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Dacryocystorhinostomy (DCR) success may depend on mucous membrane alignment across the osteotomy and entire surgical lacrimal outflow conduit. Scar tissue, obliteration of the lacrimal sac, and obstruction at the level of the common canaliculus may result from prior surgery or may occur as an isolated problem. We describe and evaluate the efficacy of a technique of grafting autologous buccal mucous membrane during external DCR in cases complicated by scarring and/or common canalicular obstruction.We retrospectively reviewed 11 nasolacrimal outflow system obstructions (in 9 patients) treated with a buccal mucous membrane graft–assisted DCR. The surgical technique is described in detail.All cases presented with insufficient nasolacrimal outflow. Ten tear ducts failed prior DCR procedures, while one case had isolated common canalicular obstruction, resistant to multiple probing and intubation and was previously recommended a Jones tube procedure. Three tear outflow systems (in 2 patients) exhibited common canalicular obstruction; the rest were obstructed at the level of the lacrimal sac. Two patients had bilateral obstruction. Ten eyes had symptomatic epiphora. One eye had dacryocystitis alone, and 2 eyes had dacryocystitis and epiphora. Six tear ducts had more than one previous DCR procedure. Four tear ducts had prior endonasal DCR procedures, while 6 had a previous external DCR. All eyes with epiphora preoperatively had complete relief of tearing. All cases of dacryocystitis resolved with no recurrences. Nine tear ducts were patent to irrigation testing postoperatively (2 were not tested).Buccal mucous membrane grafting may improve the success of DCR in cases complicated by scarring, mucosal shortage, and/or common canalicular obstruction.