https://doi.org/10.1177/2732501620974578 FACE 2020, Vol. 1(1) 33–40 © The Author(s) 2020 DOI: 10.1177/2732501620974578 journals.sagepub.com/home/fac Article Introduction Velopharyngeal insufficiency, palatal fistula formation and durability remain significant post-operative complications in cleft care, particularly in wide and challenging cleft palates. Post-operative rates of velopharyngeal insufficiency (VPI) range from 5% to 32% of patients treated for cleft palate. 1-7 Of those patients with post-operative VPI, a significant per- centage will require an additional surgical procedure to cor- rect the underlying problem with rates of secondary speech surgery reported from 4.6% to 36%. 1,3-5,7-13 This data indi- cates that in some hands, and depending on the threshold of the cleft surgeon and team, more than one third of patients undergoing primary palatoplasty will require a secondary operation for speech. Theoretically, higher rates of reopera- tion would be associated with patients that had wider and more challenging repairs. Over the past few decades, many techniques and proce- dures have been described and/or revised to address VPI. 14-22 Few of these papers postulate an underlying mechanism that pre-disposes a patient to velopharyngeal insuffi- ciency, 3,4,19,20,23 and often the complication is associated with failure to adequately address the levator sling at the time of primary palatoplasty. 19,20 Given the increased burden of care that prolonged speech therapy can impose on families and the relatively high potential for additional speech operations, it would seem prudent to address the concern for VPI at the time of initial repair, particularly in those difficult cases where there is a high likelihood of a poor outcome. Such an 974578FAC XX X 10.1177/2732501620974578FACE: Journal of the American Society of Maxillofacial SurgeonsThurston et al research-article 20202020 1 The University of Michigan Health System, Ann Arbor, MI, USA 2 The University of Kansas Medical Center, Kansas, MO, USA Corresponding Author: Steve Buchman, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Mott Children’s Hospital, Craniofacial Surgery Office 4730, 1540 East Medical Center Drive, Ann Arbor, MI 48109, USA. Email: sbuchman@med.umich.edu Filling the Void: Use of the Interpositional Buccal Fat Pad to Decrease Palatal Contraction and Fistula Formation Todd E. Thurston 1 , James Vargo 2 , Katelyn Bennett 1 , Christian Vercler 1 , Steven Kasten 1 , and Steve Buchman 1 Abstract Objective: The objective of this study was to evaluate the ability of the buccal fat pad flap (BFPF) to fill the void remaining after muscle transposition and study its effect on durability, fistula rate, palatal shortening/contraction, and relapse of muscle positioning in wide and challenging cleft repairs. Design: A retrospective chart review was performed. Charts were abstracted for standard demographics, reason for BFPF utilization, palatal length, palatal fistula, co-morbidities, and speech outcomes. Patients, Participants: Patients under age 3 who underwent primary palatoplasty between October 2007 and September 2015 which utilized a medially placed BFPF were identified. Results: Fifty-three patients were identified. Mean age at palatoplasty was 1.4 (0.78-2.55) years. Mean follow-up was 2.52 (0.02-7.26) years. Twenty-four (45.3%) patients had concerning intraoperative findings warranting flap utilization. Twenty-nine (54.7%) patients underwent BFPF for large dead- space volume. Four patients (7.55%) experienced a fistula. Thirty-nine patients had comments on their palatal length. Of these, 28 (71.8%) were of average length, and 8 (20.5%) were long. Thirty-three patients have undergone formal speech evaluation. Of these, 20 (60.6%) were of normal resonance, and 12 (36.4%) demonstrated nominal hypernasality. No patients have yet to require a secondary speech operation. Conclusion: Use of the BFPF has become more common in our practice particularly in challenging cleft palate repairs. It is a versatile technique addressing large interpositional dead space and thin outer and inner lamellae in the anterior soft palate after posterior muscle transposition. Early results, in difficult repairs, demonstrate excellent durability and that palatal length appears to be maintained, potentially lessening the need for secondary speech surgery. Keywords fat pad, buccal pad, palatal length, palatal fistula, velopharyngeal insufficiency, palatal repair complication