Medium-sized buccal mucosa defect reconstruction with buccal advancement flap in mucoepidermoid carcinoma ex pleomorphic adenoma: a case report

Introduction and importance

Mucoepidermoid carcinoma (MEC) ex pleomorphic adenoma is a rare type of salivary gland cancer. Surgical resection remains the standard therapy for this malignancy. After tumor removal, larger defects may require a local, regional, or free flap, while smaller ones can be closed primarily. Managing medium-sized defects can be challenging, especially on the buccal mucosa.

Presentation of case

A 47-year-old man had a buccal mucosa mass for 10 years, which gradually grew over a year and irritated his chewing. A 2.2×2 cm buccal mass was observed with telangiectatic and erythematous alterations in the surrounding mucosa. The preoperative tissue biopsy suggested salivary gland malignancy. The patient underwent surgical excision and a single-stage buccal advancement flap reconstruction, successfully closing the 4 cm defect. The final diagnosis was MEC ex pleomorphic adenoma. He reported mild discomfort during the first few months while opening his mouth. The patient had fully recovered after 6 months.

Clinical discussion

This is the first case of MEC arising in a pleomorphic adenoma of the buccal mucosa. For low-grade and small-sized tumors, a single modality is appropriate for treatment. Local flaps such as buccal fat pad or musculomucosal flap can repair medium-sized defects. However, the buccal advancement flap provides effective functional and esthetic benefits, optimal healing conditions, and reduces complications risk.

Conclusion

The buccal advancement flap is a valuable option for reconstructing medium-sized buccal defects up to 4 cm. The single-stage surgical procedure has been proven to yield minimal complications and provide a favorable outcome.

Anatomical and Surgical Implications of the Usage of Bichat Fat Pad in Oroantral Communication, Maxillary, Palatal, and Related Surgeries-Narrative Review

The buccal fat pad, also called the Bichat's fat pad (BFP), is an encapsulated fat mass located in the cheek. This type of specialized fat mass can be used both as a pedicular or free graft in various surgeries and approaches. Due to its easy access from the oral cavity approach, it is commonly used for oroantral and palatal fistula closure. The knowledge of its anatomy and surrounding tissues plays a role in its mobilization and suturing onto the desired defect in the palatal or maxillary region. The BFP is mostly associated with the primary approach used for a fistula or bone surgery. Alternatively, the procedure can be performed with a single approach incision, which does not compromise the appearance or the function of the operating or adjacent areas. The most important inclusion criteria for BFP usage and surgical limitations are highlighted. The BFP is used for multiple purposes in reconstructive and oncology surgery and also has its use in esthetic and facial contouring procedures. The amount, volume, and shape of the BFP are mostly associated with the scope of their usage. The aim of the following narrative review is to present the surgical and anatomical implications of fat pads in maxillary and palatal surgeries.

Selecting the Best Surgical Treatment Methods in Oro-Antral Communications

INTRODUCTION

an oro-antral communication is defined as a permanent pathological connection between the maxillary sinus and the septic oral cavity. Several flaps can be used for the closure (buccal flap, palatal flap, combination techniques) but relapses occur often in case of a large defects and underlying general conditions. Bichat fad pad flap is a multipotent pedicled fatty tissue that is easily accessible from the oral cavity that can be used for the closure of medium-sized defects, even in immunocompromised patients due to its stem cell capacity.

MATERIALS AND METHODS

the medical information of the patients diagnosed with oro-antral communications who were admitted and treated in the Oral and Maxillo-Facial Clinic Targu Mures, between 2013 and 2020 were analyzed. A database containing general information, reported causes, associated diseases, surgical methods used during admission, and relapses, was created. The information was statistically processed. The written consent and ethical approval were obtained.

RESULTS

the study shows that from a total of 140 cases, 72 were treated using buccal advancement flap, 49 using Bichat fat pad flap, and 19 using palatal flaps. The dimensions of the communications ranged between 0.3 cm and 1.5 cm. Several statistically significant results could be found when comparing the surgical methods. Of the 72 patients treated with buccal advancement flaps, 25 presented relapses as opposed to the patients treated with Bichat fat pad flaps who showed no complications, p < 0.05. Analysing this aspect further, all large defects (10 cases) ranging from 0.6 cm to 1.5 cm treated with advancement buccal flaps (Rehrmann flaps) showed relapses (p < 0.05). Considering the general conditions, out of 7 patients who received radiotherapy 4 presented relapses, as opposed to the healthy patients, p < 0.05. Regarding the reintervention for the relapsed cases, the majority of the cases treated a second time with buccal advancement flap (5 out of 7 cases) failed as opposed to the Bichat fat pad flap with no further relapses (p < 0.05).

CONCLUSIONS

the most frequently used surgical treatment is the buccal flap, which also has the highest relapse rate. Both primary treatment with Bichat fat-pad flap and re-treatment of relapses using this flap have had 100% success rates, even in patients with general associated conditions, in contrast with patients treated by using the buccal flap. The dimensions of the oro-antral communication and general conditions are crucial factors for the success of the surgical treatment.

Intensity-modulated radiotherapy does not induce volumetric changes of the Bichat fat pad in nasopharyngeal cancer

PURPOSE

To evaluate morphological and functional changes in the Bichat fat pad (BFP) after curative concurrent chemoradiotherapy in nasopharyngeal cancer (NPC) patients.

METHODS

We retrospectively analyzed the volumetric, metabolic, and dosimetry parameters of BFPs in 7 NPC patients who underwent intensity-modulated radiotherapy (IMRT) between 2015 and 2020. Inclusion criteria were i) histologically confirmed diagnosis of NPC, ii) follow-up period of at least 12 months, iii) no history of previous irradiation or surgery in the maxillofacial area, and ìv) availability of pre- and posttreatment MRI and ¹⁸F‑FDG PET-CT performed in our Institution. All patients had stage III-IVA disease (n = 7) and received platinum-based chemotherapy. Planned doses in 30 daily fractions/5 days per week were 66 Gy (2.2 Gy/die 5 days/week) to the gross tumor volume, 66 Gy (2.1-2.2 Gy/die 5 days/week) to the gross nodal volume, 60 Gy (2 Gy/die 5 days week) to clinical target volume (CTV)1, and 54 Gy (1.8 Gy/die 5 days/week) to CTV2. All patients completed the planned radiotherapy course in a median time of 42 days (range 42-43). Relationships between BFP volumes and the following DVH parameters were evaluated: mean dose, maximum dose (Dmax), and percentage of BFP volume receiving more than 5 to 65 Gy (V5 to V65).

RESULTS

The pre-RT volumes of the left and right BFPs were 12.24 cc (range 6.51-20.01 cc) and 11.55 cc (range 5.78-17.53 cc), respectively. The mean volumes of left BFP_PRE and BFP_POST were 12.24 cc (range 6.51-20.01cc) and 13.85 cc (range 7.54-20.21 cc), respectively, with no significant statistical differences (P > 0.05). No statistically significant correlations were found between dosimetry features and BFP volumetric changes (all P > 0.05).

CONCLUSION

Our original results showed that chemoradiotherapy does not induce significant volumetric changes of the BFP. Further investigations are needed to evaluate the effects of higher radiation doses on BFP. This is the first real-world study on this issue.

Application of the Buccal Fat Pad in Oral Reconstruction: Covered With Collagen Membrane or Not?

OBJECTIVE

To evaluate the clinical effectiveness of collagen membrane as biological dressing in protecting the covered buccal fat pad (BFP) from physical damage during postoperative healing phase in the reconstruction of oral soft tissue defect.

METHODS

A retrospective cohort study was performed in patients undergoing oral defects reconstruction using BFP. The predictor variable was the application of collagen membrane or not. The primary outcome variable was the wound healing. Other variables considered included age, gender, pain score, time taken for epithelialization, defect size and site. Postoperative follow-up was done at 1 week, 3 weeks, 6 months, and 1 year.

RESULTS

Thirty patients in Zhuhai People's Hospital were selected and randomly divided in 2 groups. Group I patients were reconstructed using BFP alone, whereas collagen membrane was used as a covering over BFP in group II patients. In group I, 4 patients developed dehiscence 1-week postoperative, and underwent Infection with food lodgment along with another 1 patient at 3-week follow-up, whereas none of the group II patients developed dehiscence or infection. Pain score was lesser in group II patients as compared to group I. Time taken for epithelialization was about 3 weeks in both groups.

CONCLUSIONS

Combined application of collagen membrane protects the covered BFP from masticatory physical damage and food lodgment, which reduces infection and graft loss. It is worthy of consideration as an effective method for the reconstruction of selected moderate-sized oral defects, especially in larger size or at distant location.

Buccal fat pad to improve velum competency after transoral lateral oropharyngectomy

This technical note documents an easily reproducible technique to improve velar competency after transoral lateral oropharyngectomy extending to the velum.

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.

The (in)adequacy of translational research in dentistry

Translational research, as the name suggests, "translates" research findings into clinical practice to improve the health of human beings. The translational process builds on information from experiments conducted at a basic level (i.e., in vitro and/or animal studies) and progresses over experimental human studies for efficacy, efficiency, and safety to implementation. Therefore, all steps in the process should be based on studies conducted with the highest methodological quality possible in order to provide accurate and useful information. Furthermore, the systematic dissemination of new procedures/techniques should be done only when they have been proven to be effective and safe. This focus article describes examples of new techniques/procedures in dentistry that have not resulted from an adequate translational research process since the initial evidence was published. These procedures are generally characterised by lack of good evidence, particularly on their potential harms, and lack of adequate chronological order, regarding the translational research process (i.e., human research being conducted before animal research). Even so, they seem to be widely disseminated, and their promotion involves a wide range of sources, including social media. Some guidance is proposed to improve the quality of the translational research process in dentistry, as well as the level of awareness of all parties involved with the use of this research: clinicians, researchers, and patients. By improving the translational research process, optimization of the application and use of these resources, with less risk to the patients, is expected.

Subclavicular flap: A valid reconstructive option among anterior chest flaps in oral cancer patients

BACKGROUND

The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for low-middle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results.

METHODS

Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous-cell cancer resection between June 2015 and December 2018. Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed.

RESULTS

No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results.

CONCLUSIONS

The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower-third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width.