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.

Key points

  • The buccal fat pad (BFP) is located in the masticatory space.

  • The BFP flap is categorized as an axial flap.

  • The BFP has a syssarcosis action.

  • The BFP flap is a reliable reconstructive option for intraoral moderate sized soft tissue defects.

Introduction

The Buccal Fat Pad: Evolution from Surgical Nuisance to a Reliable Reconstructive Asset

Initially the buccal fat pad (BFP) was believed to be glandular in nature and was thought to have no physiologic function. It was first described by the German anatomist and surgeon, Lorenz Heister, in 1727. In his Compendium Anatomicum , Heister referred to the BFP as the Glandula Moralis (molar gland).

In 1801, the French anatomist, Xavier Bichat, described the BFP as composed of adipose tissue. Bichat also described the BFP as a ball ( Boule ) located between the buccinator, the masseter, and the skin. In his book, he also noted that the BFP is a fatty structure independent from the adjacent adipose tissue. This is why the BFP is often referred in the literature as the Boule de Bichat.

It was not until 1977 that Peter Egyedi described the use of the BFP as a pedicled flap with an overlying skin graft for the closure of oroantral and oronasal fistulae. In 1986, Tideman demonstrated that an uncovered BFP flap would become epithelialized within 3 weeks following inset into the oral cavity.

Since then, the BFP has been widely used to cover small and medium-sized intraoral defects secondary to trauma, ablative resection, and for the closure of oroantral communications.

Anatomy of the buccal fat pad

The BFP is often described as having a main body and 4 extensions. Those extensions are named according to their location: buccal, pterygoid, pterygopalatine, and temporal. The main body and the buccal extension compose 50% to 70% of its total weight.

The BFP is also described as having 3 lobes. This nomenclature is based on anatomic studies because each lobe is surrounded by its own capsule and has its own vascular supply. The BFP is therefore described as having an anterior, intermediate, and posterior lobe. The previously listed 4 extensions would correspond and give rise to the posterior lobe.

The BFP is located within the masticatory space. As its name indicates, the pterygopalatine extension extends into the pterygopalatine fossa. The pterygoid extension extends into the pterygomandibular space, medial to the ramus, and surrounds the pterygoid muscles. The temporal extension has a superficial and deep portion. The superficial temporal portion is located between the temporalis muscle, its tendon, and the deep temporal facia. It then turns around the temporalis muscle anteriorly to occupy the space deep to it, which gives rise to the deep portion. The body extends along the anterior border of the masseter muscle, courses medially, and rests on the periosteum of the posterior maxilla and overlies the buccinator muscle. It is therefore the body extension of the BFP that it usually harvested during BFP flap reconstructive surgery. Finally, the buccal extension lies superficially within the cheek ( Fig. 1 ).

Fig. 1
The BFP anatomic.
( From Kim M-K, Han W, Kim S-G. The use of the buccal fat pad flap for oral reconstruction. Maxillofac Plast Reconstr Surg. 2017;39(1):5; with permission.)

The body and the buccal extensions are superficial to the buccinator and deep to the parotid-masseteric fascia. Just lateral to the body extension, the facial nerve (buccal and zygomatic branches) and the parotid duct are located. The parotid duct pierces the buccinator muscle at the anterior border of the body of the BFP.

The BFP is located deeper than the premasseteric fat compartments and is suspended to the surrounding structures by a series of ligaments ( Fig. 2 ).

Fig. 2
Mobilized BFP with preserved capsule.
( From Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg. 2000;58(4):391; with permission.)

The BFP is a unique anatomic structure that is distinct from the other fat compartments of the face. According to the microscopic classification of adipose tissues by Sbarbati and colleagues, the BFP could be categorized as a deposit adipose tissue type, because it is composed of nonlobular adipose tissue containing large adipocytes that are not entirely covered with a collagen network. Furthermore, the size the BFP is not altered by the overall patient weight. The BFP has a mean volume of 10 cm 3 , weight approximately 9.7 g, can cover a surface of 10 cm 2 , and has a mean thickness of 6 mm. ,

Vascularization of the buccal fat pad

The vascularization of the BFP is rich with an abundant capillary network derived from 3 branches of the maxillary artery: the deep temporal, buccal, and superior posterior alveolar arteries. Additional blood supply is derived from branches of the facial artery and from the transverse facial artery, which is a branch of the superficial temporal artery. The venous drainage is provided by the facial vein. The BFP flap is therefore categorized as an axial flap.

Functions of the buccal fat pad

One of the reported functions of the BFP is its gliding function between the muscles of mastication during function. This is termed a syssarcosis action.

It is reported that the BFP can play an important role in infants during the sucking action of feeding. The BFP helps resist negative pressure on the cheek, thereby enhancing the buccinator function and avoiding its collapse during breastfeeding.

The buccal extension of the BFP is responsible for cheek fullness and contour.

The BFP is also thought to act as a protective envelope for the neurovascular bundles in the masticatory space during function.

Indications and contraindications

The BFP has been successfully used among children and adults for the indications noted in Table 1 . , , ,

Table 1
Indication and contraindications of the buccal fat pad flap
Indications Relative Contraindications
  • Repair of oroantral fistula, such as after dental extraction

  • Repair of posterior fistula in cleft palate

  • Reconstruction after small (4 cm × 4 cm) intraoral soft tissue cancer ablative surgery (soft palate, hard palate, retromolar trigone, maxillary defect, check mucosa, tonsillar fossa)

  • Mucosal fibrosis release

  • Covering of intraoral bone graft

  • Covering of zygomatic implants

  • In temporomandibular reconstruction, as dead space filler

  • For closure of base of skull defect

  • As a membrane in sinus lift surgery

  • For coverage in gingival recession

  • As a vascularized bed in osteonecrosis therapy

  • Upper lip augmentation

  • Improvement of mid-face contour

  • Already previously used buccal fat pad flap

  • >5-cm intraoral soft tissue defect

  • Composite defect

  • May not be an option in previously irradiated patients, patients with Down syndrome, malar hypoplasia, or thin cheeks ,

Surgical technique for the buccal fat pad harvest

Material

  • Local anesthesia containing epinephrine

  • Bipolar electrocautery

  • Monopolar electrocautery

  • DeBakey forceps

  • Dean scissors, rounded tip preferable

  • Crile clamp

  • Minnesota retractor

  • 4 to 0 Polyglactin sutures

Surgical Steps (as Described by Arce)

  • 1.

    Local anesthesia in infiltrated in the posterior maxillary vestibule on the ipsilateral side as the defect.

  • 2.

    At the level of the second molar, at approximately 1 cm above the mucogingival junction, a 2-cm mucosal horizontal incision is made with the monopolar electrocautery in a posterior direction.

The next layer to be encountered after the mucosa is the buccinator muscle. Adequate tension and lateral retraction of the cheek with a Minnesota retractor can be helpful during the dissection ( Fig. 3 ).

Jun 12, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on The Buccal Fat Pad Flap
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