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

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The Cleft Palate Craniofacial Journal 0(0)

theory of improved maxillary growth with autologous BFP placement. Zhang et al 38 did fi nd better transverse and sagittal maxillary dimensions in cephalometry and in upper dental arch models; however, their study has a high risk of bias regarding some concerns about the randomization process, deviations from intended interventions, and measurement of the outcomes, and the sample size was small (15 patients in each arm). Other important consideration is that, in this study, primary palatoplasty was performed between 3-4 years of age. Data about the impact of age at time of palato plasty in maxillofacial growth is con fl icting. 69 We believe this preclude a pooled analysis with other studies where pal atoplasty was performed at a younger age. Overall, studies with follow up until facial skeletal maturity and less risk of bias are required to con fi rm these encouraging fi ndings. More important than possible maxillary growth restriction is understanding if BFP use in management of cleft palate may reduce the burden of care such as a decrease in number of dental visits or a reduction or elimination of the period of maxillary palatal expansion. Palatal Length and Speech It has been proposed that BFP may help create a longer velum. 10,15,27 Kotlarek et al 15 conducted a study to determine the surgical impact of the pedicled BFP fl ap on the levator veli palatini muscle and surrounding velopharyngeal anatomy. Through magnetic resonance imaging 2 to 5 years post-palatoplasty, the authors found that the BFP group had a longer median velar length than both the non-BFP group and non-cleft controls. The main limitation of this study is the small sample size, with only fi ve patients in each group. Some studies discussed speech outcomes. However, there was signi fi cant heterogeneity in speech assessment methodology as well as in palatoplasty technique among studies. For these reasons, we cannot include a robust anal ysis of speech outcomes related to BFP use in palatoplasty. Of note, Park et al 36 found less hypernasality in the BFP group, likely associated with an increased length of the soft palate. In this study, BFP was employed to cover a mucosal defect left by the transposition of the myomucosal posterior-based oral fl ap in secondary Furlow palatoplasty performed for VPD. Saralaya et al 35 also used BFP as an adjuvant in secondary Furlow palatoplasty for VPD correc tion. BFP was used in a similar fashion as that reported by Park. They do not report preoperative speech assessments; however, the BFP subgroup showed persistent hypernasality post-operatively (5 of 7 patients had moderate-severe hyper nasality postoperatively). Secondary Furlow palatoplasties without the addition of BFP have been performed for VPD correction with improvement in standard speech outcome measures. 70-73 Determination of the BFP ’ s impact on speech outcomes during secondary palotoplasty will require more rigorous and standardized investigation as many surgical and non-surgical factors can in fl uence speech and speech development.

BFP may have utility in oronasal fi stula repairs. Grobe et al 10 reported on twelve cases with palatal fi stulas, particu larly in the hard-soft palate junction. The authors placed BFP as an intermediate layer between oral and nasal mucosa, occluding the dead space. They reported complete healing in all cases. Saralaya et al 35 also reported a case series with 18 patients. In their study, BFP was place in a similar fashion to that described by Grobe, while also replacing oral mucosal layer after nasal closure with turnover fl aps. They also reported complete healing in all cases. Asthiani et al 19 reported on 29 patients in whom BFP was used as a pedicled fl ap over the palate rather than tunneled underneath oral mucoperiosteum as described by other authors. Re-epithelializaton was observed in all patients, and only three required surgical division of the pedicle after four weeks. One patient experienced a residual fi stula. Fistula repair is a challenging procedure due to previous scarring and paucity of tissue. 46,47 Many local fl aps have been utilized for the closure of palatal fi stulae, including tongue fl aps, 48-52 buccinator fl aps, 53-55 and facial artery based-myomucosal fl aps. 56-59 BFP has been previously used for closure of other oro-maxillary defects. 60,61 For fi stula repair, BFP has been recommended for closure of fi stulae localized to the posterior two-thirds of the palate and in defects up to 20 mm in diameter. 19 The experience presented in these studies is valuable, with high rates of success. Although they have small sample sizes, BFP appears to be a successful technique for fi stula repair. Maxillary Growth Maxillary growth disturbance is a common sequela of cleft lip and palate repair. 3,62,63 Sagittal dimensions of the upper jaw are the most affected, with orthognathic surgery in up to 38.1% of patients with bilateral clefts and 30.2% of those with unilateral clefts. 1 Transverse dimensions are also affected, which may lead to posterior crossbite, dental crowding, and occlusal interference. 21,64 Many factors have been implicated, including intrinsic growth de fi ciencies but also iatrogenic restriction due to surgical repair performed at an early age. 62 Scarring after palate repair is believed to be one of the most important extrinsic factors. Several strategies to decrease this negative impact has been described, including delayed hard palatal closure, 65 use of vomer fl aps with lip repair, 66,67 two staged palatoplasty, 3 elimination of one or both lateral relaxing incisions in narrower clefts, 68 among others. BFP application in primary cleft palate repairs has been advocated to diminish the area of exposed bone in the lateral relaxing incisions and possible subsequent scarring. 4,23-26,34,38 Lo et al 21 found that patients with BFP placed in lateral relaxing incisions had wider transverse maxillary dimensions. The authors hypothe sized that adding vascularized fat over lateral denuded surfaces minimized scar formation and associated growth restriction from soft tissue contracture. However, sagittal maxillary dimensions were similar between patients who underwent BFP placement vs Surgicel placement, confounding this