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Comparison of radial forearm free flap, pedicled buccal fat pad flap and split-thickness skin graft in reconstruction of buccal mucosal defect
Oral Oncology (2005) 41, 694–697
http://intl.elsevierhealth.com/journals/oron/
Comparison of radial forearm free flap, pedicled buccal fat pad flap and split-thickness skin graft in reconstruction of buccal mucosal defect Chih-Yen Chien a, Chung-Feng Hwang a, Hui-Ching Chuang a, Seng-Feng Jeng b, Chih-Ying Su a,* a
Department of Otolaryngology, Chang Gung Memorial Hospital at Kaohsiung 123, Ta-Pei Road, Niao-Song Hsiang, Kaohsiung County 833, Taiwan b Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Kaohsiung 123, Ta-Pei Road, Niao-Song Hsiang, Kaohsiung County 833, Taiwan Received 20 January 2005; accepted 2 March 2005
KEYWORDS
Summary There are a variety of methods to reconstruct the mucosal defect after the ablation of buccal cancer. We used the radial forearm free flap (RFFF), pedicled buccal fat pad flap (PBFPF) or split-thickness skin graft (STSG) to reconstruct the buccal mucosal defect in our series respectively and compared the mouth-open width among these methods. We found there was no significant difference in the change of mouth-open width between the Group STSG and Group PBFPF. However, the negative effect on the mouth opening was significantly less (p < 0.05) in Group RFFF when compared with the Group STSG or Group PBFPF. In conclusion, reconstruction with radial forearm free flap for buccal mucosal defect carries more chances to preserve the original mouth-open width than with pedicled buccal fat pad flap or split-thickness skin graft among the selected patients who undergo tumor resection for T2 or T3 buccal cancer. c 2005 Elsevier Ltd. All rights reserved.
Radial forearm free flap; Pedicled buccal fat pad flap; Split-thickness skin graft; Intraoral defect; Oral cavity reconstruction; Buccal cancer
Introduction
There are various kinds of surgical procedures available for reconstruction of buccal mucosal de* Corresponding author. Tel.: +886 7 7317123x2557; fax: +886 7 7313855. E-mail address: [email protected] (C.-Y. Su).
fect after wide resection of buccal cancer, such as split-thickness skin graft, mucosal graft, regional tongue flap, pedicled buccal fat pad flap,1,2 pedicled temporoparietal fascial flap3 and distant free flap. The choice option for reconstruction depends on the size of the buccal defect and the preference of the surgeons. However, limitation of mouth opening or even trismus may develop after
1368-8375/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2005.03.002
Reconstruction of buccal mucosal defect the reconstructive procedures following ablation of buccal cancer, especially among patients with somewhat extent of submucosal fibrosis in buccal area. This study is aimed to compare the width of mouth-open after reconstruction either with splitthickness skin graft, pedicled buccal fat pad flap or radial forearm free flap for patients who underwent wide resection of buccal cancer.
Patients and methods From January 2002 to June 2004, there were 37 patients who underwent primary surgical treatment for cure of buccal cancer in Chang Gung Memorial Hospital at Kaohsiung, Taiwan. All procedures about tumor extirpation were carried out solely by the first author (C.Y.C.). The buccal defect was reconstructed either with split-thickness skin graft (STSG), pedicled buccal fat pad flap (PBFPF) or radial forearm free flap (RFFF). The STSG was harvested from medial thigh with the thickness of 12/ 1000 in. to reconstruct the buccal defect. The pedicled buccal fat pad flap was designed as previously reported2 to cover the buccal defect. Nonetheless, the RFFF was performed by plastic surgeon immediately after tumor extirpation to act as the inner lining of buccal defect. The option of reconstructive procedure depended on the choice of the patient after being well explained. Patients who had previously been treated with radiotherapy or surgery were excluded in the study. For avoiding the potential scar contracture and limitation of the mouth opening following surgery, all patients were advised to start mouth-open exercises after discharge from hospital. This study was approved by the Institutional Review Board of our hospital. The mouth-open width was defined as the midline distance between the lower margin of the upper gum and the upper margin of the lower gum. The mouth-open width was measured preoperatively and at least 6 months postoperatively. The clinical data including age, gender, primary tumor (T) and histology were obtained from clinical records retrospectively. The TNM status was classified according to 1997 AJCC (American Joint Committee on Cancer) system. The age, type of reconstruction and mouth-open width were obtained for analysis. We categorized the patients into three groups. The patients who underwent reconstruction with STSG, PBFPF or RFFF were assigned as Group STSG, Group PBFPF or Group RFFF accordingly. The Student’s t-test was used to study the statistical difference of the variables such as the age and mouth-open width among these
695 groups. The statistical significance was considered if p value was less than 0.05.
Results There were 37 patients enrolled in this study. Of the 37 patients, 35 were male and 2 were female with a mean age of 50.2 years (ranged 29–77). Group STSG consisted of 10 male patients with a mean age of 46.6 (ranged 29–61). Seven cases were classified as T1 and three cases as T2. All cases were reported to be squamous cell carcinoma. Group RFFF consisted of 11 male patients with a mean age of 53.5 (ranged 40–77). Six cases were classified as T2 and five cases as T3. The histology revealed that five cases were verrucous carcinoma and six cases were squamous cell carcinoma. Group PBFPF consisted of 2 female and 14 male patients with a mean age of 50.1 (ranged 38–66). Nine cases were classified as T1 and seven cases as T2. The histology revealed that two cases were verrucous carcinoma and 14 cases were squamous cell carcinoma (Table 1). There was no significant difference in age among these groups (p > 0.05). The mean preoperative and postoperative mouth-open width in Group STSG was 5.4 (ranged 6–4.1) cm and 4.0 (ranged 5.2–2.3) cm respectively. The reduction of mouth-open width changed from 9.6% to 44% (mean ± SD = 24.5 ± 12.95%). The mean preoperative and postoperative mouth-open width in Group RFFF was 5.7 (ranged 6.3–3.5) cm and 5.2 (ranged 5.9–3.2) cm respectively. The reduction of mouth-open width changed from 4.8% to 9.8% (mean ± SD = 7.4 ± 1.40%). The mean preoperative and postoperative mouth-open width in Group PBFPF was 5.1 (ranged 6.1–2.5) cm and 3.6 (ranged 5.6–1.6) cm respectively. The reduction of mouth-open width changed from 5% to 45.5% (mean ± SD = 33.1 ± 15.72%). The change of mouth-open width showed no significant difference between Group PBFPF and Group STSG (p = 0.384). However the change of mouth-open width was significantly less in Group RFFF than that of Group PBFPF (p < 0.001) and Group STSG (p = 0.003) respectively (Table 2). In Group STSG, none of these cases underwent postoperative radiotherapy. In Group RFFF and Group PBFPF, there were three patients and two patients who underwent radiotherapy after surgery respectively. In Group RFFF, no significant damage of pterygoid muscles was noted during operation and all radial forearm free flaps survived completely after the surgery. However, the flaps in two of the group RFFF were found to be bulky
696 Table 1
C.-Y. Chien et al. Characteristics of the study population
RFFF PBFPF STSG
Age (mean)
T1
T2
T3
SCC
VC
Postoperative radiotherapy
40–77 (53.5) 38–66 (50.1) 29–61 (46.6)
0 9 7
6 7 3
5 0 0
6 14 10
5 2 0
3 2 0
RFFF: radial forearm free flap. PBFPF: pedicled buccal fat pad flap. STSG: split-thickness skin graft. SCC: squamous cell carcinoma. VC: verrucous carcinoma.
Table 2 RFFF PBFPF STSG
Profile of mouth-open width among these groups Preoperative distance (mean) (cm)
Postoperative distance (mean) (cm)
Change (%)
Mean ± SD (%)
6.3–3.5 (5.7) 6.1–2.5 (5.1) 6.0–4.1 (5.4)
5.9–3.2 (5.2) 5.6–1.6 (3.6) 5.2–2.3 (4.0)
4.8–9.8 5–45.5 9.6–44
7.4 ± 1.40 33.1 ± 15.72 24.5 ± 12.95
RFFF: radial forearm free flap. PBFPF: pedicled buccal fat pad flap. STSG: split-thickness skin graft.
and needed to be trimmed months later. In Group PBFPF, the fat pad was epithelialized within 4 weeks. No flap loss was noted. However, one patient experienced a depressed cheek that might be due to a large amount of buccal fat transfer. In Group STSG, there was only one patient whose STSG survived completely. The others presented partial loss of the grafts.
Discussion There are a variety of options available for reconstruction of intraoral defect after tumor ablation in the buccal area. In the mean time, functional outcomes after such surgeries still remain the major concerns from the patients, especially the limitation of mouth opening. Tongue flaps are to be avoided due to the disruption of a swallowing structure and lingual function.4 Pedicled temporoparietal fascial flap is a pliable and nonbulky flap but the contracture can be a limiting factor for local flap reconstruction within the oral cavity.3 Most of our patients consumed and chewed areca nut for a period of time and presented somewhat extent of oral submucosal fibrosis that is also known to be associated with squamous cell carcinoma in the oral cavity. The areca nut plays an important role in the development of oral submucosal fibrosis.5 The STSG over such kind of relative avascular recipient may result into partial or even total loss of the graft and consequently limited the mouth-open width in this group. Another
disadvantage of this method is the unpleasant scar in the donor site. The pedicled buccal fat pad is easy to be harvested during buccal reconstruction procedure for a relatively limited size of buccal mucosal defect. The epithelialization takes place over this flap within 4–6 weeks6 and was confirmed by histological study.7 Radiotherapy does not seem to influence the success of the reconstruction.6,7 However, other kind of alternative reconstructive procedure is necessary if the defect is over 5 cm in diameter.1 The complication of cheek depression that was reported by previous studies1,2 may result from a large amount of buccal fat transfer, which is usually hard to be corrected.8 In the current series, the buccal reconstruction with pedicled buccal fat pad revealed unpredictable results in preserving the original mouth-open width and this outcome has also been reported in other literatures.3,9 The dense fibrous connective tissue in the subepithelial stroma lacking for lamina propria and submucosa could lead to retraction of the buccal fat pad9 and limitation in mouth-open. Buccal reconstruction with RFFF yielded the most favorable outcome in the current study although it took more time and skills in the operation. The RFFF usually tolerates the irradiation well and leads to a satisfactory outcome if the pterygoid muscles do not disrupt significantly during surgery. Nonetheless, the thick subcutaneous adipose tissue of RFFF may cause the bulky flap intraorally and need a trimming procedure later. To avoid this bulky effect, radial forearm fasciocutaneous free flap is another alternative for reconstruction of
Reconstruction of buccal mucosal defect buccal defects. Another potential disadvantage of the RFFF reconstruction method is the masking effect of tumor recurrence beneath the flap. Consequently, the regular follow up by image study is essential although the recurrence of the current series has not been found till now. In conclusion, reconstruction with radial forearm free flap for buccal mucosal defect achieves the excellent functional outcome and carries more chances to preserve the original mouth-open width than with pedicled buccal fat pad flap or split-thickness skin graft among the selected patients who undergo buccal cancer surgery for T2 or T3 stage.
References 1. Hao SP. Reconstruction of oral defects with the pedicled buccal fat pad flap. Otolaryngo Head Neck Surg 2000;122(6):863–7.
697 2. Dean A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M. The buccal fat pad flap in oral reconstruction. Head Neck 2001;23(5):383–8. 3. Nayak VK, Deschler DG. Pedicled temporoparietal fascial flap reconstruction of select intraoral defects. Laryngoscope 2004;114(9):1545–8. 4. Komisar A, Lawson W. A compendium of intraoral flaps. Head Neck Surg 1985;8(2):91–9. 5. Caniff JP, Harvly W. The etiology of oral submucosal fibrosis. The stimulation of collagen synthesis by extracts of areca nut. Int J Oral Surg 1981;10(Suppl 1): 163–7. 6. Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986;44(6):435– 40. 7. Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22(1): 2–6. 8. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical application of the buccal fat pad. Plast Reconstr Surg 1990;85(1):29–37. 9. Colella G, Tartaro G, Giudice A. The buccal fat pad in oral reconstruction. Br J Plast Surg 2004;57(4):326–9.
http://intl.elsevierhealth.com/journals/oron/
Comparison of radial forearm free flap, pedicled buccal fat pad flap and split-thickness skin graft in reconstruction of buccal mucosal defect Chih-Yen Chien a, Chung-Feng Hwang a, Hui-Ching Chuang a, Seng-Feng Jeng b, Chih-Ying Su a,* a
Department of Otolaryngology, Chang Gung Memorial Hospital at Kaohsiung 123, Ta-Pei Road, Niao-Song Hsiang, Kaohsiung County 833, Taiwan b Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Kaohsiung 123, Ta-Pei Road, Niao-Song Hsiang, Kaohsiung County 833, Taiwan Received 20 January 2005; accepted 2 March 2005
KEYWORDS
Summary There are a variety of methods to reconstruct the mucosal defect after the ablation of buccal cancer. We used the radial forearm free flap (RFFF), pedicled buccal fat pad flap (PBFPF) or split-thickness skin graft (STSG) to reconstruct the buccal mucosal defect in our series respectively and compared the mouth-open width among these methods. We found there was no significant difference in the change of mouth-open width between the Group STSG and Group PBFPF. However, the negative effect on the mouth opening was significantly less (p < 0.05) in Group RFFF when compared with the Group STSG or Group PBFPF. In conclusion, reconstruction with radial forearm free flap for buccal mucosal defect carries more chances to preserve the original mouth-open width than with pedicled buccal fat pad flap or split-thickness skin graft among the selected patients who undergo tumor resection for T2 or T3 buccal cancer. c 2005 Elsevier Ltd. All rights reserved.
Radial forearm free flap; Pedicled buccal fat pad flap; Split-thickness skin graft; Intraoral defect; Oral cavity reconstruction; Buccal cancer
Introduction
There are various kinds of surgical procedures available for reconstruction of buccal mucosal de* Corresponding author. Tel.: +886 7 7317123x2557; fax: +886 7 7313855. E-mail address: [email protected] (C.-Y. Su).
fect after wide resection of buccal cancer, such as split-thickness skin graft, mucosal graft, regional tongue flap, pedicled buccal fat pad flap,1,2 pedicled temporoparietal fascial flap3 and distant free flap. The choice option for reconstruction depends on the size of the buccal defect and the preference of the surgeons. However, limitation of mouth opening or even trismus may develop after
1368-8375/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2005.03.002
Reconstruction of buccal mucosal defect the reconstructive procedures following ablation of buccal cancer, especially among patients with somewhat extent of submucosal fibrosis in buccal area. This study is aimed to compare the width of mouth-open after reconstruction either with splitthickness skin graft, pedicled buccal fat pad flap or radial forearm free flap for patients who underwent wide resection of buccal cancer.
Patients and methods From January 2002 to June 2004, there were 37 patients who underwent primary surgical treatment for cure of buccal cancer in Chang Gung Memorial Hospital at Kaohsiung, Taiwan. All procedures about tumor extirpation were carried out solely by the first author (C.Y.C.). The buccal defect was reconstructed either with split-thickness skin graft (STSG), pedicled buccal fat pad flap (PBFPF) or radial forearm free flap (RFFF). The STSG was harvested from medial thigh with the thickness of 12/ 1000 in. to reconstruct the buccal defect. The pedicled buccal fat pad flap was designed as previously reported2 to cover the buccal defect. Nonetheless, the RFFF was performed by plastic surgeon immediately after tumor extirpation to act as the inner lining of buccal defect. The option of reconstructive procedure depended on the choice of the patient after being well explained. Patients who had previously been treated with radiotherapy or surgery were excluded in the study. For avoiding the potential scar contracture and limitation of the mouth opening following surgery, all patients were advised to start mouth-open exercises after discharge from hospital. This study was approved by the Institutional Review Board of our hospital. The mouth-open width was defined as the midline distance between the lower margin of the upper gum and the upper margin of the lower gum. The mouth-open width was measured preoperatively and at least 6 months postoperatively. The clinical data including age, gender, primary tumor (T) and histology were obtained from clinical records retrospectively. The TNM status was classified according to 1997 AJCC (American Joint Committee on Cancer) system. The age, type of reconstruction and mouth-open width were obtained for analysis. We categorized the patients into three groups. The patients who underwent reconstruction with STSG, PBFPF or RFFF were assigned as Group STSG, Group PBFPF or Group RFFF accordingly. The Student’s t-test was used to study the statistical difference of the variables such as the age and mouth-open width among these
695 groups. The statistical significance was considered if p value was less than 0.05.
Results There were 37 patients enrolled in this study. Of the 37 patients, 35 were male and 2 were female with a mean age of 50.2 years (ranged 29–77). Group STSG consisted of 10 male patients with a mean age of 46.6 (ranged 29–61). Seven cases were classified as T1 and three cases as T2. All cases were reported to be squamous cell carcinoma. Group RFFF consisted of 11 male patients with a mean age of 53.5 (ranged 40–77). Six cases were classified as T2 and five cases as T3. The histology revealed that five cases were verrucous carcinoma and six cases were squamous cell carcinoma. Group PBFPF consisted of 2 female and 14 male patients with a mean age of 50.1 (ranged 38–66). Nine cases were classified as T1 and seven cases as T2. The histology revealed that two cases were verrucous carcinoma and 14 cases were squamous cell carcinoma (Table 1). There was no significant difference in age among these groups (p > 0.05). The mean preoperative and postoperative mouth-open width in Group STSG was 5.4 (ranged 6–4.1) cm and 4.0 (ranged 5.2–2.3) cm respectively. The reduction of mouth-open width changed from 9.6% to 44% (mean ± SD = 24.5 ± 12.95%). The mean preoperative and postoperative mouth-open width in Group RFFF was 5.7 (ranged 6.3–3.5) cm and 5.2 (ranged 5.9–3.2) cm respectively. The reduction of mouth-open width changed from 4.8% to 9.8% (mean ± SD = 7.4 ± 1.40%). The mean preoperative and postoperative mouth-open width in Group PBFPF was 5.1 (ranged 6.1–2.5) cm and 3.6 (ranged 5.6–1.6) cm respectively. The reduction of mouth-open width changed from 5% to 45.5% (mean ± SD = 33.1 ± 15.72%). The change of mouth-open width showed no significant difference between Group PBFPF and Group STSG (p = 0.384). However the change of mouth-open width was significantly less in Group RFFF than that of Group PBFPF (p < 0.001) and Group STSG (p = 0.003) respectively (Table 2). In Group STSG, none of these cases underwent postoperative radiotherapy. In Group RFFF and Group PBFPF, there were three patients and two patients who underwent radiotherapy after surgery respectively. In Group RFFF, no significant damage of pterygoid muscles was noted during operation and all radial forearm free flaps survived completely after the surgery. However, the flaps in two of the group RFFF were found to be bulky
696 Table 1
C.-Y. Chien et al. Characteristics of the study population
RFFF PBFPF STSG
Age (mean)
T1
T2
T3
SCC
VC
Postoperative radiotherapy
40–77 (53.5) 38–66 (50.1) 29–61 (46.6)
0 9 7
6 7 3
5 0 0
6 14 10
5 2 0
3 2 0
RFFF: radial forearm free flap. PBFPF: pedicled buccal fat pad flap. STSG: split-thickness skin graft. SCC: squamous cell carcinoma. VC: verrucous carcinoma.
Table 2 RFFF PBFPF STSG
Profile of mouth-open width among these groups Preoperative distance (mean) (cm)
Postoperative distance (mean) (cm)
Change (%)
Mean ± SD (%)
6.3–3.5 (5.7) 6.1–2.5 (5.1) 6.0–4.1 (5.4)
5.9–3.2 (5.2) 5.6–1.6 (3.6) 5.2–2.3 (4.0)
4.8–9.8 5–45.5 9.6–44
7.4 ± 1.40 33.1 ± 15.72 24.5 ± 12.95
RFFF: radial forearm free flap. PBFPF: pedicled buccal fat pad flap. STSG: split-thickness skin graft.
and needed to be trimmed months later. In Group PBFPF, the fat pad was epithelialized within 4 weeks. No flap loss was noted. However, one patient experienced a depressed cheek that might be due to a large amount of buccal fat transfer. In Group STSG, there was only one patient whose STSG survived completely. The others presented partial loss of the grafts.
Discussion There are a variety of options available for reconstruction of intraoral defect after tumor ablation in the buccal area. In the mean time, functional outcomes after such surgeries still remain the major concerns from the patients, especially the limitation of mouth opening. Tongue flaps are to be avoided due to the disruption of a swallowing structure and lingual function.4 Pedicled temporoparietal fascial flap is a pliable and nonbulky flap but the contracture can be a limiting factor for local flap reconstruction within the oral cavity.3 Most of our patients consumed and chewed areca nut for a period of time and presented somewhat extent of oral submucosal fibrosis that is also known to be associated with squamous cell carcinoma in the oral cavity. The areca nut plays an important role in the development of oral submucosal fibrosis.5 The STSG over such kind of relative avascular recipient may result into partial or even total loss of the graft and consequently limited the mouth-open width in this group. Another
disadvantage of this method is the unpleasant scar in the donor site. The pedicled buccal fat pad is easy to be harvested during buccal reconstruction procedure for a relatively limited size of buccal mucosal defect. The epithelialization takes place over this flap within 4–6 weeks6 and was confirmed by histological study.7 Radiotherapy does not seem to influence the success of the reconstruction.6,7 However, other kind of alternative reconstructive procedure is necessary if the defect is over 5 cm in diameter.1 The complication of cheek depression that was reported by previous studies1,2 may result from a large amount of buccal fat transfer, which is usually hard to be corrected.8 In the current series, the buccal reconstruction with pedicled buccal fat pad revealed unpredictable results in preserving the original mouth-open width and this outcome has also been reported in other literatures.3,9 The dense fibrous connective tissue in the subepithelial stroma lacking for lamina propria and submucosa could lead to retraction of the buccal fat pad9 and limitation in mouth-open. Buccal reconstruction with RFFF yielded the most favorable outcome in the current study although it took more time and skills in the operation. The RFFF usually tolerates the irradiation well and leads to a satisfactory outcome if the pterygoid muscles do not disrupt significantly during surgery. Nonetheless, the thick subcutaneous adipose tissue of RFFF may cause the bulky flap intraorally and need a trimming procedure later. To avoid this bulky effect, radial forearm fasciocutaneous free flap is another alternative for reconstruction of
Reconstruction of buccal mucosal defect buccal defects. Another potential disadvantage of the RFFF reconstruction method is the masking effect of tumor recurrence beneath the flap. Consequently, the regular follow up by image study is essential although the recurrence of the current series has not been found till now. In conclusion, reconstruction with radial forearm free flap for buccal mucosal defect achieves the excellent functional outcome and carries more chances to preserve the original mouth-open width than with pedicled buccal fat pad flap or split-thickness skin graft among the selected patients who undergo buccal cancer surgery for T2 or T3 stage.
References 1. Hao SP. Reconstruction of oral defects with the pedicled buccal fat pad flap. Otolaryngo Head Neck Surg 2000;122(6):863–7.
697 2. Dean A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M. The buccal fat pad flap in oral reconstruction. Head Neck 2001;23(5):383–8. 3. Nayak VK, Deschler DG. Pedicled temporoparietal fascial flap reconstruction of select intraoral defects. Laryngoscope 2004;114(9):1545–8. 4. Komisar A, Lawson W. A compendium of intraoral flaps. Head Neck Surg 1985;8(2):91–9. 5. Caniff JP, Harvly W. The etiology of oral submucosal fibrosis. The stimulation of collagen synthesis by extracts of areca nut. Int J Oral Surg 1981;10(Suppl 1): 163–7. 6. Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986;44(6):435– 40. 7. Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22(1): 2–6. 8. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical application of the buccal fat pad. Plast Reconstr Surg 1990;85(1):29–37. 9. Colella G, Tartaro G, Giudice A. The buccal fat pad in oral reconstruction. Br J Plast Surg 2004;57(4):326–9.