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.