Filling the Void: Use of the Interpositional Buccal Fat Pad to Decrease Palatal Contraction and Fistula Formation

Abstract

Objective: The objective of this study was to evaluate the ability of the buccal fat pad flap (BFPF) to fill the void remaining after muscle transposition and study its effect on durability, fistula rate, palatal shortening/contraction, and relapse of muscle positioning in wide and challenging cleft repairs. Design: A retrospective chart review was performed. Charts were abstracted for standard demographics, reason for BFPF utilization, palatal length, palatal fistula, co-morbidities, and speech outcomes. Patients, Participants: Patients under age 3 who underwent primary palatoplasty between October 2007 and September 2015 which utilized a medially placed BFPF were identified. Results: Fifty-three patients were identified. Mean age at palatoplasty was 1.4 (0.78-2.55) years. Mean follow-up was 2.52 (0.02-7.26) years. Twenty-four (45.3%) patients had concerning intraoperative findings warranting flap utilization. Twenty-nine (54.7%) patients underwent BFPF for large dead-space volume. Four patients (7.55%) experienced a fistula. Thirty-nine patients had comments on their palatal length. Of these, 28 (71.8%) were of average length, and 8 (20.5%) were long. Thirty-three patients have undergone formal speech evaluation. Of these, 20 (60.6%) were of normal resonance, and 12 (36.4%) demonstrated nominal hypernasality. No patients have yet to require a secondary speech operation. Conclusion: Use of the BFPF has become more common in our practice particularly in challenging cleft palate repairs. It is a versatile technique addressing large interpositional dead space and thin outer and inner lamellae in the anterior soft palate after posterior muscle transposition. Early results, in difficult repairs, demonstrate excellent durability and that palatal length appears to be maintained, potentially lessening the need for secondary speech surgery.

Reinforcing the Modified Double-Opposing Z-Plasty Approach Using the Pedicled Buccal Fat Flap as an Interpositional Layer for Cleft Palate Repair

“…Our retrospective analysis of the 6-month complication rate revealed that this modified Furlow double-opposing Z-plasty palatoplasty with the 3-layer repair of the hard and soft palates resulted in adequate cleft palate closure with rapid mucosalization of lateral relaxing incisions and no wound separation or fistula formation. This corroborates published data of satisfactory palatal healing status with reduced fistula rates following the use of pedicled buccal fat flaps in Furlow palatoplasties (Levi et al, 2009; Bennett et al, 2017; Qiu et al, 2019; Horswell and Chou, 2020; Kim et al, 2020; Thurston et al, 2020; Denadai and Lo, 2021). Interestingly, recent comparative investigations have demonstrated that adding buccal fat flaps in Furlow double-opposing Z-plasty palatoplasty improves the postoperative palatal length (Kotlarek et al, 2021a) and transverse maxillary development (Lo et al, 2021).…”

“…Interestingly, recent comparative investigations have demonstrated that adding buccal fat flaps in Furlow double-opposing Z-plasty palatoplasty improves the postoperative palatal length (Kotlarek et al, 2021a) and transverse maxillary development (Lo et al, 2021). Based on the existing objective data (Thurston et al, 2020; Lo et al, 2021; Kotlarek et al, 2021a), we hypothesized that this modified palatoplasty technique could not only reduce the wound dehiscence and fistula formation for early postoperative outcomes but also achieve a satisfactory speech outcome and reduce the probable negative influence on transverse maxillary arch development and midfacial growth. However, the potential benefit of enhanced muscle sling functioning due to less fibrotic tissue formation and prevention of maxillary growth disturbance by reducing scar contraction remains theoretical, as our 6-month follow-up interval restricts any conclusion.…”

“…In this setting, results have encouraged the use of pedicled buccal fat pad flaps in original and modified Furlow double-opposing Z-plasty palatoplasties (Levi et al, 2009; Yamaguchi et al, 2016; Bennett et al, 2017; Qiu et al, 2019; Jung and Lo, 2020; Thurston et al, 2020; Denadai and Lo, 2021; Lo et al, 2021; Kotlarek et al, 2021a, 2021b). Interpositional buccal fat flaps have been applied in the anterior region of the soft palate to fill the dead space between the oral and nasal flaps, alleviating possible palatal contraction during the healing process, and reducing dehiscence or fistula formation (Qiu et al, 2019; Thurston et al, 2020; Denadai and Lo, 2021; Kotlarek et al, 2021a). The lateral denuded bone surfaces were covered with pedicled buccal fat flaps to reduce healing by secondary intention and subsequent impairment of the maxillary arch development, and maxillary growth (Levi et al, 2009; Yamaguchi et al, 2016; Jung and Lo, 2020; Denadai and Lo, 2021; Khan et al, 2021; Lo et al, 2021).…”

“…In this setting, results have encouraged the use of pedicled buccal fat pad flaps in original and modified Furlow doubleopposing Z-plasty palatoplasties (Levi et al, 2009;Yamaguchi et al, 2016;Bennett et al, 2017;Qiu et al, 2019;Jung and Lo, 2020;Thurston et al, 2020;Denadai and Lo, 2021;Lo et al, 2021;Kotlarek et al, 2021aKotlarek et al, , 2021b. Interpositional buccal fat flaps have been applied in the anterior region of the soft palate to fill the dead space between the oral and nasal flaps, alleviating possible palatal contraction during the healing process, and reducing dehiscence or fistula formation (Qiu et al, 2019;Thurston et al, 2020;Denadai and Lo, 2021;Kotlarek et al, 2021a).…”

Split Buccal Fat Flap in Modified Furlow Palatoplasty: Surgical Technique and Early Result

“…Different groups have incorporated buccal fat pad flaps into double-opposing Z-plasty palatoplasty. [8][9][10][11][12][13][14][15][16] Technically, it adds 10 to 15 minutes Plastic and Reconstructive Surgery • January 2022 to the operative time, 8,10 with minimal facial aesthetic impact or compromise of facial symmetry in the donor-site region. 19,20 In this study, split buccal fat flaps were adopted to decrease the risk of postoperative fistula formation and palatal contraction and to reduce bone exposure during the healing process.…”