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Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis
lnL J. Oral Maxillofac. Surg. 1996; 25:130-133
Copyright 9 Munksgaard 1996
Printed in Denmark. All rights reserved
lnternationatJoumalof
Oral& MaxofacialSurgery ISSN 0901-5027
Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis
Chin-Jyh Yeh Clinic of Oral and Maxillofacial Surgery, Mackay Memorial Hospital, Taitung, Taiwan
C.-Y. Yeh: Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int. J. Oral Maxillofac. Surg. 1996; 25: 130-133. 9 Munksgaard, 1996
Abstract. The pedicled buccal fat pad has been widely used for the repair of oral defects. A new application of this flap in the treatment of patients suffering from trismus caused by oral submucous fibrosis is reported. The patients underwent incision of the fibrotic bands and coverage of the buccal defect with a pedicled buccal fat pad flap. The surgical technique is described, and the results suggest that this is a logical, convenient, and reliable technique for the treatment of oral submucous fibrosis.
The buccal fat pad (BFP) is a supple and lobulated mass, easily accessible and mobilized. In recent years, it has become a well-accepted graft for covering intraoral defects 5't3A8. EGYEDI 3 w a s the first to report on the application of the BFP as a pedicled graft lined with a split-thickness skin graft for the closure of oroantral and oronasal communications. NEDERs described the use of BFP as a free graft to cover intraoral defects. TIDEMAN et al. 16 reported that the BFP graft is epithelialized within 2-3 weeks, thus making the graft easy to apply. The anatomy of the BFP and its clinical significance have been studied by TIDEMAN et al. 16, DUBIN et al.2, and STUZINet al. 15, and the results of the studies support the clinical application of the BFP. Oral submucous fibrosis (OSF) is a chronic progressive disease of the oral cavity and has been defined as an insidious, chronic, fibrotic change in the oral mucosa H. In the late stages, mouth opening is limited by severe scarring which causes trismus; this may be treated surgically or nonsurgically, with usually unpredictable results. PINDBORG SIRSAT11 regarded OSF as an impor-
tant precancerous lesion. Surgical treatment is the method of choice in patients with marked limitation of mouth opening, but has been reported to give rise to varying results 1'6'7"9"14. The BFP is mainly used to cover defects in the posterior maxilla, the buccal region, the hard palate, the soft palate, and the retromolar and pterygomandibular regions after tumor resection, and oroantral communications after tooth extraction. The purpose of this study was to present a new application of BFP to the surgical treatment of OSF in nine patients. Material and methods
Twenty-six patients with histopathologically proven OSF were treated surgically by the author in 1984-95 at the Clinic of Oral and Maxillofacial Surgery, Mackay Memorial Hospital, Taiwan. Twelve patients were treated by cutting the fibrotic bands only, while five were also treated with a splitthickness skin graft. Nine patients (eight men and one woman), age range 25-59 years, treated in 1992-5, are included in this study. All patients had marked trismus, with involvement of the muscle layer. The defects in the huccal area were grafted with a pedi-
Key words: buccal fat pad; oral submucous fibrosis; surgical treatment. Accepted for publication 18 October 1995
cled BFP. The patients were followed up for 10-38 months. Patient evaluation included: 1) the preoperative amount of mouth opening; 2) the intraoperative mouth opening; and 3) the postoperative mouth opening. The mouth opening was measured from the edges of the first central incisors. Method
The operations were performed under general anesthesia with nasal intubation. The incisions were made with an electrosurgical knife along each side of the buccal mucosa at the level of the occlusal plane away from the Stenson's orifice. They were carried posteriorly to the pterygomandibular raphe or anterior pillar of the fauces and anteriorly as far as the corner of the mouth, depending upon the location of the fibrotic bands which restricted mouth opening. These fibrotic bands were always detectable by palpation. The wounds created were further freed by manipulation until no restrictions were felt. The mouth was then forced open with a mouth opener to an acceptable range of approximately 35 mm. The coronoid processes were approached from the wounds created and resected if a 35-mm mouth opening could not be achieved. A mouth opening of 35 mm as measured from the incisor edges was considered to be the minimum acceptable opening in an adult4. Bilateral
BFP in oral submucous fibrosis buccal defects of from 3.5x2.0 to 5.5x3.0 cm were covered with BFP grafts after hemostasis. The BFP was approached via the posterior-superior margin of the created buccal defect, and then dissected with an index finger. The BFP was teased out gently until a sufficient amount was obtained to cover the defect without tension. The BFP was then secured in place with horizontal mattress sutures (Fig. 1A). The same procedure was performed on the other site. The BFP covered the buccal defects posteriorly to the soft palate, and anteriorly to the cuspid region. The remaining defect was left for secondary epithelialization or was covered with local flaps. All patients received prophylactic anti-
biotics and a liquid diet for 1 week. Mouthopening exercises started within 36 h postoperatively, and intensive exercise was continued daily for at least 3 months. Daily exercise should last as long as 1 year.
Results The results were found to be satisfactory in all but two patients, as shown in Table 1. In nine patients, the range of the preoperative m o u ~ opening was 8 16 m m (mean: 12.1 mm). As a result of a successful surgical procedure, the size of the intraoperative mouth opening ranged from 35 to 40 mm. The patients
131
were discharged 5-7 days after the operation. The range of the mouth opening measured at that time was 28-36 mm. The pedicled grafts took uneventfully and epithelialized in 3-4 weeks (Fig. 1B). Two patients (cases 5 and 9) failed to exercise several times daily, and finally experienced a significant relapse. The remaining patients did cooperate and exercised daily, and the results were satisfactory (Fig. 2). The postoperative mouth-opening range was 16-38 m m (mean: 31.2 mm) over a follow-up period of 10-38 months (mean: 21.3 months). The average increase of the mouth opening was 19.1 mm.
:i
J
2A Fig. 1. Coverage of buccal defect with pedicled buccal fat pad graft (A); buccal fat is epithelialized 4 weeks postoperatively (B). Fig. 2. Case 1 preoperatively (A) (8-mm opening), and (B) 38 months postoperatively (35-mm opening).
132
Yeh
Table 1. Results of treatment Preoperative Intraoperative Spontaneous Late Duration of Case Age spontaneous opening opening at spontaneous observation no. (years) Sex opening ( f o r c e d ) d i s c h a r g e opening (months) 1
25
M
8
2 3 4 5 6 7 8 9
59 46 26 30 43 35 52 41
F M M M M M M M
16 14 12 15 14 12 10 8
34 36 35 37 34 35 36 36 40
Discussion
Submucous fibrosis is an insidious, chronic disease which may affect any part of the oral cavity and sometimes the pharynx, leading to stiffness of the oral mucosa, and causing trismus 11'12. This disease is most frequently found in India, and is not uncommon in Southeast Asia (southern China, Taiwan, Malaya, Singapore, Indonesia, Vietnam, and Thailand). It has also been reported from other countries, and it is no longer considered to occur exclusively in Indians and Southeast Asians, as immigration has resulted in a worldwide distribution. Betel nut chewing appears to be the main factor correlating with this disease. Most patients complain of an irritable oral mucosa during the early stage of the disease, especially when spicy foods are eaten. Clinically, there are erosions and ulcerations. Subsequently, the oral mucosa becomes blanched and loses its elasticity, and vertical bands occur in the buccal mucosa, the retromolar area, the soft palate, and the pterygomandibular raphe. A fibrotic ring forms around the entire rima otis. Some patients have difficulty in whistling and tongue movement. The literature contains few references to the successful treatment of OSE Various treatments to improve mouth opening have been attempted, including surz gical el~mination of the fibrotic bands, Mtt have been reported as generally uns~sfactory or impossible1~ YEN 17 was the first to succeed in coveting the buccal defect with a split-thickness skin graft~n treating a case of OSF. KHANNA & Ar~RADE6 recently reported the new surgical technique of covering the buccal defects with a palatal island flap in combination with temporalis myotomy
30 36 34 38 36 36 32 30 29
35 34 31 36 25 37 33 43 16
38 30 26 25 20 19 18 13 10
and coronoidectomy. They had applied it to 35 patients with good results. The main mass of the BFP occupies the buccal space bound medially by the buccinator muscle and laterally by the masseter muscle, and rests on the periosteum that covers the posterior buccal aspect of the maxilla. The BFP has a constant blood supply through the small branches of the facial artery, the internal maxillary artery, and the superficial temporal artery and vein by an abundant net of vascular anastomoses2'~5a6. On average, the volume is 9.6 cc (range 8.3-11.9 cc) 15. Defects up to 3x5 cm can be closed with a BFP alone without compromising the blood supply 16. The buccal extension and the main body of the fat pad are in close proximity to the buccal defect, and may be approached through the same incision. In addition, the buccal fat pad pedicled flap can cover the whole surgical defect and not only the superficial thin layer seen in split-thickness skin graft. The BFP also improves the physiologic functions of the cheek after the operation; e.g., suppleness and elasticity. With this technique, there is no need for a second operation site. The pedicled BFP graft is well vascularized, and is more resistant to infection than other kinds of free graft. Therefore, normal eating can begin after the surgical treatment. Patients can be discharged 5-7 days after the operation. Early and intensive postoperative mouth-opening exercises are very important to achieve adequate mouth opening afterward. Two patients did not cooperate and both had significant relapse. The grafted BFP became rigid from fibrotic change. The results demOnstrated that postopera[ive mouth opening in the remaining seven patients, who had performed adequate mouth-
opening exercises, were satisfactory. Routine temporalis myotomy, and coronoidectomy6 seemed to be unnecessary in all cases. The softness and elasticity of the buccal tissue had improved. Symptoms such as painful ulceration, burning sensation, and intolerance to spices had been eliminated in most patients. Acknowledgment. I would like to thank Mr R. E. Broadberry for assistance in correcting the English.
References 1. CANNIFFJP, HARVEYW, HARRISM. Oral submucous fibrosis: its pathogenesis and management. Br Dent J 1986: 160: 42934. 2. DuBn~B, JACKSONIT, HALIMA, TRIPLETT WW, FERREmAM. Anatomy of the buccal fat pad and its clinical significance. Hast Reconstr Surg 1989: 83: 257-62. 3. EGYEDIP. Utilization of the buccal fat pad for closure of oro-antral and/or oronasal communications. J Max-Fac Surg 1977: 5: 241-4. 4. FREIHOFERHPM. Restricted opening of the mouth with an extra-articular cause in children. J Cranio-Max-Fac Surg 1991: 19: 289-98. 5. Ho KH. Repair of palatal defects with inclined buccal fat pad graft. Oral Surg 1988: 65: 523-5. 6. KHANNAJN, ANDRADENN. Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995: 24: 433-9. 7. MORAWETZG, KATSIKERISN, WEINBERG S, LISTROMR. Oral submucous fibrosis. Int J Oral Maxillofac Surg 1987: 16: 609-14. 8. NEDER A. Use of buccal fat pad for grafts. Oral Surg 1983: 55: 349-50. 9. OLIVER AJ, RADDEN BG. Oral submucous fibrosis. Case report and review of the literature. Aust Dent J 1992: 37: 31-4. 10. PAISSATDK. Oral submucous fibrosis. IntJ Oral Surg 1981: 10: 307-12. 11. PINDBORG JJ, SIRSAT SM. Oral submucous fibrosis. Oral Surg 1966: 22: 764-79. 12. PINDBORGJJ, BHONSLERB, MURTIPR, GUPTAPC, DAFrARYDK, MEHTAFS. Incidence and early forms of oral submucous fibrosis. Oral Surg 1980: 50: 40-4. 13. SAMMAN N, CHEUNGLK, TmEMANH. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993: 22: 2-6. 14. SIMPSONW. Submucous fibrosis. Br Dent J 1969: 6: 196-200. 15. STUZlN JM, WAGSTROML, KAWAMOTO
BFP in oral submucous fibrosis HK, BAKERTJ, WOLFESA. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990: 85: 29-37. 16. TIDEMANH, BOSANQUETA, SCOTTJ. Use of the buccal fat pad as pedicled graft. J Oral Maxillofac Surg 1986: 44: 435--40.
17. YEN DJC. Surgical treatment of submucous fibrosis. Oral Surg 1982: 54: 269-71. 18. STAJClCZ. The buccal fat pad in the closure of oro-antral communications: a study of 56 cases. J Cranio-Max-FacSurg 1992: 20: 193-7.
133
Address:
Dr Chin-Jyh Yeh Clinic of Oral and Maxillofacial Surgery Mackay Memorial Hospital 1, Land 303, Chang-Sha Street, Taitung Taiwan
Copyright 9 Munksgaard 1996
Printed in Denmark. All rights reserved
lnternationatJoumalof
Oral& MaxofacialSurgery ISSN 0901-5027
Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis
Chin-Jyh Yeh Clinic of Oral and Maxillofacial Surgery, Mackay Memorial Hospital, Taitung, Taiwan
C.-Y. Yeh: Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int. J. Oral Maxillofac. Surg. 1996; 25: 130-133. 9 Munksgaard, 1996
Abstract. The pedicled buccal fat pad has been widely used for the repair of oral defects. A new application of this flap in the treatment of patients suffering from trismus caused by oral submucous fibrosis is reported. The patients underwent incision of the fibrotic bands and coverage of the buccal defect with a pedicled buccal fat pad flap. The surgical technique is described, and the results suggest that this is a logical, convenient, and reliable technique for the treatment of oral submucous fibrosis.
The buccal fat pad (BFP) is a supple and lobulated mass, easily accessible and mobilized. In recent years, it has become a well-accepted graft for covering intraoral defects 5't3A8. EGYEDI 3 w a s the first to report on the application of the BFP as a pedicled graft lined with a split-thickness skin graft for the closure of oroantral and oronasal communications. NEDERs described the use of BFP as a free graft to cover intraoral defects. TIDEMAN et al. 16 reported that the BFP graft is epithelialized within 2-3 weeks, thus making the graft easy to apply. The anatomy of the BFP and its clinical significance have been studied by TIDEMAN et al. 16, DUBIN et al.2, and STUZINet al. 15, and the results of the studies support the clinical application of the BFP. Oral submucous fibrosis (OSF) is a chronic progressive disease of the oral cavity and has been defined as an insidious, chronic, fibrotic change in the oral mucosa H. In the late stages, mouth opening is limited by severe scarring which causes trismus; this may be treated surgically or nonsurgically, with usually unpredictable results. PINDBORG SIRSAT11 regarded OSF as an impor-
tant precancerous lesion. Surgical treatment is the method of choice in patients with marked limitation of mouth opening, but has been reported to give rise to varying results 1'6'7"9"14. The BFP is mainly used to cover defects in the posterior maxilla, the buccal region, the hard palate, the soft palate, and the retromolar and pterygomandibular regions after tumor resection, and oroantral communications after tooth extraction. The purpose of this study was to present a new application of BFP to the surgical treatment of OSF in nine patients. Material and methods
Twenty-six patients with histopathologically proven OSF were treated surgically by the author in 1984-95 at the Clinic of Oral and Maxillofacial Surgery, Mackay Memorial Hospital, Taiwan. Twelve patients were treated by cutting the fibrotic bands only, while five were also treated with a splitthickness skin graft. Nine patients (eight men and one woman), age range 25-59 years, treated in 1992-5, are included in this study. All patients had marked trismus, with involvement of the muscle layer. The defects in the huccal area were grafted with a pedi-
Key words: buccal fat pad; oral submucous fibrosis; surgical treatment. Accepted for publication 18 October 1995
cled BFP. The patients were followed up for 10-38 months. Patient evaluation included: 1) the preoperative amount of mouth opening; 2) the intraoperative mouth opening; and 3) the postoperative mouth opening. The mouth opening was measured from the edges of the first central incisors. Method
The operations were performed under general anesthesia with nasal intubation. The incisions were made with an electrosurgical knife along each side of the buccal mucosa at the level of the occlusal plane away from the Stenson's orifice. They were carried posteriorly to the pterygomandibular raphe or anterior pillar of the fauces and anteriorly as far as the corner of the mouth, depending upon the location of the fibrotic bands which restricted mouth opening. These fibrotic bands were always detectable by palpation. The wounds created were further freed by manipulation until no restrictions were felt. The mouth was then forced open with a mouth opener to an acceptable range of approximately 35 mm. The coronoid processes were approached from the wounds created and resected if a 35-mm mouth opening could not be achieved. A mouth opening of 35 mm as measured from the incisor edges was considered to be the minimum acceptable opening in an adult4. Bilateral
BFP in oral submucous fibrosis buccal defects of from 3.5x2.0 to 5.5x3.0 cm were covered with BFP grafts after hemostasis. The BFP was approached via the posterior-superior margin of the created buccal defect, and then dissected with an index finger. The BFP was teased out gently until a sufficient amount was obtained to cover the defect without tension. The BFP was then secured in place with horizontal mattress sutures (Fig. 1A). The same procedure was performed on the other site. The BFP covered the buccal defects posteriorly to the soft palate, and anteriorly to the cuspid region. The remaining defect was left for secondary epithelialization or was covered with local flaps. All patients received prophylactic anti-
biotics and a liquid diet for 1 week. Mouthopening exercises started within 36 h postoperatively, and intensive exercise was continued daily for at least 3 months. Daily exercise should last as long as 1 year.
Results The results were found to be satisfactory in all but two patients, as shown in Table 1. In nine patients, the range of the preoperative m o u ~ opening was 8 16 m m (mean: 12.1 mm). As a result of a successful surgical procedure, the size of the intraoperative mouth opening ranged from 35 to 40 mm. The patients
131
were discharged 5-7 days after the operation. The range of the mouth opening measured at that time was 28-36 mm. The pedicled grafts took uneventfully and epithelialized in 3-4 weeks (Fig. 1B). Two patients (cases 5 and 9) failed to exercise several times daily, and finally experienced a significant relapse. The remaining patients did cooperate and exercised daily, and the results were satisfactory (Fig. 2). The postoperative mouth-opening range was 16-38 m m (mean: 31.2 mm) over a follow-up period of 10-38 months (mean: 21.3 months). The average increase of the mouth opening was 19.1 mm.
:i
J
2A Fig. 1. Coverage of buccal defect with pedicled buccal fat pad graft (A); buccal fat is epithelialized 4 weeks postoperatively (B). Fig. 2. Case 1 preoperatively (A) (8-mm opening), and (B) 38 months postoperatively (35-mm opening).
132
Yeh
Table 1. Results of treatment Preoperative Intraoperative Spontaneous Late Duration of Case Age spontaneous opening opening at spontaneous observation no. (years) Sex opening ( f o r c e d ) d i s c h a r g e opening (months) 1
25
M
8
2 3 4 5 6 7 8 9
59 46 26 30 43 35 52 41
F M M M M M M M
16 14 12 15 14 12 10 8
34 36 35 37 34 35 36 36 40
Discussion
Submucous fibrosis is an insidious, chronic disease which may affect any part of the oral cavity and sometimes the pharynx, leading to stiffness of the oral mucosa, and causing trismus 11'12. This disease is most frequently found in India, and is not uncommon in Southeast Asia (southern China, Taiwan, Malaya, Singapore, Indonesia, Vietnam, and Thailand). It has also been reported from other countries, and it is no longer considered to occur exclusively in Indians and Southeast Asians, as immigration has resulted in a worldwide distribution. Betel nut chewing appears to be the main factor correlating with this disease. Most patients complain of an irritable oral mucosa during the early stage of the disease, especially when spicy foods are eaten. Clinically, there are erosions and ulcerations. Subsequently, the oral mucosa becomes blanched and loses its elasticity, and vertical bands occur in the buccal mucosa, the retromolar area, the soft palate, and the pterygomandibular raphe. A fibrotic ring forms around the entire rima otis. Some patients have difficulty in whistling and tongue movement. The literature contains few references to the successful treatment of OSE Various treatments to improve mouth opening have been attempted, including surz gical el~mination of the fibrotic bands, Mtt have been reported as generally uns~sfactory or impossible1~ YEN 17 was the first to succeed in coveting the buccal defect with a split-thickness skin graft~n treating a case of OSF. KHANNA & Ar~RADE6 recently reported the new surgical technique of covering the buccal defects with a palatal island flap in combination with temporalis myotomy
30 36 34 38 36 36 32 30 29
35 34 31 36 25 37 33 43 16
38 30 26 25 20 19 18 13 10
and coronoidectomy. They had applied it to 35 patients with good results. The main mass of the BFP occupies the buccal space bound medially by the buccinator muscle and laterally by the masseter muscle, and rests on the periosteum that covers the posterior buccal aspect of the maxilla. The BFP has a constant blood supply through the small branches of the facial artery, the internal maxillary artery, and the superficial temporal artery and vein by an abundant net of vascular anastomoses2'~5a6. On average, the volume is 9.6 cc (range 8.3-11.9 cc) 15. Defects up to 3x5 cm can be closed with a BFP alone without compromising the blood supply 16. The buccal extension and the main body of the fat pad are in close proximity to the buccal defect, and may be approached through the same incision. In addition, the buccal fat pad pedicled flap can cover the whole surgical defect and not only the superficial thin layer seen in split-thickness skin graft. The BFP also improves the physiologic functions of the cheek after the operation; e.g., suppleness and elasticity. With this technique, there is no need for a second operation site. The pedicled BFP graft is well vascularized, and is more resistant to infection than other kinds of free graft. Therefore, normal eating can begin after the surgical treatment. Patients can be discharged 5-7 days after the operation. Early and intensive postoperative mouth-opening exercises are very important to achieve adequate mouth opening afterward. Two patients did not cooperate and both had significant relapse. The grafted BFP became rigid from fibrotic change. The results demOnstrated that postopera[ive mouth opening in the remaining seven patients, who had performed adequate mouth-
opening exercises, were satisfactory. Routine temporalis myotomy, and coronoidectomy6 seemed to be unnecessary in all cases. The softness and elasticity of the buccal tissue had improved. Symptoms such as painful ulceration, burning sensation, and intolerance to spices had been eliminated in most patients. Acknowledgment. I would like to thank Mr R. E. Broadberry for assistance in correcting the English.
References 1. CANNIFFJP, HARVEYW, HARRISM. Oral submucous fibrosis: its pathogenesis and management. Br Dent J 1986: 160: 42934. 2. DuBn~B, JACKSONIT, HALIMA, TRIPLETT WW, FERREmAM. Anatomy of the buccal fat pad and its clinical significance. Hast Reconstr Surg 1989: 83: 257-62. 3. EGYEDIP. Utilization of the buccal fat pad for closure of oro-antral and/or oronasal communications. J Max-Fac Surg 1977: 5: 241-4. 4. FREIHOFERHPM. Restricted opening of the mouth with an extra-articular cause in children. J Cranio-Max-Fac Surg 1991: 19: 289-98. 5. Ho KH. Repair of palatal defects with inclined buccal fat pad graft. Oral Surg 1988: 65: 523-5. 6. KHANNAJN, ANDRADENN. Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995: 24: 433-9. 7. MORAWETZG, KATSIKERISN, WEINBERG S, LISTROMR. Oral submucous fibrosis. Int J Oral Maxillofac Surg 1987: 16: 609-14. 8. NEDER A. Use of buccal fat pad for grafts. Oral Surg 1983: 55: 349-50. 9. OLIVER AJ, RADDEN BG. Oral submucous fibrosis. Case report and review of the literature. Aust Dent J 1992: 37: 31-4. 10. PAISSATDK. Oral submucous fibrosis. IntJ Oral Surg 1981: 10: 307-12. 11. PINDBORG JJ, SIRSAT SM. Oral submucous fibrosis. Oral Surg 1966: 22: 764-79. 12. PINDBORGJJ, BHONSLERB, MURTIPR, GUPTAPC, DAFrARYDK, MEHTAFS. Incidence and early forms of oral submucous fibrosis. Oral Surg 1980: 50: 40-4. 13. SAMMAN N, CHEUNGLK, TmEMANH. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993: 22: 2-6. 14. SIMPSONW. Submucous fibrosis. Br Dent J 1969: 6: 196-200. 15. STUZlN JM, WAGSTROML, KAWAMOTO
BFP in oral submucous fibrosis HK, BAKERTJ, WOLFESA. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990: 85: 29-37. 16. TIDEMANH, BOSANQUETA, SCOTTJ. Use of the buccal fat pad as pedicled graft. J Oral Maxillofac Surg 1986: 44: 435--40.
17. YEN DJC. Surgical treatment of submucous fibrosis. Oral Surg 1982: 54: 269-71. 18. STAJClCZ. The buccal fat pad in the closure of oro-antral communications: a study of 56 cases. J Cranio-Max-FacSurg 1992: 20: 193-7.
133
Address:
Dr Chin-Jyh Yeh Clinic of Oral and Maxillofacial Surgery Mackay Memorial Hospital 1, Land 303, Chang-Sha Street, Taitung Taiwan