your child goes home, they should be getting back to a normal pattern of food and drink. We recommend a sloppy diet for two weeks after the operation. This could include cereal with warm milk, custard, tinned spaghetti, mashed potato, yoghurts and fruit.

Please see our information sheet Food suggestions following cleft surgery for further foods to try. Your child should not have hard foods such as crisps, apples, toast, chips, bread or boiled sweets for the first two weeks or so.

It is also important to make sure that your child is drinking enough. Please encourage your child to rinse their mouth well with water after all food, drink and liquid medicines. This helps cleanse the palate and stops food collecting around the operation site, which could lead to infection or wound breakdown.

Your child’s swallow may feel different after the operation so please reassure them that it will improve and take time to adjust.

Some children struggle to eat for a while after the operation. Weigh your child regularly and if they seem to be losing weight, please let us know. They may need to have some high-calorie drinks or a nasogastric tube to help them maintain weight.

You can give pain relief medicines, such as paracetamol syrup or ibuprofen syrup, at home following the dosage instructions on the bottle.

We advise that you give regular pain relief medicine for at least two weeks after the operation, making sure that you give your child a dose about 30 minutes before feeding.

The stitches inside your child’s cheek are dissolvable so will gradually disappear. However, for as long as they are still there you should continue to clean your child’s mouth with cooled, boiled water each time after eating, drinking or taking medicine.

It is important to carry on brushing your child’s teeth using a soft baby toothbrush and a small amount of toothpaste. As after food and drink, it is important to clean their mouth with cooled, boiled water afterwards.

A bite block may be used for the first two to three weeks or until the second operation to separate the pedicle. If your child has a removable bite block, they should keep it in place at all times to stop chewing or biting on base of the flap or pedicle. It should only be removed to rinse the mouth with water, when you can use the opportunity to clean the bite block with a toothbrush and toothpaste, rinsing with water.

If your child’s bite block is not removable, you should encourage your child to use a mouth wash after tooth brushing to keep the area clean. If you have any questions about the bite block, please talk to our orthodontist or dental nurse.

Infection after a buccinator flap operation is rare, but signs of infection include:

• Discomfort
• Redness
• Irritability
• Raised temperature
• Loss of appetite

If your child develops any of these signs, please call the ward, as a repeat course of antibiotics may be needed.

Try to keep your child away from people with coughs and colds for the first few weeks after the operation. You may want to keep your child away from school for about two weeks.

The Speech and Language Therapy department will send you a routine follow up appointment for around six months after the operation. Sometimes, the therapist will want to see your child three months after the operation but we will have explained this when the operation was planned.