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.
ChoiKJWlodarczykJRNagengastES, et al.The likelihood of orthognathic surgery after orofacial cleft repair. J Craniofac Surg. 2021;32(3):902-906.
2.
LeviBKastenSJBuchmanSR. Utilization of the buccal fat pad flap for congenital cleft palate repair. Plast Reconstr Surg. 2009;123(3):1018-1021.
3.
ReddyRRGosla ReddySVaidhyanathanABergéSJKuijpers-JagtmanAM. Maxillofacial growth and speech outcome after one-stage or two-stage palatoplasty in unilateral cleft lip and palate. A systematic review. J Cranio-Maxillofac Surg. 2017;45(6):995-1003.
4.
LoCCDenadaiRLinHH, et al.Favorable transverse maxillary development after covering the lateral raw surfaces with buccal fat flaps in modified Furlow palatoplasty: a three-dimensional imaging-assisted long-term comparative outcome study. Plast Reconstr Surg. 2022;150(2):396e-405e.
5.
ThurstonTEVargoJBennettKVerclerCKastenSBuchmanS. Filling the void: use of the interpositional buccal fat pad to decrease palatal contraction and fistula formation. FACE. 2020;1(1):33-40.
6.
RautioJAndersenMBolundS, et al.Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 2. Surgical results. J Plast Surg Hand Surg. 2017;51(1):14-20.
7.
TseRWSieboldB. Cleft palate repair: description of an approach, its evolution, and analysis of postoperative fistulas. Plast Reconstr Surg. 2018;141(5):1201-1214.
8.
SalimiNAleksejūnienėJYenEHKLooAYC. Fistula in cleft lip and palate patients-a systematic scoping review. Ann Plast Surg. 2017;78(1):91-102.
9.
ChouikhFDierksEJ. The buccal fat pad flap. Oral Maxillofac Surg Clin N Am. 2021;33(2):177-184.
10.
GröbeAEichhornWHankenH, et al.The use of buccal fat pad (BFP) as a pedicled graft in cleft palate surgery. Int J Oral Maxillofac Surg. 2011;40(7):685-689.
BichatX. Anatomie générale, appliquée à la physiologie et à la médecine. Vol. 2. JS Chaudé; 1830.
13.
HudsonJWAndersonJGRussellRMAndersonNChambersK. Use of pedicled fat pad graft as an adjunct in the reconstruction of palatal cleft defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;80(1):24-27.
14.
ZhaoZLiSLiY. The application of the pedicled buccal fat pad graft in cleft palate repair. Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi Zhonghua Zheng Xing Shao Shang Waikf Ie Waike Zazhi Chin J Plast Surg Burns. 1998;14(3):182-185.
15.
KotlarekKJJaskolkaMSFangX, et al.A preliminary study of anatomical changes following the use of a pedicled buccal fat pad flap during primary palatoplasty. Cleft Palate Craniofac J. 2022;59(5):614-621.
SlimKNiniEForestierDKwiatkowskiFPanisYChipponiJ. Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716.
18.
HiggingsJThomasJChandlerJ, et al.Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane; 2022. https://www.training.cochrane.org/handbook.
19.
AshtianiAKBohluliBKalantar MotamediMHFatemiMJMoharamnejadN. Effectiveness of buccal fat in closing residual midpalatal and posterior palatal fistulas in patients previously treated for clefts. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 2011;69(11):e416-e419.
20.
AshtianiAKFatemiMJPooliAHHabibiM. Closure of palatal fistula with buccal fat pad flap. Int J Oral Maxillofac Surg. 2011;40(3):250-254.
21.
LoCCDenadaiRLinHH, et al.Favorable transverse palatal development after palatoplasty using buccal fat pad for covering the lateral relaxing surfaces: a comparative study at 9 years of age. Cleft Palate-Craniofac J. 2021;58(4):17.
22.
PageMJMoherDBossuytPM, et al.PRISMA 2020 Explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. Br Med J.2021;372:n160.
23.
YamaguchiKLonicDLeeCHYunCLoLJ. Modified Furlow palatoplasty using small double-opposing Z-plasty: surgical technique and outcome. Plast Reconstr Surg. 2016;137(6):1825-1831.
24.
RuslinMHajrah-YusufASTajrinALoLJForouzanfarT. Utilization of pedicled buccal fat pads for coverage of the lateral relaxing wound: a review of literature and a case series of 15 patients. J Clin Exp Dent. 2018;10(5):e502.
25.
RaufALatifTSultanNDarSH. Filling the gaps in cleft palate surgery. Pak J Med Health Sci. 2012;6(3):783-785.
26.
KhanIChoNAhmedMAhmedOBegMSA. The application of buccal fat pad to cover lateral palatal defect causes early mucolization. Cureus. 2021;13(8):e17532. DOI: https://doi.org/10.7759/cureus.17532
27.
ZhangQLiLTanWChenLGaoNBaoC. Application of unilateral pedicled buccal fat pad for nasal membrane closure in the bilateral complete cleft palate. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 2010;68(8):2029-2032.
28.
LadaniPSailerH. Application of buccal fat pad for lining of lateral defect in cleft palate repair and review of literature. J Cleft Lip Palate Craniofacial Anomalies.2016;3(2):63-66.
29.
AdeyemoWIbikunleAJamesO, et al.Buccal fat pad: a useful adjunct flap in cleft palate repair. J Maxillofac ORAL Surg. 2019;18(1):40-45.
30.
KimJYKimSGParkYWHwangDSPaengJYSeokH. The effect of buccal fat pad graft in the palatoplasty and the risk factor of postoperative palatal fistula. J Craniofac Surg. 2020;31(3):658-661.
31.
KotlarekKJPerryJLJaskolkaMS. What is the fate of the pedicled buccal fat pad flap when used during primary palatoplasty?J Craniofac Surg. 2022;33(2):e173-e175.
32.
DenadaiRLoLJ. Buccal fat pad interposition in modified small double-opposing Z-plasty palatoplasty using medial incision approach: a technical note. J Plast Reconstr Aesthetic Surg JPRAS. 2022;75(10):3877-3903.
33.
DenadaiRLoLDenadaiRLoLJ. Split buccal fat flap in modified Furlow palatoplasty: Surgical technique and early result. Plast Reconstr Surg. 2022;149(1):197-201.
34.
DenadaiRChouPYLoLJ. 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(4):503-508.
35.
SaralayaSDesaiAKGhoshR. Buccal fat pad in cleft palate repair- an institutional experience of 27 cases. Int J Pediatr Otorhinolaryngol. 2020;137:110218. doi: https://doi.org/10.1016/j.ijporl.2020.110218.
36.
ParkHChoiJMOhTS. Double-opposing Z-plasty extended with a pedicled buccal fat pad flap for correcting velopharyngeal insufficiency after primary palatoplasty. Cleft Palate-Craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc. 2022;59(12):1445-1451.
37.
ThanapaisalCPunyavongPJenwitheesukKSurakunpraphaPWinaikosolK. Buccal fat pad: adjunctive procedure for lateral defect coverage following primary palatoplasty. Plast Reconstr Surg. 2022;149(5):1180-1185.
38.
ZhangMZhangXZhengCZhangMZhangXZhengC. Application of buccal fat pads in pack palate relaxing incisions on maxillary growth: a clinical study. Int J Clin Exp Med. 2015;8(2):2689-2692.
39.
BennettKGThurstonTEVerclerCJKastenSJBuchmanSR. Harvesting the buccal fat pad does not result in aesthetic deformity in cleft patients: a retrospective analysis. Plast Reconstr Surg. 2017;140(2):362-368.
40.
HardwickeJTLandiniGRichardBM. Fistula incidence after primary cleft palate repair: a systematic review of the literature. Plast Reconstr Surg. 2014;134(4):618e-627e.
41.
SteinMJZhangZFellMMercerNMalicC. Determining postoperative outcomes after cleft palate repair: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2019;72(1):85-91.
42.
WuRCheraghlouSParsaeiYTraviesoRSteinbacherDM. Does cleft palate width correlate with Veau classification and outcome?J Craniofac Surg. 2017;28(5):1369-1374.
43.
Rossell-PerryPCaceres NanoEGavino-GutierrezAM. Association between palatal index and cleft palate repair outcomes in patients with complete unilateral cleft lip and palate. JAMA Facial Plast Surg. 2014;16(3):206-210.
44.
YiCRKangMKOhTS. Analysis of the intrinsic predictors of oronasal fistula in primary cleft palate repair using intravelar veloplasty. Cleft Palate Craniofac J. 2020;57(8):1024-1031.
45.
SeswandhanaRMakrufardiFSudjatmikoG. Fistula incidence after primary repair and correlation with cleft width-to-palatum width ratio: a prospective cohort study. Ann Med Surg. 2021;63:102183.
46.
EchlinKWhitehouseHSchwaigerMNicholasRFallicoNAthertonDD. A cadaveric study of the buccal fat pad: implications for closure of palatal fistulae and donor-site morbidity. Plast Reconstr Surg. 2020;146(6):1331-1339.
47.
Abdel-AzizMEl-HoshyHNaguibNRedaR. Furlow technique for treatment of soft palate fistula. Int J Pediatr Otorhinolaryngol. 2012;76(1):52-56.
48.
Guerrero-SantosJFernandezJM. Further experience with tongue flap in cleft palate repair. Cleft Palate J. 1973;10(2):192-202.
49.
PosnickJCGetzSB. Surgical closure of end-stage palatal fistulas using anteriorly-based dorsal tongue flaps. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 1987;45(11):907-912.
50.
ArgamasoRV. The tongue flap: Placement and fixation for closure of postpalatoplasty fistulae. Cleft Palate J. 1990;27(4):402-410.
GiuglianoCRoldánNClaurePSuarezV. Tongue flap for management of large palatal fistulas. J Craniofac Surg. 2022;33(7):2091-2094.
53.
NakakitaNMaedaKAndoSOjimiHUtsugiR. Use of a buccal musculomucosal flap to close palatal fistulae after cleft palate repair. Br J Plast Surg. 1990;43(4):452-456.
54.
RobertsonAGNMcKeownDJBello-RojasG, et al.Use of buccal myomucosal flap in secondary cleft palate repair. Plast Reconstr Surg. 2008;122(3):910-917.
55.
Abdel-AzizM. The use of buccal flap in the closure of posterior post-palatoplasty fistula. Int J Pediatr Otorhinolaryngol. 2008;72(11):1657-1661.
56.
SohailMBashirMMKhanFAAshrafN. Comparison of clinical outcome of facial artery myomucosal flap and tongue flap for closure of large anterior palatal fistulas. J Craniofac Surg. 2016;27(6):1465-1468.
57.
AshtianiAKEmamiSARastiM. Closure of complicated palatal fistula with facial artery musculomucosal flap. Plast Reconstr Surg. 2005;116(2):381-386. discussion 387-388.
58.
LahiriARichardB. Superiorly based facial artery musculomucosal flap for large anterior palatal fistulae in clefts. Cleft Palate Craniofac J. 2007;44(5):523-527.
59.
ShettyRLambaSGuptaAK. Role of facial artery musculomucosal flap in large and recurrent palatal fistulae. Cleft Palate Craniofac J. 2013;50(6):730-733.
60.
EgyediP. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J Maxillofac Surg. 1977;5(4):241-244.
61.
TidemanHBosanquetAScottJ. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 1986;44(6):435-440.
62.
BicharaLMAraújoRCFlores-MirCNormandoD. Impact of primary palatoplasty on the maxillomandibular sagittal relationship in patients with unilateral cleft lip and palate: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2015;44(1):50-56.
63.
KappenIFYoderWRvan der MolenABMBreugemCC. Long-term craniofacial morphology in young adults treated for a non-syndromal UCLP: a systematic review. J Plast Reconstr Aesthet Surg. 2018;71(4):504-517.
64.
ParkYHParkSBaekSH. Alignment strategy for constricted maxillary dental arch in patients with unilateral cleft lip and palate using fixed orthodontic appliance. J Craniofac Surg. 2018;29(2):264-269.
65.
KüselerAMølstedKMarcussonA, et al.Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: maxillary growth at eight years of age. Eur J Orthod. 2020;42(1):24-29.
66.
SommerladBC. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112(6):1542-1548.
67.
MinatelLde Luna GomesJMLemosCAAde Oliveira LimírioJPJPellizzerEP. Influence of vomer flap on craniofacial growth in patients with cleft lip and palate: a systematic review. J Cranio-Maxillofac Surg. 2019;47(6):902-908.
68.
PanBSRappSJVuAUribe-RiveraABillmireDAGordonCB. Evolution in minimal-incision palatoplasty: surgical technique and outcomes in 67 consecutive cases. Plast Reconstr Surg. 2014;134(1):102-111.
69.
SalgadoKRWendtARFernandes FagundesNCMaiaLCNormandoDLeãoPB. Early or delayed palatoplasty in complete unilateral cleft lip and palate patients? A systematic review of the effects on maxillary growth. J Cranio-Maxillo-fac Surg Off Publ Eur Assoc Cranio-Maxillo-fac Surg. 2019;47(11):1690-1698.
70.
ChimHEshraghiYIamphongsaiSGosainAK. Double-opposing Z-palatoplasty for secondary surgical management of velopharyngeal incompetence in the absence of a primary Furlow palatoplasty. Cleft Palate Craniofac J. 2015;52(5):517-524.
71.
BonanthayaKJalilJSasikumarAVShettyPN. Furlow palatoplasty for velopharyngeal dysfunction management: auditing and predicting outcomes. Cleft Palate Craniofac J. 2022;59(9):1097-1106.
72.
PetMAMarty-GramesLBlount-StahlMSaltzmanBSMolterDWWooAS. The Furlow palatoplasty for velopharyngeal dysfunction: velopharyngeal changes, speech improvements, and where they intersect. Cleft Palate Craniofac J. 2015;52(1):12-22.
73.
KimiaRSolotCBMcCormackSM, et al.Speech outcomes following operative management of velopharyngeal dysfunction (VPD) in non-syndromic post-palatoplasty cleft palate patients. Cleft Palate Craniofac J. 2023;0(0):10556656231154808. doi:https://doi.org/10.1177/10556656231154808
74.
RohrichRJStuzinJMSavetskyILAvashiaYJAgrawalNAPradaM. The role of the buccal fat pad in facial aesthetic surgery. Plast Reconstr Surg. 2021;148(2):334-338.
75.
Traboulsi-GaretBCamps-FontOTraboulsi-GaretMGay-EscodaC. Buccal fat pad excision for cheek refinement: a systematic review. Med Oral Patol Oral Cir Bucal. 2021;26(4):e474.
76.
ZhangHMYanYPQiKMWangJQLiuZF. Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg. 2002;109(7):2509-2518. discussion 2519-2520.
77.
XiaoHBayramicliMJacksonIT. Volumetric analysis of the buccal fat pad. Eur J Plast Surg. 1999;22(4):177-180.
78.
HuntOBurdenDHepperPJohnstonC. The psychosocial effects of cleft lip and palate: a systematic review. Eur J Orthod. 2005;27(3):274-285.
79.
PonduriSBradleyREllisPEBrookesSTSandyJRNessAR. The management of otitis media with early routine insertion of grommets in children with cleft palate – a systematic review. Cleft Palate Craniofac J. 2009;46(1):30-38.
80.
HorswellBruce BChouJoli. Does the Children's Hospital of Philadelphia Modification Improve the Fistula Rate in Furlow Double-Opposing Z-Plasty?. Journal of Oral and Maxillofacial Surgery. 2020;78(11):2043–2053. https://doi.org/10.1016/j.joms.2019.08.018
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
