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Traumatic herniation of the buccal fat pad
Traumatic herniation of the buccal fat pad Report of a case Kenneth L. Messenger, D.D.X.,’ Baltimore, Md. DEPARTMENT
OF ORAL
SURGERY,
and William JOHNS
HOPKINS
Cloyd, D.M.D.,“” HOSPITAL
The masticatory fat pad is a structure frequently encountered during intraoral surgical approaches to the mandibular ramus. An unusual case of herniation of the fat pad secondary to minor trauma is presented.
A
s described in separate works by Sicher and DuBrul’ and by Gaughran,’ the spaces between the masticating muscles, specifically the temporalis and pterygoids, are filled with projections of fatty tissue referred to collectively as the masticatory fat pad. The anterior aspect of this tissue fills the space between the masseter muscle and the buccinator muscle. It protrudes beyond the anterior border of the masseter as a “rounded biconvex structure limited by a thin but distinctive capsule.“l This part of the structure is especially large in neonates and infants and has often been called the “suckling pad” or the “buccal fat pad of Bichat.” Responsible for the full cheeks of young children and considered an aid in the sucking function, the buccal fat pad is relatively much smaller in older children and adults. CASE REPORT The patient, a 4-year-old black boy, was referred to the oral surgery service for evaluation of an intraoral mass. He had been seen the evening before in the pediatric emergency room, and at that time his mother stated that earlier in the day he had fallen off a scooter toy while playing in the living room and struck the right side of his face on another toy. She saw only a small trace of blood in his mouth but discovered something sticking out of the inside of the cheek. Examination by the pediatrician revealed a healthy, active, normal 4-year-old boy in no distress and with no external evidence of injury. Oral examination disclosed the presence of *Senior Resident. **Intern.
41
42
Meswager
Oral Surg. .January, 197i
and Cloyd
Fig. 1. Herniated
mass attached
to right
buccal surface.
a 2 by 1 cm. yellowish, smooth mass attached to the right buccal mucosa, apparently not present before the fall. The boy was told to stay on a liquid diet and return in the morning.
EXAMINATION The patient presented to the oral surgery clinic with only mild tenderness and slight edema in the right cheek. Oral examination was entirely normal except for a remarkable mass of about 2 by 1.5 cm., which seemed to originate from a narrow base very close to the opening of the right Stensen’s duct (Fig. 1). The lesion was bluish, smooth, soft, nontender, and completely covered with a thin membrane. There was no evidence of free hemorrhage, although there was old clotted blood contained within the membrane surrounding the mass. TREATMENT The patient was sedated with 30 mg. of Demerol, 15 mg. of Phenergan, and 15 mg. of Thorazine given intramuscularly 25 minutes before the procedure. Then 1 cc. of 2 per cent lidocaine HCl with 1 :lOO,OOOepinephrine was infiltrated at the base of the lesion. Close examination of the base of the lesion revealed a very small laceration in the buccal mucosa measuring less than 5 mm. The base of the lesion was grasped with a fine hemostat and the mass sharply excised at the clamp. The stump was tied with a 3-O chromic suture and pushed back into the small wound. The mucosa was approximated with several interrupted 3-O chromic sutures. Examination of the parotid duct orifice showed it to be in very close proximity to the wound but uninvolved. Follow-up evaluation revealed complete and uneventful healing after 10 days with normal function of the right Stensen’s duct. HISTOLOGY Microscopic examination of the submitted specimen revealed mainly adipose tissue in a light fibrous stroma with hemorrhage, fibrin disposition, and acute inflammation (Fig. 2).
Volume Number
43 1
Traumatic
Fig. 8. Photomicrograph of mass demonstrates and early inflammatory reaction.
herniation
histology
of buccal
compatible
with
fat
pad
buccal
fat
43
pad
DISCUSSION A small perforation of the buccal mucosa and buccinator muscle can allow the buccal fat pad to extrude a large portion of its substance into the oral cavity. This is a common occurrence during some oral surgical procedures. Usually an attempt is made to reposition the herniated fat and close the surgical exposure before a large portion is allowed to extrude. In this case, a tiny traumatic injury in a young child allowed the well-developed “suckling pad” to work its way out, still surrounded by its capsule, and created a very interesting lesion. The size of the mass and the inflammation precluded repositioning, so it was decided to excise the extruded fat and then close the traumatic perforation. REFERENCES
1. Sicher, H., and DuBrul, E. L.: Oral Anatomy, ed. 5, St. Louis, 1970, The C. V. Mosby Company, pp. 453-454. 2. Gaughran, G. R. L.: Fascia of the Masticator Space, Anat. Rec. 129: 383-400, 1957. Reprint requests to: Dr. Kenneth L. Messenger 1760 King Ave. Napa, Caiif. 94558
OF ORAL
SURGERY,
and William JOHNS
HOPKINS
Cloyd, D.M.D.,“” HOSPITAL
The masticatory fat pad is a structure frequently encountered during intraoral surgical approaches to the mandibular ramus. An unusual case of herniation of the fat pad secondary to minor trauma is presented.
A
s described in separate works by Sicher and DuBrul’ and by Gaughran,’ the spaces between the masticating muscles, specifically the temporalis and pterygoids, are filled with projections of fatty tissue referred to collectively as the masticatory fat pad. The anterior aspect of this tissue fills the space between the masseter muscle and the buccinator muscle. It protrudes beyond the anterior border of the masseter as a “rounded biconvex structure limited by a thin but distinctive capsule.“l This part of the structure is especially large in neonates and infants and has often been called the “suckling pad” or the “buccal fat pad of Bichat.” Responsible for the full cheeks of young children and considered an aid in the sucking function, the buccal fat pad is relatively much smaller in older children and adults. CASE REPORT The patient, a 4-year-old black boy, was referred to the oral surgery service for evaluation of an intraoral mass. He had been seen the evening before in the pediatric emergency room, and at that time his mother stated that earlier in the day he had fallen off a scooter toy while playing in the living room and struck the right side of his face on another toy. She saw only a small trace of blood in his mouth but discovered something sticking out of the inside of the cheek. Examination by the pediatrician revealed a healthy, active, normal 4-year-old boy in no distress and with no external evidence of injury. Oral examination disclosed the presence of *Senior Resident. **Intern.
41
42
Meswager
Oral Surg. .January, 197i
and Cloyd
Fig. 1. Herniated
mass attached
to right
buccal surface.
a 2 by 1 cm. yellowish, smooth mass attached to the right buccal mucosa, apparently not present before the fall. The boy was told to stay on a liquid diet and return in the morning.
EXAMINATION The patient presented to the oral surgery clinic with only mild tenderness and slight edema in the right cheek. Oral examination was entirely normal except for a remarkable mass of about 2 by 1.5 cm., which seemed to originate from a narrow base very close to the opening of the right Stensen’s duct (Fig. 1). The lesion was bluish, smooth, soft, nontender, and completely covered with a thin membrane. There was no evidence of free hemorrhage, although there was old clotted blood contained within the membrane surrounding the mass. TREATMENT The patient was sedated with 30 mg. of Demerol, 15 mg. of Phenergan, and 15 mg. of Thorazine given intramuscularly 25 minutes before the procedure. Then 1 cc. of 2 per cent lidocaine HCl with 1 :lOO,OOOepinephrine was infiltrated at the base of the lesion. Close examination of the base of the lesion revealed a very small laceration in the buccal mucosa measuring less than 5 mm. The base of the lesion was grasped with a fine hemostat and the mass sharply excised at the clamp. The stump was tied with a 3-O chromic suture and pushed back into the small wound. The mucosa was approximated with several interrupted 3-O chromic sutures. Examination of the parotid duct orifice showed it to be in very close proximity to the wound but uninvolved. Follow-up evaluation revealed complete and uneventful healing after 10 days with normal function of the right Stensen’s duct. HISTOLOGY Microscopic examination of the submitted specimen revealed mainly adipose tissue in a light fibrous stroma with hemorrhage, fibrin disposition, and acute inflammation (Fig. 2).
Volume Number
43 1
Traumatic
Fig. 8. Photomicrograph of mass demonstrates and early inflammatory reaction.
herniation
histology
of buccal
compatible
with
fat
pad
buccal
fat
43
pad
DISCUSSION A small perforation of the buccal mucosa and buccinator muscle can allow the buccal fat pad to extrude a large portion of its substance into the oral cavity. This is a common occurrence during some oral surgical procedures. Usually an attempt is made to reposition the herniated fat and close the surgical exposure before a large portion is allowed to extrude. In this case, a tiny traumatic injury in a young child allowed the well-developed “suckling pad” to work its way out, still surrounded by its capsule, and created a very interesting lesion. The size of the mass and the inflammation precluded repositioning, so it was decided to excise the extruded fat and then close the traumatic perforation. REFERENCES
1. Sicher, H., and DuBrul, E. L.: Oral Anatomy, ed. 5, St. Louis, 1970, The C. V. Mosby Company, pp. 453-454. 2. Gaughran, G. R. L.: Fascia of the Masticator Space, Anat. Rec. 129: 383-400, 1957. Reprint requests to: Dr. Kenneth L. Messenger 1760 King Ave. Napa, Caiif. 94558