PEDICLED BUCCAL PAD OF FAT: A TRUSTWORTHY ADJUNCT IN PRIMARY PALATOPLASTY- A CASE REPORT

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1 Case Report PEDICLED BUCCAL PAD OF FAT: A TRUSTWORTHY ADJUNCT IN PRIMARY PALATOPLASTY- A CASE REPORT Authors: Ashok Kumar Gupta*, Rupinder Sandhu**, Anantpreet Singh***,Vivek Prabhu****, Jay prakash Narayan*****. ABSTRACT Primary palatoplasty in cleft palate patients done by any technique leaves behind lateral raw bony surfaces. During healing period of these surfaces complications like pain, scar contracture and oronasal perforation can be there. The purpose of this article is to provide the rationale for the use of pedicled buccal fat pad grafts in patients with cleft palate when healing by secondary intention may need to be considered postoperatively. A case is being presented in which pedicled buccal fat pads were used to cover the lateral raw bony surfaces left after closure of two mucoperiosteal flaps in the centre. High success rate of buccal fat pad, easy accessibility provided by the existing incision and proximity of donor site to oral cavity proved advantageous. Key word- Buccal pad of fat, cleft palate, primary palatoplasty INTRODUCTION Cleft palate when wide becomes difficult to close without complications. Even though the surgeon performs complete closure, secondary oronasal fistulas and scar contracture can develop because of large lateral raw bony surfaces. Although the buccal fat pad has been used widely as an alternative method for reconstruction of small to medium sized intraoral defects. it has rarely been used in primary cleft palate repair. This report describes a patient in whom pedicled buccal pad of fat was used to cover the lateral raw bony Address for Correspondence: Dr. Ashok Gupta, Sanjeevani Multispeciality Dental Clinic, 111, Saugat Appartments, Near Millenium Plaza, University Road, Govindpuri, Gwalior. guptaaaz@yahoo.com, guptaaaz@gmail.com surfaces after primary palatoplasty. CASE REPORT A one year old male infant with unilateral complete cleft palate (fig.1) Figure 1 : Preoperative right unilateral complete cleft palate. was operated under general anesthesia administered by orotracheal intubation. Patient was prepared and draped. Lignocaine 2% with 1:80000 adrenaline was infiltrated into the * Assistant Professor, Department of Oral & Maxillofacial Surgery, Institute of Dental Education and Advanced Studies, Hospital & Research Centre, Gwalior, MP, India **, *****Assistant Professor, Department of Prosthodontics, Institute of Dental Education and Advanced Studies, Hospital & Research Centre, Gwalior, MP, India *** Assistant Professor, Department of Oral & Maxillofacial Surgery, Guru Gobind Singh Medical College, Faridkot, Punjab, India **** Assistant Professor, Department of Periodontics, Institute of Dental Education and Advanced Studies, Hospital & Research Centre, Gwalior, MP, India BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 2 Issue-3 Sept

2 Gupta et al lateral palatal region. Dingman retractor was placed in position. Bilateral full thickness mucoperiosteal flaps were raised and released from hamular process to minimize the tension. All the abnormal muscle attachments to the posterior border of palatine bone and edges of cleft were dissected, released and oriented toward normal position using 3-0 polyglactin 910 resorbable suture (Vicryl; Ethicon, Germany). First nasal and then oral layer was closed in midline using 4-0 polyglactin 910 resorbable suture (Vicryl; Ethicon, Germany) (fig.2). The fat pads were mobilized till the desired length (fig.4). Figure 4 : Buccal fat pad was teased out till desired length. The oral layer was then sutured to nasal layer so as to reduce the dead space between them. The fat pads were sutured medially as well as laterally with oral layer (fig.5). Postoperative healing was uneventful. The patient was kept on an oral liquid diet for 15 days and hard foods were avoided for 3 months. After 7 days we could see the start of epithelialization of buccal fat pad (fig.6). Figure 2 : Bilateral mucoperiosteal flaps raised. This results in lateral raw bony surfaces. Therefore pedicled buccal fat pad was mobilized from the distal most part of lateral incision posterior to maxillary tuberosity using blunt dissection. The BFP was dissected between the maxillary tuberosity and pterygoid hamulus and dragged gently around in the palatal vault beneath the lateral palatal mucosa (fig.3). Figure 5 : Suturing of buccal fat pad to oral layer medially and laterally. Figure 3 : Bilateral raising of pedicled buccal fat pad graft. Figure 6 : Postoperative one week start of epithelialization of buccal pad of fat. BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 2 Issue-3 Sept

3 At 4 weeks epithelialization of BFP was complete. No dehiscence, infection or graft necrosis was observed during postoperative follow up period of 3 months. At 3 months postoperatively graft was fully covered with bulky tissue (fig.7). 4 weeks epithelialization of BFP was complete. No dehiscence, infection or graft necrosis was observed during postoperative follow up p e r i o d o f 3 m o n t h s. At 3 m o n t h s postoperatively graft was fully covered with bulky tissue (fig.7). Figure 7 : Postoperative three months complete healing and covering of buccal fat pad with normal tissue. DISCUSSION Cleft palate surgeries are done using different closure techniques with their own advantages and disadvantages. But the healing of lateral raw bony surfaces caused by the displacement of the oral mucoperiosteal flaps is always a major concern for the surgeon. Large lateral bony surfaces can lead to wide spread scar contracture and lateral oronasal perforation. Buccal fat pad (BFP) is usually considered as surgical nuiscence because of the accidental encounter during surgical procedures or injury in pterygomaxillary region. BFP as an anatomic element was first mentioned by Heister[1] in 1732 and was described by Bichat[2] in Scammon[3] described the anatomy of BFP. Egydi[4] was the first to report on the use of BFP in oral reconstruction. Needer[5] is credited for the use of BFP as free graft for reconstruction of defects in oral cavity. Tideman et al[6] explained the concept of using BFP as a pedicled graft and its complete epithelialization without use of skin graft. Buccal pad of fat represents a specialized type of tissue called syssarcosis type that is distinct from the subcutaneous fat as it is not subjected to lipid metabolism[7]. Average weight of each BFP is 9.3g and volume is 9.6m[8]. In children BFP prevents indrawing of cheeks during sucking and in adults enhances intermuscular motion[2]. BFP is much bigger in children than in adults [9] that is why in children with cleft palate it is easier to fill the defect till midline. Variation exists between individuals and between right and left side of the same person regarding amount of BFP and is not proportional to the amount of fat elsewhere in the body. Defects up to 3cm 5cm can be reconstructed. BFP is suitable for closure of defects of the posterior maxilla as far as the region of the hard and soft palate and the retromolar region of the mandible [6]. BFP serves to line masticatory space separating masticatory muscles from each other and from mandibular ramus and zygoma. BFP consists of a central body and four extensions buccal, pterygoid, superficial and deep temporal. The main body is situated deeply along the posterior maxilla and upper fibers of buccinators. The buccal extension lies superficially within the cheek and is largely responsible for cheek fullness. The pterygoid extension lies deep to the medial aspect of mandibular ramus resting between ramus and lateral surfaces of lateral and medial pterygoid muscles. The buccal part is mainly mobilized for the reconstruction in oral cavity. Blood supply of BFP comes from maxillary artery, superficial temporal artery and facial artery[8]. This rich blood supply may explain the high success rate BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 2 Issue-3 Sept

4 Gupta et al of this flap due to quick epithelialization of fat. BFP must be handled with great care and with a wide base preserved otherwise a free fat graft will result. It is very important to preserve the thin capsule of this fat during traction so as not to separate the globules of fat pad otherwise small blood vessels will be damaged. The transferred BFP starts to epithelize in a week. Complete epithelialization occurs within six weeks and graft is covered with healthy looking oral mucosa. The superficial layer of fat tissue is replaced by granulation tissue and is finally covered by parakeratinized stratified squamous epithelium migrated from the regions neighboring the margins of the flap[10]. Surface of the fat is replaced by fibrous tissue at least up to the depth of 6-8 mm as seen in a biopsy specimen[11]. BFP provides vascular support to soft tissue layer thereby promoting healing. BFP graft serves as a bed for secondary granulation tissue thereby reducing dehiscence in soft tissue layer. Fat pad physically aids in closure by obliterating the space over lateral raw bony surfaces. Fat pad provides soft tissue hydrophobic layer that does not allow the fluids to pass from the oral cavity into nasal cavity in case of lateral perforation after closure of flaps in cleft surgery[12]. Using pedicled BFP in primary palatoplasty, the large lateral raw bony surfaces are covered providing tension free and water tight midline closure preventing oronasal perforation. The surgical procedures proves to be advantageous because of its simple and easy technique, high success rate, lack of visible scar at the donor site, minimal discomfort for the patient and low rate of complications[13,14]. Complications such as injury to the facial nerve, hematomas, or infection can occur[15,16,17]. Partial breakdown of graft can be there due to excessive tension. Care should be taken not to suture the graft under tension and patient should receive a liquid or soft nonchewable diet until soft tissue healing has taken place. SUMMARY Grafting of the pedicled BFP was done to cover lateral raw bony surfaces that could not be covered with conventional procedures after primary palatoplasty in cleft palate patients. It provided an excellent soft tissue support base for secondary epithelialization. The technique proved to be advantageous because of better healing at surgical site without any morbidity at donor site. CONCLUSION The transposition of pedicled BFP is an easy and safe technique to cover the lateral raw bony surfaces when there is risk of dehiscence, compromising ultimate closure of flaps between oral and nasal cavities in cleft palate surgeries. BFP should be taken into consideration and used to advantage when reconstruction in oral cavity is planned. Good vascularization, ease of access and minimal donor site morbidity make it a reliable soft tissue graft. REFERENCES 1 Heister L: Compendium Anatomicum. Notimbergae,Germany, G.C.Weberi, p146 2 Bichat F: Anatomic Generale, appliquee a la physiologie et a la medicine. Paris, France: Brosson, Gabon, et Cie, Scammon RE: On the development and finer structure of the corposum adiposum buccae. Anat Rec 1919;15: Egyedi P: Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J Maxillofac Surg Nov;5(4): Needer A: Use of buccal fat pad for grafts. Oral Surg Oral Med Oral Pathol BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 2 Issue-3 Sept

5 1983;55: Tideman H, Bosanquet A, Scott J: Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg Jun;44(6): Kahn JL, Wolfram-Gabel R, Bourjat P: Anatomy and imaging of the deep fat of the face. Clin anat 13: Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe SA: The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg Jan;85(1): Fleming P:Traumatic herniation of buccal fat pad: a report of two cases. Br J Oral Maxillofac Surg Aug;24(4): Hanazawa Y, Itoh K, Mabashi T, Sato K: Closure of oroantral communications using a pedicled buccal fat pad graft. J Oral Maxillofac Surg Jul;53(7):771-5; discussion Samman N, Cheung LK, Tideman H: The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg Feb;22(1): Hudson JW, Anderson JG, Russell RM, 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 Jul;80(1): Cho SI, Yeo HH, Kim YK, et al:closure of large oroantral fistula with pedicled buccal fat graft; a case report. The Korean Acad Maxillofac Plast Reconstr Surg. 1994;16: Kim YK, Yeo HH: Clinical application of buccal fat pad graft. J Korean Oral Maxillofac Surg. 1993;19: Martín-Granizo R, Naval L, Costas A, Goizueta C, Rodriguez F et al: Use of buccal fat pad to repair intraoral defects: review of 30 cases. Br J Oral Maxillofac Surg Apr;35(2): Dean A, Alamillos F, García-López A, Sánchez J, Peñalba M: The buccal fat pad flap in oral reconstruction. Head Neck May;23(5): 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 d e f e c t s. J L a r y n g o l O t o l Sep;113(9): Source of Support : Conflict of Interest : Date of Submission : Review Completed : NIL NOT DECLARED BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 2 Issue-3 Sept