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Application of the buccal fat pad in oral and maxillofacial reconstruction: Review of 35 cases
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 journal homepage: www.elsevier.com/locate/jomsmp
Clinical observation
Application of the buccal fat pad in oral and maxillofacial reconstruction: Review of 35 cases Virendra Singh a,∗ , Amrish Bhagol a , Ish Kumar b , Rahul Dhingra a a b
Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak 124001, Haryana, India Department of Oral and Maxillofacial Surgery, Dental College and Hospital, Sirsa, Haryana, India
a r t i c l e
i n f o
Article history: Received 29 January 2011 Received in revised form 27 March 2011 Accepted 9 May 2011 Available online 17 June 2011 Keywords: Buccal fat pad Oroantral communications Cystic defects
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 resections. In this paper we consider both the anatomical basis and the surgical technique. We also review 35 cases treated using BFP; 18 patients with oroantral communications, 10 with residual cystic defects, 5 with 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 type of reconstruction, versatile and of a simple surgical technique. However, its use is limited to small or medium defects, being sometimes scarce. © 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1. Introduction The buccal fat pad (BFP) was mentioned for the first time by Heister in 1732 and better described by Bichat in 1802. Its use as a pedicle graft, was first reported by Egyedi [1] and its embryology, vascularization, volume and function being studied by Tideman et al. [2], Marx [3] and other authors [4–6]. BFP has many possible functions: filling and allowing slippage of fascial spaces between mimetic muscles; enhancement of intermuscular motion, separating muscles of mastication from one another; to counteract negative pressure during suction in the newborn; protection and cushion of neurovascular bundles from injuries. Literature reports have illustrated that the BFP can be used as a pedicled graft for the closure of various defects of oral cavity [5,7]. These defects ranges from oroantral and oronasal communications, defects secondary to maxillary cysts and intraoral tumor resections, posterior fistula in cleft patients, covering of bone transplants in augmentation procedure and in TMJ reconstruction. The rationale for using fat as an interpositional graft following gap arthroplasty is to fill the ample tissue in the dead space left within the joint cavity following osteoarthrectomy. The BFP has more recently achieved a great importance in the field of aesthetic facial surgery with special regard to the modification of facial contours and the malar prominence [5,7,8].
∗ Corresponding author. Tel.: +91 011 9896326781; fax: +91 011 1262 213876. E-mail address: [email protected] (V. Singh).
Various local methods have been successfully employed for intraoral reconstruction as tongue flaps, temporal muscle, oral mucosal flaps or myomucosal island flap. Nowadays, use of BFP has become very popular, above all for the closure of oroantral communications [1,2,9,10], as a single layer [9], with free skin grafts [1], or even covered by lyophilized porcine dermis. There are a few series dealing with the reconstruction of defects secondary to maxillary cysts and intraoral tumor resections [2,10,11]. The aim of this paper is to show the results in a series where the buccal fat pad was employed for the reconstruction of various oral defects. 2. Patients and methods Between June 2007 and August 2009, the buccal fat pad was used to reconstruct oral defects in 35 patients ranging in age from 12 to 55 years. There were 26 men and 9 women. In all cases a postsurgical follow-up of at least 6 months, was carried out. The indications for the use of the buccal fat pad and the location of the reconstructed region are presented in Tables 1 and 2. Of the 18 patients with oroantral communications, 12 underwent primary closure with the buccal fat pad; 6 patients were treated with the buccal fat pad after an unsuccessful closure with a buccal advancement flap. Residual cystic defects were reconstructed in 10 patients. Neoplastic resections in which the buccal fat pad was used for closure included 2 pleomorphic adenomas, 1 mucoepidermoid tumor, 1 giant cell tumor, and 1 hemangioma. The location of the tumor defect was the hard palate in 3 patients; 1 patient had a tumor in maxilla, and 1 patient had a hemangioma in the cheek mucosa. The size of the
0915-6992/$ – see front matter © 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ajoms.2011.05.001
28
V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31
Table 1 Showing indications for surgery. Indications
No. of patients
OAF Tumor resection Cystic defects Interpositional material in TMJ ankylosis
18 5 10 2
Table 2 Showing location of defect in patients. Location of the defects Alveolar crest and maxilla Hard palate Buccal mucosa Retromolar region mandible Vestibular sulcus TMJInterpositional material
No. of patients 18 3 1 4 7 2
defect to be reconstructed ranged from 1 cm × 1 cm to 4 cm × 5 cm. In 2 patient of TMJ ankylosis, BFP was used as Interpositional lining material. 2.1. Surgical technique The buccal fat pad was exposed by a 2 cm horizontal vestibular incision extending backwards from above the maxillary second molar tooth. Blunt dissection through the buccinator and loose surrounding fascia, allowed the buccal fat pad to herniate into the mouth (Fig. 1). However, in neoplasm cases the buccal fat pad became exposed into the defect after resection of the tumor. The body of the buccal fat pad and the buccal extension were gently mobilised by blunt dissection, taking care not to disrupt the deli-
cate capsule and vascular plexus and to preserve as wide a base as possible. Pressure on the cheek helped to express the fat into the mouth. After the pad had been dissected free from the surrounding tissues, it was grasped with vascular forceps, gently teased out, advanced, and expanded over the defect. The pad was sutured to the mucosal edges with 3/0 polyglactin (Vicryl), ensuring that it was not under excessive tension. In TMJ reconstruction, for exploration of buccal fat pad the coronoid process was exposed by extending the dissection anteriorly in the subperiosteal plane (using Al-Kayat Bramley incision). A periosteal elevator was inserted at its anterior border for retraction. Coronoidectomy was carried out at this stage when indicated. The main body of buccal pad fat and its temporal extension lies in close proximity to coronoid process and temporalis muscle tendon. An incision was given through the periosteum and fascial envelope of BFP and blunt dissection was done with a fine curved artery forceps to expose the yellowish colored buccal fat. Further blunt dissection of tissues surrounding the BFP was done to gently pull out the emergent part and it was herniated into the defect with little teasing and applying some external pressure over the cheek. Mechanical suction was avoided once the BFP was exposed. The tension free BFP was packed around the TMJ to fill the dead space and one or 2 sutures were given just anterior to 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 to repair an oroantral communication. Definitive closure was done by a second surgical procedure with a local mucosal flap. In all the flaps, the BFP epithelization process started during the first week,
Fig. 1. Shows application of BFP in closure of oroantral communication; (A) Showing oroantral communication; (B) Showing harvesting of BFP; (C) Showing closure of defect using BFP; (D) Showing 3 month follow up of the same patient.
V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31
Fig. 2. Shows preoperative photograph in a patient of TMJ ankylosis.
and was complete by 4–5 weeks. No local infections were noticed (Table 3). Satisfactory results were achieved in both of the patients where BFP was used as interpositional material for TMJ reconstruction. No complications were noticed at the latest follow up in any of these patients. We found that the pedicled buccal fat pad could cover maxillary defects as far anteriorly as the canine tooth region and up to but not beyond the midline of the palate. Posteriorly, the tuberosity region, soft palate, and retromolar area were all easily reached by the pad. Buccal fat pad could also reach the TMJ region using the same incision; that was given for release of ankylotic mass (AlKayat Bramley incision).
Fig. 3. Shows interposition of BFP.
29
Fig. 4. Shows postoperative photograph in same patient of TMJ ankylosis.
Table 3 Showing masterchart for the patients. No.
Age
Sex
Indication
Follow up
Complication
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
28 26 42 35 40 12 33 37 22 55 47 17 50 25 30 29 34 46 52 40 30 18 28 49 41 25 30 19 33 37 28 36 32 31 45
M M F M M M F M M F M M M M M F M M F M M M M M M M M F F M F M M M F
Cystic defects Cystic defects OAF OAF OAF Cystic defects OAF OAF Cystic defects Tumor resection OAF TMJ ankylosis OAF Cystic defects OAF Cystic defects OAF OAF Tumor resection OAF Cystic defects Tumor resection Cystic defects OAF OAF Cystic defects OAF TMJ ankylosis Tumor resection OAF Cystic defects OAF OAF Tumor resection OAF
6 Months 8 Months 6 Months 6 Months 6 Months 9 Months 6 Months 6 Months 7 Months 9 Months 6 Months 8 Months 6 Months 8 Months 6 Months 6 Months 6 Months 6 Months 9 Months 6 Months 6 Months 7 Months 6 Months 6 Months 6 Months 6 Months 6 Months 7 Months 6 Months 6 Months 8 Months 6 Months 6 Months 6 Months 6 Months
None None None None None None None None None None None None None None None Partial loss None None None None None None None None None None None None None None None None None None None
OAF – oroantral fistula.
30
V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31
4. Discussion Buccal fat pad was considered a surgical nuisance for many years because of its accidental encounter during various operations in the pterygomandibular area such as tumor, orthognathic, or trauma surgeries. Egyedi [1] in 1977 first reported the use of pedicled BFP for closure of post-surgical maxillary defects. Since then, BFP has become a popular option among surgeons worldwide for the reconstruction of small to medium acquired or congenital soft tissue and bone defects in the oral cavity. Successful closure of OAF with buccal fat pad is widely reported in the literature [9,13–15]. Stajcic [9] reported the use of pedicled BFP in the closure of oronasal and oroantral communications following extractions in 56 patients with excellent results. Despite postoperative infection in 1 patient and partial necrosis in 2 patients, all his flaps were reported to be successful. In another report by el-Hakim and el-Fakharany [15] the use of pedicled BFP was compared with palatal rotation flap in closure of antral communication and palatal defects resulting from tumor resection. They found BFP to be consistently successful, preserving the normal anatomical architecture of the oral mucosa. No denuded area requiring secondary granulation was required as in the case of palatal flaps. Pedicled BFP is also considered as a reliable backup procedure in the event of failure of other techniques [14,15]. Our case series also supported the same facts. Yilmaz et al. [13], Pandolfi et al. [16] and Dolanmaz et al. [17] also reported good results with the use of BFP in the closure of oroantral/oronasal communications. Pedicled buccal fat pad has also been employed in the closure of surgical defects following tumor excision [14], excision of leukoplakia and submucous fibrosis [18,19] as well as closure of primary and secondary palatal clefts [20,21] and coverage of maxillary and mandibular bone grafts [22,23]. The complication regarding use of BFP ranges between 3.1% and 6.9% in literature [14,24–26]. These include partial necrosis, infection, excessive scarring, excessive granulation and sulcus obliteration. In our case series, complication was observed in only 1 patient (0.04%). There have been reports on the closure of defects up to 60 mm × 50 mm × 30 mm [2,10]. Assuming the calculated BFP volume is 10 ml and its lowest thickness is 6 mm [1,5,6], the closure of larger defects cannot be guaranteed without producing flap necrosis or creating a new fistulae. The largest defects covered in our study were a 40 mm × 50 mm. Complete epithelization of the BFP was observed after 4–5 weeks of inset in our patients. This is in agreement with the established facts in the literature [14,24,27]. Egyedi [1] recommended coverage of the exposed BFP with a skin graft and Fujimura et al. [10] recommended using lyophilised porcine dermis to cover the buccal fat pad, which allowed stretched pads that showed some perforations to heal without complications. However, our series confirmed the findings of other previous reports that epithelization of the flap does take place without split skin graft cover [13,16,24,27] after 3–4 weeks of inset [14,24,27]. Due to its anatomical situation, the ideal defects to be reconstructed with a BFP are the maxillary defects, from the premolar area to the posterior tuberosity. Also soft and hard palate, superior alveolar rim, cheek mucosa and tonsilar fossa, are suitable places to be employed, as suggested by other authors. We also found that the pedicled buccal fat pad could cover maxillary defects as far anteriorly as the canine tooth region and up to but not beyond the midline of the palate. Posteriorly, the tuberosity region, soft palate, and retromolar area were all easily reached by the pad.
We also used buccal pad of fat in temporomandibular joint reconstruction. The rationale for using fat as an interpositional graft following gap arthroplasty is first to fill the ample tissue in the dead space left within the joint cavity following osteoarthrectomy. Secondly it prevents direct contact between the cut bony surface and glenoid fossa and thus prevents heterotopic ossification (HO) within the TMJ. HO is recognized as a major postoperative complication after gap arthroplasty. We observed satisfactory results in both the patients and no complication in terms of reankylosis was observed at the latest followup. We are keeping our patients on regular followup. The results of the present study in using BFP in TMJ reconstruction are only the preliminary results and to actually assess the efficacy of BFP as an Interpositional material in TMJ reconstruction, a long-term prospective study should be done. Finally, we conclude that BFP seems to be one of the safest reconstructive methods for closure of oroantral communications/fistula, followed by reconstruction of maxillary defects; coverage of mucosal defects, etc. being other uses and can also be utilized in TMJ reconstruction. The easy mobilization of the BFP and its excellent blood supply and minimal donor site morbidity makes it a flap of choice. The size limitation of the BFP must be known to permit successful outcome. It should also be considered as a reliable back-up procedure in the event of failure of other techniques as demonstrated by this case series. The results have been encouraging for clinicians to make use of potential benefits of the BFP in closure of defects in the oral and maxillofacial region.
References [1] Egyedi P. Utilization of the buccal fat pad for closure of oroantral/oro-nasal communications. J Maxillofac Surg 1977;5:241–4. [2] Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicle graft. J Oral Maxillofac Surg 1986;44:435. [3] Marx RE. Discussion of ‘Reconstruction of the Maxilla with Bone Grafts Supported by the Buccal Fat Pad’ (Vuillemein et al.). J Oral Maxillofac Surg 1988;46:100. [4] Dubin B, Jackson IT, Halim A, Triplett WW, Ferreira M. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1989;82:257. [5] Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe A. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990;85:29. [6] Tharanon W, Stella JP, Epker BN. Applied surgical anatomy of the buccal fat pad. Oral Maxillofac Stag Clin North Am 1990;2:377. [7] Jackson IT. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1999;103:2059–60. [8] Ramirez OM. Buccal fat pad pedicle flap for midface augmentation. Ann Plast Surg 1999;43:109–18. [9] Stajcic Z. The buccal fat pad in the closure of oro-antral communications: a study of 56 Cases. J Craniomaxillofac Surg 1992;20:193. [10] Fujimura N, Nagura H, Enomoto S. Grafting of the buccal fat pad into palatal defects. J Craniomaxillofac Surg 1990;18:219. [11] Loh Loh. Use of the buccal fat pad for correction of intraoral defects: report of cases. J Oral Maxillofac Surg 1991;49:413. [13] Yilmaz T, Suslu AE, Gursel B. Treatment of oroantral fistula: experience with 27 cases. Am J Otolaryngol 2003;24(4):221–3. [14] Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg 2000;58:389–92. [15] el-Hakim IE, el-Fakharany AM. The use of the pedicled buccal fat pad (BFP) and palatal rotating flaps in closure of oroantral communication and palatal defects. J Laryngol Otol 1999;113(9):834–8. [16] Pandolfi PJ, Yavuzer R, Jackson IT. Three layer closure of an oroantralcutaneous defect. Int J Oral Maxillofac Surg 2000;29(1):24–6. [17] Dolanmaz D, Tuz H, Bayraktar S, Metin M, Erdem M, Baykul T. Use of pedicled buccal fat pad in the closure of oroantral communication: analysis of 75 cases. Quintessence Int 2004;35(3):241–6. [18] Ho KH. Excision of cheek leukoplakia and lining the defect with pedicled fat pad graft. Br Dent J 1989;166(12):455–6. [19] Yeh CJ. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25(2):130–3. [20] Kim YK. The use of a pedicled buccal fat pad graft for bone coverage in primary palatorrhapy: a case report. J Oral Maxillofac Surg 2001;59(12):1499–501. [21] Hudson JW, Anderson JG, Russell Jr RM, Anderson N, Chambers K. Use of pedicled fat pad graft as an adjunct in the reconstruction of palatal cleft defects. Oral Surg 1995;80:24–7.
V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31 [22] Liversedge RL, Wong K. Use of the buccal fat pad in maxillary and sinus grafting of the severely atrophic maxilla preparatory to implant reconstruction of the partially or completely edentulous patients: technical note. Int J Oral Maxillofac Implants 2002;17:424–8. [23] Vuillemin T, Raveh J, Ramon Y. Reconstruction of the maxilla with bone grafts supported by the buccal fat pad. J Oral Maxillofac Surg 1988;46:100–5. [24] Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22:2–6.
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[25] Martin-Granizo R, Naval L, Costas A, Goizueta C, Rodriguez F, Monje F, et al. Use of buccal fat pad to repair intra-oral defects: a review of 30 cases. Br J Oral Maxillofac Surg 1997;35(2):81–4. [26] Dean A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M. The buccal fat pad in oral reconstruction. Head Neck 2001;23(5):383–8. [27] Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of the buccal fat pad for reconstruction of oral defects: review of the literature and report of 15 cases. J Oral Maxillofac Surg 2000;58:158–63.
Contents lists available at ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Clinical observation
Application of the buccal fat pad in oral and maxillofacial reconstruction: Review of 35 cases Virendra Singh a,∗ , Amrish Bhagol a , Ish Kumar b , Rahul Dhingra a a b
Department of Oral and Maxillofacial Surgery, Government Dental College, Pt. B.D. Sharma University of Health Sciences, Rohtak 124001, Haryana, India Department of Oral and Maxillofacial Surgery, Dental College and Hospital, Sirsa, Haryana, India
a r t i c l e
i n f o
Article history: Received 29 January 2011 Received in revised form 27 March 2011 Accepted 9 May 2011 Available online 17 June 2011 Keywords: Buccal fat pad Oroantral communications Cystic defects
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 resections. In this paper we consider both the anatomical basis and the surgical technique. We also review 35 cases treated using BFP; 18 patients with oroantral communications, 10 with residual cystic defects, 5 with 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 type of reconstruction, versatile and of a simple surgical technique. However, its use is limited to small or medium defects, being sometimes scarce. © 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1. Introduction The buccal fat pad (BFP) was mentioned for the first time by Heister in 1732 and better described by Bichat in 1802. Its use as a pedicle graft, was first reported by Egyedi [1] and its embryology, vascularization, volume and function being studied by Tideman et al. [2], Marx [3] and other authors [4–6]. BFP has many possible functions: filling and allowing slippage of fascial spaces between mimetic muscles; enhancement of intermuscular motion, separating muscles of mastication from one another; to counteract negative pressure during suction in the newborn; protection and cushion of neurovascular bundles from injuries. Literature reports have illustrated that the BFP can be used as a pedicled graft for the closure of various defects of oral cavity [5,7]. These defects ranges from oroantral and oronasal communications, defects secondary to maxillary cysts and intraoral tumor resections, posterior fistula in cleft patients, covering of bone transplants in augmentation procedure and in TMJ reconstruction. The rationale for using fat as an interpositional graft following gap arthroplasty is to fill the ample tissue in the dead space left within the joint cavity following osteoarthrectomy. The BFP has more recently achieved a great importance in the field of aesthetic facial surgery with special regard to the modification of facial contours and the malar prominence [5,7,8].
∗ Corresponding author. Tel.: +91 011 9896326781; fax: +91 011 1262 213876. E-mail address: [email protected] (V. Singh).
Various local methods have been successfully employed for intraoral reconstruction as tongue flaps, temporal muscle, oral mucosal flaps or myomucosal island flap. Nowadays, use of BFP has become very popular, above all for the closure of oroantral communications [1,2,9,10], as a single layer [9], with free skin grafts [1], or even covered by lyophilized porcine dermis. There are a few series dealing with the reconstruction of defects secondary to maxillary cysts and intraoral tumor resections [2,10,11]. The aim of this paper is to show the results in a series where the buccal fat pad was employed for the reconstruction of various oral defects. 2. Patients and methods Between June 2007 and August 2009, the buccal fat pad was used to reconstruct oral defects in 35 patients ranging in age from 12 to 55 years. There were 26 men and 9 women. In all cases a postsurgical follow-up of at least 6 months, was carried out. The indications for the use of the buccal fat pad and the location of the reconstructed region are presented in Tables 1 and 2. Of the 18 patients with oroantral communications, 12 underwent primary closure with the buccal fat pad; 6 patients were treated with the buccal fat pad after an unsuccessful closure with a buccal advancement flap. Residual cystic defects were reconstructed in 10 patients. Neoplastic resections in which the buccal fat pad was used for closure included 2 pleomorphic adenomas, 1 mucoepidermoid tumor, 1 giant cell tumor, and 1 hemangioma. The location of the tumor defect was the hard palate in 3 patients; 1 patient had a tumor in maxilla, and 1 patient had a hemangioma in the cheek mucosa. The size of the
0915-6992/$ – see front matter © 2011 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ajoms.2011.05.001
28
V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31
Table 1 Showing indications for surgery. Indications
No. of patients
OAF Tumor resection Cystic defects Interpositional material in TMJ ankylosis
18 5 10 2
Table 2 Showing location of defect in patients. Location of the defects Alveolar crest and maxilla Hard palate Buccal mucosa Retromolar region mandible Vestibular sulcus TMJInterpositional material
No. of patients 18 3 1 4 7 2
defect to be reconstructed ranged from 1 cm × 1 cm to 4 cm × 5 cm. In 2 patient of TMJ ankylosis, BFP was used as Interpositional lining material. 2.1. Surgical technique The buccal fat pad was exposed by a 2 cm horizontal vestibular incision extending backwards from above the maxillary second molar tooth. Blunt dissection through the buccinator and loose surrounding fascia, allowed the buccal fat pad to herniate into the mouth (Fig. 1). However, in neoplasm cases the buccal fat pad became exposed into the defect after resection of the tumor. The body of the buccal fat pad and the buccal extension were gently mobilised by blunt dissection, taking care not to disrupt the deli-
cate capsule and vascular plexus and to preserve as wide a base as possible. Pressure on the cheek helped to express the fat into the mouth. After the pad had been dissected free from the surrounding tissues, it was grasped with vascular forceps, gently teased out, advanced, and expanded over the defect. The pad was sutured to the mucosal edges with 3/0 polyglactin (Vicryl), ensuring that it was not under excessive tension. In TMJ reconstruction, for exploration of buccal fat pad the coronoid process was exposed by extending the dissection anteriorly in the subperiosteal plane (using Al-Kayat Bramley incision). A periosteal elevator was inserted at its anterior border for retraction. Coronoidectomy was carried out at this stage when indicated. The main body of buccal pad fat and its temporal extension lies in close proximity to coronoid process and temporalis muscle tendon. An incision was given through the periosteum and fascial envelope of BFP and blunt dissection was done with a fine curved artery forceps to expose the yellowish colored buccal fat. Further blunt dissection of tissues surrounding the BFP was done to gently pull out the emergent part and it was herniated into the defect with little teasing and applying some external pressure over the cheek. Mechanical suction was avoided once the BFP was exposed. The tension free BFP was packed around the TMJ to fill the dead space and one or 2 sutures were given just anterior to 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 to repair an oroantral communication. Definitive closure was done by a second surgical procedure with a local mucosal flap. In all the flaps, the BFP epithelization process started during the first week,
Fig. 1. Shows application of BFP in closure of oroantral communication; (A) Showing oroantral communication; (B) Showing harvesting of BFP; (C) Showing closure of defect using BFP; (D) Showing 3 month follow up of the same patient.
V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31
Fig. 2. Shows preoperative photograph in a patient of TMJ ankylosis.
and was complete by 4–5 weeks. No local infections were noticed (Table 3). Satisfactory results were achieved in both of the patients where BFP was used as interpositional material for TMJ reconstruction. No complications were noticed at the latest follow up in any of these patients. We found that the pedicled buccal fat pad could cover maxillary defects as far anteriorly as the canine tooth region and up to but not beyond the midline of the palate. Posteriorly, the tuberosity region, soft palate, and retromolar area were all easily reached by the pad. Buccal fat pad could also reach the TMJ region using the same incision; that was given for release of ankylotic mass (AlKayat Bramley incision).
Fig. 3. Shows interposition of BFP.
29
Fig. 4. Shows postoperative photograph in same patient of TMJ ankylosis.
Table 3 Showing masterchart for the patients. No.
Age
Sex
Indication
Follow up
Complication
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
28 26 42 35 40 12 33 37 22 55 47 17 50 25 30 29 34 46 52 40 30 18 28 49 41 25 30 19 33 37 28 36 32 31 45
M M F M M M F M M F M M M M M F M M F M M M M M M M M F F M F M M M F
Cystic defects Cystic defects OAF OAF OAF Cystic defects OAF OAF Cystic defects Tumor resection OAF TMJ ankylosis OAF Cystic defects OAF Cystic defects OAF OAF Tumor resection OAF Cystic defects Tumor resection Cystic defects OAF OAF Cystic defects OAF TMJ ankylosis Tumor resection OAF Cystic defects OAF OAF Tumor resection OAF
6 Months 8 Months 6 Months 6 Months 6 Months 9 Months 6 Months 6 Months 7 Months 9 Months 6 Months 8 Months 6 Months 8 Months 6 Months 6 Months 6 Months 6 Months 9 Months 6 Months 6 Months 7 Months 6 Months 6 Months 6 Months 6 Months 6 Months 7 Months 6 Months 6 Months 8 Months 6 Months 6 Months 6 Months 6 Months
None None None None None None None None None None None None None None None Partial loss None None None None None None None None None None None None None None None None None None None
OAF – oroantral fistula.
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V. Singh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 24 (2012) 27–31
4. Discussion Buccal fat pad was considered a surgical nuisance for many years because of its accidental encounter during various operations in the pterygomandibular area such as tumor, orthognathic, or trauma surgeries. Egyedi [1] in 1977 first reported the use of pedicled BFP for closure of post-surgical maxillary defects. Since then, BFP has become a popular option among surgeons worldwide for the reconstruction of small to medium acquired or congenital soft tissue and bone defects in the oral cavity. Successful closure of OAF with buccal fat pad is widely reported in the literature [9,13–15]. Stajcic [9] reported the use of pedicled BFP in the closure of oronasal and oroantral communications following extractions in 56 patients with excellent results. Despite postoperative infection in 1 patient and partial necrosis in 2 patients, all his flaps were reported to be successful. In another report by el-Hakim and el-Fakharany [15] the use of pedicled BFP was compared with palatal rotation flap in closure of antral communication and palatal defects resulting from tumor resection. They found BFP to be consistently successful, preserving the normal anatomical architecture of the oral mucosa. No denuded area requiring secondary granulation was required as in the case of palatal flaps. Pedicled BFP is also considered as a reliable backup procedure in the event of failure of other techniques [14,15]. Our case series also supported the same facts. Yilmaz et al. [13], Pandolfi et al. [16] and Dolanmaz et al. [17] also reported good results with the use of BFP in the closure of oroantral/oronasal communications. Pedicled buccal fat pad has also been employed in the closure of surgical defects following tumor excision [14], excision of leukoplakia and submucous fibrosis [18,19] as well as closure of primary and secondary palatal clefts [20,21] and coverage of maxillary and mandibular bone grafts [22,23]. The complication regarding use of BFP ranges between 3.1% and 6.9% in literature [14,24–26]. These include partial necrosis, infection, excessive scarring, excessive granulation and sulcus obliteration. In our case series, complication was observed in only 1 patient (0.04%). There have been reports on the closure of defects up to 60 mm × 50 mm × 30 mm [2,10]. Assuming the calculated BFP volume is 10 ml and its lowest thickness is 6 mm [1,5,6], the closure of larger defects cannot be guaranteed without producing flap necrosis or creating a new fistulae. The largest defects covered in our study were a 40 mm × 50 mm. Complete epithelization of the BFP was observed after 4–5 weeks of inset in our patients. This is in agreement with the established facts in the literature [14,24,27]. Egyedi [1] recommended coverage of the exposed BFP with a skin graft and Fujimura et al. [10] recommended using lyophilised porcine dermis to cover the buccal fat pad, which allowed stretched pads that showed some perforations to heal without complications. However, our series confirmed the findings of other previous reports that epithelization of the flap does take place without split skin graft cover [13,16,24,27] after 3–4 weeks of inset [14,24,27]. Due to its anatomical situation, the ideal defects to be reconstructed with a BFP are the maxillary defects, from the premolar area to the posterior tuberosity. Also soft and hard palate, superior alveolar rim, cheek mucosa and tonsilar fossa, are suitable places to be employed, as suggested by other authors. We also found that the pedicled buccal fat pad could cover maxillary defects as far anteriorly as the canine tooth region and up to but not beyond the midline of the palate. Posteriorly, the tuberosity region, soft palate, and retromolar area were all easily reached by the pad.
We also used buccal pad of fat in temporomandibular joint reconstruction. The rationale for using fat as an interpositional graft following gap arthroplasty is first to fill the ample tissue in the dead space left within the joint cavity following osteoarthrectomy. Secondly it prevents direct contact between the cut bony surface and glenoid fossa and thus prevents heterotopic ossification (HO) within the TMJ. HO is recognized as a major postoperative complication after gap arthroplasty. We observed satisfactory results in both the patients and no complication in terms of reankylosis was observed at the latest followup. We are keeping our patients on regular followup. The results of the present study in using BFP in TMJ reconstruction are only the preliminary results and to actually assess the efficacy of BFP as an Interpositional material in TMJ reconstruction, a long-term prospective study should be done. Finally, we conclude that BFP seems to be one of the safest reconstructive methods for closure of oroantral communications/fistula, followed by reconstruction of maxillary defects; coverage of mucosal defects, etc. being other uses and can also be utilized in TMJ reconstruction. The easy mobilization of the BFP and its excellent blood supply and minimal donor site morbidity makes it a flap of choice. The size limitation of the BFP must be known to permit successful outcome. It should also be considered as a reliable back-up procedure in the event of failure of other techniques as demonstrated by this case series. The results have been encouraging for clinicians to make use of potential benefits of the BFP in closure of defects in the oral and maxillofacial region.
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