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New method of harvesting a buccal fat pad for interposition after gap arthroplasty of the temporomandibular joint
YBJOM-4613; No. of Pages 2
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Technical note
New method of harvesting a buccal fat pad for interposition after gap arthroplasty of the temporomandibular joint Sahil Parvez Gagnani, Bhaskar Agarwal, Ongkila Bhutia, Ajoy Roychoudhury ∗ Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India Accepted 3 September 2015
Keywords: Buccal Fat Pad; Temporomandibular Joint Ankylosis; Interposition Arthroplasty
Pedicled buccal fat pads are used in the reconstruction of various oral and maxillofacial defects,1 and their use as interposition material after gap arthroplasty in cases of ankylosis of the temporomandibular joint (TMJ) has been well-documented.2 Their proximity to the surgical defect, their blood supply, and their easy availability makes them a versatile option for interposition after gap arthroplasty and after replacement of the TMJ. Anatomically a buccal fat pad has a body and four processes (buccal, pterygoid, superficial, and deep temporal),1 and one of the main advantages is the pedicled blood supply. However, this is sometimes severed because it becomes detached by excessive pulling into the defect. We describe a technique to harvest a pedicled buccal fat pad, and suggest ways to predict herniation into the defect and to prevent its detachment from its pedicle.
After osteoarthrectomy a gap of about 1-1.5 cm is created by subperiosteal dissection in the direction of coronoid process. The temporalis fibres overlying the coronoid process and sigmoid notch are cauterised to prevent undue bleeding from the masseteric vessels. A malleable retractor is then inserted at the anterior border of the coronoid process, and a coronoidectomy done if indicated. A sharp stab incision is made on the periosteum followed by blunt dissection with a small haemostat. The buccal fat pad can be identified by its yellow colour, and once the fat lobules can be seen it is gently teased into the defect (Fig. 1). We prefer to simultaneous milk the maxillary buccal sulcus intraorally near the
Technique To predict if a buccal fat pad will be sufficient to obliterate a defect or not, we measure the volume of the defect by filling it with normal saline from a premeasured syringe until it just overflows the margins of the defect, the usual volume being roughly 10 ml.1 The body of the fat pad together with its buccal extension accounts for 55%-70%.3 If the measured volume of the defect is less than 7 ml, the fat pad is harvested. ∗
Corresponding author. Tel.: +91 11 26589303. E-mail address: [email protected] (A. Roychoudhury).
Fig. 1. Haemostat being used for blunt dissection and to tease out the buccal fat pad.
http://dx.doi.org/10.1016/j.bjoms.2015.09.004 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Gagnani SP, et al. New method of harvesting a buccal fat pad for interposition after gap arthroplasty of the temporomandibular joint. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.004
YBJOM-4613; No. of Pages 2
2
ARTICLE IN PRESS S.P. Gagnani et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Fig. 4. Puckering of the cheek that signifies the possibility of detachment of the pedicle after further pulling.
Fig. 2. Orientation of the buccal fat pad (BFP) and direction of intraoral milking.
second and third molar area (Fig. 2). The fat is then gently pulled by sequential grabbing with two blunt forceps and simultaneously pulling (Fig. 3). Excessive force should be avoided.
The cheek is watched for any puckering to identify the limit of extension of the buccal fat pad. Puckering indicates that further pulling would detach the pedicle (Fig. 4). Once the fat pad has herniated into the defect, two stay sutures are placed posteriorly and superiorly to prevent its retraction. This technique reduces the chances of excessive pulling on the fat pad and prevents its detachment from the pedicle. Interposition of a pedicled buccal fat pad reduces the dead space, prevents formation of a haematoma, reduces the formation of heterotopic bone, and consequently improves the range of movement of the jaw.4
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patient permission No ethical approval required.
References
Fig. 3. Buccal fat pad being pulled with two blunt forceps.
1. Colella G, Tartaro G, Giudice A. The buccal fat pad in oral reconstruction. Br J Plast Surg 2004;57:326–9. 2. Gaba S, Sharma RK, Rattan V, et al. The long-term fate of pedicled buccal pad fat used for interpositional arthroplasty in TMJ ankylosis. J Plast Reconstr Aesthet Surg 2012;65:1468–73. 3. Rattan V. A simple technique for use of buccal pad of fat in temporomandibular joint reconstruction. J Oral Maxillofac Surg 2006;64:1447–51. 4. Singh V, Dhingra R. Retrospective analysis of use of buccal fat pad as an interpositional graft in temporomandibular joint ankylosis. J Oral Maxillofac Surg 2011;69:2530–6.
Please cite this article in press as: Gagnani SP, et al. New method of harvesting a buccal fat pad for interposition after gap arthroplasty of the temporomandibular joint. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.004
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Technical note
New method of harvesting a buccal fat pad for interposition after gap arthroplasty of the temporomandibular joint Sahil Parvez Gagnani, Bhaskar Agarwal, Ongkila Bhutia, Ajoy Roychoudhury ∗ Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi, India Accepted 3 September 2015
Keywords: Buccal Fat Pad; Temporomandibular Joint Ankylosis; Interposition Arthroplasty
Pedicled buccal fat pads are used in the reconstruction of various oral and maxillofacial defects,1 and their use as interposition material after gap arthroplasty in cases of ankylosis of the temporomandibular joint (TMJ) has been well-documented.2 Their proximity to the surgical defect, their blood supply, and their easy availability makes them a versatile option for interposition after gap arthroplasty and after replacement of the TMJ. Anatomically a buccal fat pad has a body and four processes (buccal, pterygoid, superficial, and deep temporal),1 and one of the main advantages is the pedicled blood supply. However, this is sometimes severed because it becomes detached by excessive pulling into the defect. We describe a technique to harvest a pedicled buccal fat pad, and suggest ways to predict herniation into the defect and to prevent its detachment from its pedicle.
After osteoarthrectomy a gap of about 1-1.5 cm is created by subperiosteal dissection in the direction of coronoid process. The temporalis fibres overlying the coronoid process and sigmoid notch are cauterised to prevent undue bleeding from the masseteric vessels. A malleable retractor is then inserted at the anterior border of the coronoid process, and a coronoidectomy done if indicated. A sharp stab incision is made on the periosteum followed by blunt dissection with a small haemostat. The buccal fat pad can be identified by its yellow colour, and once the fat lobules can be seen it is gently teased into the defect (Fig. 1). We prefer to simultaneous milk the maxillary buccal sulcus intraorally near the
Technique To predict if a buccal fat pad will be sufficient to obliterate a defect or not, we measure the volume of the defect by filling it with normal saline from a premeasured syringe until it just overflows the margins of the defect, the usual volume being roughly 10 ml.1 The body of the fat pad together with its buccal extension accounts for 55%-70%.3 If the measured volume of the defect is less than 7 ml, the fat pad is harvested. ∗
Corresponding author. Tel.: +91 11 26589303. E-mail address: [email protected] (A. Roychoudhury).
Fig. 1. Haemostat being used for blunt dissection and to tease out the buccal fat pad.
http://dx.doi.org/10.1016/j.bjoms.2015.09.004 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Gagnani SP, et al. New method of harvesting a buccal fat pad for interposition after gap arthroplasty of the temporomandibular joint. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.004
YBJOM-4613; No. of Pages 2
2
ARTICLE IN PRESS S.P. Gagnani et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Fig. 4. Puckering of the cheek that signifies the possibility of detachment of the pedicle after further pulling.
Fig. 2. Orientation of the buccal fat pad (BFP) and direction of intraoral milking.
second and third molar area (Fig. 2). The fat is then gently pulled by sequential grabbing with two blunt forceps and simultaneously pulling (Fig. 3). Excessive force should be avoided.
The cheek is watched for any puckering to identify the limit of extension of the buccal fat pad. Puckering indicates that further pulling would detach the pedicle (Fig. 4). Once the fat pad has herniated into the defect, two stay sutures are placed posteriorly and superiorly to prevent its retraction. This technique reduces the chances of excessive pulling on the fat pad and prevents its detachment from the pedicle. Interposition of a pedicled buccal fat pad reduces the dead space, prevents formation of a haematoma, reduces the formation of heterotopic bone, and consequently improves the range of movement of the jaw.4
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patient permission No ethical approval required.
References
Fig. 3. Buccal fat pad being pulled with two blunt forceps.
1. Colella G, Tartaro G, Giudice A. The buccal fat pad in oral reconstruction. Br J Plast Surg 2004;57:326–9. 2. Gaba S, Sharma RK, Rattan V, et al. The long-term fate of pedicled buccal pad fat used for interpositional arthroplasty in TMJ ankylosis. J Plast Reconstr Aesthet Surg 2012;65:1468–73. 3. Rattan V. A simple technique for use of buccal pad of fat in temporomandibular joint reconstruction. J Oral Maxillofac Surg 2006;64:1447–51. 4. Singh V, Dhingra R. Retrospective analysis of use of buccal fat pad as an interpositional graft in temporomandibular joint ankylosis. J Oral Maxillofac Surg 2011;69:2530–6.
Please cite this article in press as: Gagnani SP, et al. New method of harvesting a buccal fat pad for interposition after gap arthroplasty of the temporomandibular joint. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.004