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Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31

Contents lists available at ScienceDirect

Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology

journa l homepage: www.e lsev ier .com/ locate / jomsmp

linical observation

pplication of the buccal fat pad in oral and maxillofacial reconstruction: Reviewf 35 cases

irendra Singha,∗, Amrish Bhagola, Ish Kumarb, Rahul Dhingraa

Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak 124001, Haryana, IndiaDepartment of Oral and Maxillofacial Surgery, Dental College and Hospital, Sirsa, Haryana, India

r t i c l e i n f o

rticle history:eceived 29 January 2011eceived in revised form 27 March 2011ccepted 9 May 2011

a b s t r a c t

The buccal fat pad has been frequently used for the closure of oroantral and oronasal communications.There are a few studies in the literature reporting its use in defects secondary to cyst and tumoral resec-tions. In this paper we consider both the anatomical basis and the surgical technique. We also review 35

vailable online 17 June 2011

eywords:uccal fat padroantral communications

cases treated using BFP; 18 patients with oroantral communications, 10 with residual cystic defects, 5with tumoral resections and in 2 for interpositional lining material in TMJ ankylosis. In all the patients,the defect was adequately repaired. There was partial loss of the flap in one case. It is an acceptable typeof reconstruction, versatile and of a simple surgical technique. However, its use is limited to small ormedium defects, being sometimes scarce.

© 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights

ystic defects

. Introduction

The buccal fat pad (BFP) was mentioned for the first time byeister in 1732 and better described by Bichat in 1802. Its use as aedicle graft, was first reported by Egyedi [1] and its embryology,ascularization, volume and function being studied by Tidemant al. [2], Marx [3] and other authors [4–6].

BFP has many possible functions: filling and allowing slip-age of fascial spaces between mimetic muscles; enhancementf intermuscular motion, separating muscles of mastication fromne another; to counteract negative pressure during suction in theewborn; protection and cushion of neurovascular bundles from

njuries.Literature reports have illustrated that the BFP can be used as a

edicled graft for the closure of various defects of oral cavity [5,7].hese defects ranges from oroantral and oronasal communications,efects secondary to maxillary cysts and intraoral tumor resections,osterior fistula in cleft patients, covering of bone transplants inugmentation procedure and in TMJ reconstruction. The rationaleor using fat as an interpositional graft following gap arthroplasty iso fill the ample tissue in the dead space left within the joint cavityollowing osteoarthrectomy. The BFP has more recently achieved a

reat importance in the field of aesthetic facial surgery with spe-ial regard to the modification of facial contours and the malarrominence [5,7,8].

∗ Corresponding author. Tel.: +91 011 9896326781; fax: +91 011 1262 213876.E-mail address: drvirendrasingh1@yahoo.co.in (V. Singh).

915-6992/$ – see front matter © 2011 Asian Association of Oral and Maxillofacial Surgeoi:10.1016/j.ajoms.2011.05.001

reserved.

Various local methods have been successfully employed forintraoral reconstruction as tongue flaps, temporal muscle, oralmucosal flaps or myomucosal island flap. Nowadays, use of BFP hasbecome very popular, above all for the closure of oroantral commu-nications [1,2,9,10], as a single layer [9], with free skin grafts [1], oreven covered by lyophilized porcine dermis. There are a few seriesdealing with the reconstruction of defects secondary to maxillarycysts and intraoral tumor resections [2,10,11].

The aim of this paper is to show the results in a series where thebuccal fat pad was employed for the reconstruction of various oraldefects.

2. Patients and methods

Between June 2007 and August 2009, the buccal fat pad was usedto reconstruct oral defects in 35 patients ranging in age from 12 to55 years. There were 26 men and 9 women. In all cases a postsurgi-cal follow-up of at least 6 months, was carried out. The indicationsfor the use of the buccal fat pad and the location of the reconstructedregion are presented in Tables 1 and 2. Of the 18 patients withoroantral communications, 12 underwent primary closure with thebuccal fat pad; 6 patients were treated with the buccal fat pad afteran unsuccessful closure with a buccal advancement flap. Residualcystic defects were reconstructed in 10 patients. Neoplastic resec-tions in which the buccal fat pad was used for closure included

2 pleomorphic adenomas, 1 mucoepidermoid tumor, 1 giant celltumor, and 1 hemangioma. The location of the tumor defect wasthe hard palate in 3 patients; 1 patient had a tumor in maxilla, and1 patient had a hemangioma in the cheek mucosa. The size of the

ons. Published by Elsevier Ltd. All rights reserved.

28 V. Singh et al. / Journal of Oral and Maxillofacial Surg

Table 1Showing indications for surgery.

Indications No. of patients

OAF 18Tumor resection 5Cystic defects 10Interpositional material in TMJ ankylosis 2

Table 2Showing location of defect in patients.

Location of the defects No. of patients

Alveolar crest and maxilla 18Hard palate 3Buccal mucosa 1Retromolar region mandible 4

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Vestibular sulcus 7TMJInterpositional material 2

efect to be reconstructed ranged from 1 cm × 1 cm to 4 cm × 5 cm.n 2 patient of TMJ ankylosis, BFP was used as Interpositional lining

aterial.

.1. Surgical technique

The buccal fat pad was exposed by a 2 cm horizontal vestibu-ar incision extending backwards from above the maxillary second

olar tooth. Blunt dissection through the buccinator and loose sur-ounding fascia, allowed the buccal fat pad to herniate into the

outh (Fig. 1). However, in neoplasm cases the buccal fat pad

ecame exposed into the defect after resection of the tumor. Theody of the buccal fat pad and the buccal extension were gentlyobilised by blunt dissection, taking care not to disrupt the deli-

ig. 1. Shows application of BFP in closure of oroantral communication; (A) Showing oroasing BFP; (D) Showing 3 month follow up of the same patient.

ery, Medicine, and Pathology 24 (2012) 27–31

cate capsule and vascular plexus and to preserve as wide a base aspossible. Pressure on the cheek helped to express the fat into themouth. After the pad had been dissected free from the surround-ing tissues, it was grasped with vascular forceps, gently teased out,advanced, and expanded over the defect. The pad was sutured tothe mucosal edges with 3/0 polyglactin (Vicryl), ensuring that itwas not under excessive tension.

In TMJ reconstruction, for exploration of buccal fat pad the coro-noid process was exposed by extending the dissection anteriorlyin the subperiosteal plane (using Al-Kayat Bramley incision). Aperiosteal elevator was inserted at its anterior border for retrac-tion. Coronoidectomy was carried out at this stage when indicated.The main body of buccal pad fat and its temporal extension liesin close proximity to coronoid process and temporalis muscletendon. An incision was given through the periosteum and fas-cial envelope of BFP and blunt dissection was done with a finecurved artery forceps to expose the yellowish colored buccal fat.Further blunt dissection of tissues surrounding the BFP was doneto gently pull out the emergent part and it was herniated intothe defect with little teasing and applying some external pres-sure over the cheek. Mechanical suction was avoided once the BFPwas exposed. The tension free BFP was packed around the TMJ tofill the dead space and one or 2 sutures were given just anteriorto the external auditory meatus to secure the position of the BFP(Figs. 2–4).

3. Results

In all the patients, the defect was adequately repaired. There

was partial loss of the flap in one case where it was employed torepair an oroantral communication. Definitive closure was done bya second surgical procedure with a local mucosal flap. In all theflaps, the BFP epithelization process started during the first week,

ntral communication; (B) Showing harvesting of BFP; (C) Showing closure of defect

V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31 29

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Fig. 4. Shows postoperative photograph in same patient of TMJ ankylosis.

Table 3Showing masterchart for the patients.

No. Age Sex Indication Follow up Complication

1 28 M Cystic defects 6 Months None2 26 M Cystic defects 8 Months None3 42 F OAF 6 Months None4 35 M OAF 6 Months None5 40 M OAF 6 Months None6 12 M Cystic defects 9 Months None7 33 F OAF 6 Months None8 37 M OAF 6 Months None9 22 M Cystic defects 7 Months None

10 55 F Tumor resection 9 Months None11 47 M OAF 6 Months None

Fig. 2. Shows preoperative photograph in a patient of TMJ ankylosis.

nd was complete by 4–5 weeks. No local infections were noticedTable 3).

Satisfactory results were achieved in both of the patients whereFP was used as interpositional material for TMJ reconstruction. Noomplications were noticed at the latest follow up in any of theseatients.

We found that the pedicled buccal fat pad could cover maxillaryefects as far anteriorly as the canine tooth region and up to butot beyond the midline of the palate. Posteriorly, the tuberosityegion, soft palate, and retromolar area were all easily reached byhe pad. Buccal fat pad could also reach the TMJ region using theame incision; that was given for release of ankylotic mass (Al-ayat Bramley incision).

Fig. 3. Shows interposition of BFP.

12 17 M TMJ ankylosis 8 Months None13 50 M OAF 6 Months None14 25 M Cystic defects 8 Months None15 30 M OAF 6 Months None16 29 F Cystic defects 6 Months Partial loss17 34 M OAF 6 Months None18 46 M OAF 6 Months None19 52 F Tumor resection 9 Months None20 40 M OAF 6 Months None21 30 M Cystic defects 6 Months None22 18 M Tumor resection 7 Months None23 28 M Cystic defects 6 Months None24 49 M OAF 6 Months None25 41 M OAF 6 Months None26 25 M Cystic defects 6 Months None27 30 M OAF 6 Months None28 19 F TMJ ankylosis 7 Months None29 33 F Tumor resection 6 Months None30 37 M OAF 6 Months None31 28 F Cystic defects 8 Months None32 36 M OAF 6 Months None33 32 M OAF 6 Months None34 31 M Tumor resection 6 Months None35 45 F OAF 6 Months None

OAF – oroantral fistula.

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. Discussion

Buccal fat pad was considered a surgical nuisance for many yearsecause of its accidental encounter during various operations in theterygomandibular area such as tumor, orthognathic, or traumaurgeries. Egyedi [1] in 1977 first reported the use of pedicled BFPor closure of post-surgical maxillary defects. Since then, BFP hasecome a popular option among surgeons worldwide for the recon-truction of small to medium acquired or congenital soft tissue andone defects in the oral cavity.

Successful closure of OAF with buccal fat pad is widelyeported in the literature [9,13–15]. Stajcic [9] reported the usef pedicled BFP in the closure of oronasal and oroantral com-unications following extractions in 56 patients with excellent

esults. Despite postoperative infection in 1 patient and partialecrosis in 2 patients, all his flaps were reported to be success-

ul.In another report by el-Hakim and el-Fakharany [15] the use of

edicled BFP was compared with palatal rotation flap in closuref antral communication and palatal defects resulting from tumoresection. They found BFP to be consistently successful, preservinghe normal anatomical architecture of the oral mucosa. No denudedrea requiring secondary granulation was required as in the casef palatal flaps. Pedicled BFP is also considered as a reliable back-p procedure in the event of failure of other techniques [14,15].ur case series also supported the same facts. Yilmaz et al. [13],andolfi et al. [16] and Dolanmaz et al. [17] also reported goodesults with the use of BFP in the closure of oroantral/oronasalommunications.

Pedicled buccal fat pad has also been employed in the closuref surgical defects following tumor excision [14], excision of leuko-lakia and submucous fibrosis [18,19] as well as closure of primarynd secondary palatal clefts [20,21] and coverage of maxillary andandibular bone grafts [22,23].The complication regarding use of BFP ranges between 3.1%

nd 6.9% in literature [14,24–26]. These include partial necro-is, infection, excessive scarring, excessive granulation and sulcusbliteration. In our case series, complication was observed in onlypatient (0.04%).

There have been reports on the closure of defects up to0 mm × 50 mm × 30 mm [2,10]. Assuming the calculated BFP vol-me is 10 ml and its lowest thickness is 6 mm [1,5,6], the closuref larger defects cannot be guaranteed without producing flapecrosis or creating a new fistulae. The largest defects covered

n our study were a 40 mm × 50 mm. Complete epithelization ofhe BFP was observed after 4–5 weeks of inset in our patients.his is in agreement with the established facts in the literature14,24,27].

Egyedi [1] recommended coverage of the exposed BFP with akin graft and Fujimura et al. [10] recommended using lyophilisedorcine dermis to cover the buccal fat pad, which allowed stretchedads that showed some perforations to heal without complica-ions. However, our series confirmed the findings of other previouseports that epithelization of the flap does take place with-ut split skin graft cover [13,16,24,27] after 3–4 weeks of inset14,24,27].

Due to its anatomical situation, the ideal defects to be recon-tructed with a BFP are the maxillary defects, from the premolarrea to the posterior tuberosity. Also soft and hard palate, supe-ior alveolar rim, cheek mucosa and tonsilar fossa, are suitablelaces to be employed, as suggested by other authors. We alsoound that the pedicled buccal fat pad could cover maxillary defects

s far anteriorly as the canine tooth region and up to but noteyond the midline of the palate. Posteriorly, the tuberosity region,oft palate, and retromolar area were all easily reached by thead.

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ery, Medicine, and Pathology 24 (2012) 27–31

We also used buccal pad of fat in temporomandibular jointreconstruction. The rationale for using fat as an interpositional graftfollowing gap arthroplasty is first to fill the ample tissue in thedead space left within the joint cavity following osteoarthrectomy.Secondly it prevents direct contact between the cut bony surfaceand glenoid fossa and thus prevents heterotopic ossification (HO)within the TMJ. HO is recognized as a major postoperative com-plication after gap arthroplasty. We observed satisfactory resultsin both the patients and no complication in terms of reankylosiswas observed at the latest followup. We are keeping our patientson regular followup. The results of the present study in usingBFP in TMJ reconstruction are only the preliminary results andto actually assess the efficacy of BFP as an Interpositional mate-rial in TMJ reconstruction, a long-term prospective study shouldbe done.

Finally, we conclude that BFP seems to be one of the safest recon-structive methods for closure of oroantral communications/fistula,followed by reconstruction of maxillary defects; coverage ofmucosal defects, etc. being other uses and can also be utilizedin TMJ reconstruction. The easy mobilization of the BFP and itsexcellent blood supply and minimal donor site morbidity makesit a flap of choice. The size limitation of the BFP must be knownto permit successful outcome. It should also be considered as areliable back-up procedure in the event of failure of other tech-niques as demonstrated by this case series. The results havebeen encouraging for clinicians to make use of potential bene-fits of the BFP in closure of defects in the oral and maxillofacialregion.

References

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