Indications and Contraindications of Buccal Fat Pad Usage: History
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Kamil Nelke
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Alicja Morawska
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Bartłomiej Błaszczyk
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Maciej Janeczek
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Edyta Pasicka
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Marceli Lukaszewski
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Krzysztof Żak
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Maciej Dobrzyński

The buccal fat pad, also called the Bichat’s fat pad (BFP), is an encapsulated fat mass located in the cheek. This type of specialized fat mass can be used both as a pedicular or free graft in various surgeries and approaches. Due to its easy access from the oral cavity approach, it is commonly used for oroantral and palatal fistula closure. The BFP is used for multiple purposes in reconstructive and oncology surgery and also has its use in esthetic and facial contouring procedures. The amount, volume, and shape of the BFP are mostly associated with the scope of their usage. 

  • buccal fat pad
  • oroantral
  • bone defect
  • wound
  • indications
  • contraindications
  • limitations

1. Introduction

The Bichat fat pad (BFP), known as Bichat Ball, Bichat’s protuberance, or buccal fat pad, is a specialized mass of adipose tissue located in the buccal region [1]. This eponym derives from the name of French anatomist Marie-Francois Xavier Bichat (1771–1802), who described it for the first time at the beginning of the XIX century. The following anatomists conducted several experimental studies, which built the foundation for modern physiology and other branches of medicine [2]. The first suggestion for using the BFP appeared in 1977. Egyedi proposed the usage of the buccal fat pad for the closure of oro-antral and oro-nasal communications for the first time. In four presented cases, the researchers found that mobilization and shifting of the buccal fat pad combined with a free skin graft may be a simple and reliable method of obtaining closure of medium-sized defects [3]. The use of the BFP as a free graft was described by Neder in 1983 and as a pedicule graft by Tideman three years later. Mentioned scholars observed that the epithelialization of the graft occurs for 2 or 3 weeks without the necessity to cover this with skin grafts [4][5][6]. The BFP can be used in various surgical situations. Their usage can be divided into several aspects. Researchers’ proposals include the following: functional (for example, covering of adjacent defects, scar revision surgery, fibrosis treatment, jaw bone necrosis, temporomandibular join ankylosis-related surgeries, and teeth root coverage), esthetic (for example, facial oval contouring and buccal esthetic procedures), and reconstructive purposes (oro-antral fistulas, bone defects coverage, oro-nasal fistulas coverage, cleft-related surgeries usage, palatal/maxillary defects after tumor treatment, peri-implant and peri-implantitis treatment, etc.) [6][7][8][9][10][11][12]. The majority of indications for BFP usage are related to its very good positioning in the facial region, good anatomical relations with the maxillary bone, hard and soft palate, easy dissection technique for harvesting and mobilization of this pedicled fat, along with good healing potential and adequate epithelialization with a low rate of complications when used [2][3][4][5][6][7][8].

2. Indications and Contraindications

The Bichat fat pad’s anatomical proximity to the location of various intraoral defects makes it a flap of choice in various congenital and acquired defects that occur in the maxillofacial area. The shape, size, and volume of the BFP might vary individually, the same as its usage for different sizes of surgical defects within its proximity. Before any surgery, a detailed patient examination is necessary. Additional CT/MR imaging might be helpful to identify and measure the size, shape, and location of the BFP and plan the spectrum of each surgery.
A major limitation of the BFP is related to the status of the bone defect or a wound in the oral cavity. The microbiological status of the wound or bone defect is very important. A clean wound, without any signs of irritations, inflammations, and local contamination, can be easy, with a good overall success rate, and closed primarily during one procedure. Microbiological swabs often help in the identification of bacteria, especially those which are atypically found in the oral cavity area. Wounds with pus and microbiological contamination should be firstly threatened pharmacologically and with local debridement. During that time, when a fistula or bone defect is present, a temporary prosthetic rehabilitation could be used. Later on, when the microbiological situation is quite stable, the defect can be closed with a secondary delayed approach. Propper healing in time is not only related to good wound care before and after the procedure. The incision type and wide approach grant not only good visibility but additional blood supply from the mucosal or mucoperiosteal flaps. When sutured, a layer-by-layer suture is advisable. Lack of tension and tension-free sutures support not only the wound’s adequate position at the deeper layer but grant graft immobility [2][3][4][13][14][15][16][17].
There are several listed indications, contraindications, and limitations of buccal fat pad usage. Well-known and often used in clinical practice, BFP flap indication is the closure of oro-antral fistulas. It was originally recommended to use it in cases of small- to moderate-size communications up to 4 cm in diameter [3]. The BFP’s size should enable good closure of the defect, regardless if it will be used with a skin graft, covered by a second layer of tissues (the mucoperiosteal flap) or left sutured in situ in the defect [6][9][13][18][19]. It is especially used in fistulas in the vestibular side of the alveolar process rather than on the palatal side due to location issues, the degree of surrounding bone, maxillary tuberosity prominence, surrounding bone volume, or other factors. The BFP’s use is limited to reconstructions in posterior regions of the oral cavity in adults since the flap can not reach the maxillary midline; however, in some cases, when a very wide exposure is granted, this is achievable. Another situation is in children. Kumar proposes that a buccal fat pad can be utilized as an appropriate pedicled flap for coverage after tumor resection in anterior maxillary defects in infants and children [14]. However, the Bichat Ball technique can be used in patients of all ages, including the elderly age, due to specific lipolysis of the tissue. It can be used even in immunocompromised patients due to its stem cell capacity (SC) [13]. The most frequently mentioned advantage is the rich vascularization of the flap. The buccal fat pad can be used as a pedicled flap or as a free graft. The great advantage of this flap is the ability to be keratinized in time when used for oral cavity reconstruction [19]. The fat cells act as stem cells, and this flap may change into any kind of tissue given the right circumstances [13][14][15][18][19]. When used to close oral wounds, it transforms into healthy oral mucosa. Complete epithelialization of the BFP can be observed within even 1 month [13][15].
The contraindication to BFP use in oroantral fistula closure is in cases when bone reconstruction is necessary to place and plan dental implant rehabilitation, where hard tissue is required [18]. The BFP can be used just once per side; an already previously used buccal fat pad flap is a contraindication. In cases of chronic sinusitis or purulent inflammations following oroantral fistula treatment, the BFP should be used when inflammation is limited. Some researchers even advise first maintaining the inflammation process with antibiotic therapy and postponing the final surgical treatment until the infectious process is stabilized [6]. Very slim or skinny persons might have an underdeveloped BFP, causing limitations in their mobilization and usage in larger defects [5][6][7][8][9][10][11][12][13][14][15][16][18][19]. From the researcher’s perspective, a very wide elevation of mucoperiosteal flaps improves the flap length and its mobilization and decreases vestibule and buccal recess reduction in volume.
Both occurrences of oro-nasal or oro-antral communication can be closed either simultaneously, in primary surgery, or closed in a secondary approach. Late closure has special considerations. This finding might require the incision of a fistula, wound debridement, excision of some tissues, and preparation of a good refreshed tissue surface for its later proper closure. Both newly formed oro-antral/oro-nasal connections and chronic fistulas require an individual approach. Closure of chronic fistulae in radiating areas or scar tissues after past surgeries may be challenging. Tissue scarring, contraction, and a lack of soft tissue material are serious problems. Oral cancer patients represent a big chapter for BFP usage. Previous head and neck radiation treatment does not represent an absolute contraindication to BFP use. A study by Bereczki-Temistocle et al. showed a statistically significant difference between healthy patients and patients with a history of radiotherapy regarding relapses and BFP usage [11][12][13][18][19]. Furthermore, ablative oncological surgeries, followed by radiotherapy (lack of adequate vessels and arteries and tissue condition), might greatly decrease the number of possibilities to treat such situations in oncological patients; however, the usage of the BFP might be a solution in the following cases [12][13][14][15][18][19]. From the researchers’ point of view, tissue and wound debridement, followed by adequate sutures layer by layer, grant a very good and stable surgical outcome.
The most common complications described were represented by flap partial necrosis, its perforation; local infection; excessive local scarring, especially in cancer patients undergoing adjuvant radiotherapy treatment; late wound dehiscence; and oroantral or oronasal fistula reoccurrence, where patients’ comorbidities and wrong indications for surgery were the main influencing factors. Other possible complications mentioned in the literature are trismus, limited mouth opening in time, facial swelling, hematoma, abscess formation, and ecchymosis on the buccal area [13][14][15][16][18][19]. Very rarely, damage to the parotid salivary duct or a major artery might occur. However, complications are not common, and the method is popular. Gonzalez et al., in their prospective study, came to the conclusion that patients were highly satisfied overall with the treatment and with phonetics, esthetics, and chewing after BFP usage [17]. Examples of various uses of the Bichat fat pad might include its role in not only maxillary/palatal defects closure but also its usage in the temporomandibular joint, orbital floor, alveolar bone, zygomatic and buccal area, etc. [13][14][15][16][17][20].
Further, atypical limitations include slim patients with underdeveloped or small portions of the BFP. This is not only related to decreased fat volume but also very troublesome BFP preparation when it is small and well attached to its ligaments and surrounding soft tissues. In that situation, even suturing the BFP is troublesome because of its limited mobility and the necessity to use deep-layer sutures. Later increased tension might impact post-operative cheek movements. Second, the BFP tends to tear or cause wound dehiscence with its sutures with tension.

This entry is adapted from the peer-reviewed paper 10.3390/jcm12154909

References

  1. Hassani, A.; Shahmirzadi, S.; Saadat, S. Applications of the Buccal Fat Pad in Oral and Maxillofacial Surgery. In A Textbook of Advanced Oral and Maxillofacial Surgery; InTech: Vienna, Austria, 2016; Volume 3.
  2. Shoja, M.M.; Tubbs, R.S.; Loukas, M.; Shokouhi, G.; Ardalan, M.R. Marie-François Xavier Bichat (1771–1802) and his contributions to the foundations of pathological anatomy and modern medicine. Ann. Anat. 2008, 190, 413–420.
  3. Egyedi, P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J. Maxillofac. Surg. 1977, 5, 241–244.
  4. Neder, A. Use of buccal fat pad for grafts. Oral Surg. Oral Med. Oral Pathol. 1983, 55, 349–350.
  5. Tideman, H.; Bosanquet, A.; Scott, J. Use of the buccal fat pad as a pedicled graft. J. Oral Maxillofac. Surg. 1986, 44, 435–440.
  6. Amaral, M.F.D.; Guerra, L.A.P.; Gerbi, M.E.M.D.M.; Melo, A.R.; Gondim, D.G.D.A.; Junior, R.M.; De Melo, S.L.; Neto, A.P.D.S. Oroantral fistulas closure using Bichat’s fat pad. RGO-Rev. Gaúcha Odontol. 2014, 62, 437–442.
  7. Kahn, J.L.; Sick, H.; Laude, M.; Koritké, J.G. The buccal adipose body (Bichat’s fat-pad). Morphological study. Acta Anat 1988, 132, 41–47.
  8. Surek, C.C.; Kochuba, A.L.; Said, S.A.-D.; Cho, K.-H.; Swanson, M.; Duraes, E.; McBride, J.; Drake, R.L.; Zins, J.E. External Approach to Buccal Fat Excision in Facelift: Anatomy and Technique. Aesthetic Surg. J. 2021, 41, 527–534.
  9. Saralaya, S.; Desai, A.K.; Ghosh, R. Buccal fat pad in cleft palate repair- An institutional experience of 27 cases. Int. J. Pediatr. Otorhinolaryngol. 2020, 137, 110218.
  10. Chouikh, F.; Dierks, E.J. The Buccal Fat Pad Flap. Oral Maxillofac. Surg. Clin. N. Am. 2021, 33, 177–184.
  11. Nozawa, A. Histological Observation on the Structural Feature and Blood Supply of Corpus Adiposum Baccae. Kokubyo-Gakkai-Zasshi 2002, 69, 128–138.
  12. Rácz, L.; Maros, T.N.; Seres-Sturm, L. Structural characteristics and functional significance of the buccal fat pad (corpus adiposum buccae). Morphol. Embryol. 1989, 35, 73–77.
  13. Bereczki-Temistocle, D.L.; Gurzu, S.; Jung, I.; Cosarca, A.; Beresescu, G.; Golu, V.; Petrovan, C.; Ormenisan, A. Selecting the Best Surgical Treatment Methods in Oro-Antral Communications. Int. J. Environ. Res. Public Health 2022, 19, 14543.
  14. Kumar, D.; Rattan, V.; Rai, S.; Yadav, S.; Sahu, G.R. Reconstruction of anterior maxillary defect with buccal pad fat after excision of melanotic neuroectodermal tumor of infancy. Ann. Maxillofac. Surg. 2015, 5, 234–236.
  15. Adeyemo, W.L.; Ibikunle, A.A.; James, O.; Taiwo, O.A. Buccal Fat Pad: A Useful Adjunct Flap in Cleft Palate Repair. J. Maxillofac. Oral Surg. 2019, 18, 40–45.
  16. Jose, A.; Rawat, A.; Nagori, S.A.; Arya, S.; Shukla, D. Outcomes of sequestrectomy and buccal fat pad reconstruction in the management of medication-related osteonecrosis of the jaws. Oral Maxillofac. Surg. 2022, 26, 147–153.
  17. Alonso-Gonzalez, R.; Penarrocha-Diago, M.; Penarrocha-Oltra, D.; Aloy-Prosper, A.; Camacho-Alonso, F.; Peñarrocha-Diago, M. Closure of oroantral communications with Bichat’s buccal fat pad. Level of patient satisfaction. J. Clin. Exp. Dent. 2015, 7, e28–e33.
  18. Mannelli, G.; Arcuri, F.; Comini, L.V.; Valente, D.; Spinelli, G. Buccal Fat Pad: Report of 24 Cases and Literature Review of 1635 Cases of Oral Defect Reconstruction. ORL J. Otorhinolaryngol. Relat. Spec. 2019, 81, 24–35.
  19. Rahpeyma, A.; Khajehahmadi, S. Buccal Fat Pad Graft in Maxillofacial Surgery. Indian J. Surg. Oncol. 2021, 12, 802–807.
  20. Khandelwal, P.; Hajira, N. Management of Oro-antral Communication and Fistula: Various Surgical Options. World J. Plast. Surg. 2017, 6, 3–8.
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