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Introduction: The buccal fat pad also known as Bichat's fat pad has the same histological characteristics as fats located in other regions of the body, however, its particularity is the wrapping of a fibrous capsule that prevents it from being metabolized. Bichectomy is the surgical procedure that partially removes oral fat, consequently it is possible to observe the volumetric reduction of the lower third of the face and the definition of contours and angulations, making the face esthetically pleasing. However, this procedure is related to several potentially serious complications in the postoperative period due to the surgical technique., Evidence Acquisition: A bibliographic search was carried out based on scientific articles, published in English and Portuguese, between 2015 and 2019. The search was carried through the electronic databases PubMed, SciELO, Medline, Bireme and Lilacs with the keywords "bichectomy," "buccal fat pad," "buccal adipose tissue" and "bichectomy and complications." Were included articles that reported the postoperative period and complications., Evidence Synthesis: The anatomical knowledge of this region is essential to avoid iatrogenesis in surgical procedures, which can result in temporary or permanent sequelae. Among the complications of greater complexity in bichectomy there are: trismus, hemorrhages, facial infections, lesion of the duct of the parotid gland and facial paralysis, however common complications that are related to any surgical procedure can occur, such as edema and hematoma, despite being considered a technically simple procedure., Conclusions: Bichectomy is a quick and technically simple esthetic-functional procedure, but it presents unpredictable risks of potentially serious complications.

Summary: Social media have triggered a buccal fat pad excision frenzy. Not surprisingly, there is tremendous appeal of having a slimmer lower face and more defined jawline after undergoing a small intraoral procedure under local anesthesia. Although this procedure is great for social media and seemingly beneficial for jawline aesthetics, the evidence remains limited as to whether or not this is an effective long-term solution. How much the buccal fat pad persists or diminishes as we age is an area of debate. However, the possibility of causing premature aging and midface distortion in the long run is disconcerting., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Purpose: This study aimed to develop a simple nomogram based on the Mayo Adhesive Probability (MAP) score combined with the RENAL nephrometry score (RNS) to predict intraoperative complications before partial nephrectomy (PN) in Asian populations., Materials and Methods: This study retrospectively collected patients undergoing PN at three medical centers. Each component of the MAP score and the RNS (6 variables) was evaluated to assess its association with intraoperative complications by multivariable logistic regression with backward elimination., Results: A total of 46 cases (7.2%) with intraoperative complications were identified among 637 patients. After backward elimination, three variables, including tumor diameter (4-7 cm vs. ≤4 cm: odds ratio [OR], 4.339; 95% confidence interval [CI], 1.943-9,692; ≥7 cm vs. ≤4 cm: OR, 8.434; 95% CI, 1.225-58.090), nearness to the collecting system (4-7 mm vs. ≥7 mm: OR, 2.988; 95% CI, 1.293-6.907; ≤4 mm vs. ≥7 mm: OR, 21.394; 95% CI, 6.122-74.756), and perirenal fat stranding type (type 1 vs. no stranding: OR, 3.119; 95% CI, 1.079-9.017; type 2 vs. no stranding: OR, 18.722; 95% CI, 6.757-51.868), were retained. The predictive power (measured by area under the curve [AUC]) of the nomogram was observed to be superior to the RNS or MAP score alone (RNS: 0.686, MAP score: 0.729, the nomogram: 0.837), but comparable to their combination (0.813)., Conclusions: The simple nomogram contains fewer components than the combination of the RNS and MAP scores yet demonstrates equivalent predictive power for intraoperative complications., Competing Interests: The authors have nothing to disclose., (© The Korean Urological Association, 2021.)

Background: Buccal Fat Pad (BFP) excision has become an aesthetic surgical procedure. Although this procedure is quite common, it is important to bear in mind that the scientific evidence supporting the efficacy of this treatment is scarce and of low quality. The purpose of this systematic review was to analyse all relevant data to assess the efficacy and safety of BFP excision for improving midface aesthetics., Material and Methods: A thorough search of MEDLINE (PubMed), Scopus and Cochrane Library databases was conducted. The PICO approach was used where healthy patients seeking cheek slimming and facial silhouette refining undergo BFP excision and were compared before and after surgery in terms of BFP volume reduction, adverse effects and patient satisfaction., Results: Of the 1,413 references identified, 4 were included in the qualitative synthesis. Only one study reported BFP volume reduction, which was 3.10 mL (95%CI: 2.38 to 3.80; P < 0.001), and the mean volume of the excised tissue was 2.74 ± 0.69 mL (range, 1.8-4.9 mL). 84.6% of the patients stated that their facial contour was much better and the remaining 15.4% noticed that the appearance of their cheeks following BFP excision was better. Seven complications were reported in the 134 cheek refinement procedures., Conclusions: BFP removal has an initially favorable outcome for facial aesthetics and a low postoperative complication rate, however, there are many procedures being performed with poor quality methodology and there is also a lack of published data on its long-term follow-up results.

Facial lipoatrophy is one of the most difficult complication in the patients with lupus profundus. In this paper, we present a case of a 55-year-old woman affected by lupus profundus, with a grade V lipoatrophy, treated with lipofilling technique. No complications were observed and results at 12 months were stable, natural, and symmetric. [ABSTRACT FROM AUTHOR]

Herein, we present the case of a patient who had complaint suggestive of carpal tunnel syndrome due to fibrolipoma of the median nerve and macrodactyly. 32-year-old male patient has macrodactyly of the right index finger and coarse skin lines and hyperkeratosis on the volar aspect of the index finger. The patient reported numbness and tingling sensation in his right hand that have woken him at night for 10 years. Electromyography, magnetic resonance imaging (MRI) of the right hand and diagnostic biopsy were performed to the patient. Sensory action potential of the right median nerve was absent. The median motor study on the right showed low amplitude of the compound muscle action potential with a markedly prolonged distal latency. MRI scan demonstrated a lesion that extended from the palm to the forearm and gave cable-like appearance to the median nerve which is pathognomonic for lipofibroma. Biopsy result was consistent with fibrolipoma. Neural fibrolipoma is a rare benign tumor of the median nerve. MRI is the best method for observing the involvement of the nerve. In one-third of the cases, macrodactyly is associated with neural fibrolipoma. In the differential diagnosis of patients with carpal tunnel syndrome symptoms, fibrolipoma of the median nerve should also be kept in mind. [ABSTRACT FROM AUTHOR]

Tarsal tunnel syndrome is an entrapment neuropathy of posterior tibial nerve under the flexor retinaculum. Patients generally present with paresthesias on the plantar side of foot and fingers and in the distal kruris. The causes of tarsal tunnel syndrome are space occupying lesions within or around the tunnel which exert pressure to the nerve, ankle deformities, systemic illnesses, trauma or lesions of the nerve itself. In this study a case of tarsal tunnel syndrome due to bilateral lipoma which was treated surgically is presented. [ABSTRACT FROM AUTHOR]

Adipose tissue physiology strongly differs between body regions. Reasonable amounts of intact RNA are required to analyze the local differences on a molecular level. Therefore, we developed an optimized RNA isolation procedure from adipose tissue samples. Excised human subcutaneous adipose tissue was obtained from elective operations, and the RNA Stabilization Reagent (RNAlater) was tested for its effect on RNA integrity. Additionally, 3 different RNA isolation kits were evaluated for efficacy in isolating RNA from tissue samples. The samples displayed a significant loss in recoverable RNA and signs of RNA degradation 30 to 60 minutes after tissue excision. The application of RNAlater significantly delayed this degradation. Using the RNeasy Lipid Tissue Kit resulted in a significantly higher RNA yield compared to the RNeasy Mini Kit. Our results demonstrate that combining the RNAlater and RNeasy Lipid Tissue Kit results in a higher yield of RNA even from relatively small tissue samples with guaranteed RNA integrity. [ABSTRACT FROM AUTHOR]

Congenital deformities involving the coverings of the nervous system are called neural tube defects (NTDs). NTD can be classified as neurulation defects, which occur by stage 12, and postneurulation defects. Cervical meningocele and myelomeningocele are rare spinal dysraphic lesions. Unlike lumbosacral dysraphic lesions, there is often no neurologic deficits and thus the subtle features of cervical cord tethering may be overlooked on imaging. The presence of meningomyelocele and/or encephaloceles at multiple (two or more) sites along the vertebral axis is a very rare event occurring in <1% of cases. Less than 10 cases have been described in the published literature. We are reporting a case of multiple NTD in same patient with no neurological deficit. [ABSTRACT FROM AUTHOR]

Removal of excess abdominal fat may be necessary to facilitate major gynaecological surgery for oncology patients. The aim of the study was to assess the feasibility, associated morbidity of such operation when combined with other major gynaecological procedures. This was a retrospective review of cases performed in a tertiary gynaecological oncology centre. All of the patients were diagnosed with gynaecological cancers. The results show a modest increase in operative time; however the procedure was feasible and safe with no other increased risk. This represents time saving for the patients and hospital in having two operations in one session. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency ablation depth can be inadequate to reach intramural or epicardial substrate, and energy delivery in the pericardium is limited by penetration through epicardial fat and coronary anatomy. We hypothesized that open irrigated microwave catheter ablation can create deep myocardial lesions endocardially and epicardially though fat while acutely sparing nearby the coronary arteries.Methods: In-house designed and constructed irrigated microwave catheters were tested in in vitro phantom models and in 15 sheep. Endocardial ablations were performed at 140 to 180 W for 4 minutes; epicardial ablations via subxiphoid access were performed at 90 to 100 W for 4 minutes at sites near coronary arteries.Results: Epicardial ablations at 90 to 100 W produced mean lesion depth of 10±4 mm, width 18±10 mm, and length 29±8 mm through median epicardial fat thickness of 1.2 mm. Endocardial ablations at 180 W reached depths of 10.7±3.3 mm, width of 16.6±5 mm, and length of 20±5 mm. Acute coronary occlusion or spasm was not observed at a median separation distance of 2.7 mm (IQR, 1.2-3.4 mm). Saline electrodes recorded unipolar and bipolar electrograms; microwave ablation caused reductions in voltage and changes in electrogram morphology with loss of pace-capture. In vitro models demonstrated the heat sink effect of coronary flow, as well as preferential microwave coupling to myocardium and blood as opposed to lung and epicardial fat phantoms.Conclusions: Irrigated microwave catheter ablation may be an effective ablation modality for deep ventricular lesion creation with capacity for fat penetration and sparing of nearby coronary arteries because of cooling endoluminal flow. Clinical translation could improve the treatment of ventricular tachycardia arising from mid myocardial or epicardial substrates. [ABSTRACT FROM AUTHOR]

Pelvic lipomatosis is an uncommon benign disease characterized by the excessive growth of mature fat tissue in the perivesical and perirectal areas. A 61-year-old male patient, who was admitted with voiding difficulty, underwent bladder-sparing surgery with excision of adipose tissue for pelvic lipomatosis. The case is presented and discussed with the relevant literature. [ABSTRACT FROM AUTHOR]

Cigarette smoke has many detrimental effects on health, with consequences such as cardiovascular diseases, respiratory diseases, and tumors. In plastic surgery, these effects appear during the wound healing process. This retrospective study showed wound healing in 57 patients who had undergone abdominal dermolipectomy surgery. The patients were divided into two groups: smokers and nonsmokers. According to the results, smokers face a great complication risk for surgical wounds, which cause aesthetically more undesirable scars than observed in nonsmokers. The authors hypothesize that abstinence from smoking for 4 to 12 weeks before surgery would improve the quality of the scars. [ABSTRACT FROM AUTHOR]

Provides guidelines for cosmetic surgeons on microliposuction and fat transfer for advanced repair of liposuction defects. Start of surgery in the usual way with infiltration of local tumescent anesthesia into the entire area; Multiple tiny incisions; Removal of fat by hand using a Coleman extractor; Collection and saving of fat for use during fat transfer; Incisions left open for drainage; Postoperative support garments.

Background. Liposuction is the most commonly performed cosmetic surgical procedure in the United States. Traditional liposuction (TL) performed under general anesthesia has been associated with reports of major systemic complications, including death. When TL is performed using only tumescent anesthesia, there have been no reported deaths and few significant systemic complications. Power liposuction (PL), a newer procedure in which a reciprocating cannula is used to evacuate fat, has reported benefits over TL. Objective. To determine the complication rate associated with PL and to compare it with TL (regardless of the type of anesthesia). Methods. In this study, 207 consecutive PL cases performed with tumescent anesthesia between August 2000 and May 2002 by a dermatologic surgeon (B.K.) and a plastic surgeon (M.B.) were reviewed retrospectively to determine the number of complications associated with the PL procedure. Results. No systemic complications were identified, and only three local complications (all seromas) were found. This represents a complication rate of 1.4%. Conclusion. Our results demonstrate fewer complications when performing PL using tumescent anesthesia compared with TL using general anesthesia. When compared with TL using tumescent anesthesia, the overall complication rate did not differ significantly. We conclude that in addition to PL previously demonstrated benefits, the complication profile compares favorably with TL under local tumescent anesthesia. Therefore, PL may assume a more prominent role in the armamentarium of the surgeon performing liposuction. [ABSTRACT FROM AUTHOR]

Benign symmetric lipomatosis is a rare form of typical fat distribution in the shoulders, the arms, and the neck that can compromise the respiratory, nutritional, and psychological status of the patient. Alcoholism, malignant tumors of the upper airways, endocrine tumors, hypothyroidism, diabetes, and hypertriglyceridemia are often associated with its occurrence. Surgical removal via lipectomy or liposuction can give good cosmetic results, although recurrences often occur. Liposuction has become the first choice to treat this disorder in patients with smaller masses. We have operated on four such cases in which liposuction failed and surgical excision had to be performed. We present a summary of the clinical characteristics of all four patients and discuss the different treatment options. [ABSTRACT FROM AUTHOR]

Different types of scaffolds are used to reconstruct muscle volume loss injuries. In this experimental study, we correlated ultrasound observations with histological findings in a muscle volume loss injury reconstructed with autologous adipose tissue. The outcome is compared with decellularized and porous matrix implants. Autologous adipose tissue, decellularized matrix, and a porous collagen matrix were implanted in volumetric muscle loss (VML) injuries generated on the anterior tibial muscles of Wistar rats. Sixty days after implantation, ultrasound findings were compared with histological and histomorphometric analysis. The muscles with an autologous adipose tissue implant exhibited an ultrasound pattern that was quite similar to that of the regenerative control muscles. From a histological point of view, the defects had been occupied by newly formed muscle tissue with certain structural abnormalities that would explain the differences between the ultrasound patterns of the normal control muscles and the regenerated ones. While the decellularized muscle matrix implant resulted in fibrosis and an inflammatory response, the porous collagen matrix implant was replaced by regenerative muscle fibers with neurogenic atrophy and fibrosis. In both cases, the ultrasound images reflected echogenic, echotextural, and vascular changes compatible with the histological findings of failed muscle regeneration. The ultrasound analysis confirmed the histological findings observed in the VML injuries reconstructed by autologous adipose tissue implantation. Ultrasound can be a useful tool for evaluating the structure of muscles reconstructed through tissue engineering.

Background: The subperiosteum, supraperiosteum, and intrasuborbicularis oculi fat have been used as planes of dissection for orbital fat transposition in transconjunctival lower blepharoplasty. The steep learning curve due to the anatomic complexity in using any of the 3 planes may deter plastic surgeons from performing the procedure. We present the use of clear anatomical midcheek spaces, the premaxillary and prezygomatic spaces, as the plane for orbital fat transposition in transconjunctival lower blepharoplasty., Methods: We performed a retrospective study of 184 consecutive patients who underwent transconjunctival orbital fat transposition using the midcheek spaces from November 2013 to July 2019. Recorded data included the patient's age, duration of surgery, postoperative complications (chemosis; bleeding; lower eyelid swelling; orbital and/or lower eyelid infection; eye misalignment on primary gaze; binocular diplopia; numbness involving the lower eyelid, cheek, and upper lip; orbicularis oculi paralysis, inferior scleral show, and lower eyelid ectropion), aesthetic result, and patient satisfaction., Results: The mean age is 35.48 ± 6.66 years. Significant aesthetic improvement was achieved not only for herniated orbital fat and prominent lid-cheek junction but also for midcheek depression over an average follow-up of 22.41 ± 16.04 months. The patient satisfaction score (98.91%) was high. No major complications occurred. The mean operating time was 46.74 ± 6.67 minutes., Conclusions: The natural midcheek spaces could be used as an ideal plane for orbital fat transposition in transconjunctival lower blepharoplasty. By using the midcheek spaces, transconjunctival orbital fat transposition can become a safe and effective technique without the steep learning curve., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The study aimed to examine the effect of focused ultrasound cavitation augmented with aerobic exercise on localized abdominal and intrahepatic fat in fatty liver patients., Methods: 34 fatty liver patients aged 30-45 with a body mass index (BMI) of 30-40 kg/m2 were randomly assigned into two equally numbered groups. Group A received focused ultrasound cavitation and moderate aerobic exercise for three months, while Group B (control group) received moderate aerobic exercise only. Abdominal subcutaneous fat volume, visceral fat volume, liver-to-spleen ratio (L/S ratio), body weight, BMI, and waist circumference were measured both before and after the study period., Results: Both groups showed significant improvements in subcutaneous fat volume, visceral fat volume, body weight, BMI, and waist circumference relative to baseline where (P < 0.001), with a higher percentage in group A. L/S ratio only showed a significant improvement in group A. Between-group differences were noteworthy regarding L/S ratio and waist circumference where (P < 0.0001)., Conclusion: While substantial risky measures in non-alcoholic fatty liver disease have been modified by aerobic exercise, its combination with focused ultrasound cavitation causes more notable effects on the reduction of abdominal and intrahepatic fat, making it a superior option., Trial Registration: ClinicalTrials.gov: NCT04161703., Competing Interests: No conflict of interest.

Background: Adherent perinephric fat (APF) is a known risk factor of surgical difficulty during laparoscopic donor nephrectomy (LDN). The Mayo Adhesive Probability (MAP) score predicts APF accurately. The aim of this study is to identify the association between MAP score and operative time in LDN., Methods: We retrospectively evaluated 154 kidney donors who underwent surgery from December 2017 to December 2019 at İstanbul Aydın University Hospital and İstinye University Hospital. All of the operations were done by 3 senior surgeons by a fully laparoscopic method. The MAP score was derived from computed tomography scans by 1 blinded reader. Demographic data, body mass index (BMI), MAP score, side selection, estimated glomerular filtration rate (eGFR), number of arteries and veins, operative time, hospital stay, and complications are recorded. Single and multiple variable analyses were used to evaluate the correlation between operative time and MAP score, BMI, side selection, and number of vascular structures., Results: A total of 154 patients (79 men, 75 women) with a mean age of 44.4 ± 12.72 were included in this study. None of the cases were converted to open nephrectomy. There were no major complications. Mean BMI was 27.59 ± 4.32 kg/m 2 , mean MAP score was 0.69 ± 1.15, and mean operative time was 40.25 ± 9.81 minutes. Although mean BMI was higher in women (28.19 ± 4.52 vs 27.03 ± 4.07; P < .05), mean MAP score was lower than in men (0.35 ± 0.86 vs 1.03 ± 1.29; P < .001). Older age, higher BMI, higher MAP score, and presence of multiple renal arteries were associated with longer operative time of LDN. The MAP score was associated with older age, male sex and higher BMI., Conclusions: This study showed that different risk factors can affect operative time in LDN. The MAP score was significantly associated with longer operative time, especially in men, so it can be useful for predicting surgical difficulty in kidney donors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Considerations of how to improve postoperative outcomes for total knee arthroplasty (TKA) have included preservation of the infrapatellar fat pad (IPFP). Although the IPFP is commonly resected during TKA procedures, there is controversy regarding whether resection or preservation should be implemented, and how this influences outcomes. Therefore, the purpose of this systematic review was to evaluate how IPFP resection and preservation impacts postoperative flexion, pain, Insall-Salvati Ratio (ISR), Knee Society Score (KSS), patellar tendon length (PTL), and satisfaction in primary TKA. PubMed, EBSCO host, and SCOPUS were queried to retrieve all reports evaluating IPFP resection or preservation during TKA, which resulted into 488 studies. Two reviewers independently reviewed these articles for eligibility based on pre-established inclusion and exclusion criteria. Eleven studies were identified for final analysis, which reported on 11,996 cases. Patient demographics, type of surgical intervention, follow-up duration, and clinical outcome measures were collected and analyzed. Complete resection was implemented in 3,723 cases (31%), partial resection in 5,458 cases (45.5%), and preservation of the IPFP in 2,815 cases (23.5%). Clinical outcome measures included PTL (5 studies), knee flexion (4 studies), pain (6 studies), KSS (3 studies), ISR (3 studies), and patient satisfaction (1 study). No differences were found following IPFP resection for patient satisfaction ( p  = 0.98), ISR ( p  > 0.05), and KSS ( p  > 0.05). There was mixed evidence for PTL, pain, and knee flexion following IPFP resection versus preservation. Studies of shorter follow-up intervals suggested improved pain following resection, while reports of longer follow-up times indicated that resection resulted in increased pain. Given the mixed data available from the current literature, we were unable to conclude that one surgical technique can definitively be considered superior over the other. More extensive research, including randomized controlled trials, is required to better elucidate potential differences between the surgical handling choices. Future studies should focus on patient conditions in which one technique would be best indicated to establish guidelines for best surgical outcomes in those patients., Competing Interests: A.F.K. reports other from AAOS, other from American Association of Hip and Knee Surgeons, other from BMC Musculoskeletal Disorders, other from Corin U.S.A., other from DePuy, A Johnson & Johnson Company, other from Heraeus Medical, other from Innomed, other from Johnson & Johnson, other from Orthofix, Inc, other from Pacira Pharmaceuticals:, other from Procter & Gamble, other from Zimmer, outside the submitted work. M.A.M. reports other from AAOS, other from American Association of Hip and Knee Surgeons, other from Cymedica, other from DJ Orthopaedics, other from Flexion Therapeutics, other from Johnson & Johnson, other from Journal of Arthroplasty, other from Journal of Knee Surgery, other from Knee Society, other from Medicus Works LLC, other from Microport, other from National Institutes of Health (NIAMS & NICHD), other from Ongoing Care Solutions, other from Orthopedics, other from Orthosensor, other from Pacira, other from Peerwell, other from Performance Dynamics, other from Pfizer, other from Skye Biologics, other from Stryker, other from Surgical Techniques International, other from Tissue Gene, other from Up-to Date, other from USMI, other from Wolters Kluwer Health - Lippincott Williams & Wilkins, outside the submitted work., (Thieme. All rights reserved.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background: Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, significant procedural variation exists between providers., Objectives: The primary purpose of this systematic review was to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone., Methods: A systematic review of the Cochrane Library and MEDLINE databases as completed was undertaken to identify all clinical reports of fat grafting combined with facelift surgery based on the following key terms: ("fat grafting" OR "lipotransfer" OR "lipofilling" OR "fat transfer") AND ("facelift" OR "rhytidectomy" OR "SMASectomy" OR "facial rejuvenation"). Data on techniques, outcomes, complications, and patient satisfaction were collected., Results: The systematic review was performed in April 2017. In total, 248 articles were identified for review. After application of exclusion criteria, 15 primary studies were included in this review. Various facelift techniques were reported, including deep-plane or sub-superficial musculoaponeurotic system (SMAS) facelift, SMAS facelift, modified minimal access cranial suspension lift, component facelift, midface lift, SMAS plication, SMAS-stacking/SMASectomy, and SMASectomy. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvements in facial volume and aesthetic assessments., Conclusions: Combined facelift and fat grafting is a safe and efficacious means to simultaneously address age-related ptosis and volume loss. Further research is required to validate and improve existing treatment modalities., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Purpose: The purpose of this study was to investigate the effectiveness of the pedicle buccal fat pad flap combined with autogenous bone grafts to reconstruct zygomaticomaxillary defects after tumor resection., Materials and Methods: A retrospective case series analysis of 11 patients that underwent zygomaticomaxillary reconstruction after tumor resection with autologous bone grafts supported by pedicle buccal fat pad flap as the lining of the maxillary sinus from January 2009 to December 2015 was performed. All the patients underwent computed tomography to measure the aesthetic appearance, bone graft formation, mucosa of the maxillary sinus, and their response to treatment, including complications., Results: With a mean follow-up period of 4.7 years, all patients were pleased with the symmetrical contours of zygomaticomaxillary and symptom improvements of the maxillary sinus except for one patient who complained of transient infraorbital numbness. Recurrence, bone infection or necrosis, and other complications were not observed in the follow-up period., Conclusion: Pedicled buccal fat pad flap promotes wound healing and prevents the exposure of bone grafts to the maxillary sinus. This technique may be a promising treatment option when reconstructing complicated zygomaticomaxillary defects., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Inflammatory responses mediated by macrophages play a role in tissue repair. However, it is unclear whether the repair in the donor site after liposuction would have any effects on fat graft retention in the recipient site. This study is designed to evaluate the effects of a macrophage-mediated inflammatory response in donor sites on long-term retention of fat grafting. In this study, mice were randomly divided into two groups. One underwent simulated liposuction, called the fat procurement plus grafting (Pro-Grafting) group, and the other underwent sham surgery, called the fat grafting only (Grafting Only) group. The prepared fat (0.3 ml each) was engrafted and cellular events over a 90-day period were assessed. We found macrophages were infiltrated into adipose tissue at the recipient site in the Grafting Only group within 7 days and the repair essentially completed within 30 days. By contrast, few macrophages infiltrated the recipient site in the Pro-Grafting group within 7 days and the entire remodeling process took 30 days longer in the Pro-Grafting than the Grafting Only group. Moreover, C-reactive protein levels were immediately upregulated after surgery, and the inflammatory factors' expression was higher at the donor rather than the recipient site. However, the repair processes and the long-term retention rate became normal when the adipose tissue was grafted after the donor site did not require macrophages for repair. Therefore, we suggest higher inflammatory factors promote macrophage infiltration and the adipose tissue regeneration process at the donor site. This process is delayed at the recipient site, which may affect long-term retention of fat grafts., (© 2020 Wiley Periodicals LLC.)

Purpose: Increased neck circumference is a major risk factor for obstructive sleep apnea (OSA). New data suggest that increased adipose tissue in the neck may be a contributory cause of OSA. The aim of this study was to investigate safety and efficacy of a recently developed injectable ice slurry in selective reduction of neck adipose tissue in a mouse model., Methods: We used the New Zealand obese mice that have increased volume of anterior neck fat, and are commonly used in OSA studies. MRI imaging was used to measure changes in fat tissue volume., Results: Thirty animals were used in this study. Volumetric measurements in MRI images showed thatchanges in anterior neck adipose tissue volume from baseline in treated mice was significantly different in comparison with the control group (-1.09/kg ± 0.33/kg vs 0.68/kg ± 0.37/kg; p < 0.01 by two-tailed Student's t test). Histological analysis of samples from the treated area of the neck did not show scarring or damage to the surrounding tissues., Conclusions: Injection of ice slurry safely, effectively, and selectively reduces upper airway fat in New Zealand obese mice without scarring or damage to surrounding tissue. Our results suggest that slurry injection may be a novel and minimally invasive method of removing neck adipose tissue. This intervention should be further investigated to determine its suitability for treatment of OSA.

Purpose: In this study we aimed to compare the effects of photobiomodulation (PBM) and dexamethasone (DXM) on pain, swelling, and the quality-of-life (QOL) of patients submitted to buccal fat pad removal., Patients and Methods: A total of 20 patients with pseudoherniation of buccal fat pad were included in the present study. The patients were divided randomly into 2 groups: the PBM group (660 nm, 100 mW, 6 seconds, 2 J/cm 2 ) and the DXM group (4 mg every 8 hours for 3 days after the procedure). Pain levels were evaluated using a visual analog scale at days 2 and 4 after surgery, whereas the edema was evaluated by measuring the distance between 6 reference points: tragus, pogonion of the soft tissue, lateral eye commissure, the gonial angle, nose wing, and mouth commissure at days 2, 4, 7, 15, 30, 60, and 90. The QOL was evaluated using the Oral Health Impact Profile 14 questionnaire at days 2 and 4 after surgery., Results: There were no differences between the PBM and DXM groups in pain or edema. In terms of the QOL, the PBM group was significantly more comfortable when chewing than the DXM group (P < .05) CONCLUSION: The use of PBM at a power of 100 mW and 2 J/cm 2 per point had similar effects to oral DXM for the control of pain and edema, as well as in the QOL, except for masticatory function, which was significantly better in the PBM group., (Copyright © 2020 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In the repair of prominent ear deformities, the main objectives are to recreate the antihelical fold, reduce projection in patients with a large concha, and normalize the distance between the ear and the cranium. This study evaluated the efficacy of the adipo-perichondrial flap-assisted posterior auricular muscle complex (PAMC) flap technique, which involves a new approach to the repair of prominent ear deformities., Materials and Methods: A medially based PAMC flap and a laterally based adipo-perichondrial flap were elevated in 22 patients with prominent ear deformities. In order to shape the ear, the PAMC flap was sutured to the transition zone between the helix and antihelix, and the adipo-perichondrial flap to the periosteum of the mastoid bone. The ear-cranium distances were measured preoperatively and at postoperative first and sixth months., Results: Thirteen patients were female and 9 were male. The mean age of the patients was 19.4 years, and the mean follow-up period was 10.6 months. The ear-cranium distance significantly decreased in the postoperative first-month and sixth-month evaluations compared to the preoperative values (P < .05). No relapse, suture exposition, hematoma, keloid scar, or infection was observed., Conclusion: Posterior auricular muscle complex is a strong anatomical structure that includes the trapezius muscle, occipital muscle, extrinsic ear muscles, temporal fascia, and sternocleidomastoid fascia. By elevating this structure as a flap and combining it with an adipo-perichondrial flap, successful results can be achieved in the repair of prominent ear deformities, which prevents relapses and maintains the shape of the ear in the long term.

Background: Anterior knee pain (AKP) is a major complication that occurs after anterior cruciate ligament reconstruction (ACLR), even when hamstring tendon (HT) grafts are used. Damage to the infrapatellar fat pad (IPFP) during arthroscopy can cause AKP. The purpose of this study was to evaluate the influence of IPFP preservation on clinical outcomes, including AKP, in patients who underwent ACLR with HT autografts using the inside-out technique., Methods: Forty-two patients who underwent primary ACLR with HT autografts were prospectively assessed for 2 years after surgery. They were randomly selected to undergo treatment with as much intercondylar IPFP preservation as possible or with intercondylar IPFP resection to confirm the ACL origin on the femoral and tibial sides, especially the femoral footprint in deep flexion of the knee joint. The total IPFP volume was calculated using sagittal MR images before and 6 months after surgery. The patients completed a subjective knee score questionnaire and were assessed for patellar tendon tenderness and pain with the half-squat test or single-leg hop test at 6 months and 2 years postoperatively., Results: There were no differences in the patient characteristics, including age, sex, BMI, time from injury to surgery, and meniscus tear. The difference in the total size of the IPFP preserved was significant (P = 0.004). However, there were no significant differences in the subjective knee scores. Moreover, there were no differences in the clinical assessment parameters between the IPFP preservation and resection groups., Conclusions: The size of the IPFP decreased more in the resection group than in the preservation group at 6 months after surgery. However, partial IPFP resection, which was used to better visualize the origin of the ACL, had no effect on the clinical outcomes, including AKP., Level of Evidence: Level II.

Purpose: To introduce an easy and effective approach for internal fixation of repositioned fat pedicles in transconjunctival lower eyelid blepharoplasty., Methods: Thirty-six consecutive patients underwent fat repositioning transconjunctival lower blepharoplasty from August 2016 to January 2018. After release of the orbicularis oculi muscle and exposure of the intraorbital fat pedicles, a supraperiosteal pocket was dissected. A 6-0 nylon suture was passed through the shaft of a hypodermic needle from the sharp tip, then the hypodermic needle was pierced through the cheek skin about 5 to 8 mm below the orbital rim into the dissected pocket, the hypodermic needle was next pull out and pierced through the same pinhole but different pathways into the dissection pocket again. The hypodermic needle was curved accordingly and passed through the lower surface tissue of the pocket, the needle was then taken out. Two ends of the 6-0 nylon suture were both brought out through the transconjunctival incison. One end of the 6-0 nylon suture was sewed through the free margin of the fat pedicle and tied tightly with the other end. The fat pads were transferred and blended well with midface fat. The severity of tear trough deformity were evaluated according to Barton's grading system by two independent plastic surgeons pre and post-operatively., Results: Tear trough deformity was improved in most cases. There were significant differences in preoperative and post-operative tear trough deformity grades (P < 0.5). All patients recover very well without significant complications. Three patients had transient mild to moderate lumpiness over the tear trough area, which were all resolved spontaneously eventually. One patient complained of retained fat tissue, and a revision surgery was given., Conclusions: In summary, The authors offered a new, simple, and effective approach to help fix the repositioned fat pads in transconjunctival lower lid blepharoplasty.

Osteoarthritis (OA) is the most common form of arthritis of the joints. The stromal vascular fraction (SVF) is a regenerative cell population that can be isolated from adipose tissue. It is the immunomodulatory properties of the stromal vascular fraction that make it a promising candidate for the regenerative treatment of OA. Patients with grade 3 and 4 osteoarthritis were treated with the stromal vascular fraction with and without platelet-rich plasma (PRP) and followed up on their Knee Injury and Osteoarthritis Outcome Score (KOOS) score for 12 months, with MRI and subjective evaluation of the procedure. Magnetic resonance imaging (MRI) revealed a widening of the joint space, a restructuring of the cartilage, and an alleviation of effusions in the treated joints. In three of the four treatment groups, a substantial improvement of the KOOS scores was documented at the 12-month follow-up time point. According to the subjective evaluation, 67% of the patients were satisfied or very satisfied with the procedure and would recommend it to others. No serious adverse events or unwanted side effects related to the SVF treatment were observed or reported. Prior to an invasive artificial joint replacement, the treatment of arthritic knee joints with the intraarticular injection of autologous adipose tissue-derived SVF should be considered a regenerative treatment option.

Complex craniofacial wounds (CCW) are those refractory to initial treatment and may involve chronic infection, exposed hardware, irradiated tissue, and soft tissue volume loss. Typical reconstruction with microvascular flaps involves considerable morbidity. While free dermal fat autografting (DFA) is used extensively in many applications, its use treating CCW remains an unexplored but attractive possibility. Data from a retrospective cohort of 34 consecutive patients (13 male; 21 female and aged 2-79-years), who underwent free DFA between 1985 and 2018 for CCW by a single plastic surgeon, were analyzed. Post-operative follow-up was 1-24 years (M = 6.53, SD = 7.91). Many patients had several concomitant wound complications. Primary pre-operative wound complications were dominated by infection (N = 20), of which over 75% (N = 15) were associated with non-autogenic material. Eighteen had resolution of their pre-operative infection. Of the total (N = 34), 79.41% had stable grafts at follow-up [X(3) = 54, P < 0.001], with only 3 experiencing observable atrophy and 1 graft necrosis. Most of the cohort was complication free [X(1) = 7.53, P = 0.006], with 73.53% experiencing no problems involving the graft. Twenty-nine (85.29%) of 34 patients had therapeutic success with free DFA [X(1) = 28.65, P < 0.001]. Pre-operative wound status (β = 1.13, P < 0.001) predicted therapeutic success [R = 0.87, F(7,9) = 8.94, P = 0.002]. While 5 (14.71%) did not have therapeutic success, no additional problems arose related to grafts. Free DFA appears to be beneficial and show low morbidity. Future studies must evaluate these findings. In this context, their use should be considered in recalcitrant craniofacial wounds.

Background: The tear trough is a prominent structure of the midface. Many surgical and nonsurgical techniques have been devised to efface this feature., Objectives: The aim of this study was to define an aesthetically pleasing tear trough and understand the effect of various surgical procedures on its appearance., Methods: We undertook a retrospective review of "ideal" subjects (ie, young men and women as well as male and female models) as well as surgical patients undergoing lower blepharoplasty with fat excision, fat transposition, erbium laser resurfacing of the eyelids and midface, or endoscopic midface lifting. Marginal reflex distance-2, lower eyelid length, and nasojugal fold depth were measured and analyzed for all patients., Results: The nasojugal fold was significantly less prominent in ideal female models than in all other groups (P < 0.0001). Lower eyelid length was significantly shorter after fat excisional lower blepharoplasty, laser resurfacing, and midface lift (P < 0.0001), and did not change after fat transpositional lower blepharoplasty. Postsurgical reduction in lower eyelid length was significantly less with fat transpositional lower blepharoplasty than in all other groups (P < 0.0001). The nasojugal fold was significantly effaced after all types of procedures (P < 0.0001), but was significantly more effaced after fat transpositional lower blepharoplasty (P < 0.01) than after all other procedures., Conclusions: A slight, medial tear trough is present in youth in many patients. The clinical tear trough is a virtual topographic structure distinct from the anatomic tear trough ligament and can be altered in a variety of ways., (© 2019 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

The dielectric characterization of tissue targets of microwave thermal ablation (MTA) have improved the efficacy and pre-procedural planning of treatment. In some clinical scenarios, the tissue target lies at the interface with an external layer of fat. The aim of this work is to investigate the influence of the dielectric contrast between fat and target tissue on the shape and size of the ablation zone. A 2.45 GHz monopole antenna is placed parallel to an interface modelled by fat and a tissue characterized by higher dielectric properties and powered at 30 and 60 W for 60 s. The performances of MTA are numerically investigated considering different interface scenarios (i.e., different widths of fat layer, shifts in the antenna alignment) and a homogeneous reference scenario. Experiments (N = 10) are conducted on ex vivo porcine tissue to validate the numerical results. Asymmetric heating patterns are obtained in the interface scenario, the ablation zone in the target tissue is two-fold to ten-fold the size of the zone in the adipose tissue, and up to four times larger than the homogenous scenario. The adipose tissue reflects the electromagnetic energy into the adjacent tissue target, reducing the heating in the opposite direction.

BACKGROUND Vertical diplopia that follows local anesthesia is usually due to inferior rectus muscle fibrosis. Here, we report a rare case of acquired Brown syndrome following local anesthesia. CASE REPORT A 36-year-old woman underwent right inferior orbital fat decompression under local anesthesia. On the first postoperative day, she developed vertical diplopia. She had left hypertropia, which increased on left gaze, with limitation of elevation of the right eye on attempted adduction. Forced duction test of the right eye revealed resistance on elevation in adduction. Magnetic resonance imaging showed signal alteration, thickening, and irregularity involving the right superior oblique tendon and trochlea region. The diagnosis of iatrogenic Brown syndrome was made. Then, a single dose of 10 mg triamcinolone injection was given near the intratrochlear region. On follow-up, complete resolution of diplopia on primary gaze occurred 12 weeks after the incident. CONCLUSIONS The reported case highlights that local anesthesia carries a risk of Brown syndrome. We believe bupivacaine-induced superior oblique hypertrophy is the underlying mechanism. The patient showed excellent outcome after medical management, with no surgical intervention required after 3 months of follow-up.

Surgical outcomes of 20 patients treated by one surgeon between March 2014 and August 2019 were reviewed retrospectively. The authors included 20 patients with subconjunctival orbital fat prolapse (SOFP) treated by a small-incision, sutureless surgical technique using local anesthesia. All patients were followed for at least 3 months postoperatively. Medical information such as patient's age, number of eyes involved, location of fat, surgical time and whether or not the prolapse recurred was reviewed. Twenty patients (16 men and 4 women) were included and had a mean age of 67.1 years. There were 7 bilateral and 13 unilateral SOFP cases. There were no intra-operative or postoperative complications and no cases of recurrence within a mean follow-up of 3 months. All surgeries were successful from both cosmetic and symptomatic perspectives. Our small-incision, sutureless surgical technique is an effective method to manage SOFP. This technique, performed with local anesthesia, is both cost- and time-effective.

Rigid reconstruction for frontal bone defects not only improves function, but also approximates more normal appearance. However, in cases involving dural scar contractures, a concave deformation remains when rigid reconstruction is performed without compensating for dead space created by swelling of the brain. This study involved 4 cases in which a 2-stage reconstruction procedure was used to first eliminate dead space by grafting dermal fat, and subsequently carry out rigid reconstruction to achieve a natural forehead configuration. This method is advantageous and considered to be effective in allowing dead space to be easily filled with minimal invasiveness for concave deformations of the dura mater with bone defects. Furthermore, the risk of artificial bone exposure is reduced by adding the dermal component of dermal fat, which is grafted to thinned frontal skin.

Background: Important differences in facial anatomy and how faces age must be considered when performing facelifts in Asian populations. Few facelift methods are specifically designed for Asian patients., Objective: This study evaluated the efficacy of lateral superficial muscular aponeurotic system (SMAS)-stacking/SMAS-ectomy with orbicularis-malar fat repositioning., Materials and Methods: Between February 2013 and December 2016, 62 women underwent the evaluated technique and completed the follow-up (15 months, ranging from 3 to 38.5 months). Three blinded, independent observers graded wrinkles, laxity, nasolabial fold depth, malar prominence, and tear trough deformity using quantitative comprehensive grading scales. FACE-Q scale items were assessed, and complications were recorded., Results: The mean postoperative scores for wrinkles, laxity, nasolabial fold depth, malar prominence, and tear trough deformity decreased from 2.64, 2.62, 2.01, 2.06, and 2.40 to 1.48, 1.34, 0.93, 1.21, and 1.27, respectively. The preoperative and postoperative scores differed significantly for all parameters (p < .05). The FACE-Q results showed that the patients were highly satisfied with their appearance, quality of life, adverse effects, and care., Conclusion: The authors' technique allows midfacial and periorbital rejuvenation and offers dual benefits by correcting individual facial asymmetries and reshaping the jowls and neck contour in Asian patients.

A 34-year-old man with Basedow disease consulted us to treat disfiguring proptosis. On examination, the patient showed right lower eyelid retraction and right inferior rectus muscle enlargement, which were consistent with thyroid eye disease. Hertel's exophthalmometric examination demonstrated proptosis of 25.5 and 24.0 mm on the right and left sides, respectively. Computed tomography (CT) images revealed absence of the sphenoid door jamb. To correct both exorbitism and exophthalmos, the patient underwent bilateral "shallow" decompression of the lateral and medial orbital walls with orbital fat removal under general anesthesia. The authors removed 2.5 and 1.0 mL of orbital fat from the inferolateral quadrant of the right and left orbits, respectively. At 3 months postoperatively, based on the measurements of the axial globe position on sagittal CT images, postoperative proptosis reductions of 7.5 and 6.5 mm were observed on the right and left sides, respectively.

Background: Modern microsurgical reconstruction aims to achieve functional and satisfactory esthetic outcome and the primary thinning procedure results in one-stage reconstruction. However, current techniques are lacking preoperative knowledge of the peripheral perforator in the adipose layer. We hypothesized that the combination of the knowledge of microvasculature and visualization of such small vessels in the adipose layer by Color Doppler ultrasonography (CDU) will make the dissection of these vessels with simultaneous flap thinning of the perforator branch flap technique feasible and provide consistent results in variety of flaps., Methods: Retrospective chart review of consecutive cases in which perforator branch flap technique was used from 2011 to 2019 was conducted. Entire course of branch of the perforator in the adipose layer were traced up to the dermis by CDU, and marked on the skin surface. Based on CDU finding, perforator branches were dissected in the adipose layer simultaneously with the primary thinning of the skin flap., Results: Thirty perforator branch flaps in 28 cases were elevated. Courses of the perforator branches detected by CDU accurately corresponded to surgical findings in all cases. There was no total flap loss in any of the cases and partial necrosis in one case. In five flaps, a secondary debulking procedure was needed., Conclusions: The combination of knowledge of microvasculature with CDU guidance has made the perforator branch technique possible and allowed to safely transfer the skin flap from various body areas to the defect, thereby, achieving "like with like" reconstruction in one-stage., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Hemangiomas are relatively rare tumors representing approximately 0.4% of all the salivary gland tumors and occur predominantly in the parotid. Most of the hemangiomas appear during the first year of life; however, are uncommon in adults. Moreover, the rich fat hemangiomas in the parotid are extremely rare. Magnetic resonance imaging is the most important radiologic methods for the diagnosis of the disease as its high resolution of soft tissue which helps to show the relationship with the adjacent structures.

Two patients with malignant lymphoma in the medial area of the upper eyelid mimicking medial fat pad prolapse have been reported. Both of them did not notice any eyelid/orbital mass before presentation to us. They were managed with a complete excisional biopsy of the mass, respectively. In both the patients, pathologic results were compatible with extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. Neither any other lesion was detected nor any recurrence was seen, without the need of further treatment in either of them. Although the medial fat pad prolapse can be easily diagnosed by inspection only, the results of our study elucidate the importance of palpation for its definite diagnosis.

Background: Bronchial sleeve lobectomy is essential surgical approach to treat centralized lung cancer. It is the best reflected the principle of lung cancer surgery, "remove tumor completely while minimize pulmonary function loss". Bronchial pleural fistula (BPF) is not common but very severe complication of bronchial sleeve lobectomy, that is usually fatal. Present article is to explore clinical effect on prevention of bronchial pleural fistula (BPF) in bronchial sleeve lobectomy, by wrapping brachial anastomosis with pedicled pericardial fat flap., Methods: Clinical data of 39 non-small cell lung cancer (NSCLC) patients who underwent surgical resection during January 2016 to May 2019 in Lung Cancer Center of West China Hospital, Sichuan University were collected and retrospectively analyzed. All of the patients underwent bronchial sleeve lobectomy and a brachial anastomosis wrapping with pedicled pericardial fat flap., Results: All patients recovered well and were discharged within 6 d-14 d after operation. No BPF occurred, nor other severe complications, such as reoperation needing intrathoracic bleeding, several pneumonia and respiratory failure, and life threatening cardiac arrhythmia. Only one patient (1/39) had several anastomotic stenosis and consequential atelectasis of residual lung in operative side 6 months after surgery., Conclusions: Wrapping bronchial anastomosis with pedicled pericardial fat flap in bronchial lobectomy for centralized NSCLC is a simple and effective approach to prevent BPF, thus safety of the operation could be significantly improved.

There is still no unified standardized or optimal procedure for lipoaspirate purification and we explored the optimal parameters of 3 purification techniques and compared their efficiencies and effects on the metabolic activity of adipose tissue. The purification efficiency of each technique was compared by analyzing the composition ratio of the processed compounds. The effects of the purification techniques on the dynamic metabolic activity of adipose tissue were evaluated in vitro using the glucose transfer assay. We found that the cotton pad adsorption technique displayed the greatest ability to remove aqueous and oil fractions, followed by centrifugation and sedimentation techniques (P < 0.01). The in vitro metabolic activity of adipose tissue peaked at 4 hours. The glucose transfer rates in the cotton pad group and the sedimentation group were significantly higher (P < 0.05) than that of the centrifugation group, and the centrifugation method exerted the greatest effect on the metabolic activity of adipose tissue. To sum up, the optimal processing parameters were the following: sedimentation technique, 30 minutes of sedimentation; centrifugation technique, 3 to 5 minutes of centrifugation and centrifugation force of 200 g; and cotton pad adsorption technique, contact area of 5 cm/mL and contact time of 5 minutes. The cotton pad adsorption technique yielded the best purification of the aqueous and oil fractions, followed by the centrifugation technique, whereas the sedimentation technique exhibited the lowest efficiency. The in vitro metabolic activity of adipose tissue peaked at 4 hours, and the cotton pad and sedimentation technique exerted decreased effects on metabolic activity than the centrifugation technique.

Purpose: The aim of this study was to evaluate the effect of buccal fat pad (BFP) in the palatoplasty and to investigate the risk factors associated with postoperative palatal fistula formation., Materials and Methods: Sixty-five cleft palate patients were enrolled for this study. Clinical data regarding sex, age, type of cleft, surgical technique, the ratio of cleft width, and BFP graft were collected. The ratio of cleft width was measured and calculated using preoperative clinical photographs. In 36 patients, the BFP was harvested and grafted on the cleft palate to prevent palatal fistula formation. The patients were followed up, the incidence of fistula formation was investigated, and the risk factors related with the fistula were evaluated., Results: Four patients had postoperative palatal fistula and were not BFP grafted during operation. The BFP graft and ratio of cleft width are significant factors in palatal fistula formation (P = .035, .003). There was a significant difference in the ratio of cleft width between the normal and fistula groups (P = .006). In the logistic regression analysis, there was significant association between high ratio of cleft width and palatal fistula formation in the no BFP group (odds ratio; 11.15, P = .036)., Conclusions: The ratio of cleft width and BFP graft was a significant factor in palatal fistula formation. The BFP graft is a reliable procedure to prevent palatal fistula formation and increase the success of palatoplasty.