The buccal fat pad flap in oral reconstruction

Anatomy of the Buccal Space: Surgical and Radiological Perspectives

Among the anatomical spaces in the head and neck area, the buccal space has often been studied in dental/oral surgery and cosmetic surgery because it contains the facial vessels, mandibular and facial nerves, and adipose tissue called the buccal fat pad. In addition, as the space can communicate with other spaces, it can be significant in infections. Although the anatomy of the buccal space has been reported in several studies, there have been discrepancies concerning its boundaries, and its communications have often been overlooked. The aim of this review is to examine the anatomy of buccal space including its boundaries, contents, continuity with adjacent spaces, and clinical significance. A literature review was performed on Google Scholar and PubMed. The literature has depicted the anterior, medial, and lateral boundaries more or less consistently, but descriptions of the posterior, superior, and inferior borders are controversial. The buccal space includes the facial arteries, veins, facial nerves, parotid duct, and lymph nodes, which can be described differently depending on definitions and the extent of the space. As it communicates with other anatomical spaces including the masticatory space, it can be a reservoir and a channel for infections and tumors. Buccal fat pads have various clinical applications, from a candidate for flap reconstruction to a target for removal for cosmetic purposes. This review will help understand the anatomy of the buccal space including its boundaries, residing structures, and communication with other spaces from surgical and radiological perspectives.

Systematic review of minimally-invasive reconstructive options for oral cavity defects

The oral cavity is a primary site for malignant neoplasms of the head and neck region. Surgery, with or without adjuvant therapy, offers the highest probability of cure by focusing on radical tumour removal and organ function restoration. Reconstructive options are represented by local and free flaps, while small defects can be managed without reconstruction. For medium-sized defects without bone involvement, local flaps can be a good alternative to free flaps in selected patients. The purposes of this article are to analyse the main minimally-invasive reconstructive techniques in oral cancer surgery through a systematic review of the literature and develop a reconstructive algorithm based on the site and size of the defect. We defined minimally-invasive reconstruction as any reconstructive option not involving flap dissection from the neck or other distant areas from the oral cavity. Options considered include: local myo-mucosal or mucosal flaps (based on the facial or buccal arteries, and palatal flap), Bichat’s fat pad flap, and nasolabial flap. Use of biological or synthetic materials is also described. In selected patients with small to moderate-sized defects, the possibility of reconstruction with local flaps can be a viable option.

Successful reconstruction using a buccal fat pad flap in misdiagnosed buccinators intramuscular synovial sarcoma: A case report

INTRODUCTION

Synovial sarcoma (SS) is a subtype of soft tissue sarcoma that primarily usually occurs in the lower extremities but rarely arises in the head and neck areas, including the oral cavity. Due to its variable presentation and similarity to benign masses in terms of age at onset, growth rate, and favorable outcomes, SS is often misdiagnosed as a benign tumor. However, it is a malignant tumor.

PATIENT CONCERNS

We report the case of intramuscular SS in the oral cavity. Initially, the lesion was clinically suspected as a benign mass but was ultimately confirmed as malignant SS.

DIAGNOSIS

Although histopathological examination is the first step in diagnosing SS, molecular testing to confirm the presence of SYT-SSX fusion can provide a definitive diagnosis when the histopathology is inconclusive. In this patient as well, the postoperative pathological report confirmed the diagnosis of biphasic SS, and molecular testing revealed positive SYT/SSX fusion.

THERAPEUTICS INTERVENTIONS

Following the recommendation of multidisciplinary care system, a wide excision was performed including the buccinators muscle, and reconstruction was performed using a buccal fat pad flap to prevent cheek depression.

OUTCOMES

On the final pathologic report, SS was removed margin-free, and there were no metastatic lymph nodes. No evidence of cheek dimpling was observed, and follow-up neck CT showed no significant changes in the lymph nodes. As a result of observation up to several months after surgery, there were no functional and aesthetic complications.

CONCLUSIONS

We report a successful case of intramuscular SS resection, initially misdiagnosed as a benign mass, using a buccal fat pad flap. We also highlight the importance of correctly diagnosing SS, especially in the craniofacial region where it can be mistaken for benign masses.

The Buccal Fat Pad as a Primary Flap for the Reconstruction of Intraoral Defect After Resection of Oral Cavity Malignant Tumors: A Retrospective Study

BACKGROUND

Among the various local and regional flaps used for the reconstruction of intraoral defects after oral cavity cancer surgery, the pedicled buccal fat pad (BFP) flap is considered a reliable alternative. Reconstruction with a BFP flap is particularly feasible in oral cavity areas, such as the posterior maxilla, buccal mucosa, retromolar trigone, and gingivobuccal sulcus. The purpose of this study was to analyze the outcomes of pedicled BFP as a primary reconstruction flap for small to medium intraoral posterior oral cavity postresection defects operated in our institute.

METHODS

This study was designed as a retrospective study. Thirty-seven patients with oral cavity cancer underwent wide local excision with adequate margins, followed by reconstruction of the defect with a pedicled BFP flap. Defect size, postoperative healing of the surgical site, mouth opening at 6 months, and any associated complications were assessed.

RESULTS

The mean age of the patients was 47.38±9.95 years with a male-to-female ratio of 3.6:1. Mean defect size at the greatest dimension was 5.01±1.39 cm. The mean preoperative mouth opening of patients was 35±6.4 mm, whereas the mean postoperative mouth opening after 6 months of follow-up was 27.8±9.2 cm.

CONCLUSION

The BFP flap is a convenient, reliable, and feasible reconstruction modality after oncological resection of posterior oral cavity cancers. Harvesting a BFP flap is minimally invasive with fewer complications, shorter recovery time, no donor site morbidity, and allows early initiation of adjuvant therapy postoperatively.

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

An Anatomical Dissection Method for Observation of Fibrous Facial Structures

BACKGROUND

In recent years, structures including the superficial musculoaponeurotic system and retaining ligaments that support the facial soft tissue have been clarified. However, these structures are very difficult to observe in their entirety by the standard gross anatomical procedure (ie, dissection from superficial to deep layers). Furthermore, accurate descriptions of these structures are rare in both anatomical and plastic surgery textbooks. The aim of this study was to clarify the facial fibrous structures in a gross anatomical view.

METHODS

The authors' novel method used soft facial tissue and bone. The tissue was fixed in gelatin and sectioned at a thickness of 5 to 10 mm. Each section was placed on a wooden board; the bone was then pinned, and the skin was pulled outward with sutures to hyperextend the soft tissue. Subsequently, the loose connective tissue was torn and fat tissue was removed under a surgical microscope. After the removal of fat tissue, the fibrous facial structures (eg, the superficial musculoaponeurotic system and retaining ligaments) could be observed clearly.

RESULTS

The thickness of the sections allowed three-dimensional observation, such that a structure located deep within a section could be clearly observed. The expansion of soft tissue facilitated observation of the facial layer and fibrous structures, and the locations of nerves and vessels. Therefore, the facial layer structure was readily discerned.

CONCLUSION

This method is likely to be very useful in the field of plastic surgery because it enabled intuitive identification of facial layers and their characteristics.

CLINICAL RELEVANCE STATEMENT

The dissection method developed by the authors reveals the connected morphology of each tissue of the face, thus providing basic data for analyzing soft tissue changes due to aging and gravity. This will be useful for the development of anti-aging medicine.

Effectiveness of bandage in the incidence of major complications on bichectomy: literature review and case series of 643 bichectomies

Buccal fat pad removal or bichectomy is an esthetic surgical procedure that is gaining notoriety and increasing number worldwide. This paper aims to discuss the effectiveness of bandage in bichectomy postoperative concerning major complications like bleeding and subcutaneous emphysema. This is a retrospective case series according to PROCESS guidelines of 643 bichectomy surgeries performed by two different surgeons with the same technique from January 2018 until December 2020. Effectiveness of bandage is evaluated in complications rate decrease with statistical tests (p < 0.05). A literature review was performed to sediment knowledge about this theme. Female patients search for buccal fat pad removal more for esthetic reasons and male patients for functional purposes. Bichectomy has a low incidence of major complications, and this incidence decreases more with a bandage use (95%CI). Bandages are effective in the decrease of major complications related to bichectomy.

Surgery for Cystadenoma of the Retromolar Pad Area With Reconstruction Using a Buccal Fat Pad Flap: A Case Report

Salivary gland tumors can also occur rarely in the retromolar area, though common near the junction of hard and soft palate, labial mucosa, and buccal mucosa. Most salivary gland tumors in the retromolar pad area are malignant and should be excised. The cystadenoma is a rare, benign, salivary gland tumor. Importantly, incomplete resection of this tumor can lead to recurrence or cervical lymph node metastasis. We reported herein a case of cystadenoma arising in the right retromolar pad area in a 63-year-old male patient who underwent reconstruction using a buccal fat pad flap (BFPF) after the surgical removal of the tumor with a 10-mm margin left a defect with bone exposure. No evidence of recurrence or complication was found at the postoperative, three-year follow-up.

A novel method of hard palate reconstruction utilizing a combination of the buccal fat pad and palatal island flap

The palatal island flap is reliable for single-staged reconstruction of select oral defects. However, fistula formation is a disruptive potential complication. The authors employed this technique in five patients and present a representative case of a 65-year-old female with a left-sided palatal salivary neoplasm. The patient underwent resection and was reconstructed utilizing a combination of the buccal fat pad and palatal island flap. Four of the five patients healed uneventfully. One patient experienced partial loss of the marginal zone of the palatal island flap which successfully granulated and did not lead to an oroantral fistula. The representative patient recovered uneventfully. At 2 weeks, she felt well, with no evidence of fistula. The anterior palate demonstrated early mucosalization. We present the novel, combined use of the palatal island flap and buccal fat pad flap to create a two-layer closure and describe its advantages for posterior palate reconstruction.

Chilean Patients' Perception of Their Oral Health-Related Quality of Life After Bichectomy

OBJECTIVE

To describe the quality of life associated with oral health in patients who have had bichectomy surgery in Chile using the Spanish version of the health-Related Quality of Life instrument (HRQOL-sp).

MATERIAL AND METHODS

We designed a cross-sectional study. The HRQOL-sp scale was administered to dental patients in a private clinic who had bichectomy surgery between December 2020 and June 2021. The HRQOL-sp instrument has four domains: oral function, general activity, postoperative signs, symptoms or complications, and pain level. The instrument was administered by telephone survey on days 1, 3, 5 and 7 post-surgery. Interference in quality of life was defined as when patients selected the options "quite a few problems" or "many problems" for oral function and general activity. Signs and symptoms related to post-surgical complications and pain were also described with a verbal rating scale from one to ten. All results were compared between postoperative days according to the domains of the HRQOL-sp scale.

RESULTS

Seventy-three patients (age 27.75 ± 8.06 years; 93.15% female) participated. Bichectomy patients report the highest interference in quality of life on the first postoperative day because most were unable to chew (71.23%). On the first and third postoperative days, the most frequent complication was swelling (97.26%), and on the fifth day was ecchymosis (42.47%). The average worst perceived pain was 3.34±2.32 on the verbal analogue scale. The rest of the evaluated items significantly decreased towards the seventh postoperative day (p<0.05).

CONCLUSION

Interference in quality of life associated with bichectomy surgery is greatest on the first postoperative day. Complications and pain levels decreased significantly over time.

Management of Oroantral Communications

Oroantral communication and fistula are commonly seen complications in the field of oral and maxillofacial surgery. Oral surgeons must be familiar with the diagnosis and proper management including multiple soft and hard tissue approaches to this surgical dilemma.

The Buccal Fat Pad Flap

This article presents an overview of the history of the buccal fat pad flap, its relevant anatomy, and its indications and contraindications. The surgical technique for its harvest is described, as are the postoperative care and possible complications.

An Intraoperative Salvage After Transection of the Greater Palatine Artery During Cleft Palate Repair: A Case for Buccal Fat and Buccal Myomucosal Flaps

Recently, several adjunctive procedures have gained traction to aid cleft surgeons in repairing especially challenging palatal clefts. Buccal fat flaps and buccal myomucosal flaps have demonstrated particular utility in reinforcing thin palatal flaps or tissue deficits. Although their use has not been widely accepted, they may be particularly helpful in the setting of significant scarring or vascular compromise. Here the authors describe the case of an intraoperative salvage using bilateral buccal fat flaps and a right buccal myomucosal flap after transection of the right Greater Palatine artery (GPA) during palatoplasty on a 14-month old female with Pierre Robin Sequence and a wide Veau II cleft palate. For this operative salvage, bilateral buccal fat flaps were used to reinforce the hard-soft palate junction and a 4 cm × 2 cm flap of the right-sided buccal mucosa and buccinator muscle was inset along the majority of the right-sided soft and posterior hard palate. At 2 years follow-up, the patient had no significant complications and was doing well with healthy-appearing palatal tissue and age-appropriate speech.

Buccal Fat Pad a Forgotten Option of Reconstruction in Oral Cancer

The buccal fat pad (BFP) originally described as an anatomic structure without any obvious function. For long period it was considered to be surgical nuisance. However during the last four decades buccal fat is successively used tool for maxillofacial surgery for reconstruction of small to medium sized acquired or congenital soft tissue and bony defect in oral cavity. The aim of present article is to review the database available regarding BFP including its anatomy, clinical usage in oral malignancy as tool of reconstruction after ablative procedures it's success and its adoptability with other loco-regional flap for oral reconstruction in different scenario and our experience with it in tertiary cancer centre in India.

Reconstruction of cheek mucosal defect with a buccal fat pad flap in a squamous cell carcinoma patient: a case report and literature review

Background

Squamous cell carcinoma (SCC) is the most commonly occurring malignant tumor in the oral cavity. In South Korea, it occurs most frequently in the mandible, tongue, maxilla, buccal mucosa, other areas of the oral cavity, and lips. Radial forearm free flap (RFFF) is the most widely used reconstruction method for the buccal mucosal defect. The scar of the forearm donor, however, is highly visible and unsightly, and a secondary surgical site is needed when such technique is applied. For these reasons, buccal fat pad (BFP) flap has been commonly used for closing post-surgical excision sites since the recent decades because of its reliability, ease of harvest, and low complication rate.

Case presentation

In the case reported herein, BFP flap was used to reconstruct a cheek mucosal defect after excision. The defect was completely covered by the BFP flap, without any complications.

Conclusion

Discussed herein is the usefulness of BFP flap for the repair of the cheek mucosal defect. Also, further studies are needed to determine the possibility of using BFP flap when the defect is deep, and the maximum volume that can be harvested considering the changes in volume with age.

Dental implants after the use of bichat's buccal fat pad for the sealing of oro-antral communications. A case report and literature review

Oro-antral communications are frequent complications in oral surgery, and generally occur after molar extractions, maxillary sinus elevations or dental implant procedures. The presence of these defects may increase the morbidity and often need a surgical approach. The present report describes an oro-antral communication in a 52-year-old female who presented a 2 week-course of painless nasal obstruction and rhinorrea after a right maxillary sinus floor elevationwith simultaneous dental implant placement. Based on the anamnesis, clinical examination and a computed tomographyof the paranasal sinuses, a diagnosis of odontogenic rhinosinusitis associated with a 1.5 cm diameter oro-antral communicationwas establishedand its surgical closure using Bichat’s buccal fat pad was planned.After 15 months, the patient was successfully rehabilitated with an implant-supported 3 unit fixed partial denture.

Key words:Dental implants, buccal fat pad, oro-antral communications.

Anterior lateral thigh flap for buccal mucosal defect after resection of buccal cancer

Objective

To preserve oral function after buccal cancer resection, a free anterior lateral thigh flap (ALTF) was used to cover the buccal mucosal defect.

Study Design and Setting

Nine patients who underwent primary surgical treatment between June 2005 and September 2006 for buccal cancer were enrolled in this study. An ALTF was used to repair the defect immediately after tumor resection. Oral function, including mouth-opening width, oral intake, and teeth cleaning, were compared pre- and postoperatively.

Results

No difference was observed in the mouth-opening width between that preoperatively and three months postoperatively ( P = 0.54). The oral intake and teeth cleaning also remained unchanged three months postoperatively.

Conclusion

Repair of a buccal mucosa defect with a free anterior lateral thigh flap is a good alternative for selected patients who undergo resection of buccal cancer; oral function is likely to be preserved.

Random Cheek Skin Flap: a Simple Alternative for Intraoral Defects

Oral cavity squamous cell carcinoma is one of the common cancers in India. The lesion usually presents as an ulcer and sometimes as a nodule. A variety of premalignant lesions and submucous fibrosis are common. The mucosal defect after resection needs to be covered. We present a new and simpler way of reconstruction of the oral cavity lining by using extra cheek skin.

The Feasibility of Buccal Fat Pad Flap in Oral Reconstruction Based on Clinical Experience in a Governmental Hospital, Alexandria, Egypt

OBJECTIVE

The purpose of this study was to evaluate the pedicled buccal fat pad flap for its applicability in the reconstruction of surgically created oral defects. We highlighted the technique of flap harvesting, its different applications, and limitations.

DESIGN

Prospective analysis of patients with intraoral defects repaired by the buccal fat pad flap.

SETTING

Institutional center.

PATIENTS/PARTICIPANTS

Twenty-nine patients with surgical defects of the palate, maxilla, upper gingiva, buccal mucosa, lower gingiva, retromolar region, oral floor, and temporomandibular joint.

INTERVENTIONS

Pedicled buccal fat pad flap for treatment of small to medium-sized intraoral defects.

OUTCOME MEASURES

Patients had repair using a pedicled buccal fat pad flap between 2012 and 2014. Patients' photographs and clinical records were collected. The technique of flap harvesting, its advantages, and its drawbacks are described in this study.

RESULTS

Patients were followed up over a mean period of 13.7 months to check flap viability, competent repair, and donor site function and aesthetics. Complete epithelialization was observed within 4 to 6 weeks postoperatively according to the extent of the defect. All patients showed uneventful healing without complications.

CONCLUSIONS

Buccal fat pad flap proved to be feasible for the reconstruction of surgically induced proximal small to medium-sized defects and can be extended to the palate, mandible, mouth angle, and temporomandibular joint region. Further research using preoperative computed tomography or magnetic resonance imaging for evaluation of the size of the buccal fat pad is needed when reconstructing large distal defects.

Use of buccal fat pad to repair post-extraction peri-implant bone defects in the posterior maxilla. A preliminary prospective study

Background

Extensive literature exists about the use of the BFP in the treatment of oral defects but, to our knowledge, no article refers to the use of the BFP as a substitute of the membrane barriers for treatment of peri-implant bone defects. The aim was to evaluate the use of the buccal fat pad as a coating material for bone grafting in the peri-implant bone defect regeneration of immediate implants placed in the posterior maxilla.

Material and Methods

A preliminary prospective study of patients involving immediate implants in which the buccal fat pad was used as a coating material to peri-implant bone defects was carried out. The outcome measures assessed were: postoperative pain and swelling, complications related to buccal fat pad surgery, implant survival and success rates and peri-implant marginal bone loss at 12 months of prosthetic loading.

Results

Twenty-seven patients (17 women and 10 men) with a mean age of 55.3 ± 8.9 years, and a total of 43 implants were included. Two-thirds of the patients reported either no pain or only mild intensity pain and moderate inflammation, two days after surgery. Post-operative period was well tolerated by the patients and no serious complications occurred. None wound dehiscence occurred. Implant survival and success rates were 97.6% and the average marginal bone loss 1 year after loading was 0.58 ± 0.27 mm.

Conclusions

Within the limits of this preliminary study, the use of the buccal fat pad as a coating material for bone grafting in peri-implant bone defects placed in the upper posterior maxilla was a well-tolerated technique by patients; high implant success rate was achieved with a minimal peri-implant marginal bone loss at 12 months of prosthetic loading.

Key words:Buccal fat pad, immediate implant, peri-implant bone defect.

Stage 3 Medication-Related Osteonecrosis of the Posterior Maxilla: Surgical Treatment Using a Pedicled Buccal Fat Pad Flap: Case Reports

PURPOSE

Stage 3 medication-related osteonecrosis of the jaw (MRONJ) sometimes requires surgical treatment for resolution of the pathology and, in many cases, leads to oroantral communication in the posterior maxilla. The buccal fat pad flap is considered the best surgical choice for closure of large oroantral communications because it provides primary closure and guarantees adequate bone protection with sufficient blood supply for an effective bone healing process.

MATERIALS AND METHODS

Five consecutive patients affected by stage 3 posterior maxillary MRONJ were treated with surgical removal of the necrotic bone and primary closure of the oroantral communication using a buccal fat pad flap.

RESULTS

In each case, the size of the flap was always sufficient to perfectly close the defect without tension. There were no postoperative complications and the average postoperative hospital stay was 3 ± 1 days. The patients were seen at monthly follow-ups; after 12 ± 4 months of follow-up, no problems were noted in the treated area.

CONCLUSION

Despite the limited number of cases, the results of this study suggest that, for stage 3 posterior maxilla MRONJ, managing the site with a pedicled buccal fat pad flap and primary closure might guarantee adequate bone protection with sufficient blood supply for an effective bone healing process.

Use of the buccal fat pad in the immediate reconstruction of palatal defects related to cancer surgery with postoperative radiation therapy

PURPOSE

To evaluate the use of the buccal fat pad (BFP) in the immediate reconstruction of oncologic palate defects and the influence of postoperative radiotherapy on reconstruction.

PATIENTS AND METHODS

Patients who were diagnosed with moderate- to high-grade malignancies of the palate underwent partial maxillectomy. The BFP was used as a pedicled flap to reconstruct the defects. All patients received postoperative radiotherapy 4 to 5 weeks after surgery.

RESULTS

Eighteen patients (9 men and 9 women; age range, 37 to 81 yr) underwent surgery and subsequent radiotherapy. The size of all defects ranged from 7.5 to 19.2 cm2. Adequate closure of the defects was achieved during surgery and all flaps were epithelialized within 3 weeks after surgery, with no complications of dehiscence or flap failure. Furthermore, there were no complications derived from postoperative radiotherapy.

CONCLUSIONS

This study suggests that BFP grafting is an effective and reliable method for the reconstruction of small to medium-size palate defects. Furthermore, postoperative radiotherapy does not influence the success of reconstruction.

Repair of oral mucosal defects with cryopreserved human amniotic membrane grafts: prospective clinical study

The aim of this study was to evaluate the clinical outcome of the surgical repair of oral mucosal defects using cryopreserved human amniotic membrane (HAM) as a graft material. Thirty-four patients with precancerous lesions such as leukoplakia, erythroplakia, and verrucous hyperplasia were included. Fresh amniotic membrane was obtained from women undergoing elective caesarean section; the membrane was cleaned, prepared in antibiotic solutions, and preserved at -80°C. Results suggested that HAM promotes healing and epithelialization without specific complications. Thus we conclude that the use of HAM gives promising results in the repair of post-surgical oral mucosal defects.

Intraoral reconstruction using local and regional flaps

Choosing a pedicled flap to reconstruct an intraoral defect depends on the size and the anatomic position of the tissue defect. The goals are to restore form and function and minimize donor site morbidity. Regional pedicled flaps available for intraoral reconstruction are the buccal fat pad flap, facial artery musculomucosal flap, platysma, pectoralis major, temporalis muscle flap, and trapezius flaps. We give a concise illustration of anatomy, our harvesting technique, indications, and eventual pitfalls for each of the six flaps.

Buccal fat pad versus sandwich graft for treatment of oroantral defects: A comparison

AIM

To compare the efficacy of buccal fat pad (BFP) graft with sandwich graft (hydroxyapatite crystals embedded within collagen sheath) in closure of oroantral defects.

MATERIALS AND METHODS

A 2-year prospective study was conducted; 20 patients were included in the study were divided into two groups having 10 patients in each. Group I patients underwent surgical closure of oroantral fistula with sandwich graft and Group II patients with buccal pad of fat.

RESULTS

In Group I, the mean pain scores were 7.60 ± 0.84, 3.90 ± 1.10, 2.30 ± 1.16, 1.10 ± 0.99 and 0.40 ± 0.70 at immediate post-op., 1, 3, 6 and 12 week time intervals, respectively, whereas in Group II these were 7.30 ± 0.67, 3.50 ± 0.53, 1.70 ± 0.48, 1.00 ± 0.47 and 0.30 ± 0.48, respectively, at the corresponding time intervals. In Group I, swelling was seen to be present in 10 (100%), 7 (70%), 2 (20%) and nil (0%) patients at 1, 3, 6 and 12 weeks, respectively, whereas in Group II, it was seen to be present in 10 (100%), 10 (100%), 2 (20%) and nil (0%) patients at the corresponding time intervals. At 1 week, infection was seen to be present in 1 (10%) patient of Group I and 2 (20%) patients of Group II. At 3 and 6 weeks, infection was seen to be present in 1 (10%) patient of Group I and none of the patients of group II. No radiologic evidence of bone formation was seen in either group up to 1 week. At 3 week interval, there were 6 (60%) patients in Group I and nil (0%) in Group II showing bone formation, thus showing a statistically significant difference between the two groups. By 6 week time interval, radiologic evidence of bone formation was seen in 9 (90%) patients of Group I but in no patients of Group II, thereby showing a statistically very highly significant (P < 0.001) difference between the two groups. In Group I, in 1 (10%) patient, graft was rejected by first week; however, no further graft rejection took place. In Group II, no case of graft rejection was reported.

CONCLUSIONS

The sandwich graft technique yielded a more promising closure of oroantral communication by provision of a more biologically apt base in terms of regeneration of lost bone structure at the floor of the maxillary sinus.

Surgical options in oroantral fistula treatment

Oral fistula (OAF) is a pathological communication between the oral cavity and maxillary sinus which has its origin either from iatrogenic complications or from dental infections, osteomyelitis, radiation therapy or trauma. OAF closures can be achieved using different flaps which show both advantages and limitations. Therefore they all need careful consideration in order to select the best approach depending on the situation. The most widely employed flaps are of three types: vestibular flap, palatal flap and buccal fat pad Flap(BFP). The authors present three cases of OAF with the different techniques. It is suggested that the buccal flap is best applied in the case of large fistulas located in the anterior region, the palatal flap is suitable to correct premolar defects and the BFP flap for wide posterior OAFs.

[Foreign body in the maxillary sinus. Considerations on maxillary sinus approaches wound closure]

INTRODUCTION

Paranasal intra-sinus foreign bodies are often related to wounding agents or to penetrating trauma, as caused by car crashes. The maxillary sinus is the most often affected region. We present an atypical clinical case of a foreign body in the maxillary sinus.

CASE REPORT

A 27-year-old male patient, consulted for right facial pain associated to a yellow and fetid nasal discharge. Tooth no. 16 had been extracted five months before. Twenty days after extraction, there was an oro-antral fistula which was closed with surgical dental cement. At consultation, the fistula was patent in the tooth alveolus. A "cone beam" CT scan showed a 2-cm long hyper dense image with well-defined margins within the right maxillary sinus, associated with sinusal mucosa thickening. The diagnosis was an oro-antral fistula complicated by maxillary sinusitis due to a foreign body. The foreign body was removed under general anesthesia and antibiotic therapy, through an antero-lateral antrotomy, and sinus curettage was performed. The anterior cortical wall was fixed with a titanium miniplate. The fistula was closed with a buccal fat pad. There was no complication during the 24-month follow-up.

DISCUSSION

Foreign bodies may be found in the sinuses, especially in the maxillary sinus. They are often of iatrogenic origin. CT scan may confirm the diagnosis. The treatment is surgical removal.

Pedicled buccal fat pad flap for intraoral malignant defects: A series of 29 cases

A buccal fat pad (BFP) as a flap for reconstruction of defects in the oral cavity has been described for a variety of benign conditions. We describe the indications, advantages, and complications of the BFP flap and report our clinical experience with the flap for intraoral reconstruction after tumor removal. From 2005 to 2008, we analyzed 29 patients in the age range of 32 to 82 years old who underwent a pedicled BFP flap reconstruction for oral defects after intraoral tumor removal. Postoperative wound healing and complications including any recurrence was followed-up prospectively. Most of the patients had an uneventful immediate postoperative period with signs of buccal fat pad epithelialization by the end of the first week and complete epithelialization at the end of the first month. On continued follow-up, a linear band of fibrous tissue under the epithelialized mucosa replaced the once reconstructed buccal fat pad. Three patients had varying degrees of hemorrhage: one of them had hematoma that healed with severe fibrosis and of the remaining two, one had a partial flap loss and one had a complete flap loss. Judicious use of buccal fat pad reconstruction offers a simple, convenient, and reliable way to reconstruct small to medium defects of the oral cavity with low morbidity, even in older patients who would not be able to tolerate time-consuming flap reconstruction procedures.

The use of the buccal fat pad for reconstruction of oral defects: review of the literature and report of cases

Although the buccal fat pad (BFP) was originally used as an alternative method for the closure of small to medium-sized oroantral and oronasal communications, its use has now been extended to use after excision of oral pre malignant lesions. This report describes experience with this technique.

Closure of oroantral communications with Bichat's buccal fat pad

PURPOSE

The aim of the present study was to evaluate the use of the pedicled buccal fat pad for the closure of oroantral communications (OACs) and to describe our experience with this surgical procedure.

PATIENTS AND METHODS

A retrospective review of 161 patients treated at the University Hospital for Cranio-Maxillofacial and Oral Surgery in Vienna, Austria, from 2000 to 2005, with the diagnosis of an OAC was performed. All defects were closed by application of a buccal fat pad. Data were obtained from chart review, a compiled database, and clinical follow-up and included the location of the defect, the cause of the OAC, the modality of anesthesia, intraoperative complications, any complications during the process of wound healing, and any late adverse effects.

RESULTS

The buccal fat pad for closure of an OAC was successfully used in 161 patients at our department. In 12 patients (7.5%), the closure of the OAC was insufficient, and a second operation was necessary. Excluding all severe and complicating cases such as tumor-related defects or previously treated cases, the overall success rate for closure of the OAC was nearly 98%. No late complications occurred, and all patients were free of pain or any limitations after the 6-month follow-up period.

CONCLUSIONS

According to the recommendations and anatomic limitations reported in published studies and discussed in the present report, the application of the buccal fat pad is a safe and reliable procedure for closing an OAC.

Measurement of volume changes of sinus floor augmentation covered with buccal fat pad: a case series study

OBJECTIVES

The purpose of this study was to evaluate the volumetric changes of the maxillary sinus graft in conjunction with buccal fat pad (BFP) covering the lateral sinus wall.

STUDY DESIGN

In this article, the radiographic results are presented on 11 consecutively treated patients using an equal mixture of the autogenous bone harvested from the tuberosity and natural bone mineral (Bio-Oss) used to augment the maxillary sinus. Buccal fat pad was used over the lateral sinus wall in all cases as a membrane to cover the augmentation material. The mean initial bone height (IBH) was 3.82 mm as measured in the posterior maxilla. Three months after sinus elevation, radiographic evaluation was performed for the patients and secondary bone height was measured (SBH(1)). Fifty-two implants were placed in augmented sinuses. Prosthetic rehabilitation of the patients was done 4 months after inserting the implants. Radiographs were taken 6 months after implant placement and secondary bone height was measured (SBH(2)).

RESULTS

Of 52 implants, 51 (98%) were considered clinically successful. One implant was removed because of mobility at the time of surgical exposure. Clinically, no complications were observed, and all implants were considered clinically osseointegrated after 6 months. Mean bone height was measured as 3.82 mm before sinus grafting. SBH(1) and SBH(2) were measured as 12.22 mm and 10.5 mm respectively.

CONCLUSION

The clinical findings suggested that BFP might be a substitute for bioresorbable collagen membranes in maxillary and sinus floor bone grafts.

Use of pedicled buccal fat pad in root coverage of severe gingival recession defect

BACKGROUND

Gingival recession in its localized or generalized form is an undesirable condition resulting in root exposure. Sites exhibiting Miller Class IV gingival recession are not suitable for treatment with surgical root coverage techniques, and their prognoses are very poor with current techniques. The aim of this case report is to establish a new technique for the root coverage of severe gingival recession defects (Miller Class IV) by providing a new source of enough tissue with good blood supply using the pedicled buccal fat pad (PBFP).

METHODS

The PBFP was mobilized through an incision in the base of the buccal flap at the level of the upper second molar; the vascularized flap was secured to the buccal surface of the upper first molar tooth and premolar teeth and sutured with the wound margins.

RESULTS

A clinically significant amount of keratinized gingiva that covered the root recession defect was obtained. Epithelialization of the buccal fat pad was completed after 6 weeks, with formation of healthy-looking keratinized mucosa in the anatomic site of the keratinized gingiva.

CONCLUSIONS

The PBFP technique is simple and easy to handle. It may also be considered a novel application with promising results for the root coverage of severe gingival recession defects (Miller Class IV) that may provide a considerable amount of keratinized tissue used for root coverage of the upper posterior molar teeth.

A novel technique for cheek mucosa defect reconstruction using a pedicled buccal fat pad and buccinator myomucosal island flap

Reconstruction of cheek mucosa defects following tumor resections can be approached with several techniques, depending on size of the defect. Fasciocutaneous and perforators free flaps are widely employed today for such reconstructions. However, small defects or general health of the patient may limit their indications. Furthermore, approaching moderate size defects, some techniques, like temporalis muscle or fascia pedicled flaps, lead to contracture with limitation of mouth opening or trisma, and others, like intraoral local flaps, do not provide enough tissue for the reconstructions. In this work the authors propose, for reconstructing these kind of defects, the use of a buccinator myomucosal island flap and a buccal fat pad pedicled flap association. A case is reported and the surgical technique is explained. This new reconstructive technique can easily be used for reconstructing moderate-sized cheek defects, achieving optimal results: the internal mucosal lining is restored in few weeks without any retraction, contracture, of scars on the face limiting the aesthetic outcome and mouth opening.

Free mucosa graft from the lateral tongue for reconstruction of intraoral buccal/lip mucosal defects after tumor resection

OBJECTIVES

To develop a functional and morphologic reconstruction for intraoral buccal/lip mucosal defects after tumor resection.

STUDY DESIGN

A prospective clinical series.

METHODS

From November 2003 to July 2006, 32 patients underwent free tongue mucosa graft reconstruction after resection of buccal or lip tumors. Graft validity and acceptability, donor site morbidity, and postoperative articulation and swallowing functions were evaluated.

RESULTS

Regular postoperative follow-up for at least 6 (mean, 18.5; range, 6-38) months revealed good functional outcomes and satisfactory cosmetic results of grafts at recipient sites in 29 of 32 (90.6%) patients. There were minimal to mild postoperative pain and minor complications at the donor sites. Mouth opening width was preserved, and all patients could tolerate either soft or regular diets. None of the patients had postoperative functional deficiencies involving articulation, swallowing, mastication, or sense of taste.

CONCLUSION

This study demonstrated that free mucosa grafts from the lateral tongue are an excellent alternative for reconstruction of buccal/lip mucosal defects after tumor resection.

Gross anatomical, CT and MRI analyses of the buccal fat pad with special emphasis on volumetric variations

The use of the buccal fat pad (BFP) has increased in popularity in recent years because of its reliability, ease of harvest, and low complication rate during oral and maxillofacial procedures. The aim of this study was to evaluate the volumetric variations of the BFP with a CT and MRI, as well as the thickness, weight and volume with conventional methods. We have examined the BFP from 80 formalin fixed adult cadavers (mean age 59) derived from both males (45) and females (35). In addition, we also examined 20 cadaveric BFPs using MR and CT imaging. Digital image analysis software was used to measure the volumetric distribution and to characterize the morphology of BFP. The BFP can be divided into three lobes (anterior, intermediate, and posterior) and has four extensions (buccal, pterygoid, pterygopalatine, and temporal). The BFP is fixed by six ligaments, to the maxilla, posterior zygoma, inner and outer rim of infraorbital fissure, temporalis tendon, and buccinator membrane. The mean volume in males was 10.2 ml and ranged 7.8-11.2 ml, while in females the mean volume was 8.9 ml and ranged 7.2-10.8 ml. Additionally, the mean thickness was 6 mm, with a mean weight of 9.7 g. These facts may be important when considering the use of the BFP in reconstruction, particularly whether the correct volume has been removed from each side in aesthetic, oral, or maxillofacial procedures.