Anatomy of the buccal fat pad and its clinical significance

Prevalence of complications of buccal fat removal: A systematic review and meta-analysis

Removal of the buccal fat pad can be considered safe as long as there is a detailed analysis of anatomical landmarks. The objective of this study was to estimate the prevalence of intra- and postoperative complications resulting from buccal fat pad removal through a systematic review. The search strategy involved observational and/or interventional studies in humans that included at least one case of buccal fat pad removal with a description of the surgery, postoperative progress, and complications. Methodological quality assessment was performed using the JBI checklist. Study heterogeneity was assessed using the I2 test. In total, 12 studies were included. Out of 308 patients who underwent buccal fat pad removal, 81 experienced some form of complication, with an overall prevalence of 25% (95% CI = 0.04-0.46). Complications found in the data collection included edema (38.40%), trismus (30.09%), pain (19.41%), asymmetry (11.65%), facial nerve paralysis (0.97%), infection (0.48%), hematoma (0.48%), and unilateral emphysema (0.48%). All complications occurred in the postoperative period. There was high heterogeneity among the studies. One in four patients undergoing buccal fat pad removal experiences some form of postoperative complication. Consequently, the procedure should be recommended with caution because there is evidence for safety concerns and a lack of predictability in the evaluated studies.

Transient facial paresis as a complication of buccal fat removal

Aim

This case highlights the rarely reported complication of facial paresis following buccal fat pad removal and its management.

Background

The buccal fat pad is a vital structure in facial aesthetics. In recent years, buccal fat pad removal for mid facial sculpting has gained popularity among patients owing in part to the rise of social media in plastic surgery. Although buccal fat pad removal is usually a safe procedure, potential complications can be quite severe, and can include infection, over-resection, asymmetry, hematoma, facial nerve or parotid duct injury and trismus.

Case description

Herein we describe a case of iatrogenic left facial paresis secondary to buccal fat removal, and discuss the importance of appropriate patient counseling, meticulous technique, and post-operative care in the event of a complication.

Conclusion

High dose corticosteroids and facial therapy can be effective in treating iatrogenic facial palsy secondary to buccal fat pad removal.

Clinical significance

Although buccal fat pad removal has become a common procedure for midface sculpting, the risks remain serious and patient counseling regarding possible complications, including transient facial palsy, is paramount. Meticulous technique as well as knowledge of the relationships between the buccal fat pad, the parotid duct, and the buccal branches of the facial nerve are vital in the prevention of facial paresis when removing buccal fat.

Comparative evaluation of nasolabial flap and buccal fat pad flap in the surgical management of oral submucous fibrosis: a systematic review and meta-analysis

PURPOSE

Oral submucous fibrosis (OSMF) is a chronic, potentially malignant condition affecting any part of the oral cavity and is prevalent in Southeast Asia and the Indian subcontinent. The aim of this study is to compare the efficacy of buccal fat pad flap with the nasolabial flap in the management of OSMF.

METHODS

We systematically compared two commonly used constructive techniques in the management of OSMF: the buccal pad of fat flap and the nasolabial flap. We performed a comprehensive search in four databases for all articles published between 1982 and November 2021. We assessed the risk of bias using the Cochrane Handbook and Newcastle-Ottawa Scale. We used the mean difference (MD) for pooling the data with 95% confidence intervals (CIs) and evaluated the heterogeneity between pooled studies using χ2 and I2 tests.

RESULTS

Out of 917 studies, six were included in this review. The meta-analysis significantly favored conventional nasolabial flap over buccal fat pad flap in improving the maximal mouth opening (MD, - 2.52; 95% CI, - 4.44 to - 0.60; P = 0.01; I2 = 0%) after OSMF reconstructive surgery. Conversely, when it comes to esthetic outcomes, these studies favored buccal fat pad flap.

CONCLUSION

Our meta-analysis found that nasolabial flap was better than buccal fat pad flap in terms of mouth opening restoration after OSMF reconstructive surgery. Also, the included studies found better results, favoring nasolabial flap over buccal fat pad flap in terms of oral commissural width restoration. Also, these studies reported better outcomes in terms of esthetics, favoring buccal fat pad flap. Further studies with larger sample sizes and different populations/races are needed to confirm our findings.

Assessment of clinical and ultrasonographic parameters as indicators for buccal fat pad excision by esthetic reasons

PURPOSE

The selection of candidates for buccal fat pad (BFP) removal depends on the patient's requirements, the subjective surgeons' evaluation, and objective clinical factors. This cross-sectional observational study aimed to identify objective clinical and ultrasonographic parameters as indicators of cheek contouring with BFP excision.

METHODS

Sixty-six patients with cheek fullness complaints were examined by two experienced surgeons to determine if they were good candidates for the procedure. Thereafter, participants underwent clinical and ultrasonographic assessments in a separate session to aid in the surgical decision-making. The association between the clinical judgment for BFP excision and the study variables was analyzed individually and adjusted for confounders using binary logistic regression and grouping analyses.

RESULTS

Forty-nine participants were regarded as suitable and 17 as non-suitable for the procedure. After regression analysis, cheek skin-fold thickness > 6.00 mm, midfacial contour > 2.20 mm, ovoid/triangular facial form, and ultrasonographic BFP volume > 2.05 mL remained as robust individual indicators for the suitability for the procedure. However, the grouping analysis showed that patients having three-to-four significant criteria synchronously had significantly higher odds for eligibility with excellent discrimination capability.

CONCLUSION

Although high values of cheek skin-fold thickness, midfacial contour, and ultrasonographic BFP volume, as well as an ovoid/triangular facial form, might be robust indicators for the suitability for BFP excision, the surgical decision-making should not be based on isolated parameters. Instead, those patients possessing a combination of at least three of these specific eligibility criteria above the threshold value might be considered the best candidates for the procedure.

Paradoxical Temporal Enlargement: An Expansion of Superficial Temporal Fat Pad Following Interfacial Technique for Pterional Craniotomy

OBJECTIVE

Contour irregularities in the temporal region have been reported previously after procedures involving temporal dissection. In this study, we report paradoxical temporal enlargement (PTE) following interfascial pterional craniotomy.

METHODS

A retrospective review of patients who underwent a unilateral transcranial procedure with frontotemporal approach at our institution between September 2013 and December 2017 was performed. Patients with a previous craniotomy or bilateral craniotomy were excluded. Radiological imaging series including computed tomography and magnetic resonance imaging were utilized to calculate temporal soft tissue volumes both preoperatively and postoperatively by using advanced software technology. Relative soft tissue volume differences between the operative side and the contralateral side were calculated at different time-points including preoperative, 3-months follow-up (3M), 12-months (12M) follow-up, and the last follow-up (LFU, over 1-year).

RESULTS

Forty-three patients were included. Mean age was 52.7 ± 4.5 years. Mean follow-up was 27.9 ± 15.8 months. Significant changes of temporal fat pad relative-volume difference were observed between the preoperative and the corresponding 3M (t [82] = -2.8865, P = 0.0050); 12M (t [77] = -4.4321, P < 0.0001), and LFU (t [74] = -4.9862, P < 0.0001) postoperative time points. No significant change of the temporalis muscle was observed between the preoperative and the corresponding 3M (P = 0.3629), 12M (P = 0.1553), or LFU (P = 0.0715). Soft tissue volume showed a significant increase on the operative side between the preoperative and the corresponding LFU (t [74] = -2.5866, P =  0.0117).

CONCLUSIONS

Paradoxical temporal enlargement with more than 10% volumetric change was observed in 24% of the patients at their LFU (>1-year). This change was not due to temporalis muscle changes. Paradoxical temporal enlargement was due to hypertrophy of the superficial temporal fat pad. Before surgical correction of postoperative temporal contour changes, it is important to obtain imaging and characterize the etiology of the deformity.

Management of Complications Related to Removal of the Buccal Fat Pad

ABSTRACT

Removal of the buccal fat pad (BFP) is an important topic of discussion in the literature. Several studies have reported improvements in facial esthetics as a result of this technique. The BFP is close to vital structures, such as the facial nerve, parotid duct, and vessels. Injuries related to these structures may occur during the surgical procedure. This manuscript aimed to report and discuss 2 clinical cases of the complications after removal of the BFP. Besides the case presentation, a comprehensive review of the literature was also provided. The reported cases were 2 patients aged 31 and 38 years who were attended by the oral and maxillofacial surgery teams after a complication in the BFP surgery. The first case involved swelling due to Stensen's duct injury, and the second involved uncontrolled bleeding from the internal maxillary artery. Removal of the BFP must have precise indications. Complications may occur during or after surgery; hence, anatomical knowledge is fundamental to appropriate patient management.

A Cadaveric Study of the Buccal Fat Pad: Implications for Closure of Palatal Fistulae and Donor-Site Morbidity

BACKGROUND

For the cleft surgeon, palatal fistulae after cleft palate repair remain a difficult problem, with a paucity of local tissue options to aid closure. Small clinical series have described the use of the buccal fat pad flap to repair palatal fistulae; however, there is no literature detailing the anatomical coverage of the flap. This study delineates the anatomy of the buccal fat pad flap to guide surgeons in patient selection and examines the residual buccal fat after flap harvest to provide new information with regard to possible effects on the donor site.

METHODS

Buccal fat pad flaps were raised in 30 hemicadavers. The reach of the flap across the midline, anteriorly and posteriorly, was recorded. In 18 hemicadavers, the entire buccal fat pad was then exposed to determine the effects of flap harvest on movement and volume of the residual fat.

RESULTS

All buccal fat pad flaps provided coverage from the soft palate to the posterior third of the hard palate and all across the midline. Approximately three-fourths of flaps would cover the mid hard palate. The flap constitutes 36 percent of the total buccal fat pad on average, and a series of retaining ligaments were identified that may prevent overresection.

CONCLUSIONS

The buccal fat pad flap is a useful tool for coverage of fistulae in the soft palate to the posterior third of the hard palate. In most cases, it will also reach the middle third; however, it is not suitable for more anterior defects. On average, two-thirds of the buccal fat pad remains within the cheek after flap harvest, which may protect against unwanted alteration in aesthetics.

Mesenchymal Stem Cell-Mediated Mitochondrial Transfer: a Therapeutic Approach for Ischemic Stroke

Stroke is the leading cause of death and adult disability worldwide. Mitochondrial dysfunction is one of the hallmarks of stroke-induced neuronal death, and maintaining mitochondrial function is essential in cell survival and neurological progress following ischemic stroke. Stem cell-mediated mitochondrial transfer represents an emerging therapeutic approach for ischemic stroke. Accumulating evidence suggests that mesenchymal stem cells (MSCs) can directly transfer healthy mitochondria to damaged cells, and rescue mitochondrial damage-provoked tissue degeneration. This review summarizes the research on MSCs-mediated mitochondrial transfer as a therapeutic strategy against ischemic stroke.

Mitochondrial Transfer as a Therapeutic Strategy Against Ischemic Stroke

Stroke is a debilitating disease that remains the second leading cause of death and disability worldwide. Despite accumulating knowledge of the disease pathology, treatments for stroke are limited, and clinical translation of the neuroprotective agents has not been a complete success. Accumulating evidence links mitochondrial dysfunction to brain impairments after stroke. Recent studies have implicated the important roles of healthy mitochondria in neuroprotection and neural recovery following ischemic stroke. New and convincing studies have shown that mitochondrial transfer to the damaged cells can help revive cells energetic in the recipient cells. Hence, mitochondrial transplantation has shown to replace impaired or dysfunctional mitochondria with exogenous healthy mitochondria after ischemic stroke. We highlight the potential of mitochondrial transfer by stem cells as a therapeutic strategy for the treatment of ischemic stroke. This review captures the recent advances in the mitochondrial transfer as a novel and promising treatment for ischemic stroke.

Sub-SMAS Transposition of the Buccal Fat Pad

BACKGROUND

Regardless of the technique chosen to treat the aging midface, the isolated lateral approach facelift has a limited impact on the midface volume deficit. In an effort to overcome this limitation, modern facial rejuvenation procedures incorporate an additional modality for replenishing the midface volume. Some of the author's facelift patients present with bulging buccal fat pads despite volume deficiency in the inframalar region. The author's technique is designed to utilize the buccal fat pad to replenish the inframalar volume deficit.

OBJECTIVES

The author sought to present the fat pad transposition surgical technique along with objective outcome data.

METHODS

This study was a retrospective review of nonconsecutive cases where the sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad was performed. A total of 22 patients underwent the fat pad transposition technique by the author (O.B.) between July 2013 and December 2017. Patient data were obtained from patient records, 3-dimensional models, magnetic resonance images, and standardized photography. Preoperative differences in midface volume were assessed utilizing curvilinear surface measurements on 3-dimensional models and the Allergan midface volume deficit scale on standardized photography.

RESULTS

The average midface volume deficit score significantly improved, and the average midfacial curvilinear surface measurement significantly increased after surgery. Magnetic resonance imaging confirmed a stable position of the buccal fat pad after surgery.

CONCLUSIONS

The sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad is an effective technique that can be safely employed for autologous inframalar augmentation in patients with a favorable facial morphology.

LEVEL OF EVIDENCE: 4

Bilateral buccal space lipoma: A rare case presentation

Background

The lipoma of the oral cavity is a relatively rare pathology, characterized by overgrowth of the mature adipocytes. Buccal fat pad lipomas usually interfere with the esthetics and the function of the face.

Case Report

A sixteen-year-old patient reported slow-growing swelling, which started two years ago. Clinical examination revealed two bilateral masses in the soft tissue. MRI imaging revealed a characteristic image of bilateral lipomas connected to the buccal fat pad. Surgical removal was conducted and the histology report confirmed our clinical diagnosis of common lipoma.

Discussion

The lipoma of the buccal fat pad is a benign neoplasm of the adipose tissue. It should be removed when functional or esthetic problems occur and emphasis should be put on the correct surgical technique.

Conclusions

The bilateral buccal fat pad lipoma is an extremely rare condition of the oral cavity. Surgical removal with intraoral approach is the preferable treatment, together with intense care of the anatomical structures of the buccal space. Key words:Buccal space lipoma, oral cavity, buccal space, bilateral, buccal fat pad lipoma.

Does the Deep Layer of the Deep Temporalis Fascia Really Exist?

PURPOSE

It has been widely accepted that a split of the deep temporal fascia occurs approximately 2 to 3 cm above the zygomatic arch and extends into the superficial and deep layers. The deep layer of the deep temporal fascia is between the superficial temporal fat pad and the temporal muscle. However, during procedures, the authors noted the absence of the deep layer of the deep temporal fascia between the superficial temporal fat pad and the temporal muscle. This prospective study was conducted to clarify the presence or absence of a deep layer of the deep temporal fascia.

MATERIALS AND METHODS

Anatomic layers of the soft tissues of the temporal region, with reference to the deep temporal fascia, were investigated in 130 cases operated on for zygomaticofacial fractures using the supratemporal approach from June 2013 to June 2017.

RESULTS

Of 130 surgeries, the authors found the absence of a thick, obviously identifiable, fascial layer between the superficial temporal fat pad and the temporal muscle. In fact, the authors found nothing above the temporal muscle in most cases. In a few cases, the authors observed only a small amount of scattered loose connective tissue between the superficial temporal fat pad and the temporal muscle.

CONCLUSIONS

This clinical study showed the absence of a thick, obviously identifiable, fascial layer between the superficial temporal fat pad and the temporal muscle, which suggests that a "deep layer of the deep temporal fascia" might not exist.

Buccal fat pad removal to improve facial aesthetics: an established technique?

Background

Buccal fat pad (BFP) is a singular structure between the facial muscles. Its removal may enhance the zygomatic prominences resulting in an inverted triangle of beauty. Objective: The aim of this study was to perform a systematic review of literature about BFP removal for facial aesthetic improvement. In order to answer the following research question: What are the indications, complication types and rates, surgical techniques and outcomes of the technique?

Material and Methods

The initial search in Pubmed, Scopus, and Cochrane databases recognized 220 articles. The final review included eight of them. None of the included studies were clinical trials.

Results

BPF removal was performed by intraoral incision or associated with the face lift procedure. In 71 patients submitted to the procedure and evaluated about complications, only 8.45% presented minor complications. Parotid duct and facial nerve injuries were not found. No study evaluated facial aging and long-term effects, therefore the harmless effect of the procedure to those features is not clear.

Conclusions

Although it is not a novel procedure, there is a lack of information about long-term outcomes. Thus, controlled clinical studies should be performed to achieve adequate clinical evidence of those aspects.

Key words:Buccal fat pad, facial sculpting, cheek surgery, buccal lipectomy.

A Comparative Clinical Evaluation of the Buccal Fat Pad and Extended Nasolabial Flap in the Reconstruction of the Surgical Defect in Oral Submucous Fibrosis Patients

PURPOSE

The aim of this study was to compare the efficacy of locally available nasolabial and buccal fat pad flaps for increasing postoperative mouth opening in the reconstruction of the defect created after fiberotomy in surgically treated cases of oral submucous fibrosis (OSMF).

MATERIALS AND METHODS

Of 32 patients selected for the study, 21 patients underwent closure of the surgical defect using the buccal fat pad (group 1) and 11 patients underwent closure of the surgical defect using a nasolabial flap (group 2). Histologically proven cases of OSMF with a mouth opening no larger than 25 mm were included in the study. Patients in groups 1 and 2 were evaluated at regular intervals and mouth opening was documented preoperatively, intraoperatively, and at 3 and 6 months of follow-up. The results were analyzed by paired and unpaired t tests.

RESULTS

In groups 1 and 2, mouth opening differed substantially at all periods of follow-up from preoperative values. At 3-month follow-up, mean mouth opening increased to 32.41 mm in group 2 compared with 30.47 in group 1. No relevant difference was observed in mouth opening between groups 1 and 2 at the end of 6 months. The effective increase in mouth opening at the end of 6 months compared with the preoperative value was statistically different in group 2 (mean increase, 24.2 mm) compared with group 1 (mean increase, 19.2 mm).

CONCLUSION

Nasolabial flaps are a good option for the coverage of surgically treated defects in OSMF compared with the buccal fat pad.

The Buccal Fat Pad for Closure of Oroantral Communication

The buccal fat pad (BFP) is a well-established tool in oral and maxillofacial surgery and its use has proved of value for the closure of oroantral communications. Oroantral communication may be a common complication after sequestrectomy in "bisphosphonate-related osteonecrosis of the jaws."The authors report a clinical case of a 70-year-old female patient in bisphosphonate therapy presented with right maxillary sinusitis and oroantral communication after implants insertion.The BFP was used to close the defect. The patient had an uneventful postoperative healing without dehiscence, infection, and necrosis.The authors postulate that the primary closure of the site with BFP may ensure a sufficient blood supply and adequate protection for an effective bone-healing response to occur.

Immediate versus delayed aggressive physical therapy following buccal fat pad interposition in oral submucous fibrosis-a prospective study in Central India

PURPOSE

Oral submucous fibrosis is a disease of an Indian subcontinent with obscure aetiology and poorly treated with varying signs and symptoms. OSMF occurs at any age but is most commonly seen in teenagers and adults in the age ranging between 16 and 35 years. A number of surgical treatments have been used for the treatment of oral submucous fibrosis with unpredictable results.

PATIENTS AND METHOD

In this study, 220 patients were randomly divided into two groups with mouth opening less than 16 mm and evaluated with immediate and delayed aggressive physiotherapy with buccal fat pad interposition after fibrotomy. Group A (n = 110) patients underwent aggressive mouth opening exercise from the next postoperative day while in group B (n = 110), patients underwent physiotherapy 7th day postoperatively. Pain and discomfort, mucosalization, infection, flap dehiscence and necrosis were noted. Patients were followed for 1 year on a regular interval basis.

RESULTS

At the end of 1-year follow up, the post-operative mean mouth opening in group A was 38.63 mm and 34.19 mm in group B. In group A, the immediate physiotherapy results in mild to moderate pain and discomfort to the patients as compared to no apparent pain in the group B. The mean mucosalization time in group A and group B was 4.2 and 5.1 weeks, respectively. Postoperatively, all patients achieve satisfactory mouth opening.

CONCLUSION

Immediate aggressive physiotherapy yields a comparatively superior result than delayed physiotherapy with respect to mouth opening in 1 year of follow-up.

Efficacy of buccal fat pad in the surgical management of oral submucous fibrosis: a prospective study

PURPOSE

Various surgical treatment modalities have been advocated in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of buccal fat pad in the surgical treatment of oral submucous fibrosis.

PATIENTS AND METHOD

In the present study, 20 patients were treated for oral submucous fibrosis with interincisal mouth opening less than 16 mm. Surgical procedure included fibrotomy, all third molar extractions, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with buccal pad of fat. Postoperatively, patients were prescribed nutritional and antioxidant supplements along with vigorous mouth opening exercise for 6 months. Regular follow-up was carried out for 2 years.

RESULTS

Excellent increase in the interincisal mouth opening was noticed relieving trismus. Patient's ability of masticate and tolerance to regular food was increased significantly. Buccal fat pad underwent rapid epithelization within a period of 5-7 weeks.

CONCLUSION

Buccal fat pad can be used effectively in the surgical management of oral submucous fibrosis with good functional and esthetic outcome, with only drawback of supple lobulated fat, which requires delicate handling and its limitation to reach anteriorly beyond the canine region.

The use of Buccal fat pad free graft in regenerative treatment of peri-implantitis: A new and predictable technique

Introduction:

Peri-implantitis is a common condition, but no particular treatment protocol has shown to be definitively effective. Fat tissue in the oral cavity is widely available and easily accessed. The aim of the current study is to present a novel technique in the treatment of peri-implant lesions, utilizing a free fat tissue graft from the buccal fat pad (BFP).

Patients and Methods:

Free fat graft (FFG) was harvested from the BFP in eight patients and used with bone substitutes to regenerate 22 peri-implant lesions. Mechanical debridement of the implants surface and the granulation tissue were made with curettes or with Er: YAG laser. Clinical parameters such as plaque index, bleeding on probing, pocket depth, gingival recession, and the clinical attachment level were recorded as a baseline during the follow-up period. In addition, radiological evaluation was made preoperative during the follow-up period.

Results:

The donor site of the free fat graft was healed without cosmetic defect in all patients. Twenty-two peri-implant lesions were followed up for 12 months. Bleeding on probing and the pocket depth were significantly improved, and the clinical attachment level was achieved and maintained during the follow-up period due to the fibrous healing of the free fat graft. Satisfactory esthetic and functional outcomes of the treated implants were achieved and maintained.

Conclusions:

Free buccal fat graft heals by fibrosis. The fibrotic tissue adheres strongly to the implant surface and with stand the recurrence of the peri-implant lesion and provides stable and predictable outcome.

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.

Surgical anatomy of the facial nerve relating to facial rejuvenation surgery

The aim of this review was to familiarize the reader with critical facial nerve anatomy relating to facial rejuvenation surgeries. The temporal branch to the upper orbicularis oculi muscle (OOM): The temporal branch was under the temporoparietal fascia above the zygomatic arch and divided into 2 to 4 branches. The highest level of the twigs that entered the OOM on the x axis and the y axis with the origin of the lateral canthus is +2.51 ± 0.23 cm and +2.70 ± 0.35 cm; and the lowest, 0 cm and +2.68 ± 0.32 cm, respectively. The zygomatic and the buccal branch to the lower OOM: All pretarsal and preseptal OOMs were innervated by 5 to 7 terminal twigs of the zygomatic branches of the facial nerve that approached the muscle at a right angle. The medial portion of the lower OOM was innervated by 1 to 2 terminal twigs of the buccal branch, and the middle portion was innervated with 2 to 3 twigs of the zygomatic branch. The lateral portion was supplied by the uppermost zygomatic branch, which split into 2 to 4 twigs. The temporal branch to the corrugator supercilii muscle: A plexus mainly from the inferior ramus partly from the middle ramus of the temporal branch of the facial nerve enters the corrugator supercilii muscle in the supraorbital area. The temporal branch has as many as 4 to 7 rami, with interconnection among them. The buccal branch to the procerus muscle: The buccal branch crosses the intercanthal line (the nasion to the medial canthus) at approximately one third laterally. The nerve entrance was within a circle with a diameter of 5 mm, and its center was located 9 mm lateral and 10 mm superior from the nasion. It was approximately at the midpoint of the lateral half of the intercanthal line and the lower one third between the intercanthal line and the tangential line of the supraorbital rim. The buccal branch, the buccal fat pad, and the parotid duct: The buccal branches and the parotid duct crossed each other within a semicircle with a 30-mm radius. The base (diameter) was parallel to a horizontal line passing the corner of the mouth and 12 mm above. Its center was located 53 mm lateral to it. The buccal branches of the facial nerve have 2 locations at the buccal fat pad: type I, branches crossing superficial to the buccal fat pad in 14 (73.7%) of 19 specimens, and type II, 2 twigs passing through the buccal extension of the buccal fat pad in 5 (26.3%) of 19 specimens. The buccal branch to the upper orbicularis oris muscle: Approximately 4 branches (4.06 ± 0.83) entering the pars marginalis were found. Most ramifying points (14/17, 82%) were located within a circle with a 5-mm radius, and the center was 12 mm lateral and 26 mm superior to the mouth corner. The mandibular branch according to the neck position: At the one-fourth point, the border-nerve distance decreased (4.32 ± 2.60 mm) with the neck in ipsilateral rotation and the border-nerve distance increased (5.97 ± 2.62 mm) with the neck in contralateral rotation. We hope that this knowledge will aid surgeons in achieving successful outcomes.

Buccal fat pad lifting: an alternative open technique for malar augmentation

PURPOSE

The purpose of the study was to introduce a novel technique for malar augmentation using buccal fat pad pedicle flaps and to evaluate the long-term results and complications of the technique.

MATERIALS AND METHODS

The investigators designed and conducted a prospective clinical trial. Patients underwent unilateral malar augmentation surgery using buccal fat pad pedicle flaps from June 2011 through June 2012. Patients underwent surgery for esthetic reasons or for trauma with severely comminuted or old zygomaticomaxillary complex fractures that could not be reduced precisely. The primary predictor variable was the buccal fat pad pedicle flap technique. The primary outcome variables included the amount of augmentation and resorption (which was estimated by comparing pre- with postsurgical photographic views), pain, edema, bruising, and nerve and parotid duct injuries.

RESULTS

Thirteen patients (8 men and 5 women) underwent malar augmentation in the cheekbone area using the buccal fat pad pedicle flap technique. One year after surgery, the average amount of resorption was 0.376 mm. Other major complications, such as prolonged bruising, massive hematoma, intense pain, asymmetry, and parotid duct injury, were not observed.

CONCLUSION

These results indicate that this new open-access technique should be considered an alternative method for the management of mild to moderate malar depression in patients undergoing esthetic and post-trauma surgery.

Traumatic pseudo-lipoma in 3-year-old child

The buccal fat pad is relatively large and prominent in neonates, infants and young children. The main function of this fat pad is considered as a cushioning tissue and sucking pad. A minor tear of buccal mucosa and buccinator muscle can result in herniation of large volume of fat into oral cavity that is termed as "pseudolipoma." The young children tend to be very playful while brushing their teeth. Improper brushing technique resulted in severe trauma to the buccal fat, including soft-tissue between buccinator and retromolar area. This article presents a case-report of a female child who developed traumatic pseudolipoma after faulty tooth brushing for long duration and its management along with its detail review of literature.

Traumatic pseudolipoma causing facial asymmetry: An uncommon pathology and review of its pathogenesis

We present an uncommon case of traumatic pseudolipoma in a 24-year-old female, causing facial asymmetry. Literature review suggests trauma as a possible etiology for its pathogenesis, which was present in this case. Microscopically, sometimes it is difficult to differentiate between normal adipose tissue and lipoma. Clinician must provide accurate clinical information in order to make a definitive diagnosis of traumatic pseudolipoma. Its pathogenesis has also been highlighted in this article.

Buccal fat pad in intraoral defect reconstruction

The use of buccal fat pad as a graft for intraoral defects is an uncommonly reported procedure but, it has been frequently used for closure of oro-antral and oro-nasal communications. Buccal fat pad was used to reconstruct 3 medium sized defects due to tumoral resection and oro-antral communication. It was used as an unlined pedicled graft. Three cases are discussed along with anatomical aspect of the buccal fat pad. The findings support the view that the buccal fat pad is versatile, logical, convenient, and reliable method for the reconstruction of oral defects up to 4-5 cm in diameter and it healed within 4-5 weeks.

Delayed buccal fat pad herniation: An unusual complication of buccal flap in cleft surgery

Buccal musculomucosal flap is commonly used in cleft palate surgery for providing additional lining when nasal mucosa is inadequate. We report an unusual complication of progressively increasing fat herniation from the sutured donor site which started appearing on the third postoperative day. This necessitated excision of the protruding fat pad on the seventh postoperative day. The possible mechanism and precautions for prevention of this complication are discussed.

Traumatic pseudolipoma: herniation of buccal fat pad, a report of two cases

Traumatic pseudolipoma is a term used to describe intra-oral herniation of the buccal fat pad. A tear of the buccinator muscle and buccal mucosa allows the buccal fat pad to extrude into the oral cavity. Initially, the lesion can suggest a more sinister cause, but a history of trauma, an absence of mass before the accident, anatomical site and fatty appearance should suggest a diagnosis of traumatic herniation of buccal fat pad. This injury is rare, but two cases presented to the authors' hospital over a period of 3 months.

The superficial temporal fat pad and its ramifications for temporalis muscle construction in facial approximation

The construction of the facial muscles (particularly those of mastication) is generally thought to enhance the accuracy of facial approximation methods because they increase attention paid to face anatomy. However, the lack of consideration for non-muscular structures of the face when using these "anatomical" methods ironically forces one of the two large masticatory muscles to be exaggerated beyond reality. To demonstrate and resolve this issue the temporal region of nineteen caucasoid human cadavers (10 females, 9 males; mean age=84 years, s=9 years, range=58-97 years) were investigated. Soft tissue depths were measured at regular intervals across the temporal fossa in 10 cadavers, and the thickness of the muscle and fat components quantified in nine other cadavers. The measurements indicated that the temporalis muscle generally accounts for <50% of the total soft tissue depth, and does not fill the entirety of the fossa (as generally known in the anatomical literature, but not as followed in facial approximation practice). In addition, a soft tissue bulge was consistently observed in the anteroinferior portion of the temporal fossa (as also evident in younger individuals), and during dissection, this bulge was found to closely correspond to the superficial temporal fat pad (STFP). Thus, the facial surface does not follow a simple undulating curve of the temporalis muscle as currently undertaken in facial approximation methods. New metric-based facial approximation guidelines are presented to facilitate accurate construction of the STFP and the temporalis muscle for future facial approximation casework. This study warrants further investigations of the temporalis muscle and the STFP in younger age groups and demonstrates that untested facial approximation guidelines, including those propounded to be anatomical, should be cautiously regarded.

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.

Complications of third molar surgery

This article addresses the incidence of specific complications and, where possible, offers a preventive or management strategy. Injuries of the inferior alveolar and lingual nerves are significant issues that are discussed separately in this text. Surgical removal of third molars is often associated with postoperative pain, swelling, and trismus. Factors thought to influence the incidence of complications after third molar removal include age, gender, medical history, oral contraceptives, presence of pericoronitis, poor oral hygiene, smoking, type of impaction, relationship of third molar to the inferior alveolar nerve, surgical time, surgical technique, surgeon experience, use of perioperative antibiotics, use of topical antiseptics, use of intra-socket medications, and anesthetic technique. Complications that are discussed further include alveolar osteitis, postoperative infection, hemorrhage, oro-antral communication, damage to adjacent teeth, displaced teeth, and fractures.

An anatomical study of the temporal fascia and related temporal pads of fat

BACKGROUND

Numerous reports have discussed the use of the temporal fascia in reconstructive surgery, an issue mandating a detailed study of the anatomy of this structure and its vasculature.

METHODS

The material of the present study consisted of 44 specimens, obtained from two stillbirths and 20 embalmed cadavers after injecting the external carotid artery with lead oxide solution. The superficial temporal fascia was visualized by means of radiography to delineate its vasculature.

RESULTS

The superficial temporal fascia split into two laminae: superficial and deep, the former being thicker over the lower third of the temporalis muscle resplit into two further layers. Its arterial supply was derived mainly from the superficial temporal artery, describing a proximal tortuous course in 13.6 percent of specimens supplemented by the zygomaticotemporal, zygomaticofacial, and posterior auricular arteries; the musculocutaneous perforators; and the zygomaticoorbital artery in 9.1 percent of specimens. The superficial temporal vein provided the venous drainage. The deep temporal fascia was thicker over the lower half of the temporalis where it split into superficial and deep layers. The fascial branch of the middle temporal artery provided its arterial supply and the muscular branch joined the loose areolar arterial network. Three temporal pads of fat (superficial, intermediate, and deep) were demonstrated. A temporal venous sinus was embedded within the deep and intermediate temporal pads of fat.

CONCLUSIONS

The superficial temporal artery provides an extra length for raising superficial temporal artery-based flaps. Caution should be exercised whenever the temporalis myofascial flap is raised, to avoid injuring the temporal venous sinus.

Combined Approach for Facial Contour Restoration: Treatment of Malar and Cheek Areas during Rhytidectomy

BACKGROUND

One of the main objectives in facial lifting is to achieve an adequate facial contour, to enhance facial characteristics. Sometimes, facial areas are more or less accentuated, resulting in an unbalanced or inharmonious facial contour; this can be resolved in the context of a face lift. In the middle third of the face, two anatomical regions define the facial silhouette: the malar contour, with its bone support and superficial structures and, at the cheek level, intimately associated with the mastication system and the facial nerve, the buccal fat pad or Bichat fat pad.

METHODS

The authors describe their experience since 1998 using the double approach to malar atrophy and buccal fat pad hypertrophy in 194 patients with facial aging signs undergoing a face lift. All patients were offered a face lift with partial resection of the fat pad through facial incisions and a stronger malar projection using an inverse superficial musculoaponeurotic system flap.

RESULTS

The main complications observed regarding this surgical technique, in order of appearance, were light asymmetry, caused by a persistent hematoma or swelling; paresthesia of the buccal and zygomatic branches, which resolved spontaneously; and a light sinking of the cheek caused by excessive resection. One patient underwent correction with a fat injection.

CONCLUSIONS

The superior superficial musculoaponeurotic system flap and buccal fat pad resection provided excellent aesthetic results for a more harmonic and proportioned facial contour during rhytidectomy. Particularly in patients with round faces, the authors were able to obtain permanent malar symmetry and projection in addition to diminishing the cheek fullness.

Lorenz Heister's "molar gland"

The buccal fat pad is a mass of specialized adipose tissue described in 1801 by famous French anatomist Xavier Bichat and referred to in medical literature as the "boule de Bichat." This study considered medical publications from 1538 to 1801 and found no descriptions of the buccal fat pad until 1727, when Lorenz Heister, anatomist and surgeon from Altdorf, Germany, first identified the "glandula molaris" and painted it in his Compendium Anatomicum, which appeared in several Latin editions during the eighteenth century.

Interrelated Buccal Fat Pad With Facial Buccal Branches and Parotid Duct

The facial nerve branches are vulnerable during manipulation of the buccal fat pad. The aim of this study is to describe the precise anatomical interrelation among the buccal fat pad, buccal branches of the facial nerve, and parotid duct. Nineteen hemifaces of Korean cadavers (11 male and 8 female) fixed in 10% formaldehyde solution were dissected. An average 3.6 buccal branches of the facial nerve were found. The facial buccal branches and parotid duct crossed each other within a semicircle with a 30-mm radius. The base (diameter) is parallel to a horizontal line passing the corner of the mouth and 12 mm above. Its center is located 53 mm lateral to it. The buccal branches of the facial nerve have two locations at the buccal fat pad: Type I, branches crossing superficial to the buccal fat pad in 14 of 19 (73.7%) specimens; and Type II, two twigs passing through buccal extension of the buccal fat pad in 5 of 19 (26.3%). An interrelation of parotid duct and buccal fat pad is as follows: parotid duct crossing superficial to the buccal extension of buccal fat pad in 8 of 19 (42.1%) specimens, crossing deep to the buccal extension of buccal fat pad in 5 of 19 (26.3%) specimens and crossing along the superior border of the buccal extension of buccal fat pad in 6 of 19 (31.6%) specimens. There is a 26.3% chance of injury to the buccal branch during total removal of buccal fat pad. The parotid duct runs deep to the buccal extension of buccal fat pad in 26.3% of cases.

Use of the buccal fat pad in the reconstruction and prosthetic rehabilitation of oncological maxillary defects

We evaluated the effectiveness of the buccal fat pad as a pedicled flap for intraoral reconstruction after partial maxillectomy for neoplastic disease in 24 patients, and subsequently, in providing support for a denture. In all patients the buccal fat pad was covered with a split-skin graft and an acrylic plate. There was complete healing of the buccal fat pad flap within 6 weeks in 18 patients with no major complications, and minimal effects on speech and eating. In six cases there was partial dehiscence of the flap, which healed spontaneously in one patient and was repaired with local flaps in two others. There were no cases of complete breakdown 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 of reconstruction of small to medium-sized posterior maxillary alveolar defects.