Abstract
The buccal fat pad (BFP) as pedicled graft was originally used in reconstructing medium sized intraoral defects. Promising results concerning the use of BFP in cleft palate surgery have been published recently. The aim of this article is to report on the use of BFP as a pedicled graft in cleft palate surgery and to discuss promising results for this reconstructive surgical concept. A retrospective evaluation of 24 patients who had BFP pedicled flaps used for the prevention and repair of Type III (Pittsburgh Fistula Classification) cleft palate fistulas, to obstruct the retromolar space of Ernst and in case of wide clefts, from 2005 to 2010, was conducted. In all cleft palate patients, the recipient area fully epithelialized within 4 weeks or less. No recurrence was seen and the donor site healed well without aesthetic or significant functional impairment. This series confirms the excellent and predictable healing of BFP intraorally and the minimal morbidity associated with the use of such grafts. The results of this study allow the authors to recommend that the BFP pedicled flap is considered as a reliable alternative procedure to expand the therapeutic options. The BFP graft provides an advantage in reconstructive cleft palate surgery.
The buccal fat pad (BFP) is a mass of specialized fatty tissue distinct from subcutaneous fat in the masticatory space. It consists of a main part and four extensions separating the masticatory muscles from each other and from boney structures such as the zygomatic arch and the ramus of the mandible. Despite being mentioned by Heister in 1732 and Winslow in 1753 and being described by B ichat in 1802 , for a long time there was no detailed anatomical description of the BFP in the literature. S cammon first mentioned its anatomy briefly, followed by G aughran and more detailed accounts followed by T ideman et al. , S tuzin et al. and D ubin et al. . They found the central body of the BFP situated close to and above the parotid duct on the anterior border of the masseter muscle extending deeply to the posterior maxilla between the buccinator muscle medially and the mandibular ramus laterally. The buccal extension, as the most superficial part of the BFP, descends to the mandibular retromolar region. The pterygoid part extends in a more downward and backward direction to the lateral parts of the pterygoid plates. The superficial and the deep temporal extensions pass upwards separating the temporal muscle from the zygomatic arch. The whole body is covered by a fascial envelope preventing spontaneous herniation during surgery.
The blood supply of the BFP comes mainly from three sources: the buccal and deep temporal branches of the maxillary artery, the transverse facial branch of the superficial temporal artery and small branches from the facial artery. Its function in the adult is enhancing intermuscular movement and it may function as a cushion to protect the deep facial neurovascular bundles from injury caused by the extrusion of muscle contraction. In the infant, the BFP prevents the collapse of the cheek during suckling.
Encouraging results concerning the use of BFP in various cases can be found in the literature , but little is known about the use of BFP grafts in cleft palate surgery. Clefting of the lip, alveolus and palate (the most common congenital malformations of the head and neck) are the second most common congenital malformation of the entire body (just before clubfoot in incidence). Palatal fistulas and transverse growth restriction remain arguably the most significant problems for cleft lip and palate surgeons, second only to the patient’s resultant quality of speech after surgery.
Despite isolated accounts, no widely accepted and regularly utilized standardized classification system for palatal fistulas has evolved. Nonetheless, a clear nomenclature is required to discuss the results meaningfully. Recently, the Pittsburgh Fistula Classification system has been developed, this is a logical and anatomically based classification system to standardize fistula-related terminology, which includes seven fistula types . Reports on the most frequent site of fistula formation vary, but the consensus appears to be that these lesions occur most commonly at the junction of the hard and the soft palate (Pittsburgh Type III) .
The aim of this article is to report on the use of BFP as a pedicled graft in cleft palate surgery and to discuss promising results concerning this reconstructive surgical concept.
Patients and methods
A retrospective evaluation of 24 patients who had BFP pedicled flaps used for the prevention and for the repair of Type III cleft palate fistulas, further to obstruct the retromolar space of Ernst and in case of wide clefts, from 2005 to 2010 was conducted. All of the patients were treated by one of the authors. The group comprised 8 male and 16 female children aged between 6 months and 17 years with a mean age of 4.7 years. The operation was performed under general anaesthesia after obtaining informed consent.
All patients received the pedicled BFP as an additional reconstructive concept, after determining whether an ordinary or conventional surgical cleft palate repair would not have been sufficient due to insufficient amount of tissue that could cause an extraordinary scarring tension. The main objective of employing BFP was to relieve scarring tension. The concept aims to prevent or treat type III palatal fistulas by transferring fatty tissue in a locus minoris resistentiae , which is an area with a lack of tissue causing tension at the closure site, between the nasal and palatal layer at the junction of the soft and the hard palate ( Fig. 1 ). Inclusion criteria for the use of the BFP were expected tension between the tissue layers even after complete release; palatal fistula formations after primary reconstruction in the most common area between the hard and the soft palate (Pittsburgh Class III fistulas) and a defect size about 2 cm × 2 cm × 1 cm in children. The BFP was used for soft tissue support, to prevent the soft palate shortening after surgery. The authors excluded cases in which ordinary palatoplasty with an expected sufficient amount of tissues was possible and supplementary tissue formation was not necessary.
To harvest the BFP, an incision was made in the superior buccal sulcus just lateral to the maxillary tuberositas. The BFP herniated spontaneously and was mobilized by blunt dissection with forceps, transferred into the defect and sutured to the margins ( Figs. 2 and 3 ). Postoperative follow-up 2, 4, 6 and 12 weeks after surgery included clinical evaluation and examination of patients. There were 12 cases of cleft palate fistulas particularly between the hard and soft palate after primary reconstruction. This study also included 7 patients in whom BFP was used without skin graft coverage to obstruct the space of Ernest for minimizing scarring tension and an additional 5 patients suffering from wide clefts of the hard and soft palate. The authors conducted no split grafts with additional BFP skin coverage from a different harvesting site to avoid a further surgical donor problem with associated morbidity. This would not be reasonable, particularly in the case of children. All patients received prophylactic antibiotics and a soft diet for 1 week after surgery.
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