- Email: [email protected]
Immediate reconstruction of maxilla with bone grafts supported by pedicled buccal fat pad graft
Immediate reconstruction of maxilla with bone grafts supported by pedicled buccal fat pad graft Lai-ping Zhong, PhD, MD,a Guan-fu Chen, DDS,b Li-jie Fan, DDS, PhD,c and Shi-fang Zhao, DDS, PhD,d Hangzhou, China ZHEJIANG UNIVERSITY COLLEGE OF MEDICINE DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
Purpose. To reconstruct immediately the maxilla with bone grafts after partial maxillary resection and solve complications of exposed bone grafts to the maxillary sinus leading to a high rate of bone infection and sequestration. Study design. Thirty-eight patients were treated by immediate reconstruction of the maxilla with bone grafts supported by pedicled buccal fat pad (BFP) graft. The facial contour, the bone healing of the bone grafts, and the function of the maxillary sinus were evaluated with the Waters radiograph and speech evaluation. Results. The postoperative healing was satisfactory with normal mouth opening and symmetrical contour of the face. The function of the maxillary sinus was restored with satisfactory speech and symmetrical density on radiograph and the healing of the bone grafts was good without complications such as bone resorption and sequestration. Conclusions. Immediate reconstruction of the maxilla with bone grafts supported by pedicled BFP grafts can restore the facial contour and the function of the maxillary sinus for the patients with partial maxillary resection. It provides a good method to reconstruct the maxillary defects and function in the mouth. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:147-54)
Reconstructing the contour and function of the maxilla after the resection because of tumor or trauma has been a difficult problem for a long time. Congenital and acquired loss of the middle-third of the face can lead to malformation and malfunction. Many scholars have tried to address this problem,1-5 but there are 3 difficult problems. The first was the restoration of the contour of the maxillary sinus walls and zygoma. The second was reconstruction of the palate to provide a proper skeletal support for a denture. Third was the recovery of the physiological function of the maxillary sinus. The traditional treatment for partial maxillary resection is the use of an obturator to fill the bony defect and separate the nasal cavity from the oral cavity, and providing prosthetic dentition. But the lack of easy drainage, obvious scar formation, and neuralgiform pain were always observed after traditional treatment.6 Even when local flaps or distant cylindrical flaps are used to fill the defect, the bony support for a denture and function restoration of the maxillary sinus cannot be realized. So bone transplantation is considered to a
Resident, Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital, College of Medicine, Zhejiang University, China. b Professor, Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital, College of Medicine, Zhejiang University, China. c Resident, Department of Oral and Maxillofacial Surgery, Affiliated Hospital, College of Medicine, Zhejiang University, China. d Professor, Department of Oral and Maxillofacial Surgery, Affiliated Hospital, College of Medicine, Zhejiang University, China. 1079-2104/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.tripleo.2003.09.011
reconstruct the maxilla, but the bone grafts are always exposed to the maxillary sinus without adequate vascularization of the recipient bed. Thin soft respiratory mucosa is not suitable for the transplanted recipient bed. The bone grafts without revascularization exposed to the sinus secretions and bacterial flora always have delayed consolidation, creating the potential for contamination with a high risk of infection and sequestration. Based on a series of studies on the anatomy and histogical changes of the pedicled buccal fat pad (BFP),7-9 we provided morphological and histological evidence to help design the pedicled BFP graft and direct its clinical application. Thirty-eight patients were treated with partial maxillary resection with immediate reconstruction of the maxilla with bone grafts supported by the pedicled BFP graft from 1988 to 2000. The results were a major improvement over past techniques. PATIENTS AND METHODS Clinical application of pedicled BFP From 1988 to 2000, the pedicled BFP was used to support the bone grafts on the maxillary sinus side for the immediate reconstruction of the maxillary defects after partial maxillary resection in 38 patients. The subjects ages ranged from 14 to 54 years with a mean age of 26 years, and there were 26 men and 12 women. Among the 38 patients with block bone grafts, 23 patients were treated with the ribs and 15 with the iliac crest grafts. All of the patients’ diagnoses were confirmed with pathology consisting of 5 myxomas, 5 147
148 Zhong et al
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004
Table I. Summary of the patients Case 1 2 3
Sex
Age Side of (years) maxilla
Male Male Male
27 41 14
Right Right Right
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Male Male Male Female Male Male Female Male Male Male Male Female Female Male Male Female
17 27 24 15 17 16 28 27 37 20 26 32 34 30 22 24
Left Right Left Left Left Left Left Right Right Right Left Left Left Left Right Right
20 21 22 23 24 25 26 27 28 29 30
Male Male Female Male Female Male Female Male Male Female Male
31 24 20 34 31 26 22 24 21 15 22
Left Right Left Left Right Right Left Left Right Left Left
31 32 33 34 35 36 37 38
Female Male Male Male Female Male Female Male
27 32 54 35 29 26 17 33
Right Right Left Right Left Left Right Right
Pathologic diagnosis Myxoma Ameloblastoma Calcifying epithelial odontogenic tumor Osteofibroma Osteofibroma Giant cell tumor of bone Osteofibroma Keratocyst Desmoid tumor of maxilla Ameloblastoma Fibrous dysplasia of bone Osteofibroma Osteofibroma Fibrous dysplasia of bone Myxoma Giant cell tumor of bone Myxoma Osteofibroma Calcifying epithelial odontogenic tumor Osteofibroma Fibrous dysplasia of bone Osteofibroma Giant cell tumor of bone Ameloblastoma Myxoma Keratocyst Ameloblastoma Osteofibroma Desmoid tumor of maxilla Calcifying epithelial odontogenic tumor Myxoma Osteofibroma Giant cell tumor of bone Ameloblastoma Fibrous dysplasia of bone Osteofibroma Osteofibroma Osteofibroma
ameloblastomas, 3 calcifying epithelial odontogenic tumors, 13 osteofibromas, 4 giant cell tumors of bone, 2 keratocysts, 4 fibrous dysplasias, and 2 desmoid tumors (Table I). Surgical technique Under general anesthesia, partial maxillary resection is performed, and the healthy mucosa of the nasal cavity and maxillary sinus preserved as much as possible. If the mucosa is broken, it would be sutured tightly up to maintain the continuity of the mucosa, but the mucosal defect at the floor of maxillary sinus may be left unrepaired. The buccinator is then incised and the BFP exposed in the
Bone graft
Bone Density of both Speech Follow-up Complications healing maxillary sinus evaluation years
Rib Ilium Rib
No No No
Good Good Good
Symmetrical Symmetrical Symmetrical
Good Good Good
12 12 12
Rib Rib Ilium Rib Rib Rib Ilium Rib Rib Rib Ilium Rib Ilium Ilium Rib Rib
No No No No No No No No Fistula No No No No No No No
Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good
Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical
Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good
11 9.5 9 9 9 8.5 8.5 8 8 7 7 7 7 6.5 6 6
Rib Ilium Rib Rib Rib Ilium Rib Rib Rib Ilium Ilium
No Fistula No No No No No Fistula No No No
Good Good Good Good Good Good Good Good Good Good Good
Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical
Good Good Good Good Good Good Good Good Good Good Good
5.5 5 5 5 5 4.5 4.5 4 4 3.5 3.5
Ilium Rib Ilium Ilium Ilium Rib Ilium Rib
No No No No No No No No
Good Good Good Good Good Good Good Good
Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical
Good Good Good Good Good Good Good Good
3 3 3 2.5 2 2 1 1
buccal space directly through the buccal incision. The BFP, with thin and intact envelope, is gently pulled out from its bed. Excess trauma should be avoided. Then the BFP is shaped with a pedicle and rotated medially to the floor of the maxillary sinus. There it is positioned between the bone graft and the surface of mucosal wound. The mucosa of maxillary sinus should keep in contact with the surface of pedicled BFP as far as possible for regeneration. In order to attach the pedicled BFP tightly to the transplanted bone, small burr holes are made in the transplanted bone, and the pedicled BFP sutured to the transplanted bone to close the communication between the maxillary sinus and the transplanted bones (Fig 1, A). The
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97, Number 2
Zhong et al 149
Fig 1. Schematic illustration shows the reconstruction of the maxilla after half or part resection of the maxilla. A, Reconstructed palate, maxillary sinus and part of zygoma. Autologous bone grafts (B) were isolated by the pedicled BFP graft from the new-formed maxillary sinus, the mucosa of the maxillary sinus (C) and the oral mucosa (D) were not completely resected to close the communication between the maxillary sinus and the transplanted bone. B, To reconstruct the maxilla, the bone grafts (B) were used to reconstruct the zygoma, the anterior wall of maxillary sinus, palatine, and alveolar bone with the application of the pedicled BFP (A).
fifth and sixth rib or iliac crest is transplanted to the maxillary defect. Before fixation, the transplanted bone should be reshaped according to the position and size of the defect to reconstruct the zygoma, the anterior wall of maxillary sinus, palatine, and alveolar bone (Fig 1, B). Then the transplanted bone is fixed to the remaining maxilla bone with wire ligatures or titanium microplates. The oral surface of the transplanted bone is closed with the buccal mucosa and palatal mucoperiosteum. Follow-up During the follow-up period from 1 to 12 years, all of the patients were re-examined with Waters films for a comparison between both maxillary sinuses, and the bone density between the bone grafts. The remaining maxilla bone was also compared in order to evaluate the bone healing. The speech function was evaluated by at least 3 doctors to determine whether the patients could pronounce and express themselves clearly. Typical Cases Case 1. A 27-year-old man presented with myxoma involving the right maxilla (Fig 2, A and B). The partial maxillary resection was performed, including the tumor and part of the right maxilla (the seven teeth from the right maxillary lateral incisor to the right maxillary third molar). The mucosa of the right maxillary sinus was preserved. The pedicled BFP was gently
pulled out from its bed and transposed to the defect at the floor of the maxillary sinus. There it was sutured to the margins of the remaining maxilla bone. His sixth rib was resected and transplanted to reconstruct the anterior wall of the maxillary sinus, alveolar and palatal processes of the remaining maxilla, and fixed with wires. Palatal mucoperiosteum was stripped and sutured to the margin of the buccal mucosa to close the wound. The wound healed well and the appearances of the face and palate were good. Twenty months later, a postoperative radiograph revealed good healing of the bone grafts and normal shape and lucency of the maxillary sinuses (Fig 2, C). The facial contour was symmetrical 6 years after the surgical operation (Fig 2, D). Case 2. A 41-year-old man presented with ameloblastoma of right maxilla (Fig 3, A and B). The resection included the tumor, most of the right maxilla (the seven teeth from the right maxillary lateral incisor to the right maxillary third molar), and part of the zygoma, but the infraorbital rim was preserved (Fig 3, C and D). The mucosa of the right maxillary sinus was also preserved. The pedicled BFP was pulled out from its bed and transposed to the defect, and sutured to the margins of the bone (Fig 3, E and F). The iliac crest was dissected and transplanted to reconstruct the anterior wall of maxilla sinus and the alveolar and palatal processes of the remaining maxilla and the zygoma, and was fixed with titanium microplates (Fig 3, G). Palatal mucoperiosteum was
150 Zhong et al
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004
Fig 2. Use of the pedicled BFP graft and rib graft after partial maxillary resection. A, Preoperative view of the right maxilla with myxoma. B, Radiograph of the myxoma involving right maxilla. C, Radiograph 20 months after surgical operation showing the good healing of the bone grafts and the normal shape and density of the maxillary sinus. D, Appearance of the patient 6 years after surgical operation with satisfactory facial contour and good pronunciation.
stripped and sutured to the margin of the buccal mucosa to close the wound. The wound healed well, and the appearances of face and palate were good (Fig 3, H and I). One year later, the postoperative radiograph revealed the good healing of the bone grafts and the normal shape and density of the maxillary sinus. The pre-existing symmetrical facial contour was unchanged during the follow-up period of 7 years (Fig 3, J). RESULTS All patients were treated surgically with partial maxillary resection including the tumor. The mucosa of the maxillary sinus floor was partially interrupted with the exception of 6 patients in which it remained intact. Im-
mediate reconstruction of the maxilla was performed with rib or iliac crest autografts supported by the pedicled BFP graft. The postoperative healing was good except in 3 cases which had small fistulas in the oral cavity, which were probably caused by tension and could be routinely managed secondarily. The follow-up period ranged from 1 to 12 years. Results were good with normal mouth opening (not less than 37 mm), symmetry of facial contour, and the ability to restore the dentitions with removable partial dentures. Normal function of maxillary sinus was also restored. The speech function in all the patients was considered satisfactory with clear language expression, and was much better than those patients without reconstruction of maxilla with bone grafts supported by
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97, Number 2
Zhong et al 151
Fig 3. Pedicled BFP graft and iliac crest bone grafts for reconstruction of the maxilla. A, B, Patient presented with ameloblastoma of the right maxilla. C, Intraoperative view of the tumor. D, Partial maxillary Resection including the seven teeth from the right maxillary lateral incisor to the right maxillary third molar, and part of the zygoma. E, F, The pedicled BFP was transposed to the inner aspect of the transplanted bone. G, Iliac crest was transplanted to the anterior wall of maxillary sinus, alveolar and palatine fixing with titanium micropalates. H, I, Appearance of the patient 14 days after surgical operation. J, Appearance of the patient 7 years after surgical operation with symmetrical facial contour and good pronunciation.
pedicled BFP graft. The lucency of the maxillary sinus was symmetric about 6 months after surgical operation. Patients did not feel obvious limitation of sinus drainage or neuralgiform pain. The bone density between the bone grafts and the remaining maxilla bone was mainly coincident; the bone healing of the grafts was good without bone resorption and sequestration (Table I). DISCUSSION When tumors of the maxilla are resected, the reconstruction of the contour and function of the maxilla has
always been difficult for surgeons. The traditional treatment to partial maxillary resection is the use of an obturator to fill the defect and separate the nasal cavity from the oral cavity and restore the dentition prosthetically. But the obliteration of drainage, obvious scar formation, and neuralgiform pain are commonly observed after traditional treatment.6 Efforts have been made to reconstruct the maxilla using bone grafts, but the bone grafts are always exposed to the maxillary sinus without an adequate recipient bed. Thin soft respiratory mucosa is not suitable for the transplanted recipient bed. The bone
152 Zhong et al
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004
Fig 3. Continued.
grafts without revascularization exposed to the sinus secretions and bacterial flora always have delayed consolidation, with the potential for contamination with a risk of infection and sequestration. The BFP is a specially organized tissue that is distinct from subcutaneous fat. It is described as consisting of a central body and four extensions: buccal, pterygomandibular, superficial, and deep temporal extension. The blood supply to the BFP comes from 3 sources: the buccal and deep temporal branches of the maxillary artery, the transverse facial branch of the superficial temporal artery, and small branches of the facial artery.10 The BFP was first used as a pedicled graft by Egyedi,11 followed by Neder12 and then Tideman,10
who used the pedicled BFP to close the intraoral defect. As a pedicled graft, the anatomical region of the BFP is uniformly well vascularized, providing a proximate donor site to the recipient site to reduce the need for extensive dissection.13-15 Its use was extended to repair all kinds of intraoral defects such as oroantral and oronasal communication, palatine defect, cleft palate, defect caused by tumor resection and other etiologies.16-38 The blood supply to the pedicled BFP ensured the success rate of this graft with rapid epithelialization. In our previous study on the pedicled BFP graft, we found the epithelialization began 2-3 weeks after operation, and complete epithelization was realized in 4-6 weeks. The new epithelium was similar to the adjacent
Zhong et al 153
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97, Number 2
Fig 3. Continued.
mucosa but thinner than normal mucosa.8 The pedicled BFP graft is an ideal graft because of its easy mobilization, excellent blood supply, and limited donor site morbidity. It has been debated whether the BFP is suitable for the reconstruction of the maxilla with bone grafts. In 1988, Vuillemin et al39 used the BFP as a pedicled flap to cover bone grafts in 8 cases of reconstruction of maxilla. Although fat tissue cannot induce osteoblasts, the pedicled BFP graft has strong ability of infection resistence, with little necrosis and absorption.12,32,34,39 The epithelium of local mucosa and BFP can regenerate and recover its function.6,7 Marx has questioned the method of immediate reconstruction of maxilla with bone grafts because of the high incidence of complication (25%), and limits its use to cases of benign osseous tumors and cystic lesions.40 The obturator is traditionally used to fill the defect caused by maxillectomy or partial maxillary resection for treating the maxillary tumor or trauma, and the postoperative obliteration of drainage, obvious scar formation, and neuralgiform pain are usually observed. Because the bone grafts were used to reconstruct the maxilla, the facial contour can be more satisfactory, and dental prostheses have a bony support. Unfortunately, the bone grafts are always exposed to the maxillary sinus without adequate vascularization of the recipient bed and have a potential for contamination by sinus secretions and/or flora with a high risk of inflammation and sequestration. However, the pedicled BFP serves as a good lining tissue at the maxillary sinus side, and the bone grafts heal well
without infection and sequenstration. Also the function of the maxillary sinus recovers with good speech evaluation. The recovery of function of the maxillary sinus is as important as the recovery of facial contour. Good healing of the unresected end and transplanted bone after operation occurs owing to excellent blood supply from the soft tissues. Without the pedicled BFP as a lining tissue, the transplanted bone would be exposed to bacterial flora of the maxillary sinus, and the infection and sequestration are believed to delay the consolidation of the bones. In the 38 cases treated with the bone grafts supported by pedicled BFP, the pedicled BFP served as a recipient bed and a barrier of the grafts against the maxillary sinus to avoid infection and bone resorption and sequestration. Three fistulas in the oral cavity side occurred and were repaired. In order to avoid the postoperative fistula and infection, the wound of the oral cavity side should be closed tightly but without tension. Care should be taken when pulling the BFP out from its bed and transposed to the defect because the vascular inflow and outflow of the pedicled graft are very easily destroyed by violence when separating from the surrounding tissue.6,7,26 It is suggested that the pedicled BFP should cover the surgical defect adequately and be sutured to the bone without tension. In order to reconstruct the maxilla adequately, preservation of as much of the maxillary bone and mucosa of the maxillary sinus as possible is necessary, but the tumor tissues must be resected completely. However, the maxillary
154 Zhong et al
benign tumors with normal maxillary sinus are considered the most suitable for this method. Immediate reconstruction of the maxilla with bone grafts supported by pedicled BFP graft restores the facial contour and the function of the maxillary sinus in patients with partial maxillary resection. The pedicled BFP is helpful to prevent exposing bone grafts to the maxillary sinus or nasal cavity, preventing a high rate of bone resorption and sequestration previously seen when reconstructing the maxilla. REFERENCES 1. Edgerton MT, Devito RV. Reconstruction of palatal defects resulting from treatment of palate. Plast Reconstr Surg 1961;28: 306. 2. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in head and neck. Plast Reconstr Surg 1979;63:73-81. 3. Serafin D, Riefkohi R, Thomas I, Georgiade NG. Vascularized rib periosteal and osteocutaneous reconstruction of the maxilla and mandible. Plast Reconstr Surg 1980;66:718-27. 4. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530-45. 5. Herring SM. Reconstruction of facial contour deformity with the buccal fat pad flap. Ann Plast Surg 1992;29:450-3. 6. Lindorf HH. Osteoplastic surgery of the sinus maxillaris—the “Bone Lid” method. J Maxillofac Surg 1984;12:271-6. 7. Chen GF. Clinical application of the buccal fat pad as a pedicled graft. Chinese J Microsurg 1998;21:215-6. 8. Chen GF, Fan LJ, Hu JA. Clinical application and histological study of buccal fat pad. Chinese J ZheJiang U Med Sci 1998; 27:216-8. 9. Chen GF, Fan LJ, Hu JA. Experimental study of the buccal fat pad as a pedicled graft. Chinese J Oral Maxillofac Surg 2000; 10:121-3. 10. Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986;44:435-40. 11. Egyedi P. Utilization of the buccal fat pad for closure of oroantral and/or oro-nasal fistula. J Oral Maxillofac Surg 1977;5: 241-4. 12. Neder A. Use of buccal fat pad. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1983;55:349-50. 13. Fujimura N, Nagura H, Enomot S. Grafting of the buccal fat pad into palatal defects. J Craniomaxillofac Surg 1990;18:219-22. 14. Loh FC, Loh HS. Use of the buccal fat pad for correction of intraoral defects: report of cases. J Oral Maxillofac Surg 1991; 49:413-6. 15. Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg 2000;58:389-92. 16. Dea A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M. The buccal fat pad flap in oral reconstruction. Head Neck 2001;23: 383-8. 17. Hao SP. Reconstruction of oral defects with the pedicled buccal fat pad flap. Otolaryngol Head Neck Surg 2000;122:863-7. 18. Pandolfi PJ, Yavuzer R, Jackson IT. Three-layer closure of an oroantral-cutaneous defect. Int J Oral Maxillofac Surg 2000;29: 24-6. 19. 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. 20. 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: 834-8.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004 21. Ramirez OM. Buccal fat pad pedicle flap for midface augmentation. Ann Plast Surg 1999;43:109-18. 22. Jackson IT. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1999;103:2059-60. 23. Sailer HF, Haers PE, Gratz KW. The Le Fort I osteotomy as a surgical approach for removal of tumors of the midface. J Craniomaxillofac Surg 1999;27:1-6. 24. Chen GF, Fan LJ, Hu JA. Use of the pedicled buccal fat pad for defects of palatal tumor. Chinese J Oral Maxillofac Surg 1999; 9:100-2. 25. Zhao Z, Li S, Li Y. The application of the pedicled buccal fat pad graft in cleft palate repair. Chinese J Plast Surg Burns 1998;14: 182-5. 26. Chen GF, Xie L. Use of the buccal fat pad for buccal carcinoma. Chinese J Pract Oncology 1998;13:240-1. 27. Martin-Granizo R, Naval L, Costas A, Goizueta C, Rodriguez F, Monje F, et al. Use of buccal fat pad to repair intraoral defects: review of 30 cases. Br J Oral Maxillofac Surg 1997;35:81-4. 28. Shibahara T, Watanabe Y, Yamaguchi S, Noma H, Yamane GY, Abe S, et al. Use of the buccal fat pad as a pedicle graft. Bull Tokyo Dent Coll 1996;37:161-5. 29. Yeh CJ. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25:130-3. 30. Hudson JW, Anderson JG, Russell RM, Anderson N, Chambers K. Use of pedicled fat pad graft as an adjunct in the reconstruction of palatal cleft defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:24-7. 31. Hanazawa Y, Itoh K, Mabashi T, Sato K. Closure of oroantral communications using a pedicled buccal fat pad graft. J Oral Maxillofac Surg 1995;53:771-5. 32. Chen GF. Use of hydroxyapatite and buccal fat pad reconstruction the maxilla bone defects. Chinese J Oral Maxillofac Surg 1994;4:112-3. 33. Cheung LK, Samman N, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22:2-6. 34. Chen GF, Ping FY. Immediate reconstruction of the maxillary with bone grafts supported by the buccal fat pad. Chinese J Stomatol 1992;27:88-9. 35. Stajcic Z. The buccal fat pad in the closure of oro-antral communications: a study of 56 cases. J Craniomaxillofac Surg 1992; 20:193-7. 36. Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe SA. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990;85:29-37. 37. Dubin B, Jackson IT, Halim A, Triplett WW, Ferreira M. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1989;83:257-64. 38. Hai HK. Repair of palatal defects with unlined buccal fat pad grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1988;65:523-5. 39. 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. 40. Marx RE. Reconstruction of the maxilla with bone grafts supported by the buccal fat pad. Discussion. J Oral Maxillofac Surg 1988;46:105-6. Reprint requests: Lai-ping Zhong Department of Oral and Maxillofacial Surgery Second Affiliated Hospital College of Medicine Zhejiang University No. 88 Jiefang Road Hangzhou 310009, China [email protected]
Purpose. To reconstruct immediately the maxilla with bone grafts after partial maxillary resection and solve complications of exposed bone grafts to the maxillary sinus leading to a high rate of bone infection and sequestration. Study design. Thirty-eight patients were treated by immediate reconstruction of the maxilla with bone grafts supported by pedicled buccal fat pad (BFP) graft. The facial contour, the bone healing of the bone grafts, and the function of the maxillary sinus were evaluated with the Waters radiograph and speech evaluation. Results. The postoperative healing was satisfactory with normal mouth opening and symmetrical contour of the face. The function of the maxillary sinus was restored with satisfactory speech and symmetrical density on radiograph and the healing of the bone grafts was good without complications such as bone resorption and sequestration. Conclusions. Immediate reconstruction of the maxilla with bone grafts supported by pedicled BFP grafts can restore the facial contour and the function of the maxillary sinus for the patients with partial maxillary resection. It provides a good method to reconstruct the maxillary defects and function in the mouth. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:147-54)
Reconstructing the contour and function of the maxilla after the resection because of tumor or trauma has been a difficult problem for a long time. Congenital and acquired loss of the middle-third of the face can lead to malformation and malfunction. Many scholars have tried to address this problem,1-5 but there are 3 difficult problems. The first was the restoration of the contour of the maxillary sinus walls and zygoma. The second was reconstruction of the palate to provide a proper skeletal support for a denture. Third was the recovery of the physiological function of the maxillary sinus. The traditional treatment for partial maxillary resection is the use of an obturator to fill the bony defect and separate the nasal cavity from the oral cavity, and providing prosthetic dentition. But the lack of easy drainage, obvious scar formation, and neuralgiform pain were always observed after traditional treatment.6 Even when local flaps or distant cylindrical flaps are used to fill the defect, the bony support for a denture and function restoration of the maxillary sinus cannot be realized. So bone transplantation is considered to a
Resident, Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital, College of Medicine, Zhejiang University, China. b Professor, Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital, College of Medicine, Zhejiang University, China. c Resident, Department of Oral and Maxillofacial Surgery, Affiliated Hospital, College of Medicine, Zhejiang University, China. d Professor, Department of Oral and Maxillofacial Surgery, Affiliated Hospital, College of Medicine, Zhejiang University, China. 1079-2104/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.tripleo.2003.09.011
reconstruct the maxilla, but the bone grafts are always exposed to the maxillary sinus without adequate vascularization of the recipient bed. Thin soft respiratory mucosa is not suitable for the transplanted recipient bed. The bone grafts without revascularization exposed to the sinus secretions and bacterial flora always have delayed consolidation, creating the potential for contamination with a high risk of infection and sequestration. Based on a series of studies on the anatomy and histogical changes of the pedicled buccal fat pad (BFP),7-9 we provided morphological and histological evidence to help design the pedicled BFP graft and direct its clinical application. Thirty-eight patients were treated with partial maxillary resection with immediate reconstruction of the maxilla with bone grafts supported by the pedicled BFP graft from 1988 to 2000. The results were a major improvement over past techniques. PATIENTS AND METHODS Clinical application of pedicled BFP From 1988 to 2000, the pedicled BFP was used to support the bone grafts on the maxillary sinus side for the immediate reconstruction of the maxillary defects after partial maxillary resection in 38 patients. The subjects ages ranged from 14 to 54 years with a mean age of 26 years, and there were 26 men and 12 women. Among the 38 patients with block bone grafts, 23 patients were treated with the ribs and 15 with the iliac crest grafts. All of the patients’ diagnoses were confirmed with pathology consisting of 5 myxomas, 5 147
148 Zhong et al
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004
Table I. Summary of the patients Case 1 2 3
Sex
Age Side of (years) maxilla
Male Male Male
27 41 14
Right Right Right
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Male Male Male Female Male Male Female Male Male Male Male Female Female Male Male Female
17 27 24 15 17 16 28 27 37 20 26 32 34 30 22 24
Left Right Left Left Left Left Left Right Right Right Left Left Left Left Right Right
20 21 22 23 24 25 26 27 28 29 30
Male Male Female Male Female Male Female Male Male Female Male
31 24 20 34 31 26 22 24 21 15 22
Left Right Left Left Right Right Left Left Right Left Left
31 32 33 34 35 36 37 38
Female Male Male Male Female Male Female Male
27 32 54 35 29 26 17 33
Right Right Left Right Left Left Right Right
Pathologic diagnosis Myxoma Ameloblastoma Calcifying epithelial odontogenic tumor Osteofibroma Osteofibroma Giant cell tumor of bone Osteofibroma Keratocyst Desmoid tumor of maxilla Ameloblastoma Fibrous dysplasia of bone Osteofibroma Osteofibroma Fibrous dysplasia of bone Myxoma Giant cell tumor of bone Myxoma Osteofibroma Calcifying epithelial odontogenic tumor Osteofibroma Fibrous dysplasia of bone Osteofibroma Giant cell tumor of bone Ameloblastoma Myxoma Keratocyst Ameloblastoma Osteofibroma Desmoid tumor of maxilla Calcifying epithelial odontogenic tumor Myxoma Osteofibroma Giant cell tumor of bone Ameloblastoma Fibrous dysplasia of bone Osteofibroma Osteofibroma Osteofibroma
ameloblastomas, 3 calcifying epithelial odontogenic tumors, 13 osteofibromas, 4 giant cell tumors of bone, 2 keratocysts, 4 fibrous dysplasias, and 2 desmoid tumors (Table I). Surgical technique Under general anesthesia, partial maxillary resection is performed, and the healthy mucosa of the nasal cavity and maxillary sinus preserved as much as possible. If the mucosa is broken, it would be sutured tightly up to maintain the continuity of the mucosa, but the mucosal defect at the floor of maxillary sinus may be left unrepaired. The buccinator is then incised and the BFP exposed in the
Bone graft
Bone Density of both Speech Follow-up Complications healing maxillary sinus evaluation years
Rib Ilium Rib
No No No
Good Good Good
Symmetrical Symmetrical Symmetrical
Good Good Good
12 12 12
Rib Rib Ilium Rib Rib Rib Ilium Rib Rib Rib Ilium Rib Ilium Ilium Rib Rib
No No No No No No No No Fistula No No No No No No No
Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good
Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical
Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good
11 9.5 9 9 9 8.5 8.5 8 8 7 7 7 7 6.5 6 6
Rib Ilium Rib Rib Rib Ilium Rib Rib Rib Ilium Ilium
No Fistula No No No No No Fistula No No No
Good Good Good Good Good Good Good Good Good Good Good
Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical
Good Good Good Good Good Good Good Good Good Good Good
5.5 5 5 5 5 4.5 4.5 4 4 3.5 3.5
Ilium Rib Ilium Ilium Ilium Rib Ilium Rib
No No No No No No No No
Good Good Good Good Good Good Good Good
Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical Symmetrical
Good Good Good Good Good Good Good Good
3 3 3 2.5 2 2 1 1
buccal space directly through the buccal incision. The BFP, with thin and intact envelope, is gently pulled out from its bed. Excess trauma should be avoided. Then the BFP is shaped with a pedicle and rotated medially to the floor of the maxillary sinus. There it is positioned between the bone graft and the surface of mucosal wound. The mucosa of maxillary sinus should keep in contact with the surface of pedicled BFP as far as possible for regeneration. In order to attach the pedicled BFP tightly to the transplanted bone, small burr holes are made in the transplanted bone, and the pedicled BFP sutured to the transplanted bone to close the communication between the maxillary sinus and the transplanted bones (Fig 1, A). The
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97, Number 2
Zhong et al 149
Fig 1. Schematic illustration shows the reconstruction of the maxilla after half or part resection of the maxilla. A, Reconstructed palate, maxillary sinus and part of zygoma. Autologous bone grafts (B) were isolated by the pedicled BFP graft from the new-formed maxillary sinus, the mucosa of the maxillary sinus (C) and the oral mucosa (D) were not completely resected to close the communication between the maxillary sinus and the transplanted bone. B, To reconstruct the maxilla, the bone grafts (B) were used to reconstruct the zygoma, the anterior wall of maxillary sinus, palatine, and alveolar bone with the application of the pedicled BFP (A).
fifth and sixth rib or iliac crest is transplanted to the maxillary defect. Before fixation, the transplanted bone should be reshaped according to the position and size of the defect to reconstruct the zygoma, the anterior wall of maxillary sinus, palatine, and alveolar bone (Fig 1, B). Then the transplanted bone is fixed to the remaining maxilla bone with wire ligatures or titanium microplates. The oral surface of the transplanted bone is closed with the buccal mucosa and palatal mucoperiosteum. Follow-up During the follow-up period from 1 to 12 years, all of the patients were re-examined with Waters films for a comparison between both maxillary sinuses, and the bone density between the bone grafts. The remaining maxilla bone was also compared in order to evaluate the bone healing. The speech function was evaluated by at least 3 doctors to determine whether the patients could pronounce and express themselves clearly. Typical Cases Case 1. A 27-year-old man presented with myxoma involving the right maxilla (Fig 2, A and B). The partial maxillary resection was performed, including the tumor and part of the right maxilla (the seven teeth from the right maxillary lateral incisor to the right maxillary third molar). The mucosa of the right maxillary sinus was preserved. The pedicled BFP was gently
pulled out from its bed and transposed to the defect at the floor of the maxillary sinus. There it was sutured to the margins of the remaining maxilla bone. His sixth rib was resected and transplanted to reconstruct the anterior wall of the maxillary sinus, alveolar and palatal processes of the remaining maxilla, and fixed with wires. Palatal mucoperiosteum was stripped and sutured to the margin of the buccal mucosa to close the wound. The wound healed well and the appearances of the face and palate were good. Twenty months later, a postoperative radiograph revealed good healing of the bone grafts and normal shape and lucency of the maxillary sinuses (Fig 2, C). The facial contour was symmetrical 6 years after the surgical operation (Fig 2, D). Case 2. A 41-year-old man presented with ameloblastoma of right maxilla (Fig 3, A and B). The resection included the tumor, most of the right maxilla (the seven teeth from the right maxillary lateral incisor to the right maxillary third molar), and part of the zygoma, but the infraorbital rim was preserved (Fig 3, C and D). The mucosa of the right maxillary sinus was also preserved. The pedicled BFP was pulled out from its bed and transposed to the defect, and sutured to the margins of the bone (Fig 3, E and F). The iliac crest was dissected and transplanted to reconstruct the anterior wall of maxilla sinus and the alveolar and palatal processes of the remaining maxilla and the zygoma, and was fixed with titanium microplates (Fig 3, G). Palatal mucoperiosteum was
150 Zhong et al
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004
Fig 2. Use of the pedicled BFP graft and rib graft after partial maxillary resection. A, Preoperative view of the right maxilla with myxoma. B, Radiograph of the myxoma involving right maxilla. C, Radiograph 20 months after surgical operation showing the good healing of the bone grafts and the normal shape and density of the maxillary sinus. D, Appearance of the patient 6 years after surgical operation with satisfactory facial contour and good pronunciation.
stripped and sutured to the margin of the buccal mucosa to close the wound. The wound healed well, and the appearances of face and palate were good (Fig 3, H and I). One year later, the postoperative radiograph revealed the good healing of the bone grafts and the normal shape and density of the maxillary sinus. The pre-existing symmetrical facial contour was unchanged during the follow-up period of 7 years (Fig 3, J). RESULTS All patients were treated surgically with partial maxillary resection including the tumor. The mucosa of the maxillary sinus floor was partially interrupted with the exception of 6 patients in which it remained intact. Im-
mediate reconstruction of the maxilla was performed with rib or iliac crest autografts supported by the pedicled BFP graft. The postoperative healing was good except in 3 cases which had small fistulas in the oral cavity, which were probably caused by tension and could be routinely managed secondarily. The follow-up period ranged from 1 to 12 years. Results were good with normal mouth opening (not less than 37 mm), symmetry of facial contour, and the ability to restore the dentitions with removable partial dentures. Normal function of maxillary sinus was also restored. The speech function in all the patients was considered satisfactory with clear language expression, and was much better than those patients without reconstruction of maxilla with bone grafts supported by
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97, Number 2
Zhong et al 151
Fig 3. Pedicled BFP graft and iliac crest bone grafts for reconstruction of the maxilla. A, B, Patient presented with ameloblastoma of the right maxilla. C, Intraoperative view of the tumor. D, Partial maxillary Resection including the seven teeth from the right maxillary lateral incisor to the right maxillary third molar, and part of the zygoma. E, F, The pedicled BFP was transposed to the inner aspect of the transplanted bone. G, Iliac crest was transplanted to the anterior wall of maxillary sinus, alveolar and palatine fixing with titanium micropalates. H, I, Appearance of the patient 14 days after surgical operation. J, Appearance of the patient 7 years after surgical operation with symmetrical facial contour and good pronunciation.
pedicled BFP graft. The lucency of the maxillary sinus was symmetric about 6 months after surgical operation. Patients did not feel obvious limitation of sinus drainage or neuralgiform pain. The bone density between the bone grafts and the remaining maxilla bone was mainly coincident; the bone healing of the grafts was good without bone resorption and sequestration (Table I). DISCUSSION When tumors of the maxilla are resected, the reconstruction of the contour and function of the maxilla has
always been difficult for surgeons. The traditional treatment to partial maxillary resection is the use of an obturator to fill the defect and separate the nasal cavity from the oral cavity and restore the dentition prosthetically. But the obliteration of drainage, obvious scar formation, and neuralgiform pain are commonly observed after traditional treatment.6 Efforts have been made to reconstruct the maxilla using bone grafts, but the bone grafts are always exposed to the maxillary sinus without an adequate recipient bed. Thin soft respiratory mucosa is not suitable for the transplanted recipient bed. The bone
152 Zhong et al
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004
Fig 3. Continued.
grafts without revascularization exposed to the sinus secretions and bacterial flora always have delayed consolidation, with the potential for contamination with a risk of infection and sequestration. The BFP is a specially organized tissue that is distinct from subcutaneous fat. It is described as consisting of a central body and four extensions: buccal, pterygomandibular, superficial, and deep temporal extension. The blood supply to the BFP comes from 3 sources: the buccal and deep temporal branches of the maxillary artery, the transverse facial branch of the superficial temporal artery, and small branches of the facial artery.10 The BFP was first used as a pedicled graft by Egyedi,11 followed by Neder12 and then Tideman,10
who used the pedicled BFP to close the intraoral defect. As a pedicled graft, the anatomical region of the BFP is uniformly well vascularized, providing a proximate donor site to the recipient site to reduce the need for extensive dissection.13-15 Its use was extended to repair all kinds of intraoral defects such as oroantral and oronasal communication, palatine defect, cleft palate, defect caused by tumor resection and other etiologies.16-38 The blood supply to the pedicled BFP ensured the success rate of this graft with rapid epithelialization. In our previous study on the pedicled BFP graft, we found the epithelialization began 2-3 weeks after operation, and complete epithelization was realized in 4-6 weeks. The new epithelium was similar to the adjacent
Zhong et al 153
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97, Number 2
Fig 3. Continued.
mucosa but thinner than normal mucosa.8 The pedicled BFP graft is an ideal graft because of its easy mobilization, excellent blood supply, and limited donor site morbidity. It has been debated whether the BFP is suitable for the reconstruction of the maxilla with bone grafts. In 1988, Vuillemin et al39 used the BFP as a pedicled flap to cover bone grafts in 8 cases of reconstruction of maxilla. Although fat tissue cannot induce osteoblasts, the pedicled BFP graft has strong ability of infection resistence, with little necrosis and absorption.12,32,34,39 The epithelium of local mucosa and BFP can regenerate and recover its function.6,7 Marx has questioned the method of immediate reconstruction of maxilla with bone grafts because of the high incidence of complication (25%), and limits its use to cases of benign osseous tumors and cystic lesions.40 The obturator is traditionally used to fill the defect caused by maxillectomy or partial maxillary resection for treating the maxillary tumor or trauma, and the postoperative obliteration of drainage, obvious scar formation, and neuralgiform pain are usually observed. Because the bone grafts were used to reconstruct the maxilla, the facial contour can be more satisfactory, and dental prostheses have a bony support. Unfortunately, the bone grafts are always exposed to the maxillary sinus without adequate vascularization of the recipient bed and have a potential for contamination by sinus secretions and/or flora with a high risk of inflammation and sequestration. However, the pedicled BFP serves as a good lining tissue at the maxillary sinus side, and the bone grafts heal well
without infection and sequenstration. Also the function of the maxillary sinus recovers with good speech evaluation. The recovery of function of the maxillary sinus is as important as the recovery of facial contour. Good healing of the unresected end and transplanted bone after operation occurs owing to excellent blood supply from the soft tissues. Without the pedicled BFP as a lining tissue, the transplanted bone would be exposed to bacterial flora of the maxillary sinus, and the infection and sequestration are believed to delay the consolidation of the bones. In the 38 cases treated with the bone grafts supported by pedicled BFP, the pedicled BFP served as a recipient bed and a barrier of the grafts against the maxillary sinus to avoid infection and bone resorption and sequestration. Three fistulas in the oral cavity side occurred and were repaired. In order to avoid the postoperative fistula and infection, the wound of the oral cavity side should be closed tightly but without tension. Care should be taken when pulling the BFP out from its bed and transposed to the defect because the vascular inflow and outflow of the pedicled graft are very easily destroyed by violence when separating from the surrounding tissue.6,7,26 It is suggested that the pedicled BFP should cover the surgical defect adequately and be sutured to the bone without tension. In order to reconstruct the maxilla adequately, preservation of as much of the maxillary bone and mucosa of the maxillary sinus as possible is necessary, but the tumor tissues must be resected completely. However, the maxillary
154 Zhong et al
benign tumors with normal maxillary sinus are considered the most suitable for this method. Immediate reconstruction of the maxilla with bone grafts supported by pedicled BFP graft restores the facial contour and the function of the maxillary sinus in patients with partial maxillary resection. The pedicled BFP is helpful to prevent exposing bone grafts to the maxillary sinus or nasal cavity, preventing a high rate of bone resorption and sequestration previously seen when reconstructing the maxilla. REFERENCES 1. Edgerton MT, Devito RV. Reconstruction of palatal defects resulting from treatment of palate. Plast Reconstr Surg 1961;28: 306. 2. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in head and neck. Plast Reconstr Surg 1979;63:73-81. 3. Serafin D, Riefkohi R, Thomas I, Georgiade NG. Vascularized rib periosteal and osteocutaneous reconstruction of the maxilla and mandible. Plast Reconstr Surg 1980;66:718-27. 4. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530-45. 5. Herring SM. Reconstruction of facial contour deformity with the buccal fat pad flap. Ann Plast Surg 1992;29:450-3. 6. Lindorf HH. Osteoplastic surgery of the sinus maxillaris—the “Bone Lid” method. J Maxillofac Surg 1984;12:271-6. 7. Chen GF. Clinical application of the buccal fat pad as a pedicled graft. Chinese J Microsurg 1998;21:215-6. 8. Chen GF, Fan LJ, Hu JA. Clinical application and histological study of buccal fat pad. Chinese J ZheJiang U Med Sci 1998; 27:216-8. 9. Chen GF, Fan LJ, Hu JA. Experimental study of the buccal fat pad as a pedicled graft. Chinese J Oral Maxillofac Surg 2000; 10:121-3. 10. Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986;44:435-40. 11. Egyedi P. Utilization of the buccal fat pad for closure of oroantral and/or oro-nasal fistula. J Oral Maxillofac Surg 1977;5: 241-4. 12. Neder A. Use of buccal fat pad. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1983;55:349-50. 13. Fujimura N, Nagura H, Enomot S. Grafting of the buccal fat pad into palatal defects. J Craniomaxillofac Surg 1990;18:219-22. 14. Loh FC, Loh HS. Use of the buccal fat pad for correction of intraoral defects: report of cases. J Oral Maxillofac Surg 1991; 49:413-6. 15. Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg 2000;58:389-92. 16. Dea A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M. The buccal fat pad flap in oral reconstruction. Head Neck 2001;23: 383-8. 17. Hao SP. Reconstruction of oral defects with the pedicled buccal fat pad flap. Otolaryngol Head Neck Surg 2000;122:863-7. 18. Pandolfi PJ, Yavuzer R, Jackson IT. Three-layer closure of an oroantral-cutaneous defect. Int J Oral Maxillofac Surg 2000;29: 24-6. 19. 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. 20. 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: 834-8.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY February 2004 21. Ramirez OM. Buccal fat pad pedicle flap for midface augmentation. Ann Plast Surg 1999;43:109-18. 22. Jackson IT. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1999;103:2059-60. 23. Sailer HF, Haers PE, Gratz KW. The Le Fort I osteotomy as a surgical approach for removal of tumors of the midface. J Craniomaxillofac Surg 1999;27:1-6. 24. Chen GF, Fan LJ, Hu JA. Use of the pedicled buccal fat pad for defects of palatal tumor. Chinese J Oral Maxillofac Surg 1999; 9:100-2. 25. Zhao Z, Li S, Li Y. The application of the pedicled buccal fat pad graft in cleft palate repair. Chinese J Plast Surg Burns 1998;14: 182-5. 26. Chen GF, Xie L. Use of the buccal fat pad for buccal carcinoma. Chinese J Pract Oncology 1998;13:240-1. 27. Martin-Granizo R, Naval L, Costas A, Goizueta C, Rodriguez F, Monje F, et al. Use of buccal fat pad to repair intraoral defects: review of 30 cases. Br J Oral Maxillofac Surg 1997;35:81-4. 28. Shibahara T, Watanabe Y, Yamaguchi S, Noma H, Yamane GY, Abe S, et al. Use of the buccal fat pad as a pedicle graft. Bull Tokyo Dent Coll 1996;37:161-5. 29. Yeh CJ. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25:130-3. 30. Hudson JW, Anderson JG, Russell RM, Anderson N, Chambers K. Use of pedicled fat pad graft as an adjunct in the reconstruction of palatal cleft defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:24-7. 31. Hanazawa Y, Itoh K, Mabashi T, Sato K. Closure of oroantral communications using a pedicled buccal fat pad graft. J Oral Maxillofac Surg 1995;53:771-5. 32. Chen GF. Use of hydroxyapatite and buccal fat pad reconstruction the maxilla bone defects. Chinese J Oral Maxillofac Surg 1994;4:112-3. 33. Cheung LK, Samman N, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22:2-6. 34. Chen GF, Ping FY. Immediate reconstruction of the maxillary with bone grafts supported by the buccal fat pad. Chinese J Stomatol 1992;27:88-9. 35. Stajcic Z. The buccal fat pad in the closure of oro-antral communications: a study of 56 cases. J Craniomaxillofac Surg 1992; 20:193-7. 36. Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe SA. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990;85:29-37. 37. Dubin B, Jackson IT, Halim A, Triplett WW, Ferreira M. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1989;83:257-64. 38. Hai HK. Repair of palatal defects with unlined buccal fat pad grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1988;65:523-5. 39. 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. 40. Marx RE. Reconstruction of the maxilla with bone grafts supported by the buccal fat pad. Discussion. J Oral Maxillofac Surg 1988;46:105-6. Reprint requests: Lai-ping Zhong Department of Oral and Maxillofacial Surgery Second Affiliated Hospital College of Medicine Zhejiang University No. 88 Jiefang Road Hangzhou 310009, China [email protected]