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Adekunle AA, James O, Olanbiwonnu AO, Adeyemo WL. A Review of the Use of Buccal Fat Pad in Cleft Palate Repair. Cleft Palate Craniofac J 2024; 61:1116-1124. [PMID: 36760091 DOI: 10.1177/10556656231155768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVE To review the available evidence on the use of the Buccal Fat Pad in primary and secondary Cleft Palate repair. METHODS This is a narrative review. A computerized literature search was conducted for articles published till February 2022 using the Mesh phrases buccal fat pad AND cleft palate, Bichat's Fat pad AND cleft palate, buccal fat pad OR Bichats Fat pad AND cleft palate. RESULTS A total of 35 articles were included in this review based on the set eligibility criteria. Most of the studies were retrospective case reviews (n = 16, 45.7%), and the aggregate number of patients from all included studies was 666. Reported uses of the buccal fat pad (BFP) in association with cleft palate repair include the closure of central cleft palate defect and nasal floor in primary cleft palate repair, oronasal fistula repair following primary repair of cleft palate, and closure of relieving incision defect in primary repair of cleft palate. Complications reported were 24 cases of Oronasal Fistula (ONF), 2 dehiscences, and 4 transient mucosal defects. CONCLUSION The high success rate, vascularity, ease of tissue harvest, and low donor site morbidity all support its use as an adjunct flap in cleft palate repair, especially in the closure of wide palatal clefts, to prevent post-palatal repair fistula, wound contracture, and subsequently velopharyngeal insufficiency and possibly midface hypoplasia.
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Affiliation(s)
- Adegbayi Adeola Adekunle
- Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Olutayo James
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Wasiu Lanre Adeyemo
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
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Phillips JB, Galarza LI, Sink MC, Goza SD, Brown MI, Hopper SJ, Brown KW, Fernstrum CJ, Hoppe IC, Humphries LS. Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution. Ann Plast Surg 2024; 92:S404-S407. [PMID: 38857004 DOI: 10.1097/sap.0000000000003957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.
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Affiliation(s)
- John B Phillips
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | | | - Matthew C Sink
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Shelby D Goza
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Madyson I Brown
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Samuel J Hopper
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
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Lerner JL, Vishwanath N, Crozier J, Rao V, Woo A. Single Oral Z-Plasty: A Clinical Validation of a Technique for Palatal Lengthening in Primary and Secondary Cleft Palate Repair. Plast Reconstr Surg 2024; 153:130e-138e. [PMID: 37036320 DOI: 10.1097/prs.0000000000010524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
BACKGROUND In cleft palate repair, palate length is associated with improved speech outcomes. Although direct closure offers poor palatal lengthening, use of two opposing Z-plasties may reorient palatal musculature and lengthen the velum. The authors previously described a novel overlapping intravelar veloplasty to achieve longitudinal closure of the nasal mucosa with a single oral Z-plasty (1ZP), lengthening the palate in cadaver studies. This study aims to corroborate this finding in clinical cases. METHODS A retrospective comparative study of patients with a cleft palate was conducted. Patients underwent cleft palate closure with 1ZP or intravelar veloplasty with straight-line closure. Preoperative and postoperative measurements of the palate along four dimensions were recorded. Analysis was conducted on preoperative and postoperative measurements within and between groups using the Mann-Whitney-Wilcoxon or chi-square test. RESULTS Eighty-five patients were included (1ZP, n = 65; straight-line closure, n = 20). 1ZP increased soft palate length (SPL) by 33% ( P < 0.001) and total palate length (TPL) by 10% ( P < 0.001). Primary 1ZP increased SPL by 33% ( P < 0.001) and TPL by 10% ( P < 0.001). Secondary 1ZP increased SPL by 28% ( P < 0.001) and TPL by 8% ( P < 0.001). When comparing between primary and secondary 1ZP, 1ZP was equal with regard to percentage lengthening in SPL ( P > 0.9) and TPL ( P > 0.3). When compared with straight-line closure, 1ZP showed superior percentage lengthening in SPL ( P < 0.001) and TPL ( P = 0.038). CONCLUSIONS 1ZP results in a statistically significant increase in palate length in both primary and secondary cleft palate repair. This technique provides an effective alternative in patients for whom 2ZP is not feasible. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Julia L Lerner
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University
| | - Neel Vishwanath
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University
| | - Joseph Crozier
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University
| | - Vinay Rao
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University
| | - Albert Woo
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University
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Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2023; 81:E120-E146. [PMID: 37833020 DOI: 10.1016/j.joms.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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Ku YC, Al-Malak M, Mulvihill L, Deleonibus A, Maasarani S, Bassiri Gharb B, Rampazzo A. Tissue adjuncts in primary cleft palate reconstruction: A systematic review. J Plast Reconstr Aesthet Surg 2023; 86:300-314. [PMID: 37797378 DOI: 10.1016/j.bjps.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/13/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty. METHODS A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables. RESULTS A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03). CONCLUSIONS Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.
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Affiliation(s)
- Ying C Ku
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mazen Al-Malak
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lianne Mulvihill
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anthony Deleonibus
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samantha Maasarani
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bahar Bassiri Gharb
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Antonio Rampazzo
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Romero-Narvaez C, Lin LO, Kirschner RE. Buccal Fat Pad in Primary and Secondary Cleft Palate Repair: A Systematic Review of the Literature. Cleft Palate Craniofac J 2023:10556656231206238. [PMID: 37853550 DOI: 10.1177/10556656231206238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVE To review the evidence supporting the use of buccal fat pad (BFP) in primary and secondary cleft palate repair and its short- and long- term clinical outcomes. DESIGN Systematic review conducted by 2 independent reviewers following PRISMA guidelines. SETTING: NONE PARTICIPANTS Articles were identified from three databases (Pubmed/Medline, Embase and Web of Science). Search terms included "cleft palate", "palatoplasty", "palate repair", "buccal fat pad". INTERVENTIONS Use of BFP in primary and secondary cleft palatoplasty. MAIN OUTCOME MEASURES Primary outcomes were immediate postoperative complications, postoperative fistula, and maxillary growth. Secondary outcomes were palatal length, speech, and donor site morbidity. RESULTS Ninety-one reports were retrieved after excluding duplicates. Twenty-three studies were included (13 case series and 10 comparative studies). Overall level of evidence was low. Randomized and non-randomized studies had a high risk of bias. In primary palatoplasty, BFP was more frequently used filling lateral relaxing incisions(57.4%), or in the hard-soft palate junction and covering mucosal defects(30.1%). In these patients, post operative fistula incidence was 2.8%. Two studies found wider transverse maxillary dimensions after BFP use. No higher incidence of bleeding, infection, dehiscence, or flap necrosis was reported. In secondary palatoplasty, no recurrent fistulas were reported for patients undergoing BFP for fistula repair. CONCLUSIONS BFP appears to be associated with a favorable impact in fistula prevention and management, as well as in transverse maxillary growth. However, there is a high heterogeneity among studies, high risk of bias and overall low quality of evidence. More high-quality research with long-term follow-up is warranted.
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Affiliation(s)
- Carolina Romero-Narvaez
- Plastic and Reconstructive Surgery Service, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Lawrence O Lin
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Richard E Kirschner
- Plastic and Reconstructive Surgery Service, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
- Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
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Denadai R, Chou PY, Lo LJ. Reinforcing the Modified Double-Opposing Z-Plasty Approach Using the Pedicled Buccal Fat Flap as an Interpositional Layer for Cleft Palate Repair. Cleft Palate Craniofac J 2023; 60:503-508. [PMID: 34860607 DOI: 10.1177/10556656211064769] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pedicled buccal fat flaps have been adopted in primary Furlow double-opposing Z-plasty palatoplasty to reduce oronasal fistula formation or to attenuate maxillary growth disturbance. We combined both goals in a single intervention. This study describes a series of 33 modified Furlow small double-opposing Z-plasty palatoplasties reinforced with a middle layer of pedicled buccal fat flaps between the oral and nasal layers for full coverage of the dissected palatal surfaces, with rapid mucosalization of lateral relaxing incisions and no dehiscence or fistula formation.
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Affiliation(s)
- Rafael Denadai
- Plastic and Cleft-Craniofacial Surgery, A&D DermePlastique, Sao Paulo, Brazil
| | - Pang-Yun Chou
- The Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Lun-Jou Lo
- The Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Incidence of fistula after primary cleft palate repair: a 25-year assessment of one surgeon’s experience. Arch Plast Surg 2022; 49:43-49. [PMID: 35086308 PMCID: PMC8795648 DOI: 10.5999/aps.2021.01396] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022] Open
Abstract
Background Cleft lip and cleft palate are the most frequent congenital craniofacial deformities, with an incidence of approximately 1 per 700 people. Postoperative palatal fistula is one of the most significant long-term complications. This study investigated the incidence of postoperative palatal fistula and its predictive factors based on 25 years of experience at our hospital. Methods We retrospectively reviewed 636 consecutive palatal repairs performed between January 1996 and October 2020 by a single surgeon. Data from patients’ medical records regarding cleft palate repair were analyzed. The preoperative extent of the cleft was evaluated using the Veau classification system, and the cleft palate repair technique was chosen according to the extent of the cleft. SPSS version 25.0 was used for all statistical analyses, and exploratory univariate associations were investigated using the t-test. Results Fistulas occurred in 20 of the 636 patients; thus, the incidence of palatal fistula was 3.1%. The most common fistula location was the hard palate (9/20, 45%), followed by the junction of the hard and soft palate (6/20, 30%) and the soft palate (5/20, 25%). The cleft palate repair technique significantly predicted the incidence of palatal fistula following cleft palate repair (P=0.042). Fistula incidence was significantly higher in patients who underwent surgery using the Furlow double-opposing Z-plasty technique (12.1%) than in cases where the Busan modification (3.0%) or two-flap technique (2.0%) was used. Conclusions The overall incidence of palatal fistulas was 3.1% in this study. Moreover, the technique of cleft palate repair predicted fistula incidence.
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What is the Fate of the Pedicled Buccal Fat Pad Flap When Used During Primary Palatoplasty? J Craniofac Surg 2022; 33:e173-e175. [PMID: 34560738 PMCID: PMC8943470 DOI: 10.1097/scs.0000000000008238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
ABSTRACT Pedicled buccal fat pad flaps have more recently been applied to primary cleft palate reconstruction, and yet the integrity of the flap and the long-term impact on the palate has not yet been studied. This case study uses magnetic resonance imaging to evaluate the composition of the soft palate 5 years after the interpositional placement of bilateral pedicled buccal fat pad flaps during primary palatoplasty. Anatomical measures are used to quantify the flap and surrounding velopharynx using magnetic resonance imaging and three-dimensional computer technology, indicating that this surgical technique may have a lasting impact for children with cleft palate.
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Split Buccal Fat Flap in Modified Furlow Palatoplasty: Surgical Technique and Early Result. Plast Reconstr Surg 2022; 149:197-201. [PMID: 34936623 DOI: 10.1097/prs.0000000000008648] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
SUMMARY Encouraging results have been described for the use of pedicled buccal fat pad flap in primary cleft palate repair. This retrospective study describes the surgical technique and early results of a technical innovation utilizing the split buccal fat flaps in modified Furlow palatoplasty with small double-opposing Z-plasty. This technique introduces buccal fat tissue for coverage of lateral denuded palate surfaces to reduce the bone exposure and scar formation to potentially attenuate maxillary growth interference and for reinforcement of the palatal areas of high tension or with incomplete closure to decrease the risk of postoperative dehiscence and oronasal fistula formation. Consecutive nonsyndromic patients (n = 56) with cleft palate were treated with this method, all of whom demonstrated fast mucosalization of lateral palatal recipient regions within 3 weeks postoperatively and showed no fistula with 12 months' follow-up. Of 19 patients (33.9 percent) who underwent auditory-perceptual assessment, 15 (78.9 percent) had normal resonance. Surgeons could add this alternative surgical maneuver to their armamentarium during the primary palatoplasty, in which coverage of lateral surfaces and reinforcement with fat tissue in the anterior soft palate space are of paramount relevance. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Abstract
PURPOSE OF REVIEW The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients. RECENT FINDINGS Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication. SUMMARY Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.
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Affiliation(s)
- Florence Othieno
- Department of Otolaryngology - Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
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Kotlarek KJ, Jaskolka MS, Fang X, Ellis C, Blemker SS, Horswell B, Kloostra P, Perry JL. A Preliminary Study of Anatomical Changes Following the Use of a Pedicled Buccal Fat Pad Flap During Primary Palatoplasty. Cleft Palate Craniofac J 2021; 59:614-621. [PMID: 33973484 DOI: 10.1177/10556656211014070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The purpose of this study was to examine the surgical impact of the pedicled buccal fat pad (BFP) flap on the levator veli palatini (LVP) muscle and surrounding velopharyngeal (VP) anatomy following primary palatoplasty using magnetic resonance imaging (MRI). DESIGN Observational, prospective. SETTING MRI studies were completed at 3 different facilities. All participants with BFP flap were operated on by the same surgeon. PARTICIPANTS Five pediatric participants with cleft palate with or without cleft lip (CP±L) who underwent primary palatoplasty with BFP flap placement. Comparison groups consisted of 10 participants: 5 with CP±L who did not receive the BFP flap and 5 healthy controls. INTERVENTIONS All participants underwent nonsedated MRI 2 to 5 years postoperatively. MAIN OUTCOMES AND MEASURES Anatomical measures of the velopharynx and LVP among the 3 participant groups. RESULTS Median values were significantly different among groups for velar length (P = .042), effective velar length (P = .048), effective VP ratio (P = .046), LVP length (P = .021), extravelar LVP length (P = .009), and LVP origin-origin distance (P = .030). Post hoc analysis revealed a statistically significant difference between the BFP and traditional repair groups for effective VP ratio (P = .040), extravelar LVP length (P = .033), and LVP length (P = .022). CONCLUSIONS This study provides preliminary support that the BFP flap creates a longer velum, with increased distance between the posterior hard palate and the LVP, and a larger effective VP ratio compared to traditional surgical techniques. Future research is needed to determine whether this procedure provides a more favorable mechanism for VP closure.
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Affiliation(s)
- Katelyn J Kotlarek
- Division of Communication Disorders, University of Wyoming, Laramie, WY, USA
| | | | - Xiangming Fang
- Department of Biostatistics, East Carolina University, Greenville, NC, USA
| | - Charles Ellis
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
| | - Silvia S Blemker
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
| | | | | | - Jamie L Perry
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, NC, USA
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