Ideas and Innovations The Buccal Fat Pad Flap for Periorbital Reconstruction: A Cadaver Dissection and Report of Two Cases

The buccal fat pad is a trilobed collection of adipose tissue found in the midface. It is located behind the zygomatic arch, medial to the masseter muscle and lateral to the buccinator muscle from which it derives its name.1–4 It consists of a body and four processes: the buccal, pterygoid, superficial, and deep temporal.1–3 The body lies behind the zygomatic arch and the processes extend from the body to their respective surrounding tissue spaces.4 The buccal fat pad has recently been described as having three lobes: an anterior lobe, an intermediate lobe, and a posterior lobe.4 The pad receives an abundant vascular supply from three well-defined sources, namely, the facial and internal maxillary arteries and the deep transverse facial vessels.2,4 The major vascular supply enters the posterior lobe, requiring that this lobe remain attached when the buccal fat pad is used as a pedicled flap. Notably, the size of the pad remains relatively constant from childhood throughout adulthood, and it appears to be resistant to wasting even in the most cachectic patients. The buccal fat pad has been proposed to have a number of native functions. It fills the masticatory space and has traditionally been suggested to have a role in mastication and suckling, especially in the newborn. The pad functions as a gliding pad during the contraction of the masticatory and mimetic muscles.4 In addition, it protects the deep facial neurovascular bundles from outside forces as well as from extrusion of muscle contraction. It may serve as a venous network involved in cranial blood flow through the pterygoid plexus.5 Despite these various proposed functions, the buccal fat pad can be safely sacrificed in the adult patient. Clinically, the buccal fat pad has been used for aesthetic and reconstructive applications.1–3,6,7,8–11 In cosmetic surgery, buccal fat pad lipectomy has been used to improve midface width in full-faced individuals.6–8 Similarly, buccal fat pad removal has been used alone and in conjunction with face lift surgery to modify facial contours and enhance the malar prominence.2,6,8,9 In addition, it has been described in rhytidectomy for improvement of the nasolabial fold.4 As early as 1977, the reconstructive use of a pedicled buccal fat pad flap was described by Egyedi10 for the closure of oroantral and oronasal communications following oncologic resection. In 1983, Neder11 elucidated its use as a free graft for the oral cavity. A number of other studies have further described the use of buccal fat pad flaps and grafts for the reconstruction of intraoral defects. The versatility of the buccal fat pad is evident from the variety of other novel reconstructive uses that have been described, including coverage of irregularities following bony trauma, closure of nasal defects, and use as vascularized filler material.3,10,11 There is, however, no literature describing its use in orbital reconstruction. Using a cadaver study, we demonstrate that the buccal fat pad can be reliably mobilized to provide sufficient coverage for orbital reconstructions. In addition, we present two case