xRead - Treatment of Cleft Lip and Cleft Palate (May 2025)

Volume 153, Number 2 • Cleft Palate Surgery

Adjunct Procedures Buccal Fat Flap

The buccal fat pad flap became popularized as an adjunctive procedure to cleft palate repairs in the late 1990s to minimize transverse maxillary growth restriction caused by scar contraction and healing by secondary intention from raw bony surfaces at the time of primary cleft palate repair. Lateral relaxing incisions are unavoidable to aid in tensionless closure of wide clefts. The vascular ized buccal fat pad flap is a pedicled flap based on an encapsulated aggregate of fatty tissue con sisting of a central body and four projections. Its application in head and neck reconstruction is well documented, and the flap has shown capacity to epithelialize intraorally. 62 Pedicled fat pad flaps can be dissected and used to cover denuded hard palate. Other authors have applied the buccal fat pad flap in between the nasal and oral mucosa at the hard and soft palate junction to prevent fistula formation and to facilitate use of the Furlow pala toplasty for repair of wider clefts (Fig. 9). 55,63 [ See Video 6 (online) , which displays buccal fat flaps.] A recent study by Kotlarek et al. examined the role of buccal fat pad flaps on velum length and levator veli palatini position. The authors found that when buccal fat flaps were used in between mucosal layers at the posterior edge of the hard palate, the velum was lengthened and the levator muscle remained posteriorly positioned. 64 Long term comparative outcome analysis of transverse maxillary development in patients undergoing coverage of lateral denuded surfaces with buccal fat pad flaps compared with Surgicel showed a sig nificantly wider total transverse maxillary dimen sions on computed tomography at the time of alveolar bone grafting for the buccal fat pad flap cohort. 65 Opponents of this adjunctive procedure argue the lack of long-term studies evaluating the donor-site morbidity on midface aesthetics, especially with a fuller, contoured cheek being viewed as a marker of youth. A recent study com pared three-dimensional volumetric cheek size in patients undergoing unilateral buccal fat pad har vest to the nonharvested cheek and found no sig nificant volumetric changes or clinical differences with mean follow-up of 55 months. 66 Vomer Flap The vomer flap is another useful adjunct pro cedure for hard palate repair (Fig. 10). Superiorly based mucoperiosteal flaps are raised off the vomerine bone and turned over to line the nasal layer of the hard palate. Its theoretical advan tage derives from minimizing denuded bone and

scarring left behind during palatoplasty compared with other repairs such as the von Langenbeck and Bardach palatoplasty. This technique is most often used for Veau type II to IV clefts. Recent lit erature has supported no adverse effect on maxil lary growth when comparing vomer flaps to other Fig. 9. Buccal fat flap. ( Above ) Harvest of right buccal fat flap, shown emerging from deep to the buccinator muscle and pulled toward the midline of the repair by the forceps. ( Center ) Early postoperative appearance of buccal fat flaps used for bilateral cleft palate at 2 weeks with nearly complete mucosalization. Arrow points to base of left buccal fat flap. ( Below ) Late postop erative appearance of buccal fat flaps used for bilateral cleft pal ate, demonstrating complete mucosalization at 8 weeks.

457e

Copyright © 2024 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.