British Journal of Oral and Maxillofacial Surgery (2005) 43, 148—154

Use of the buccal fat pad in the reconstructionand prosthetic rehabilitation of oncologicalmaxillary defects

M.A. Amina,b,∗, B.M.W. Baileya, B. Swinsona, H. Witherowa

a S.W. London Regional Maxillofacial Service, St. George’s Hospital Medical School,Blackshaw Road, Tooting, London SW170QT, UKb Department of Oral and Maxillofacial Surgery, Wexham Park Hospital, Wexham,

Slough, Berks SL24HL, UK

Accepted 3 October 2004Available online 21 December 2004

KEYWORDSMaxillectomy;Buccal fat pad;Reconstruction

Summary We evaluated the effectiveness of the buccal fat pad as a pedicled flapfor intraoral reconstruction after partial maxillectomy for neoplastic disease in 24patients, and subsequently, in providing support for a denture. In all patients thebuccal fat pad was covered with a split-skin graft and an acrylic plate. There wascomplete healing of the buccal fat pad flap within 6 weeks in 18 patients with nomajor complications, and minimal effects on speech and eating. In six cases therewas partial dehiscence of the flap, which healed spontaneously in one patient andwas repaired with local flaps in two others. There were no cases of complete break-down of the flap. Eight patients so far have been rehabilitated with small dentures.In conclusion, the buccal fat pad flap is a simple, quick, and reliable method ofreconstruction of small to medium-sized posterior maxillary alveolar defects.© 2004 The British Association of Oral and Maxillofacial Surgeons. Published byElsevier Ltd. All rights reserved.

Introduction

Maxillectomy defects should be treated either witha conventional obturator or by surgical reconstruc-tion, to aid speech and eating, and to minimise cos-metic and psychological problems. Obturation hasbeen the traditional form of rehabilitation and is

still widely practised, but there is now an increas-ing number of reconstructive options available.1,2

Immediate repair of a maxillary defect after re-section of a tumour has traditionally been rejected,as it was thought that it would not allow closeobservation of the tumour site for possible recur-rence. However, there is no convincing evidencethat patients who have reconstructions have worsesurvival.3—5 Furthermore, the use of postoperative

* Corresponding author. Tel.: +44 1753 633000;fax: +44 1753 634825.

E-mail address: michael@amin75.

computed tomography (CT), magnetic resonance

0266-4356/$ — see front matter © 2004doi:10.1016/j.bjoms.2004.10.014

fsnet.co.uk (M.A. Amin). imaging (MRI), and positron emission tomography

The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Use of the buccal fat pad 149

(PET) combined with endoscopic examination al-lows continued monitoring of the tumour site.4,5

Some surgeons think that the prognosis after localrecurrence is poor, which invalidates the argumentnot to offer immediate reconstruction.6

Conventional obturators ideally require access toa restorative dental service7 and are often asso-ciated with problems of poor fit and oronasal re-flux that requires frequent adjustment. They canbe bulky and difficult to insert in the presenceof trismus or poor manual dexterity, and requiredaily cleaning to remove crusting. Immediate re-construction avoids these potential problems andis often superior from a functional, aesthetic, andpsychological point of view. The use of osseointe-grated implants as part of the immediate recon-struction in selected patients further improves thescope for subsequent dental rehabilitation.8 A sur-vey in the UK in 1995 showed that 38% of maxillo-facial surgeons do reconstruct after maxillectomybut in only 10% of the patients operated on.6 Themethod of reconstruction used depends on the ex-tent of the resection and the size of the defectas well as the experience and personal preferenceof the surgeon, and ranges from the use of lo-ct

The fatty nature of the buccal fat pad was firstdescribed by Bichat in 1802,9 and since then itsembryology, vascularity, volume, and function havebeen studied in detail by several authors.10,11 Itconsists of a lobulated mass of specialised fatty tis-sue lying within the masticatory space, and locatedbetween the buccinator muscle and the mandibu-lar ramus, separating the muscles from each other(Fig. 1). It is covered by a delicate fascial envelopewith septa that divide it into a series of fibroadi-pose compartments. Functionally it is thought to in-crease intermuscular movement and to contributeto the soft tissue contours of the face. It is oftenencountered accidentally during maxillary orthog-nathic operations and there have been reports inchildren, of spontaneous or traumatic herniation ofthe buccal fat pad.12

The use of the buccal fat pad has increased inpopularity in recent years because of its reliability,ease of harvest, and low complication rate. It hasbeen used as a pedicled graft in facial augmenta-tion procedures,13 for the repair of persistent oro-antral fistulas after dental extractions,14 and in thetreatment of oral submucous fibrosis.15 There havebeen several reports of its successful use as a pedi-cm

Fi

al and regional flaps to microvascular free tissueransfer.1,2,4,5

igure 1 Diagrammatic representation of the main body ofmportant adjacent structures.

led graft in reconstructing small to medium sizedaxillary defects after resection of a tumour.16—23

the buccal fat pad and its extensions and relations with

150 M.A. Amin et al.

Anatomical considerations

The anatomy of the buccal fat pad is complex and adetailed review, based on a series of cadaveric dis-sections, can be found in the publications of Stuzinet al.11 It consists of a main body and four exten-sions: buccal, pterygoid, superficial temporal, anddeep temporal (Fig. 1). The main body lies on theanterior border of the masseter muscle and extendsdeeply to lie on the posterior maxilla and forwardalong the buccal vestibule. The parotid duct andzygomatic and buccal branches of the facial nervecross the lateral surface of the fat pad. The buc-cal extension, which together with the body ac-counts for about half the total weight, lies super-ficially within the cheek and is largely responsiblefor the contour of the cheek. The pterygoid andtemporal extensions are smaller and situated moredeeply.Stuzin et al. reported that in all their dissections,

the anatomical relations of the buccal fat withinthe masticatory space and to the surrounding fa-cial structures were constant.11 The mean weightof each fat pad was 9.3 g and the mean volume

9.6ml. Variations between the right and left sideswere small and the size of the buccal fat pad cor-related poorly with the general adiposity of the ca-daver. Even thin specimens with little subcutaneousfat had buccal pads that were of normal weight andvolume. The buccal fat pad has a rich plexus ofblood vessels from branches of the maxillary, super-ficial temporal, and facial arteries, which allow itto be used as an axial-pattern pedicled flap. It alsocontains lymphatics and myelinated nerves, andthe veins are tributaries of the pterygoid venousplexus.

Patients and methods

From 1998 to 2003, the buccal fat pad was usedas a pedicled flap to reconstruct maxillary defectsafter resection of tumours in 24 patients (Table 1).There were 11 men and 13 women, whose agesranged from 49 to 91 years (mean 68). Twenty-twopatients had reconstructions immediately afterthe tumour had been excised. In two patientsthe fat pad was used in the delayed closure of

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Table 1 Summary of clinical details.

Sex and age (years) Site of tumour Histolo

Male, 76 Left maxilla/retromolar SCCMale, 74 Right maxilla SCCMale, 76 Right maxilla SCCFemale, 65 Right maxilla SCCMale, 71 Right maxilla SCCFemale, 50 Right maxilla MyxomMale, 73 Left posterior maxilla GiantFemale, 69 Left posterior maxilla SCCFemale, 82 Right anterior maxilla MalignMale, 60 Left maxilla SCCMale, 81 Left maxilla SCCFemale, 51 Right maxilla SCCMale, 76 Left posterior maxilla SCCMale, 49 Right anterior maxilla SCCFemale, 58 Left posterior maxilla SCCFemale, 64 Right maxilla SCCFemale, 91 Left posterior maxilla SCCMale, 64 Right posterior maxilla Acinic

Age/sex of Pt Location of tumour Histolo

Female, 77 Right posterior maxilla SCCFemale, 72 Right posterior maxilla SCC

Female, 77 Right posterior maxilla SCCMale, 58 Right posterior maxilla SCCFemale, 56 Right maxilla Mucoepide

carcinomaFemale, 63 Left maxilla Adenocarc

SCC: squamous cell carcinoma.

l type Size of defect (cm) Complications

4× 3.5× 2 None4.5× 3× 1.5 Local recurrence6× 5× 4 Hollowing of cheek5× 4.5 Local recurrence3× 1.2× 1 None4.5× 4× 4 Small fistula

umour 3.7× 2.4× 2 None3.2× 2.5× 1.5 Small fistula

elanoma 4× 2.2× 3 None1.3× 1.2× 1 Small fistula? None4.5× 2.5× 2 None4× 2× 2 None4.5× 2.5× 2.5 Small fistula4× 3× 1 Trismus5.5× 3.5× 2.5 None3× 2.8× 2.2 Small fistula

carcinoma 3× 2.5× 2.5 None

l type Size of defect (cm) Complications

1.7× 2× 2 None3× 1.2× 1.5 None

4× 2.5× 1.8 None3.5× 3× 2 None

rmoid ? Small fistula

inoma 1.5× 1.5× 1 None

Use of the buccal fat pad 151

maxillary defects. One of these patients had hada mucoepidermoid carcinoma excised from thepalate 27 years previously and we repaired theresidual defect with a pedicled buccal fat pad. Theother patient had had an adenocarcinoma excised4 years previously, but could not tolerate theobturator, and we reconstructed the defect with apedicled buccal fat pad flap and bone graft, withsubsequent insertion of maxillary osseointegratedimplants.All operations were either done or supervised

by the senior surgeon (BMWB). Patients were as-sessed preoperatively in the multidisciplinary on-cology clinic. An incisional biopsy specimen wastaken to confirm the diagnosis, and plain radio-graphs and CTs were taken to assess the full extentof the lesion and the degree of involvement of boneand maxillary sinus. Dental impressions were takenfor construction of a pre-fabricated acrylic coverplate.Under endotracheal general anaesthesia we did a

low level, limited, or inferior partial maxillectomy(Class I or 2a maxillectomy24), with frozen sectionhistological examination of the margins to ensurecomplete excision of the tumour (Fig. 2). Most op-epapsTttmo

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Surgical technique

The buccal fat pad was exposed by a 2 cm horizontalvestibular incision extending backwards from abovethe maxillary second molar tooth.Blunt dissection through the buccinator and

loose surrounding fascia, allowed the buccal fat padto herniate into the mouth. In most cases, however,the buccal fat pad became exposed into the de-fect after resection of the tumour. The body of thebuccal fat pad and the buccal extension were gen-tly mobilised by blunt dissection, taking care notto disrupt the delicate capsule and vascular plexusand to preserve as wide a base as possible. Pres-sure on the cheek helped to express the fat intothe mouth. After the pad had been dissected freefrom the surrounding tissues, it was grasped withvascular forceps, gently teased out, advanced, andexpanded over the defect. The pad was sutured tothe mucosal edges with 4/0 polyglactin 910 (Vicryl),ensuring that it was not under excessive tension.Where possible, the lining of the maxillary sinuswas preserved as an additional layer over which todrape the buccal fat pad. One patient, a 60-year-old edentulous man, had simultaneous insertion ofmp

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rations were done through the mouth. In threeatients with large tumours, the Weber-Fergusonpproach was used. Four patients had ipsilateralalpable cervical lymph nodes and had a neck dis-ection in conjunction with the maxillary resection.he resection margin extended as far anteriorly ashe ipsilateral canine tooth in five patients, and upo the midline of the palate in three patients. Tu-ours extended into the retromolar trigone in threether patients.

igure 2 Clinical photograph showing resection of aquamous cell carcinoma of the left maxillary alveolus.

axillary and transzygomatic osseointegrated im-lants after resection of the tumour.We found that the pedicled buccal fat pad could

over maxillary defects as far anteriorly as the ca-ine tooth region and up to but not beyond theidline of the palate. Posteriorly, the tuberosityegion, soft palate, and retromolar area were all

igure 3 The skin graft and pre-fabricated cover platere inserted.

152 M.A. Amin et al.

Figure 4 The result 4 weeks postoperatively.

easily reached by the pad. In two cases in whichthe resection was large, tissue from the buccal mu-cosa was also mobilised and used to augment thefat pad repair. A split skin graft was harvested froma suitable donor site, usually the outer thigh, andlaid over the inner surface of the cover plate, whichwas then inserted and secured with two or threescrews drilled through the plate directly into thehard palate (Fig. 3). All patients were given pro-phylactic antibiotics and postoperative chlorhexi-dine mouth rinses.A soft diet was usually tolerated the day after

operation and patients were instructed not to blowtheir nose forcefully. The cover plate was removed4 weeks postoperatively in the clinic to allow in-spection of the site and gentle oral hygiene (Fig. 4).Postoperative radiotherapy was given if there

was histological evidence of close or involved mar-gins.

Results

Of the 24 patients, 18 (75%) healed well withoutcomplications and with complete take of the split

of the buccal fat pad and loss of the skin graft(25%), with the development of small fistulas, whichgradually reduced in size over the next few weeks.There was no case of complete loss of the pad. Inone patient the fistula closed spontaneously afterradiotherapy and in two others it was repaired withlocal flaps. One patient had several unsuccessful at-tempts to close the fistula with local palatal flapsand, like two other patients, now uses an upperdenture to prevent oronasal regurgitation.Ten patients were given external beam radio-

therapy postoperatively, starting 4—6 weeks afteroperation, with no apparent short-term effects onthe buccal fat pad repair. Two patients developedlocal recurrences at 6 months and 9 months, re-spectively. This was visible on clinical examinationat the site of the healed repair and confirmed by in-cisional biopsy and repeat CT. Both patients subse-quently had extended maxillectomy and repair withconventional prosthetic obturators.Eight patients have so far been successfully

rehabilitated with dentures. In four patients,osseointegrated implants have been used to helpretain a dental prosthesis. One patient, a 63-year-old woman, who had repair of a maxillectomydtiw

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skin graft on the buccal fat pad within 4 weeks,with minimal scarring and contracture of the graftsite. Speech and eating were not affected. The sizeof the largest maxillary defect successfully recon-structed was 6 cm× 5 cm× 4 cm but in most casesthe defect was smaller. None of the patients in ourseries developed haematomas, weakness of the fa-cial nerve, or stenosis of the parotid duct, but twopatients developed minor infections at the graftsite that resolved with antibiotics and oral hygiene.One patient, who had a large defect repaired, de-veloped hollowing of the cheek presumably becauseof the large amount of buccal fat that was har-vested. There were six cases of partial dehiscence

efect after resection of an adenocarcinoma ofhe palate, had osseointegrated implants insertednto the maxilla as a secondary procedure and nowears an implant-retained prosthesis.Another patient, a 60-year-oldman, had a partialaxillectomy for a squamous cell carcinoma andimultaneous insertion of maxillary and transzygo-atic implants, followed by repair of the defectith buccal fat pad.

iscussion

gyedi was the first to report the successful use ofhe buccal fat pad as a pedicled graft, lined withsplit-thickness skin graft, for the closure of per-istent oroantral and oronasal defects in four pa-ients after resection of tumours.16 Fujimura et al.ecommended using lyophilised porcine dermis toover the buccal fat pad, which allowed stretchedads that showed some perforations to heal with-ut complications.17 Samman et al. reported goodesults with minimal morbidity in 28/29 patientsho had immediate reconstruction with unlineduccal fat pads after resections for both benignnd malignant diseases.18 They had one case ofreakdown of the pad, which was brought throughhe antrum to repair a defect of the central hardalate. This failure was attributed to excessive ten-ion and thin spreading of the flap and the defectas subsequently repaired with a tongue flap. They

Use of the buccal fat pad 153

recommended the use of the buccal fat pad forthe repair of defects up to 4 cm in diameter andalso showed epithelialisation and partial fibrous re-placement of the buccal fat pad histologically. Theyalso described the use of a buccal fat pad togetherwith a temporalis flap as an additional option inthe reconstruction of large defects. Martin-Granizoet al. reported a 97% success rate using a buccalfat pad to repair defects in the maxilla and cheekup to 4 cm× 3.5 cm in diameter, after tumour re-sections, cyst enucleation, and for the closure oforo-nasal fistulas.19 Baumann et al. used an un-lined buccal fat pad in 29 patients to repair vari-ous defects of the oral cavity and as covering forbone grafts, with good results.20 The largest defectin their series was 5.5 cm× 4 cm. Small postopera-tive fistulas were seen in two patients, which wereclosed by local tissue adaptation. Three patientsdeveloped trismus when the buccal fat pad wasused to repair defects in the area of the retromo-lar mandible and soft palate, which improved withexercises.Hao reported a series of 21 patients who had

immediate reconstruction with pedicled buccal fatpads after resection of tumours.21 Sixteen defectswtcimrtmmftrca1cttoftsActlctstt

operatively, which may have had a deleterious ef-fect on healing. Although Stuzin et al.11 in theirseries of cadaveric dissections, reported that thebuccal fat pad was a constant size and weight evenin cachectic specimens, in our series one patient, a58-year-old woman, was found at operation to havea buccal fat pad of poor quality, resulting in a de-gree of tension across the repair with subsequentpartial breakdown.With a small defect, discrepancy in volume is of

little importance, but in larger defects is probablythe single most important factor that leads to par-tial dehiscence and formation of fistulas. Preoper-ative estimation of the volume of buccal fat pad onMRI scans may be useful.25

We agree with Samman et al.18 that the defectafter resection of a tumour can be reduced in sizeby local approximation of tissues, enabling easierrepair with the buccal fat pad. We think that theuse of a split skin graft to line the oral side of thegraft, in conjunction with protection by an acryliccover plate, prevents the delicate graft from beingdamaged in the initial postoperative phase, and re-duces healing time and possible shrinkage and scar-ring of the graft. The cover plate helps to maintainatfip

R

ere in the buccal mucosa, two in the retromolarrigone, two in the palate, and one in both the buc-al and gingival areas. There was only one failure,n a patient in whom it was used to cover exposedandibular bone and who was given postoperativeadiotherapy. Rapidis et al. used the buccal fat pado reconstruct defects in 15 patients up to a maxi-um size of 4 cm× 4 cm× 3 cm after excision of tu-ours in the maxilla and up to 7 cm× 5 cm× 2 cmor buccal and retromandibular defects.22 Two pa-ients in their series had partial loss of the graft,equiring the additional use of an obturator in onease and a tongue flap in another. They reportedn overall complication rate of 16% in a review of65 published cases of buccal fat pad repair. Mostomplications resulted from partial breakdown ofhe flap and required either additional operation orhe use of an obturator. Excessive scarring devel-ped in 5% of these 165 cases and the overall in-ection rate was low at 0.6%. Dean et al. reportedhe use of the buccal fat pad for intraoral recon-truction after removal of tumours in 32 patients.23

dequate closure of the defect was achieved in allases. In five cases there was some retraction ofhe flap, and in only one case was there partialoss. In our series we had six cases of partial dehis-ence of the buccal fat pad. This was attributed inwo patients to over-enthusiastic attempts at clo-ure of large defects extending anteriorly beyondhe canine tooth region and across the midline ofhe palate. One patient continued to smoke post-

degree of depth of the sulcus for the flange ofhe denture and, when fully healed, the repair wasrm enough to support an upper denture in eightatients in our series.

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