THE BUCCAL FAT PAD FLAP

Oral Maxillofacial Surg Clin N Am (2021)

Maj Muhammad Ramzan Adeel

Resident
Oral and Maxillofacial Surgery
 PRESENTATION LAYOUT

• Introduction

• Anatomy of buccal fat pad

• Functions of buccal fat pad

• Indications and contra indications

• Surgical technique for the buccal fat pad harvest

• Complications

• Advantages and disadvantages of the buccal fat pad

 DEFINITIONS

• FLAP is transferred with its blood supply intact,

• GRAFT is a transfer of tissue without its own blood supply

• AXIAL PATTERN FLAP incorporates an anatomically named vascular

pedicle

• RANDOM FLAP lacks a specific named vessel. It is perfused from

perforators located near the anatomic base of the flap
 DEFINITIONS

• PEDICLED FLAP transferred while still attached to their original

blood supply

• Sys-sarcosis An anatomical term referring to a union between parts

of the skeleton through muscles alone such as the scapula with the
thorax or the hyoid with the mandible and sternum)

• Cachexia loss of body weight and muscle mass, and weakness that
may occur in patients with cancer, AIDS, or other chronic diseases
 INTRODUCTION
Evolution from Surgical
Nuisance to a Reliable Reconstructive Asset

German anatomist and surgeon, Lorenz Heister,1727

1801, the French anatomist, Xavier Bichat

 Composed of adipose tissue

 1977 Peter Egyedi

 BFP pedicled flap for the closure of OAF and oronasal fistulae
 ANATOMY

 Main body and 4 extensions

 Main body extends

 Along the anterior border of the masseter muscle

 Courses medially, and rests on the periosteum of the posterior maxilla

 overlies the buccinator muscle

 ANATOMY

• 4 x extension according to location

• Buccal

• Pterygoid
Posterior lobe
• Pterygopalatine

• Temporal

 Main body + buccal extension 50 to 70 % of the weight

 ANATOMY

 3 lobes with own capsule and blood supply

• Anterior

• Intermediate

• Posterior lobes
 ANATOMY

 BFP is located in masticatory space

 The body and the buccal extensions

 superficial to the buccinator and

 deep to the parotidmasseteric fascia

 Facial nerve(zygomatic and buccal branches) and parotid duct lateral to

body extension
 ANATOMY

The BFP is located deeper than the premasseteric fat compartments and is

suspended to the surrounding structures by a series of ligaments

 Body extension harvested for reconstructive surgery

 ANATOMY
 Size not altered by weight of patient

 Mean volume
• 10 cm3

 Weight approximately
• 9.7 g

 Cover a surface
• 10 cm2

 Mean thickness
• 6 mm
 VASCULARIZATION OF THE BFP
 Rich abundant capillary network

 Maxillary artery branches

• Deep temporal
• Buccal
• Superior posterior alveolar arteries

 Additional blood supply

• Facial

• Transverse facial

 Venous drainage---- facial vein

 FUNCTIONS OF THE BFP

 Gliding function between the muscles of mastication

• Syssarcosis

 Sucking action of feeding in infants

 Buccal extension cheek fullness and contour

 Protective envelop for neurovascular bundle in masticatory space

 INDICATIONS OF THE BFP FLAP

 Repair of oroantral fistula, such as after dental extraction

 Repair of posterior fistula in cleft palate

 Reconstruction after small (4 cm x 4 cm) intraoral soft tissue

cancer ablative surgery (soft palate, hard palate, retromolar

trigone, maxillary defect, check mucosa, tonsillar fossa)

 INDICATIONS OF THE BFP FLAP

 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

 INDICATIONS OF THE BFP FLAP

 For coverage in gingival recession

 As a vascularized bed in osteonecrosis therapy

 Upper lip augmentation

 Improvement of mid-face contour

 As a membrane in sinus lift surgery

 RELATIVE CONTRA-INDICATIONS OF THE BFP FLAP

 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 BFP HARVEST

 Materials
• 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 TECHNIQUE FOR THE BFP HARVEST
 SURGICAL TECHNIQUE FOR THE BFP HARVEST

 SURGICAL STEPS

1. Local anesthesia infiltrated posterior maxillary vestibule

2. 2cm mucosal horizontal incision at 2nd molar level 2cm above

mucogingival junction

(Mucosa then buccinator muscle then maxillary periosteum)

3. Cut periosteum with monopolar electric cautery

 SURGICAL TECHNIQUE FOR THE BFP HARVEST

3. Blunt dissection with dean scissor to release from surrounding

tissues

4. Flap available immobilized with debakey forcep and sutured

over defect ( big bites and mattress sutures )

5. No need to cover with mucosa as it epithelizes in 4 weeks

 SURGICAL TECHNIQUE FOR THE BFP HARVEST

 If the fat pad does not bulge out easily after adequate peripheral blunt

dissection

• Consider lengthening the incision

• Judicious sharp dissection with the dean scissors around the periphery

• The assistant apply downward pressure on the cheek skin above the

zygomatic arch
 SPECIAL SITUITIONS

1. Sulcular incision already made then just incise periosteum

2. Approach through existing surgical defect

 SPECIAL SITUITIONS

3. Defect inferior in mouth retromolar area

• Vertical incision in the posterior buccal mucosa

• Lateral to the ascending ramus

• Below and posterior to the stensen duct orifice

• Zig zag incision to decrease contracture

 IMMEDIATE POST OP CARE

 Sinus precautions in case of OAF

 Peri op antibiotic and antiseptic mouth rinse

 Mouth opening exercises to prevent contracture

 Inform patient about color change of the flap

 COMPLICATIONS

 Infection
Subperiosteal tunnel for
 Vestibule obliteration === OAF
Temporaray
 Hemorrhage/hematoma

 Partial or complete flap necrosis

Large
 Change in cheek contour ( rare )
defects and
 Persistent trismus large harvest

 Excessive scaring with contracture

 BFP POTENTIAL SOURCE OF STEM CELLS

 Adipose derived stem cells

 Differentiation into cartilage, bone or muscle

 BFP stem cells can differentiate into

• Chondroblasts

• Adipocytes

• Osteoblasts
 ADVANTAGES OF BFP FLAP

 Easy flap to perform

 Low complication rate and low morbidity

 Well accepted by the patients

 Buccal fat pad is of Dependable size even in thin and cachexic patients

 Highly vascularized, prevent infection in susceptible patients or recipient

sites

 Surgery can be done under local anesthesia

 There is no visible scar

 DISADVANTAGES OF BFP FLAP

 Unsuitable for large defects

 Can be harvested only once

 May not be an option in previously irradiated patients, or patients with Down

syndrome or malar hypoplasia

 Will not add bulk to the reconstructed defect

 SUMMARY

 The BFP was initially considered a surgical nuisance but now proved to be a

versatile and reliable reconstructive option for intraoral moderate sized Soft

tissue defects.

 Its high success rate, 97.02% and its ease of harvest explain its current and

future popularity among surgeons of all disciplines who operate in the oral

cavity