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

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Romero-Narvaez et al

study showed wider transverse dimensions in total maxillary width for patients with BFP use. There were no signi fi cant dif ferences in sagittal development of the maxilla between the groups. Zhang et al 38 conducted a randomized trial comparing BFP (n = 15) vs. iodoform gauze (n = 15) in relaxing incisions during primary palatoplasty at ages between 3-4 years old. At the 5-year follow-up visit, the BFP group demonstrated better cephalometry measurements, including SNA, SNB and ANB, as well as greater transverse width and sagittal length based on upper arch dental models. Speech Several case series reported speech-related outcomes. 5,23,33-35 However, these studies utilized heterogeneous speech assess ment methods and palatoplasty techniques. Notably, Park et al 36 evaluated hypernasality in patients with VPD undergo ing secondary Furlow where BFP fi lled an oral defect created by incomplete advancement of the anteriorly-based oral mucosal fl ap. The BFP group developed less severe hyperna sality and lower hypernasality scores. Donor Site Morbidity Mild donor-site pain was reported in 16 of 29 (55.2%) patients in one of the studies. 19 Patients may also experience cheek swelling for 2-5 days postoperatively. 19,29,35 There were no reports of donor-site hematoma 33,34 or facial nerve or parotid duct injuries. 24,27 Long-term facial symmetry has also been studied following unilateral BFP harvest. 19,27 Bennet et al 39 investigated facial dimensions measured by 3-dimensional photography in patients who underwent unilateral BFP for primary or second ary palatoplasty after a mean follow-up of 55 [45.9, 64.1] months. They found no signi fi cant facial differences between the donor-side and the non-donor side even when controlling for cleft-related facial asymmetries. On blind subjective evalu ation of clinical photographs by subject matter experts, there was a near equal percentage of correct-incorrect identi fi cation of cheek donor side with poor inter-evaluator agreement. Discussion This systematic review addresses the current role of the buccal fat pad in primary and secondary cleft palate surgery, as well as immediate and long-term clinical outcomes. Twenty- fi ve articles were reviewed from an initial search of 152 records. Unfortunately, the level of evidence was generally low. Comparative studies had evidence grades between 3b-4 according to the Oxford Centre for Evidence-Based Medicine, and a RCT with a grade of 2b but with a high risk of bias according to Cochrane RoB2. Non-randomized studies, including case series and comparative studies, also have a high risk of bias according to MINORS assessment tool.

Table 3. Cochrane Risk of Bias Tool v.2.0 for RCT.

Zhang, 2015

Randomization process

Some concerns Some concerns

Deviations from intended interventions

Missing outcome data

Low High Low High

Measurement of the outcome Selection of the reported result

Overall bias

with a prospective cohort comparison study with 21 patients in each group. They found that patients undergoing BFP place ment in lateral relaxing incisions mucosalized faster than com parable patients with Surgicel placed (100% vs. 14.3% for complete healing on POD21, P <.001). Fistula Fistula formation was the outcome most frequently reported. For primary repair, we found 10 case series and 3 comparative studies that evaluate this outcome. The incidence of postoper ative fi stula was 0%, 2,10,24,27,28,32-34 0.4% 23 and 7.55% 5 in the case series, with samples between 5 and 231 patients. Comparative studies found a higher incidence in patients who do not undergo BFP, 25,30,37 ranging from 0%-10% in BFP groups vs. 13.8%-21.28% in non-BFP groups. In summary, approximately 19 (2.8%) patients undergoing primary palatoplasty with BFP use developed a fi stula. Of note, there was variable follow-up duration, and the de fi nition of fi stula was not strictly adhered to across studies. Patients who do not undergo BFP experienced a larger median fi stula size 37 and higher rates of secondary fi stula closure. 25,37 Three cases series were included for secondary palate repair, as well as a comparative study. No recurrent fi stulas are reported for patients undergoing BFP for oronasal fi stula repair though follow-up duration is either not speci fi ed or between 2 to 3 years. 10,19,35,36 Palatal Length Some studies describe increased palatal length in long-term follow-up following palatoplasty where BFP was an added layer at the hard-soft palate junction. One case series 5 noted 92.3% of patients had a subjective adequate or “ long ” palate post-palatoplasty. Kotlarek et al 31 found a longer velar length, increased distance between posterior hard palate and levator veli palatini muscle, and a larger effective velopharyng eal ratio in patients who underwent primary palatoplasty with BFP. Maxillary Dimensions Lo et al 4 compared BFP (n = 22) vs. Surgicel (n = 32) in relax ing incisions during primary palatoplasty at 9-10 months of age with cone beam CT scans taken at 9-year follow-up visits. This