Systematic review of autologous midface reconstruction methods: palatal and limited midfacial defects.

While use of buccal fat pad flaps (BFPF) in primary palatoplasty has been shown to improve speech and reduce velopharyngeal insufficiency risk, the risk for obstructive sleep apnea (OSA) remains unknown. We hypothesize that using BFPFs in primary palatoplasty does not confer additional risk for OSA due to its favorable influence on palatal development and velopharyngeal mechanics. A retrospective review identified patients who underwent cleft palatoplasty with or without BFPFs from 1995-2016. The primary outcome measure was the rate of OSA diagnosed by pulmonary sleep medicine with prescription for continuous positive airway pressure (CPAP) therapy. Secondary outcomes included need for adenotonsillectomy (T/A), resolution of obstructive sleep symptoms with T/A, and development of OSA after speech surgery. During primary palatoplasty, 100 patients received BFPF(s), while 110 patients did not. Incidence of OSA with BFPFs was 9.0% (n=9) compared to 8.2% (n=9) without BFPFs (p=0.832), with an adjusted risk difference of 1.3% (±6.6%). Neither the quantity nor location of BFPFs was associated with increased risk for OSA. There was no significant difference in the rate of T/A or the rate of symptom resolution following T/A. One patient with BFPFs and four patients without BFPFs developed OSA after speech surgery. Two patients without BFPFs developed OSA after revision for palatal fistula. This study demonstrates no statistically meaningful increase in risk for development of OSA when BFPFs are incorporated into primary cleft repair. Given the favorable impact BFPFs have on speech we continue to recommend their use in primary palatoplasty.

Oroantral communications (OACs) are frequently iatrogenic, most commonly occurring after the extraction of maxillary posterior teeth in close proximity to the maxillary sinus. They may also result from tumor surgery, implant placement, trauma, or orthognathic surgery involving the maxilla. An untreated OAC creates a pathological communication between the oral cavity and the maxillary sinus, often leading to maxillary sinusitis and a significant deterioration in the patient’s quality of life. Numerous surgical techniques have been described for the management of OACs, ranging from mucosal flap procedures to the use of bone substitutes or highly conservative alternative methods. However, recurrence after treatment has been reported, and selecting the most appropriate technique according to the clinical situation remains challenging. This study aims to highlight the usefulness of a pedicled buccal fat pad flap in the reconstruction of oroantral communications.

Objective: The aim of this study was to investigate and compare the treatment methods of large size oroantral defects (OADs) and their clinical outcomes. Methods: Patients referred our clinic between 2017 and 2023 suffering from oroantral fistula (OAF) and cases of oroantral communication (OAC) larger than 5 mm during oral procedures were included in the study. The size, type, and cause of OAD; treatment method; and the patient’s demographic data were recorded. Visual analogue scale (VAS), analgesic requirement, edema, and mouth opening measurements were obtained from preoperative and postoperative records at 3, 7, and 10 days after surgery. Results: 23 patients (eight OAF and 15 OAC) was included in this study. Nine patients were treated with buccal advancement flap (BAF), ten with buccal fat pad (BFP) flap, and four with the press-fit technique. There were no problems with the healing process. One patient had a failed BFP and after 2 months, a second surgery was performed to fully cover the area. According to postoperative clinical outcomes, there was no significant difference between groups in the terms of VAS, analgesic requirement, edema, or trismus at any timepoint (P>.05). Although there was no significant difference observed between treatment groups, VAS scale and analgesic requirement was less with the press-fit methoid than BAF and BFP flap. Conclusion: BAF, BFP flaps, and press-fit methods are reliable and well-known techniques for OAD management, however, further clinical studies with larger sample sizes are needed to create a treatment algorithm for OAD.

Deep plane face lift in patients with previous permanent filler injections is a formidable reconstructive and aesthetic procedure. Various reconstructive techniques have been previously described in the literature to address the defects after removal of permanent fillers. However, no comparative study in the literature has been conducted to demonstrate the effectiveness and complications of these reconstructive procedures in the pursuit of achieving aesthetically favorable results with safe techniques. The study aimed to describe the effectiveness and complications of 3 reconstructive techniques: micro-fat grafting, dermal fat grafting, and pedicled flap reconstruction. A multiarm, randomized, parallel study was conducted among patients who had undergone permanent filler injections between 2014 and 2022. Patients were divided randomly into 3 groups, each comprising 160 individuals; all patients were managed by removal of the permanent fillers, deep plane face lift, and reconstruction of the defects as a consequence of the filler removal. Participants were randomly assigned to 3 groups. This allocation was based on the defect reconstruction method, including dermofat grafting (group A), fat grafting (group B), and a pedicled buccal fat pad flap (group C). The minimum follow-up was 6 months. The most prevalent complications detected were contour irregularity. Fat graft surgery was associated with the highest rates of complications. The pedicled flap technique had the fewest postoperative complications and was superior to fat and dermal fat graft techniques. The results could guide surgeons in optimizing patient selection and surgical techniques to improve patient outcomes.

Reconstruction of bimaxillary stage 3 medication-related osteonecrosis of the jaw (MRONJ) defects remains a significant challenge due to extensive lesions and patients' complex comorbidities. This study reports a case of a female patient with metastatic breast cancer who had received long-term denosumab therapy. A partial maxillectomy was performed, and the defect was closed using the double-layer soft tissue closure technique based on the buccal fat pad (BFP). A segmental mandibulectomy was performed through an extraoral approach, and the defect was reconstructed using the reconstruction plate combined with submandibular gland flap (SMGF). The total operative time was 154 minutes, and the postoperative hospital stay was 8 days. At the 6-month follow-up, the scar extending from the midline of the lower lip to the right submandibular region healed well. The intraoral mucosa of both jaws was intact without dehiscence or fistula. Radiographic examination showed resolution of maxillary sinusitis, no osteolytic changes at the resection margins, stable fixation of the reconstruction plate, and bony bridge formation. No recurrence of MRONJ or progression of the primary malignancy was observed. These findings suggest that the combined use of the BFP flap and SMGF can effectively reconstruct bimaxillary stage 3 MRONJ defects with favorable outcomes.

ObjectiveTo investigate whether the use of buccal fat pad flap during cleft palate repair reduces the risk of post-operative palatal fistula formation.DesignRetrospective analysis of cleft palate repairs undertaken by a single surgeon over the period 2013-2025.SettingTertiary care institution in London.PatientsTwo hundred and seventy-seven patients (146 female, 131 male) who underwent cleft palate repair between 2013 and 2025 were included in the study. One hundred and seventy-three patients had an isolated cleft palate, 78 patients had a unilateral cleft lip and palate, and 26 patients had a bilateral cleft lip and palate. The range of cleft width treated was 3-22 mm. The standard surgical technique employed a Sommerlad style intravelar veloplasty with von Langenbeck releases where necessary.InterventionsThe utilization of pedicled buccal fat pad flap in primary cleft palate repairs.Main Outcome Measure(s)Development of post-operative palatal fistula.ResultsAmong 277 patients, 21 (7.6%) patients developed a post-operative fistula, most commonly in Zone IV (52%). The fistula rate was 3.7% with buccal fat pad flap use compared with 8.5% without (P = 0.39). Bayesian logistic regression showed a two-thirds reduction in the odds of fistula formation (odds ratio [OR] = 0.33; 95% credible interval [CrI]: 0.15-0.74), suggesting a high probability of a protective effect.ConclusionsThis study demonstrates that the use of buccal fat pad flaps in primary cleft palate repair is an effective adjunct associated with a reduced incidence of post-operative oronasal fistula.

A decision tree was constructed to guide incision and flap selection during primary surgery, based on five anatomical factors: bone discontinuities identified on CBCT, palatal mucosa thickness, expected implant platform position (channel vs. tunnel), buccal keratinized tissue width, and skeletal or dental Class III relationships. Five flap types were defined: ZAGA Palatal Roll Flap, Partial Thickness Flap, Double Pedicle Flap, Buccal Fat Pad Flap, and Scarf Graft. Each flap showed specific indications depending on the anatomical context. When properly selected, incision and flap designs improved soft tissue coverage, preserved or increased keratinized mucosa, and reduced soft tissue complications. The decision tree enabled systematic and reproducible selection of main incision and flap type based on patient-specific anatomy. Integrating incision and flap design into surgical planning allows for individualized soft tissue management in zygomatic implant therapy. The proposed decision tree offers a practical, anatomy-driven protocol to optimize outcomes in the rehabilitation of the atrophic maxilla.

Medication-related osteonecrosis (MRONJ) and osteoradionecrosis (ORN) present a significant reconstructive challenge. Assessing the suitability of pedicled flap (PF) reconstruction in the context of a compromised tissue bed is essential for effective surgical management. This systematic review evaluates the outcomes of PF reconstruction in MRONJ and ORN. PubMed, Ovid (MEDLINE ALL, Embase), and Cochrane CENTRAL were searched for outcomes of PF reconstruction from inception through to November 2024. A total of 48 studies met inclusion criteria (32 MRONJ, 16 ORN). Analysis included 575 patients (MRONJ: n=478; ORN: n=97) receiving 607 flaps (MRONJ: n=509; ORN: n=98). The pooled success rate was 90% (95% CI: 87% to 92%) for MRONJ and 98% (95% CI: 94 to 100%) for ORN. Both conditions showed an 18% pooled complication rate (MRONJ: 95% CI, 14% to 23%; ORN: 95% CI: 11% to 28%). In MRONJ, buccal fat pad flap was most common (n=189, 37.13%), while submental island flap with mylohyoid muscle showed the highest success rate (94%, 95% CI: 67% to 99%). There were significant differences in complication rates across flap types (p<0.0001), with the mylohyoid flap showing the lowest rate (9%, 95% CI: 2% to 36%). For ORN, pectoralis major musculofascial flap was most common (n=36, 36.73%). Pedicled flaps demonstrate high success rates (>90%) in MRONJ and ORN reconstruction, supporting their use as a reliable option in compromised tissue beds. Flap selection should be individualised based on defect characteristics and patient factors. Further research is needed to better define indications and optimise patient selection.

This case series report aims at assessment of coronoidotomy as compared to coronoidectomy in the treatment of oral submucous fibrosis (OSMF) cases. With the increasing incidence of OSMF, the aim of the study is to depict our experience with coronoidotomy and its efficiency. This case series report looks to compare the efficacy of coronoidotomy with the more traditional approach of coronoidectomy. A retrospective study of 40 Patients were divided into 2 groups of Coronoidotomy vs Coronoidectomy using buccal fat pad (BFP) for reconstruction carried out under local anesthesia (LA)/General anesthesia (GA) and Coronoidotomy vs Coronoidectomy using Nasolabial flap reconstruction carried out under GA. A comparison of pain scale during physiotherapy using Visual analog scale VAS and Verbal response score VRS (along with ease of physiotherapy), duration required to attain adequate mouth opening,interincisal mouth opening and duration of the surgery was done. The secondary outcome variables includes division between nasolabial and buccal fat pad flaps. Time since cessation of habit and the overall time period of the habit were recorded. Statistical comparison of all values with a P value ≤ 0.05. Among the 40 study participants, Patients undergoing Coronoidotomy tend to respond better with a statistically significant lower pain scale during physiotherapy and tend to have a shorter operating time with comparable interincisal results to coronoidectomy even on a 2year follow-up, irrespective of the type of reconstruction. Coronoidotomy have comparable end results to that of coronoidectomy with faster operating time and lesser pain during physiotherapy and thus is now becoming the treatment of choice in Grade III/IV cases of OSMF. It is also seen that similar results can be attained when the procedure is done using buccal fat pad and coronoidotomy under local anesthesia under certain circumstances.

Facial paralysis sequelae result in functional and cosmetic deficits. Myectomy for facial contractures has been reported, and recently, selective myectomy of the smile antagonists (depressor anguli oris [DAO]) for perioral synkinesis has gained attention. Although less invasive, this approach can lead to postoperative depressed deformities of the myectomy site. We report two cases of facial nerve paralysis. In one case, DAO myectomy was performed for synkinesis with the upper lip levator muscles. In the other, the DAO and depressor labii inferioris were myectomized for facial contractures centered on the lower lip. A pedicled buccal fat pad flap was elevated to cover the myectomy defect, preventing postoperative depressed deformity. One year postoperatively, no depressed deformities were observed; lower lip symmetry and oral commissure movement improved, achieving a natural smile. As the procedure involves the transfer of vascularized blood-rich buccal fat, the risk of postoperative induration and contracture is lower than that with fat injections.

The buccal fat pad (BFP) is an easily accessible fat tissue, available in the majority of patients, with minimal donor site morbidity. Applications of the BFP include treatment of perforated maxillary sinus membranes among others. The purpose of this review was to assess the use of the BFP in maxillary sinus floor elevation (SFE) procedures. A literature search was performed using the PubMed and Europe PMC electronic databases until November 2024 by 2 independent reviewers. Four studies were included in the review. In 2 of the studies included BFP was used to cover large perforations of the maxillary sinus membrane (SM). In one study the BFP was used to cover the lateral window of the SFE and enhance bone grafting. In one study the BFP was used as a free flap to fill the space under the elevated SM, acting as the only grafting material and at the same time covering relatively small perforations of the SΜ. Macroscopic and microscopic features of the BFP render the use of a BFP flap or graft a reliable treatment option in many cases. Clear conclusions regarding the use of the BFP in SFE could not be drawn due to limited research in the field. Possible uses include coverage of SM perforations, coverage of the lateral window and filling of the sinus cavity as an alternative to other grafting materials. Well-designed studies are needed to investigate the effect of the BFP on bone formation in SFE procedures.

Background: An oroantral fistula (OAF) is a pathological void or defect that forms a passage between the maxillary sinus and the oral cavity. This condition arises most commonly due to an extraction of a posterior maxillary tooth or any traumatic event involving the posterior maxilla region. Untreated OAFs can lead to chronic sinusitis, impaired oral function, and other infections. Closure of OAF with buccal fat pad flap has emerged as a simple and reliable technique because BFP is well vascularized supply. To assess the clinical outcomes of using the buccal fat pad flap in the surgical repair of oroantral fistulae, particularly in patients with maxillofacial trauma or extraction-related defects. Methods: A prospective case series was conducted at Burn and plastic surgery center Hayatabad Peshawar from feburary 2023 to October 2024, enrolling 51 patients diagnosed with OAF. After detailed assessment, all patients underwent surgical closure using a pedicled BFP flap. Variables recorded included flap viability, presence of post-operative infection, and fistula closure at three-month follow-up. Associations between patient factors and surgical outcomes were analyzed. Results: The mean age of participants was within the 30–45 year range, with a slight female predominance. Tooth extraction (41.2%) and trauma (35.3%) were the leading causes of OAF. The success rate of fistula closure was 84.3%. Flap viability was maintained in 76.5% of patients, while 19.6% experienced postoperative infection. Flap viability was significantly associated with closure outcome (p &lt; 0.05), whereas smoking and comorbidities were not. Conclusion: The buccal fat pad flap is an effective, minimally invasive solution for closing oroantral fistulae, particularly in trauma-related cases. Its high success rate, low complication profile, and adaptability make it a valuable option in oral and maxillofacial surgical practice.

ABSTRACTAimThis study aimed to describe an additional application of the free buccal fat pad graft (FBFPG), assess its effectiveness in closing oroantral communication (OAC), and compare its impact on postoperative edema with that of the pedicled buccal fat pad flap (PBFPF).Materials and MethodsThe sample consisted of 22 patients who developed OAC following tooth extraction. The patients were randomly divided into two groups: the study group, consisting of 11 patients treated with FBFPG, and the control group, consisting of 11 patients treated with PBFPF. All patients were assessed on the first, third, and seventh postoperative days to measure edema. Success of closure was evaluated on the 7th, 14th, and 45th postoperative days. Both groups were followed up for 3 months to monitor for any recurrence of OAC.ResultsThe success rate of closure in the control group (PBFPF) was 100%, whereas the success rate in the study group (FBFPG) was 81.8%, with two cases failing to close. There was no statistically significant difference between the two groups in terms of closure success (χ2 = 2.2, p = 0.138). In terms of edema, the FBFPG group exhibited mild edema, while the PBFPF group showed edema ranging from mild to moderate, with a clinically and statistically significant difference between the two groups, especially on the first and third postoperative days (p &lt; 0.001 for both). Edema gradually decreased and nearly disappeared by the seventh day. No statistically significant difference was observed between the two techniques on the seventh day (p = 0.094).ConclusionWithin the limitations of this study, the use of FBFPG is an effective technique for the closure of OACs, demonstrating a good success rate compared to PBFPF without causing any pathological reactions within the maxillary sinus. Additionally, FBFPG is a safe, simple technique that causes less trauma than PBFPF.

Contraindicated? Not So Fast-The Buccal Fat Pad Flap in Down Syndrome.

The buccal fat pad and buccal mucosa are anatomical structures closely related to palatal clefts which can provide additional tissues for defect reconstruction which is crucial for practitioners aiming to lessen the need for additional corrective surgeries in patients with cleft palates and to lower the rates of residual palatal fistulae. Objectives: Aims to explore the recent scientific data available on the applications and outcomes of two surgical techniques involving the buccal fat pad and buccal mucosal flap in primary and secondary palatoplasty. Methods: The analyzed articles published between 2020 and 2025 from PubMed, Web of Science, and Scopus. The search strategy included terms related to buccal fat pad flaps, buccal mucosal flaps, and cleft palate repair. Results: After performing the search, including eligible articles and removing duplicates, 15 articles were included in this review. Eight studies explored the effectiveness of buccal fat pad or buccal mucosal flap during primary palatoplasty and seven studies for secondary palatoplasty. The articles included in this review provide insights on the usefulness of buccal fat pad flaps and buccal mucosal flaps in primary and secondary palatoplasty. Conclusions: The buccal fat pad and buccal mucosal flaps are highly effective in secondary palatoplasty, particularly for velopharyngeal dysfunction and fistula closure. In primary palatoplasty, the buccal fat pad flap aids mucosal healing, reduces complications, and improves speech, while the buccal mucosal flap is beneficial for wide palatal defects.

Introduction: Primary cleft palate repair is associated with significant psychosocial burdens for patients and their families. The abundance of operations and appointments create financial and non-financial hardships for the patient and health care system alike. Therefore, the financial implications of cleft care have become an area of focus in craniofacial surgery. The purpose of this study was to evaluate the financial implications of utilization of the buccal fat pad flap (BFPF) during primary cleft palate repair. We hypothesized that utilization of the BFPF as vascularized soft tissue filler would decrease the need for secondary speech operations, therefore decreasing the financial burden of cleft care on patients and the health care system. Methods: A retrospective cohort study was performed that included 146 patients who underwent primary cleft palate repair between 1996 and 2022. Medicare.gov national average costs were utilized to establish standardized direct secondary cleft palate procedural costs, and the total direct and indirect financial cost associated with secondary speech operations was also determined. Results: It was found that usage of the BFPF resulted in a reduction of roughly $1000 in direct secondary procedural costs and a reduction of roughly $3000 in total financial secondary procedural costs for patients. Furthermore, the BFPF’s role in reducing a patient’s need for a secondary speech procedure was reaffirmed with a 15% absolute risk reduction for BFPF patients. Discussion: Overall, cleft palate patients treated with BFPF at the time of initial surgery benefited due to the decreased likelihood of requiring a secondary speech operation as this resulted in a reduction in financial and non-financial costs associated with cleft palate repair, reducing financial toxicity as a whole.

Midface augmentation and lower face fullness reduction is commonly performed in facial feminization surgery. Traditionally, approaches such as fillers, fat grafting, bone repositioning, and alloplastic implants have been performed. In the evolving landscape of FFS, we present a case series utilizing a pedicled buccal fat pad flap to augment the midface while reducing lower facial volume. This case series consisted of 4 patients who elected to proceed with gender-affirming facial surgery to augment the midface and contour the lower face. Buccal fat transposition involves accessing the fat pad through an intraoral incision and resuspending the fat pad to the desired midface position. The fat pad is then secured to the periosteum in the desired position. Concomitant procedures performed included mandibular contouring and genioplasty, partial masseter muscle resection, and facial fat grafting. No postoperative complications were observed. Subjective improvement in midface fullness and a reduction in lower-face fullness were appreciated. Our case series indicates that buccal fat pad transposition is a promising technique in gender-affirming facial surgery. Contrary to alternatives, such as fat grafting or implants alone, this method can simultaneously improve midface fullness while contouring the submalar and lower facial region. Careful patient selection, good fixation technique, and appropriate adjunctive procedure utilization are essential to achieve consistent results.

Background: The management of OSMF aims to alleviate the signs and symptoms, such as burning sensation and release of the fibrotic bands to assist oral opening. Surgical excision of the fibrotic bands is the best choice in the treatment of advanced OSMF. Interpositional grafts are used to cover the raw surgical defects following the fibrotic bands' excision. They can be local (tongue flap, palatal island flap, buccal fat pad, nasolabial flap, and temporalis fascia flap) or distant (abdominal dermal fat graft, anterolateral thigh flap). This systematic review was conducted to evaluate which type of interpositional graft is effective in the surgical management of advanced oral submucous fibrosis. Material and method: A Literature search was performed in 12 electronic databases for articles published between 2000, and August 31, 2023. Two reviewers independently reviewed the articles. Ten articles (Non randomized controlled trial (NRCT)-5 and randomized controlled trial (RCT)-5) were selected based on the inclusion criteria. For NRCTs, Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies and ROB b tool for RCT were used to evaluate the risk of bias. Results: Ten studies were selected based on the inclusion and exclusion criteria. It included; 5 NRCTs and 5 RCTs. Meta-analysis was performed, and the mouth opening was greater in subjects treated with nasolabial flap than other flap designs at sixth month and 12th month follow up. However, the difference between the two groups was statistically non-significant (p = 0.19). The Buccal Fat pad flap also shows successful results but not statistically significant. Conclusion: The observations of this review can help enhance awareness among the healthcare professionals, and clinicians about recommending nasolabial flap as an interpositional graft in advanced OSMF cases making the best use of its advantages.

Oral submucous fibrosis (OSMF) is a chronic condition that involves any portion of the oral cavity and causes restricted mouth opening due to increasing sub mucosal fibrosis. Various surgical treatment approaches have been used to correct the OSMF. Therefore, it is of interest to compare the efficiency of amniotic membrane, collagen membrane and buccal fat pad in OSMF patients. Hence, a total 30 patient's diagnosed with OSMF were alienated equally into 3 groups based on treatment method; Group I: buccal pad of fat (BPF), Group II: mucosal defect with amniotic membrane (AM) and Group III-xenogenous collagen membrane (CM). Results show that AM grafts are advisable alternative for oral tissue restoration than buccal fat pad flaps and collagen membranes in terms of discomfort reduction, mouth opening improvement and epithelisation.