Buccal Fat Pad: Adjunctive Procedure for Lateral Defect Coverage following Primary Palatoplasty

Modified Furlow Palatoplasty Using Small Double-Opposing Z-Plasty: Long-Term Outcome and Comparison with 2-Flap Palatoplasty

BACKGROUND

Postpalatoplasty velopharyngeal function needs to be evaluated through long-term follow-up, but such reports are limited in the literature, and there has been no consensus as to which surgical technique yields optimal velopharyngeal function with minimum complication rate. This study aimed to evaluate the long-term outcome of the modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ).

METHODS

A retrospective review was conducted of consecutive patients who underwent palatoplasty performed by the senior author (L.J.L.) between January of 2000 and March of 2014. Nonsyndromic patients who underwent palatoplasty before the age of 18 months and followed up until at least 9 years of age were included. Comparisons between the small-DOZ and 2-flap methods for soft palate repair were made.

RESULTS

A total of 196 small-DOZ and 167 2-flap palatoplasty patients were eligible in the study. Among the small-DOZ palatoplasty patients, 1 patient (0.5%) developed oronasal fistula and 18 patients (9.2%) developed velopharyngeal insufficiency (VPI) surgery (10 patients at preschool age, and 8 at 9 years of age). Compared with the small-DOZ palatoplasty, the oronasal fistula rate, VPI surgery rate, and the need for myringotomy tube insertion were significantly higher in the 2-flap group (P = 0.01, P < 0.01, and P < 0.01, respectively). Patients who developed oronasal fistula had significantly higher likelihood of having VPI (P < 0.01).

CONCLUSIONS

The small-DOZ provided successful palatal repair with low rates of oronasal fistula and VPI in the long term. Wound closure under minimal tension facilitated avoiding oronasal fistula. Reconstruction of the functional muscle sling enabled the authors to achieve normal velopharyngeal function with favorable speech outcome and middle ear function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Longitudinal Experience Using Pedicled Buccal Fat Pad Flaps in Cleft Palatoplasty: Mitigating Velopharyngeal Insufficiency Risk and Severity

BACKGROUND

Cleft palatoplasty commonly results in denuded maxillary bone in the lateral gutters and a posterior void between oral and nasal closures. Bony exposure of the anterior palate subjects the maxilla to scarring and growth restriction; scar contracture of the posterior void may result in velopharyngeal insufficiency and fistula formation. Use of the buccal fat pad flap (BFPF) at the time of palatoplasty provides vascularized tissue over these critical areas, thereby reducing the rate of secondary surgery for speech and fistula revision.

METHODS

A single-center, retrospective review identified patients who underwent palatoplasty with or without BFPF between 1995 and 2015. Data collected included cleft type, surgical technique, follow-up duration, and complications. Outcomes included rate of speech surgery and palatal fistula development. Veau phenotype index was computed on a scale of 2 to 4 as a weighted mean to reflect the frequency of cleft type (Veau II through IV) in BFPF and non-BFPF groups.

RESULTS

Charts of 866 patients were reviewed; 212 met inclusion criteria. Of these, 101 received a BFPF. Mean follow-up duration was 11.4 years. Despite a selection bias for more severe clefts, the BFPF group had lower incidence of speech surgery (9.9% versus 36.9%; P = 0.0072). The BFPF group had milder cases treatable with fat injection (7.9% versus 2.7%; P = 0.0346) and developed fewer fistulas (6.9% versus 18.0%; P = 0.0280).

CONCLUSIONS

Despite the presence of more severe clefts, the BFPF group had a significantly lower rate of speech surgery. The BFPF is a valuable adjunct in primary palatoplasty, reducing velopharyngeal insufficiency and fistula formation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Effect of Presurgical Nasoalveolar Molding on Oronasal Fistula Following Primary Palatoplasty

OBJECTIVE

Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty.

METHODS

A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups.

RESULTS

Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P =0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold ( P =0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P =0.003).

CONCLUSION

Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

OBJECTIVE

An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach.

DESIGN

Retrospective single-surgeon study.

PATIENTS

Consecutive nonsyndromic patients (n  =  27) with Veau I cleft palate.

INTERVENTIONS

Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD).

MEAN OUTCOME MEASURES

Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n  =  24) was retrieved for comparison purposes.

RESULTS

Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P  =  .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P  =  .546), age (10.2  ±  1.7 vs 9.6  ±  1.2 months; P  =  .143), rate of lateral incision (18.5% vs 4.2%; P  =  .195), and postoperative complication rate (0% vs 0%).

CONCLUSION

This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

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.

Buccal Fat Pad in Primary and Secondary Cleft Palate Repair: A Systematic Review of the Literature

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.

Anatomical and Surgical Implications of the Usage of Bichat Fat Pad in Oroantral Communication, Maxillary, Palatal, and Related Surgeries-Narrative Review

The buccal fat pad, also called the Bichat's fat pad (BFP), is an encapsulated fat mass located in the cheek. This type of specialized fat mass can be used both as a pedicular or free graft in various surgeries and approaches. Due to its easy access from the oral cavity approach, it is commonly used for oroantral and palatal fistula closure. The knowledge of its anatomy and surrounding tissues plays a role in its mobilization and suturing onto the desired defect in the palatal or maxillary region. The BFP is mostly associated with the primary approach used for a fistula or bone surgery. Alternatively, the procedure can be performed with a single approach incision, which does not compromise the appearance or the function of the operating or adjacent areas. The most important inclusion criteria for BFP usage and surgical limitations are highlighted. The BFP is used for multiple purposes in reconstructive and oncology surgery and also has its use in esthetic and facial contouring procedures. The amount, volume, and shape of the BFP are mostly associated with the scope of their usage. The aim of the following narrative review is to present the surgical and anatomical implications of fat pads in maxillary and palatal surgeries.