Int. J. Oral Maxillofac. Surg.

2013; 42: 604–610

http://dx.doi.org/10.1016/j.ijom.2012.07.009, available online at http://www.sciencedirect.com

Clinical Paper
Clinical Pathology

Applicability of buccal fat pad Y. Toshihiro1, Y. Nariai1,

Y. Takamura1,2, H. Yoshimura3,
T. Tobita3, A. Yoshino1, H. Tatsumi1,
K. Tsunematsu1, S. Ohba4, S.
grafting for oral reconstruction Kondo5, C. Yanai6, H. Ishibashi1,
J. Sekine1
1
Department of Oral and Maxillofacial
Surgery, Shimane University Faculty of
Y. Toshihiro, Y. Nariai, Y. Takamura, H. Yoshimura, T. Tobita, A. Yoshino, H. Medicine, Shimane, Japan; 2Section of
Tatsumi, K. Tsunematsu, S. Ohba, S. Kondo, C. Yanai, H. Ishibashi, J. Sekine: Orthodontics, Department of Oral Growth &
Development, Division of Clinical Dentistry,
Applicability of buccal fat pad grafting for oral reconstruction. Int. J. Oral Fukuoka Dental College, Fukuoka, Japan;
Maxillofac. Surg. 2013; 42: 604–610. # 2012 International Association of Oral and 3
Division of Dentistry and Oral Surgery,
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Department of Sensory and Locomotor
Medicine, Faculty of Medical Sciences,
University of Fukui, Japan; 4Department of
Abstract. This study evaluated the applicability of pedicled buccal fat pad grafting for Regenerative Oral Surgery, Nagasaki
the reconstruction of defects surgically created during oral surgery. A buccal fat pad University Graduate School of Medical
graft was applied in 23 patients (5 males, 18 females; mean age 68.3 years) between Science, Japan; 5Department of Oral and
2003 and 2011. The graft was used to cover surgical defects of the palate, maxilla, Maxillofacial Surgery, Showa University,
Tokyo, Japan; 6The Nippon Dental University
upper gingiva, buccal mucosa, lower gingiva, oral floor, and temporomandibular Hospital, Oral and Maxillofacial Surgery,
joint region. Size of the surgical defects ranged from 15 mm  12 mm to Tokyo, Japan
30 mm  40 mm; size of the buccal fat pad ranged from 15 mm  12 mm to
43 mm  38 mm. A pedicled buccal fat pad was prepared by incising the maxillary
vestibule following primary surgery, and the surrounding connective tissue was
preserved to supply nutrition to the pedicle during surgery. The buccal fat pad was
placed on the raw surface of soft tissue or bone surface and sutured to the
surrounding tissue of the defect. Complete epithelialization was observed within 4
Key words: buccal fat pad grafting; oral tu-
weeks postoperatively. There were no complications or functional disorders during mour; surgical defect; reconstruction.
follow-up. Buccal fat pad grafting appears to be feasible for the reconstruction of
surgically induced defects, and can be extended to the palate, mandible, mouth Accepted for publication 19 July 2012
angle, and temporomandibular joint region. Available online 16 August 2012

Egyedi first reported the successful appli-
cation of a buccal fat pad (BFP) as a
pedicled graft to the closure of persistent
oroantral and oronasal defects in 4 patients
after tumour resection.1 Since then, there
have been several studies on the use of this
flap for oral reconstruction,2–8 including
that of the authors on the utility of pedicled
BFP grafting in surgically induced defects
following the resection of oral lesions in
which they observed no severe contraction
of soft tissues during postoperative fol-
low-up ranging from 4 months to 5 years
11 months.9 BFP grafting is considered
feasible for the repair of surgically
induced defects in the maxilla, palate,
and buccal mucosa. In Singh et al.’s
review on the efficacy of BFP grafting,
which covered 509 cases,10 most cases
involved mainly BFP grafting for oroan-
tral communication and cleft palate, and
grafting to defects induced by ablative
surgery, such as tumour excision, was
relatively rare.
The authors have applied BFP grafting in
cases of surgically induced defects, except
those involving oroantral communication
and cleft palate. The purpose of this study
was to evaluate the applicability of pedicled
BFP grafting for the reconstruction of sur-
gically induced oral defects.
Materials and methods
BFP grafting was applied as a pedicled
graft in the reconstruction of surgical
defects in 23 patients (5 males, 18 females;
mean age 68.3 years) between 2003 and
2011. Data on these cases was retrospec-
tively collected and analyzed. Detailed
clinical information for each case is shown
in Table 1.

0901-5027/050604 + 07 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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 Buccal fat pad for oral reconstruction 605

The graft was used to cover the surgical
defects of the palate (n = 6), maxilla
(n = 2), upper gingiva (n = 7), buccal
mucosa (n = 4), lower gingiva (n = 2), oral
floor (n = 1), and temporomandibular joint
(TMJ) region (n = 1). A pedicled BFP was
prepared by making a maxillary vestibular
incision following the primary surgery.
Extra attention was paid to preserving
the surrounding connective tissue to sup-
ply nutrition to the pedicle during surgery.
The grafts were placed on the raw surface
of the soft tissue or bone surface and
sutured to the surrounding tissue of the
defect.
The condition of the BFP graft to the
surgical defect, including epithelialization,
graft infection, and fistula recurrence, was
evaluated postoperatively. 1 year after sur-
gery, facial contour deficiency was assessed
from pre- and postoperative photographs,
and functional recovery including limitation
of opening mouth and facial nerve palsy was
evaluated.
The study was conducted in compliance
with the Declaration of Helsinki. Informed
consent was provided by all participants.
Results
For defects of the palate, a BFP graft was
used in 3 cases of pleomorphic adenoma
and 1 case each of mucoepidermoid
carcinoma, myoepithelial carcinoma, and
schwannoma. These 6 patients (mean age
60.6 years) had defects ranging in size from
25 mm  25 mm to 40 mm  40 mm in
the hard and soft palates. Five cases were
complete defects penetrating to the nasal
cavity, in which a skin substitute (TERU-
DERMIS1, Olympus Terumo Biomater-
ials, Tokyo, Japan) accompanied the graft
to cover the surgical defect, and the remain-
ing case was a partial defect of the palate
requiring use of the graft only.
Regarding defects of the maxilla and
upper gingiva, BFP grafting was indicated
in 9 patients (mean age 74.5 years): 5 cases
of squamous cell carcinoma and 1 case each
of lymphocytic proliferation, ameloblas-
toma, leukoplakia, and bisphosphonate-
related osteonecrosis of the jaw (BRONJ).
The size of the surgical defects ranged from
15 mm  12 mm to 30 mm  40 mm,
while the size of the BFP graft ranged from
15 mm  12 mm to 43 mm  38 mm.
Grafts were placed on the bone surface in
all cases.
Regarding defects of the buccal mucosa, a
pedicled BFP was prepared, placed, and
sutured on the raw surface of the mucosa
in 4 patients (mean age 70.5 years); 3 cases
of squamous cell carcinoma and 1 of sia-
loadenitis. The surgical defects ranged in
size from 20 mm  20 mm to 50 mm
 33 mm.
Defects of the lower gingiva were recon-
structed by BFP grafting in 2 cases (mean
age 61 years) following resection of squa-
mous cell carcinoma in the lower gingiva.
The surgical defects ranged in size from
28 mm  28 mm to 30 mm  25 mm. The
pedicled BFP was placed on the raw surface
of the marginally resected mandible
(Fig. 1).
In 3 cases (mean age 71 years), BFP
grafting was applied to cover the inner
surface of a facial flap following resection
of squamous cell carcinoma, ameloblas-
toma, or pleomorphic adenoma of the max-
illa. The BFP graft could be extended to
cover the lateral area of the mouth angle
(Fig. 2).
In the TMJ region, a BFP graft was used to
repair the postoperative defect left by a
Synovial chordromatosis resected from the
left condylar head in a 58-year-old female.
The size of the defect was 20 mm  25 mm
and the size of the BFP was 30 mm
 30 mm. Although the tumour was
resected via an extraoral approach, BFP
grafting was prepared intraorally and tun-
nelled to the TMJ region (Fig. 3).
Complete epithelialization of the BFP
graft occurred within 4 weeks in all cases.
There was no contraction of soft tissues or

Table 1. Clinical summary of the patients who underwent pedicled buccal fat pad (BFP) grafting.
No. Age Sex Location Pathological diagnosis Size of defect (mm) Size of BFP (mm) Follow-up term
1 26 F Palate Mucoepidermoid carcinoma 40  40 20  40 6 years 6 months
2 59 F Palate Pleomorphic adenoma 32  30 32  30 8 years 10 months
3 57 F Palate Pleomorphic adenoma 35  30 15  10 3 years 7 months
4 83 F Palate Myoepithelial carcinoma 40  20 40  20 1 year 2 months
5 73 F Palate Schwannoma 25  25 25  25 1 year 1 month
6 66 F Palate Pleomorphic adenoma Covering inner 20  25 1 year
surface of facial flap
7 73 M Maxilla Ameloblastoma Covering inner 43  38 3 years 6 months
surface of facial flap
8 87 F Maxilla Bisphosphonate-related 40  20 40  20 4 months
osteonecrosis of the jaw
9 74 M Upper gingiva Squamous cell carcinoma Covering inner surface 40  30 3 years 5 months
of facial flap
10 76 M Upper gingiva Squamous cell carcinoma 25  20 30  25 2 years 8 months
11 78 F Upper gingiva Leukoplakia 20  20 20  20 2 years 8 months
12 82 F Upper gingiva Squamous cell carcinoma 22  20 22  20 2 years 2 months
13 45 F Upper gingiva Squamous cell carcinoma 30  30 35  35 1 year 3 months
14 76 F Upper gingiva Squamous cell carcinoma 30  40 30  40 5 months
15 80 F Upper gingiva Lymphocytic proliferation 15  12 15  12 4 months
16 59 F Buccal mucosa Squamous cell carcinoma 27  22 27  22 5 years 6 months
17 78 F Buccal mucosa Squamous cell carcinoma 50  33 25  20 3 years 8 months
18 76 F Buccal mucosa Sialoadenitis of the minor 25  20 25  20 3 years 8 months
salivary glands
19 69 F Buccal mucosa Squamous cell carcinoma 20  20 25  25 3 years
20 63 F Lower gingiva Squamous cell carcinoma 30  25 30  30 1 year 2 months
21 59 M Lower gingiva Squamous cell carcinoma 28  28 28  28 3 weeks
22 75 M Oral floor Ulcer 25  20 25  20 6 months
23 58 F TMJ Synovial chordromatosis 20  25 30  30 3 years 5 months
TMJ, temporomandibular joint.

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606 Toshihiro et al.

Fig. 1. Reconstruction of an alveolar defect of the mandible in a 59-year-old male (Case 21) following resection of a squamous cell carcinoma of
the left side lower gingiva. (A) Surgical defect of the alveolous (arrowheads). (B) Buccal fat pad (*) covers the surgical defect completely. (C) At 1
week postoperatively (arrowheads). (D) At 2 weeks postoperatively, surface of adipose tissue is almost epithelialized (arrowheads).

Fig. 2. Reconstruction of the inner surface of a facial flap in a 73-year-old male (Case 7) following resection of an ameloblastoma of the right
upper gingiva. (A) BFP covers the inner surface of the facial flap (*). (B) At 1 year and 7 months postoperatively, cicatricial contracture is slight
(arrowheads).

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 Buccal fat pad for oral reconstruction 607

Fig. 3. Reconstruction of a defect in the temporomandibular joint (TMJ) region in a 58-year-old female (Case 23) following resection of a
Synovial chordromatosis of the left TMJ. (A) Preoperative view. (B) Resection of the mandibular condyle with the tumour (arrowheads). (C)
Extension of the BFP to the surgical defect (*).

functional disorder of the TMJ during
follow-up that ranged from 4 weeks to 8
years 10 months. None of the patients have
experienced facial contour deficiency,
limited mouth opening, or facial paralysis
in follow up to date. No other additional or
revised surgical intervention was required
except in one case which required volume
reduction of the BFP flap (Case 22).
Discussion
The BFP consists of a main body and
four extensions, namely, the buccal,
pterygoid, superficial temporal, and deep
temporal extensions.3 The main body
lies on the anterior border of the mass-
eter muscle and extends deeply to lie on
the posterior maxilla and forward along
the buccal vestibule.4 Stuzin et al.
reported that in all their dissections,
the anatomical relations of the buccal
fat within the masticatory space and to
the surrounding facial structures were
constant.11 The mean weight of each
fat pad was 9.3 g and the mean volume
9.6 ml.4 Variations between the right and
left sides were small and the size of the
BFP correlated poorly with the general
adiposity of the cadaver. Loukas et al.
reported volumetric variations of the
BFP based on a gross anatomical, com-
puted tomography (CT), and magnetic
resonance image (MRI) analysis.12 They
found that mean volume was 10.2 ml
(range 7.8–11.2 ml) in males and
8.9 ml (range 7.2–10.8 ml) in females.
The authors referred to the review arti-
cle by Singh et al. (covering reports from
February 2004 to July 2009) and reviewed
18 English articles discussing BFP graft-
ing (from 2010 to 2012) identified by a
PubMed database search10,13–29 (Table 2).
These previous reports concerned several
case series of BFP grafting to cover
defects induced by ablative surgery only,
excluding grafting for oroantral commu-
nication and cleft palate. The indications
for the use of BFP grafts have been also
reported to include buccal reconstruction,
cleft palate20,21,23 and TMJ ankylosis.17,26
In the authors’ series, they evaluated BFP
grafting for the reconstruction of various
defects in the oral and maxillofacial
region. In their hospital, BFP has been
used to reconstruct defects in the hard
and soft palates, the buccal mucosa, pos-
terior maxilla, and mandible (Fig. 4). In
addition, the authors have used this tech-
nique successfully to cover the inner raw
surface of a facial flap for maxillectomy,
because the raw surface of the facial flap
caused limitation of mouth opening by
contraction of the facial flap. They also
successfully applied it to a patient with a
defect in the TMJ region. Thus, the indi-
cations for pedicled BFP grafting have
been expanded.
The authors observed complete epithe-
lialization of the BFP graft within 4 weeks
of surgery in all patients. The rich blood
supply of the BFP contributed to the
epithelialization. The histological nature
of the healing process of the buccal fat pad

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 Table 2. Summary of application of BFP grafting in the English literature from 2010 to 2012.

608
No. of Results/
Author(s) (year) patients Purpose/region Size of defect Type of flap Follow-up healing Complication

Toshihiro et al.
Case series
1. Jain MK 15 OAC closure 0.6–6.1 cm  1.5 cm Pedicled (13), 3 months Uneventful –
et al.13 (2012)
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Pedicled BFP with

buccal flap (2)
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2. Cherekaev VA 188 Closure of skull base defect after Pedicled (176), 1–7 years – Cerebrospinal
et al.14 (2012) tumorectomy free (12) fluid leak (1)
3. Nezafati S 10 Comparison pedicled BFP with buccal – Pedicled 1 month Uneventful –
et al.15 (2012) flap for OAC closure,
4. Gallego L 3 OAC due to BRONJ – Pedicled 6 weeks–20 months Uneventful –
et al.16 (2012)
5. Singh V et al.17 (2012) 10 Lining of sternoclavicular graft in – pedicled 6 months – –
TMJ reconstruction
6. Hariram Pal US 10 Comparison pedicled BFP with buccal Mean size Pedicled 3 months – Immediate
et al.18 (2012) flap for OAC closure, 4.90  1.37 mm 2 complication: pain,
swelling, infection
7. Sharma R 28 Coverage of buccal defect after – Pedicled 52 weeks – Recurrence of
et al.19 (2011) excision of OSMF trismus (2)
8. Gröbe A 24 Prevention and closure of cleft Maximum size Pedicled 12 weeks Uneventful –
et al.20 (2011) palate fistula 4 cm  4 cm  3 cm
9. Ashtiani AK 29 Prevention and closure of cleft Maximum size Pedicled 28 months Dehiscence
et al.21 (2011) palate fistula 1 cm  2 cm (relieved
spontaneously)
10. Abad-Gallegos 8 OAC closure 1 cm Pedicled 4–18 months – Immediate
M et al.22 (2011) complication:
pain (37.5%)
inflammation (37.5%)
oedema (32.5%)
trismus (37.5%)
halitosis (14.3%)
suppuration (12.5%)
rhinorrhea (12.5%)
11. Zhang Q 8 Closure of nasal menbrane of cleft palate – Pedicled 6 months Uneventful –
et al.23 (2010)
12. Robiony M24 3 Reconstruction of palatal defect after – Pedicled – Uneventful –
(2010) tumorectomy
13. Kim JT 17 Prevention of Frey syndrome and Pedicled, free 24 months – –
et al.25 (2010) maintenance of facial contouring
following parotidectomy
14. Ko EC 2 Interpositional material of – Pedicled 24 months – –
et al.26 (2009) osteotomied gap in TMJ ankylosis
Case reports
15. Khojasteh A 1 Coverage of augumented bone by – Pedicled 24 months Uneventful –
et al.27 (2010) Le Fort I down graft
16. Kumari BN Root coverage Pedicled
et al. (2010)
17. Surej KL 1 Coverage of buccal defect after – Pedicled – Uneventful –
et al.28 (2012) excision of OSMF
18. Hernando J 1 OAC closure 1.5 cm Pedicled – Uneventful –
et al.29 (2010)
OAC, oroantral communication; BRONJ, bisphosphonate-related osteonecrosis of the jaw; OSMF, oral submucous fibrosis.

Fig. 4. Applicability of the BFP. The graft
could be extended in four directions to the
palate via the maxilla, mandible, mouth angle,
and TMJ region.
was first reported by Samman et al.; no fat
cells were seen in sections taken from
healed sites, indicating fibrosis of the fat
tissue, and the reconstructed area was
covered by parakeratotic stratified squa-
mous epithelium.6 Its easy mobilization
and fewer complications make it an ideal
flap.30
The indications for BFP grafting should
be determined carefully because of limited
volume and length of the pedicled BFP.
The normal volume of the BFP would be
enough to cover a small and proximal area,
but BFP grafting should be applied with
great care to large or distal defects. In
these latter cases, blood supply to the
pedicled BFP and tension free grafting
are the most important considerations,
so the authors endeavoured to handle
the BFP atraumatically and maintain the
thickness of the pedicled pad. Preopera-
tive CT or MRI analysis of total BFP
volume and amount would be necessary
to decide the detailed anatomy of the BFP.
It appears that there was a discrepancy
between the size of the defect and the
volume of the BFP grafted in several cases
in previous reports; for example, the lar-
gest defect size of 6 cm  5 cm  4 cm,
or an average filling volume of about
20 ml, which greatly exceeded the mean
volume of BFP that was reported.2,25
Therefore, a preoperative estimation of
BFP volume by CT or MRI would offer
surgeons some degree of information
about the size of the BFP needed.
Given the authors’ results, BFP grafting
is considered feasible for the reconstruc-
tion of surgically induced defects, includ-
ing those involving the palate via the
maxilla, mandible, mouth angle, and
TMJ region. More studies with CT or
MRI evaluation of the size of both the
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personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
Buccal fat pad for oral reconstruction
defect and the BFP needed are warranted
to establish detailed indications for BFP
grafting in the reconstruction of various
defects in the oral and maxillofacial
region.
Competing interests
None declared.
Funding
None.
Ethical approval
Not required.
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Address:
Joji Sekine
Department of Oral and Maxillofacial Surgery
Shimane University Faculty of Medicine 89-1
Enya-cho Izumo Shimane 693-8501
Japan
Tel: +81 853 20 2301; Fax: +81 853 20 2299
E-mail: georges@med.shimane-u.ac.jp

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