Buccal Fat Pad Herniation, Repositioning Versus Excision: A New Algorithm of Treatment

Buccal fat pad herniation is a rare clinical entity that occurs mainly in children. The buccal fat pad, a fatty tissue located in the cheek between the masseter and buccinator muscles,¹ serves as a sliding pad when these muscles are contracted. It also serves as a protection for neurovascular fibers and plays an important role in the facial aesthetics.² The buccal fat pad is larger and most prominent in infants than in any other age group, and infants frequently introduce foreign objects into the mouth; this behavior can cause a wound to the cheek, and further sucking action can result in the fat being pulled into the oral cavity.³

Different management approaches have been performed for this pathology. So far, there are no published reports that unify the information and generate a treatment for clinicians who must choose between repositioning versus excision. For this reason, we present the following systematic review of the literature and a case report.

A systematic review of the literature was performed through searches of PubMed, Elsevier, Ovid, Cochrane, ResearchGate, and Google Scholar for reports published from 1968 (when the first case report was published) through May 2021. The search keywords used were traumatic herniation of the buccal fat pad, buccal fat pad herniation, traumatic pseudolipoma, and traumatic lipoma. We included only those reports of herniations into the oral cavity that detailed type of treatment and characteristics of the buccal fat pad; patients of any age were included. English translation of non–English-language and non–Spanish-language papers was performed using Google Translate. Articles reporting herniation to other space rather than the oral cavity were excluded. A total of 39 case reports (44 patients) were found.

The treatment of the 44 patients was reported, of whom 36 underwent excision, 7 underwent repositioning, and 1 underwent observation only. With the exception of 1 patient aged 58 years, the patients’ ages ranged from 7 months to 12 years.⁴ Most patients were male (28 vs 16) with a male-to-female ratio of 1.75:1.

We analyzed all the variables for treatment and incorporated the following in the decision-making algorithm: type of treatment, time since trauma, size of the fat pad herniated, size of the wound in mucosa, physical characteristics of the fat herniated, and follow-up time.^5-10 In 23 patients, the size of the wound was not reported,^1-3,11-27 and in 15 patients, 2 or more of the aforementioned data were unknown.^1,4,5,28-39 In 2 cases, the patients were admitted for observation, 1 for 5 days and the other for 1 month, to determine whether the mass would shrink or exfoliate spontaneously; however, in both cases, the fat pad increased in size and inflammation worsened, thus excision was finally performed.^1,9 In another case, the decision was made to reposition the fat pad to maintain facial function and aesthetics.² Of the 44 patients included in our review, only 1 patient treated with excision experienced facial asymmetry.³⁶

In the patients who underwent repositioning, the maximum time elapsed since sustaining the trauma was 4 hours,^11,14,18 and the size of the largest herniated buccal fat pad that was repositioned was 3.5 cm.¹¹ None of the patients who underwent repositioning had necrosis.^{2,6,11,14,18,29,31} Of the cases that were treated with excision, most had a large buccal fat pad, prolonged time since trauma, or important inflammatory changes or necrosis.^{4,7,9,17,18,23,25,30-32,39} In other cases, excision was done to prevent infection and necrosis.^4,20,26,28 In a 10-month-old male patient, excision was performed due to fear of presenting respiratory complications; the size of the fatty tissue was 3 × 2 × 1 cm, and 3 hours had passed since the trauma was sustained.¹⁴ 

We report the case of a 2-year-old boy who, while sucking on a pen, tripped and fell from his own height. The end of the pen stuck in his left cheek, causing immediate pain and bleeding. His parents noticed a yellow tissue in the oral cavity and went to their pediatrician, who referred him to our unit. On clinical examination, we found a fatty tissue measuring approximately 5 × 2 cm in the oral cavity toward the back of the left cheek (Figure 1); the wound was approximately 1 cm long. Maxillofacial computed tomography was performed, which ruled out a maxillary or mandibular fracture. Due to the pandemic, mandatory COVID-19 polymerase chain reaction test was done; after 24 hours, a negative result was obtained. Shortly thereafter, the buccal fat pad was found to be clinically necrotic and resection was performed under general anesthesia (Figure 2). No immediate complications were observed, and the wound edges were resected and sutured with 1 stitch using polyglactin absorbable 4-0 suture. The pathology report showed adipose tissue with focal fibrin deposits on its surface; also on the surface were areas of adipocytes of homogeneous coloration and loss of nuclear detail. The rest of the adipose tissue was viable and infiltrated with moderate amount of neutrophils. The patient was discharged the following day to continue follow-up at an outpatient clinic. Subsequent revisions showed adequate evolution, and no facial asymmetry has been observed (Figure 3).

Intraoral lesions that cause herniation of the buccal fat pad are rare, with no more than 50 cases published in the English-speaking literature. In 2018, a classification system of posttraumatic craniofacial fatty masses was published⁴⁰ where the correct nomenclature for each type of lesion was established by Khadilkar et al. In our report, we use this classification system to describe grade I lesions as intraoral traumatic herniations of the buccal fat pad, grade II as antral traumatic herniations of the buccal fat pad, grade III as inward pseudoherniations of the buccal fat pad, grade IV as outward pseudoherniations of the buccal fat pad, grade V as posttraumatic pseudolipomas, and grade VI as posttraumatic lipomas. 

In our report, we present a case that, according to this classification, was grade l and presented the dilemma of repositioning versus excision of the herniated fatty tissue. We searched the literature to identify the potential criteria for repositioning versus the potential criteria for excision. In our review of 39 articles that included 44 patients, certain characteristics were named as factors to consider in the decision between repositioning or excision. These factors, shown in the Table, were analyzed and used as the basis for creating a treatment algorithm.

We found a very low incidence of this pathology in the last 50 years. The first case was reported in 1968 by Clawson et al, who performed repositioning of the buccal fat pad without any complications.²⁸ In 1981, Wolford et al were the first to mention that either repositioning or excision could be performed; in their case, they excised the fatty tissue because of the size of the mass but did not mention the criteria used to decide which of the 2 treatments should be performed.²⁹ In 1994, Berk et al recommended repositioning in cases where there is early evaluation, the lesion is small, and there are minimal inflammatory changes without necrosis.³¹ In 2012, Rathi et al mentioned that early diagnosis should be defined as occurring less than 4 hours since the trauma was sustained; after that time, important inflammatory changes start to occur.³ The size of the largest herniated buccal fat pad to be repositioned was reported to be 3.5 cm with no recurrence or complication; excision appears to be preferred for lesions larger than this,^1,4,20 so we decided to take this value as the cutoff size.

The analysis was made only with the cases that met the criteria to be classified as grade l of the Khadilkar et al classification. The clinical characteristics considered for our algorithm were time since trauma, size of the herniated buccal fat pad, and the presence of important inflammatory changes (necrosis). The size of the mucosal wound was not considered since only 7 articles mentioned the length in their case report.^5-10,21 In fact, multiple articles mentioned that the wound can be extended further to reposition the protruded fat, taking care not to injure the Stensen duct.^{8,10,13,17,27}  For the design of the algorithm, we decided to use 4 hours as the cutoff time as well as the clinical characteristics of inflammatory changes and size of the mass protruded (Figure 4).

In our case, 4 hours had already passed since the patient had sustained the trauma, and the treatment was delayed due to the new contingency and isolation protocols to reduce the risk of COVID-19 virus infections. At the time of the surgery, the fat pad presented necrotic changes and was greater than 3.5 cm (5 cm) in length. Looking to our proposed algorithm, we performed the excision and wound closure with 1 polyglactin absorbable suture. At the 11-month follow-up appointment, the patient presented with good evolution without any facial asymmetry.

Traumatic herniation of the buccal fat pad is a condition with a very low incidence. Due to the alteration of several anatomic structures and risk of necrosis and infection, we developed an algorithm for its management to make the best decision.