The anatomy and clinical applications of the buccal fat pad

The buccal fat pad is an anatomically complex structure that has great importance in facial contour. In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in facial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated and its relationship to the masticatory space, facial nerve, and parotid duct is defined. An intraoral approach for buccal fat harvesting is described based on these anatomic findings. Clinical experience manipulating the buccal fat pad for aesthetic modification of facial contour is illustrated.     

Anatomy of the buccal fat pad and its clinical significance

Interest in the anatomy of the buccal fat pad was aroused by two clinical cases where the fat pad was involved by pathology. In one, there was an extensive lipoma of the buccal fat pad which had been unsuccessfully operated on on two previous occasions. The reason for the lack of success was incomplete removal of the fat pad. In the second case, there was an arteriovenous malformation involving the fat pad which necessitated complete removal. Fresh cadaver dissections were carried out to accurately determine the anatomy. Particular attention was paid to the temporal extension, since this area is frequently disregarded.     

Anatomical structure of the buccal fat pad and its clinical adaptations

Before performing plastic and aesthetic surgery around the buccal area, the authors reviewed the anatomical structures of the buccal fat pad in 11 head specimens (i.e., 22 sides of the face). The enveloping, fixed tissues and the source of the nutritional vessels to the buccal fat pad and its relationship with surrounding structures were observed in detail, with the dissection procedure described step by step. The dissection showed that the buccal fat pad can be divided into three lobes-anterior, intermediate, and posterior-according to the structure of the lobar envelopes, the formation of the ligaments, and the source of the nutritional vessels. The buccal, pterygoid, pterygopalatine, and temporal extensions (superficial and profound) are derived from the posterior lobe. The buccal fat pad is fixed by six ligaments to the maxilla, posterior zygoma, and inner and outer rim of the infraorbital fissure, temporalis tendon, or buccinator membrane. Several nutritional vessels exist in each lobe and in the subcapsular vascular plexus forms. The buccal fat pads function to fill the deep tissue spaces, to act as gliding pads when masticatory and mimetic muscles contract, and to cushion important structures from the extrusion of muscle contraction or outer force impulsion. The volume of the buccal fat pad may change throughout a person's life. Based on the findings of the dissections, the authors provide several clinical applications for the buccal fat pad, such as the mechanism of deepening the nasolabial fold and possible rhytidectomy to suspend the anterior lobe upward and backward. They suggest that relaxation, poor development of the ligaments, or rupture of the buccal fat pad capsules can make the buccal extension drop or prolapse to the mouth or subcutaneous layer. As such, the authors refined their methods and heightened their focus when using the buccal fat pad to perform a random or pedicled buccal fat pad fat flap or to correct a buccal skin protrusion or hollow.     

The reverse auricular flap: a new flap for nose reconstruction.

In the present article, the authors describe a new chondrocutaneous island flap from the ear helix for nose reconstruction. Anatomic studies showed that helix vascularization depends mainly on the superficial temporal vessels. The presence of vascular communications between the anterior frontal branch of the superficial temporal system and the supraorbital and supratrochlear arterial systems allows this flap to be used in a reverse vascular flow fashion. This new flap has been used successfully in seven cases for reconstructing composite defects of the nasal tip and ala. The donor-site defect is repaired with an advancement and rotation flap from the helical rim, leaving an inconspicuous scar and giving an acceptable cosmetic result of the donor area.     

Structural characteristics and functional significance of the buccal fat pad (corpus adiposum buccae)

Corpus adiposum buccae (c.a.b.) was studied on 42 human subjects (fetuses and adults) using microdissection under magnifying glass after injection of the great vessels of the head with plastics, transparency technique of Spalteholtz and current histological methods. In fetuses, c.a.b. appeared as a well-developed mass located between Buccinator and inferior border of the Masseter. In adults, it emanated three prolongations among which the anteriorly directed molar prolongation was more conspicuous in edentulous old people. Externally, it was covered by a fine conjunctival wrap, which sent septa dividing the buccal fat pad in a series of minute fibroadipous compartments. C.a.b. contained a rich vascular network deriving from the branches of the facial and maxillary arteries. In this vascular net a more developed artery emanated branches to the prolongations of the c.a.b. The veins were tributaries of the pterygoid venous plexus. Beside the vessels, c.a.b. contained also lymphatics and myelinated nerves. The authors postulated that c.a.b. assumed the following functions: a) It filled up the masseter-zygomaticus-buccinator space forming an amortizing and a slipping platform for the masticatory muscles in action; b) in the baby, it resisted to the negative pressure which acted into the buccal cavity during sucking; c) its rich venous net, provided with valve-like structures, may be implicated in the exo-endocranial blood flow by means of the pterygoid plexus.     

Peroneal flap for reconstruction in the extremity: preliminary report

The peroneal flap has many advantages, such as thin subcutaneous tissue, availability of a large-diameter artery and vein for anastomosis, a long pedicle, and freely designed size and shape. This technique is introduced because it has many outstanding features that allow it to be used to meet a variety of specific needs, such as a free peroneal flap, a peroneal island flap, a free vascularized fibular graft with skin, and a monitoring flap in free vascularized fibular grafts. We have found the peroneal flap to be especially useful.     

Olfactory functioning and callosotomy: a report of two cases

Two callosotomy patients with presumably intact anterior commissures were evaluated on a battery of olfactory tasks including sensitivity, discrimination, memory, identification, cross-modality matching, bilateral summation (dirhinic vs. monorhinic thresholds), and localization of odorants. One case was evaluated both pre- and post-surgery. He showed marked decrements after surgery in odor memory and in matching across modalities. After surgery, both patients were better able to name odorants presented to the left nostril than the right nostril. The patient who was asked to remember odorants that could be readily labeled was better able to remember those odorants presented to the left nostril. The findings that both cases performed equally well whether olfactory and tactile information was projected to the same hemisphere or a different one, that some bilateral summation was evident, and that the cases were unable to localize odorants suggests that the remaining neuronal pathways allow for some communication between hemispheres.