S.O.R.G.

Modular Course Series

Eric Dierks Portland, Oregon USA

Buccal Flap and Tongue Flap

Indianapolis, IN | April 5 – 7
 BUCCAL FAT PAD AND
TONGUE FLAPS

Eric J. Dierks, MD, DMD, FACS, FACD, FRCS(Ed)

Head and Neck Surgical Associates
Head and Neck Institute
Affiliate Professor of Oral and Maxillofacial Surgery
Oregon Health & Science University
Portland, Oregon USA
 Buccal Fat Pad Flap
The Fat Pad of Bichat
Marie Francois Xavier Bichat: 1801
• Fat pad was not a gland

Peter Egyedi: 1977

• described BFP as a rotational flap for oral
reconstruction
J Maxillofacial Surg 1977

Henk Tideman: 1986

• BFP readily epithelializes in 2-3 weeks
when brought into the oral cavity
JOMS 1986
Scammon 1918
 Buccal fat pad flap: “Buckie”
Blood supply:
• Maxillary artery
– Buccal br
– Deep temporal br
• Superficial temporal artery
– Transverse facial br.
• Facial artery
– Multiple small br.
Lobes and
extensions
3 lobes:
• Anterior
• Intermediate
• Posterior: 4 extensions
– Buccal*
– Pterygoid
– Pterygopalatine
– Temporal
Buccal fat pad
“Syssarcosis”

Lies between:
Buccinator - medial
Masseter - lateral

Thin fascial envelope

Mean volume: 10ml
Anatomy
Retromolar trigone defect
BFP “ Buckie” used to
cover trans oral bone
graft
 Buckie fills in defect after
osteomyelitis marginal resection
Morphology is more like
orbital fat

• Function: in infants: resists negative

pressure on cheek during suckling

• Size: Uniform size and shape regardless of

nutritional status or obesity

Racz and Maros, Morphol-Embryol 1989

 Buccal fat pad flap
applications:

• Closure:
– oral-antral fistulae*
• Coverage:
– retromolar trigone
– marginal
mandibulectomy
– soft palate
– buccal defects from
submucous fibrosis
release
Surgical approaches to harvest Buckie:
Srivastava

1.. An incision through the mucosa on the buccal

aspect of the vestibule in the molar region.
2.. A vertical mucosal incision slightly lateral to the
anterior margin of the ascending ramus (fig 4).
3. Elevate mucoperiosteal flap in the molar region
on the lateral aspect of the maxillary alveolar
process and incision of the periosteum at the level
of buccal sulcus
Approach
 Be
gentle…

Harvest
• BFP may be visible through defect
• Dean scissors + Debakey forceps
- “extracapsular dissection”
• Release BFP along margin you need to
advance
Instrumentation

DeBakey forceps
Dean scissors
 Adequate access
• Large incision
• Don’t pull Buckie out
• Let him flow out

Johan Fagan MBChB, FCORL

Professor and Chairman
Division of ENT
University of Cape Town
SCCA lateral soft
palate
 Baumann and Ewers JOMS 2000

• N= 29 patients
• Largest defect = 4 X
5.5 cm
• Epithelialization
within 3-4 wks
 Shrivastava et al, Buccal Fat Pad to Repair Intraoral Defects
International Journal of Scientific and Research Publications,
Volume 3, Issue 2, February 2013 1 - 6
 Shrivastava et al

10 days 3 months
 Post op course
what to inform your patients
The Buckie Owners Manual

• Granulating surface
– It looks terrible!
– And it smells!
• Granulates to a
beautiful mucosal
surface in about 3-5
weeks
• Trismus: 1-2 months
– may require physical
therapy
OA Fistula 3 molar area
rd
OA Fistula 3 molar area
rd
OA Fistula 1 molar area
st
The Jurassic Period
“Only a man who is familiar with the art and
science of the past is competent to aid in its
progress in the future.”
– Theodor Billroth, 1863
OA Fistula 1 molar area
st
OA Fistula 1 molar area
st
OA Fistula 1 molar area
st
Maxillary alveolar ridge defect
Approx 2 weeks later
Approx 3 weeks later
Small SCCa buccal mucosa
Approx 2 weeks later
Bilateral BFP: David Hirsch MD, DDS
TONGUE FLAP
 Tongue flap:
Sites of harvest
• Midline most commonly used
• Hemi-tongue set-back
• Lateral
• Anterior, bipedicle
• Posterior
 History of tongue flappage:

1901 von Eiselberg & Gersuny

1904 Ranzi & Sultan
1956 Kloop described use for oral
reconstruction
1972 Ian Jackson described tongue
flap for closure of palatal fistulas
1966 Guerro-Santos
4 branches of lingual artery:

suprahyoid
deep lingual
dorsal lingual
sublingual
Anterior median tongue flap:
• location: middle 1/3 of tongue
• width: > than defect width
• length: ~ 5 cm
• thickness: ~ 4 - 5 mm
• fixation: 3 weeks
• IMF: rarely needed
 Midline tongue flaps:
35 specimens

• anastomotic arcades cross midline at tongue tip

- may support anterior based flaps
• posteriorly based flaps fill better, but midline
flaps can be perfused from either end
• submucosal plexus fills before muscle
- Bracka, Br J Plast Surg, 1981
 Midline tongue flaps for oral fistulae:

• palatal fistulae> 1.5 cm diameter

• all cleft palate breakdowns
• flap length 5 - 6 cm
• thickness: 5 - 7 mm with 2 - 4 mm muscle
• IMF for 2 - 3 days 
• pedicle division @ 3 weeks
• 17/19 successful

- Busic et al. Int J Oral Maxillofac Surg, 1989

Anterior median tongue flap
applications:

• oral-nasal/antral fistulae
• alveolar clefts
• other median and paramedian defects
Anteriorly based, midline tongue flap
very useful

Prior radiation therapy

Anteriorly based, midline tongue flap

• oral-nasal/antral fistulae
• alveolar clefts
• other median and paramedian defects
Rotational flap ?
Looks good in pictures
usually doesn’t work
Stage 1 overview
You can’t directly close the posterior aspect
of the fistula
Stage 2: 3 weeks later
Methods to avoid tongue flap detachment
Agrawal and Panda PRS 2007

IMF

K-wire fixation !

Chin cap !!
 Set-back tongue flap

Seidl et al, HNO 2003

Tongue tip reconstruction with
dorsal/ventral
reversed Z-plasties
 Posteriorly based
lateral tongue flap

• tonsillar defects
• lateral pharyngeal wall defects
•Rarely used
 Palatal flap
based on opposite greater palatine artery
 Greater palatine artery axial flap

Trick #1:
• Sharply separate the greater palatine artery
from the undersurface of the flap in the area
of potential kinking
 Greater palatine artery axial flap

Trick #2:
• Curette away bone around the greater
palatine foramen
• Enlarge the foramen
• Allows rotation of the vessel without kinking
Post-rotational Flap Floposis
Correction of Flap Floptosis
 Greater palatine artery axial flap

Trick #3:
• Avoid flap flaptosis by suturing flap to palate
• Consider paired, drilled or punched holes to
suture through
One year later
eric.dierks@gmail.com
• Yousuf S, Shane Tubbs R, Wartmann CT, Kapos T, Cohen-Gadol AA, Loukas M. A review of the gross anatomy, functions, pathology, and
clinical uses of the buccal fat pad. Surg Radiol Anat. 2009 Nov 25.

• Paul W. Poeschl, Arnulf Baumann, Guenter Russmueller, Ellen Poeschl, Clemens Klug, Rolf Ewers Closure of Oroantral Communications With
Bichat's Buccal Fat Pad JOMS, Vol 67:7, July 2009, pp 1460-1466

• Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications.J Maxillofac Surg. 1977 Nov;5(4):241-4.
•  
• Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg. 1993 Feb;22(1):2-6.
•  
• Hudson JW, Anderson JG, Russell RM Jr, Anderson N, Chambers K. Use of pedicled fat pad graft as an adjunct in the reconstruction of palatal
cleft defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 Jul;80(1):24-7.
•  
• Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP.The use of the buccal fat pad for reconstruction of oral defects: review of the
literature and report of 15 cases. J Oral Maxillofac Surg. 2000 Feb;58(2):158-63.
•  
• Jackson IT.Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg. 1999 Jun;103(7):2059-60.11. Zhang HM, Yan YP, Qi
KM, Wang JQ, Liu ZF. Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg.109:2509, 2002.
•  
• Baumann A, Ewers E. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Sur. 58:389, 2000.
•  
• Colella G, Tartaro G, Giudice A. The buccal fat pad in oral reconstruction. Br J Plast Surg. 57:326, 2004.
•  
• Jackson IT, Moreira-Gonzalez AA, Rogers A, Beal BJ.The buccal flap--a useful technique in cleft palate repair Cleft Palate Craniofac J. 2004
Mar;41(2):144-51
•  
• Alkan A, Dolanmaz D, Uzun E, Erdem E. The reconstruction of oral defects with buccal fat pad. Swiss Med Wkly. 23:465, 2003.
•  
• Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of the buccal fat pad for reconstruction of oral defects: review of the
literature and report of 15 cases. J Oral Maxillofac Surg. 85:29, 2000.
•  
• el-Hakim IE, el-Fakharany AM.The use of the pedicled buccal fat pad (BFP) and palatal rotating flaps in closure of oroantral communication
and palatal defects. J Laryngol Otol. 1999 Sep;113:834-8.
Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications.J
Maxillofac Surg. 1977 Nov;5(4):241-4.
 
Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg. 1993
Feb;22(1):2-6.
 
Hudson JW, Anderson JG, Russell RM Jr, Anderson N, Chambers K. Use of pedicled fat pad graft as an adjunct
in the reconstruction of palatal cleft defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995
Jul;80(1):24-7.
 
Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP.The use of the buccal fat pad for reconstruction
of oral defects: review of the literature and report of 15 cases. J Oral Maxillofac Surg. 2000 Feb;58(2):158-63.
 
Jackson IT. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg. 1999
Jun;103(7):2059-60.11. Zhang HM, Yan YP, Qi KM, Wang JQ, Liu ZF. Anatomical structure of the buccal fat pad
and its clinical adaptations. Plast Reconstr Surg.109:2509, 2002.
 
Baumann A, Ewers E. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Sur. 58:389,
2000.
 
Colella G, Tartaro G, Giudice A. The buccal fat pad in oral reconstruction. Br J Plast Surg. 57:326, 2004.
 
Jackson IT, Moreira-Gonzalez AA, Rogers A, Beal BJ.The buccal flap--a useful technique in cleft palate repair
Cleft Palate Craniofac J. 2004 Mar;41(2):144-51
 
Alkan A, Dolanmaz D, Uzun E, Erdem E. The reconstruction of oral defects with buccal fat pad. Swiss Med
Wkly. 23:465, 2003.
 
Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of the buccal fat pad for reconstruction
of oral defects: review of the literature and report of 15 cases. J Oral Maxillofac Surg. 85:29, 2000.
 
el-Hakim IE, el-Fakharany AM.The use of the pedicled buccal fat pad (BFP) and palatal rotating flaps in closure
of oroantral communication and palatal defects. J Laryngol Otol. 1999 Sep;113:834-8.