Buccal Fat Pad Herniation A Novel Case Report

Buccal Fat Pad Herniation: A Novel Case Report in a Neonate Allan Damian, MD 1; Trent Filler, DDS 2; Carmen Prieto, MD 3; Alireza Torabi, MD 4 1 PGY-3, Department of Pediatrics, Texas Tech University Health Sciences Center PLF-SOM of Oral and Maxillofacial Surgery, Texas Tech University Health Sciences Center PLF-SOM 3 Director of Well Baby Nursery, University Medical Center, El Paso 4 Department of Pathology, Texas Tech University Health Sciences Center PLF-SOM 2 Department Abstract The buccal fat pad is a thinly encapsulated mass of adipose tissue situated between the buccinators and masseter muscles. It is more prominent in the pediatric population. It is often referred to as the suckling fat pad, as its primary function is to prevent indrawing of the cheeks in the infant. Herniation of this tissue is usually brought about by trauma, and the pedunculated form is often termed a pseudolipoma. There have been less than forty cases reported in English literature since it was first described in 1968. It has only been reported once in an infant. Here we present a Newborn, perhaps the first in literature, to have the said condition. the buccinator and inferior border of the masseter [3]. It is prominent, globular-shaped and well-defined in the fetus [3, 4] and in the adult develops prolongations [3]. Because of its prominence in neonates and infants, it has been termed the suckling pad [6]. Minor tears of the buccal mucosa, usually due to trauma [4] may lead to herniation of the buccal fat into the oral cavity [6]. Figure 3 (below). Anatomic location and the relations of the buccal fat pad. Objectives 1) To review the normal anatomy of the buccal fat pad. 2) To review the functions of the buccal fat pad. 3) To familiarize the clinician with buccal fat pad herniation (traumatic pseudolipoma). 4) To emphasize the need for specialist consultation in the treatment of traumatic pseudolipoma. Case Summary The patient is two-day-old male, born term to a 20 year-old G 1 P 0. Mother had regular prenatal checks and denies any complication during pregnancy. Infant was born via spontaneous vaginal delivery. Delivery was attended by Neonatology due to lightly meconium stained amniotic fluid. The patient had APGARs of 8 and 9. During routine newborn assessment however, a pedunculated yellowish mass was noted protruding from the infant’s right pharynx (Figure 1). Mass was noted to be soft, measuring about 1. 0 x 0. 5 cm. Infant had a good and normal cry and mass did not seem to obstruct the airway. Infant was sent to the regular nursery in the absence of any other concern. Infant fed normally and had been doing well. Meanwhile, ENT/ OMFS consult was sought for evaluation. On closer inspection, the mass appeared yellowish to flesh-colored with no bleeding or areas of necrosis (Figure 2). It was noted to be arising from a defect in the buccal mucosa, near the posterior maxillary area. Protrusion of the mass caudad was exaggerated during suckling. The mass was noted to be avascular and was excised without any complication or bleeding. The tissue was sent for pathology (Figures 3 and 4). The patient tolerated the procedure without any complication and decision was made to manage the lesion conservatively – without suturing the defect. Plan was to close the defect if there was recurrence of the herniation or persistence of the defect. On follow-up with the pediatrician however, the lesion was noted to have closed on its own without any issue. Functional Significance It had been recognized that in the neonate and infant, with is prominence, the buccal fat pad aids in suckling. It fills the masseter-zygomaticusbuccinator space and acts to resist the negative pressure of suckling [3], i. e. , indrawing of the cheeks. As it fills the deep tissue space, it also acts as a gliding pad when masticatory and mimetic muscles contract [4, 5]. Also, it cushions neurovascular bundles during muscle contraction and outer forces [5]. Pathologies Traumatic pseudolipoma has been the term used since the 1970 s to refer to the pathologic protrusion of the buccal fat pad into the oral cavity after trauma [4]. Often there is a time gap between the trauma and the discovery of the mass. As a result, the mass usually has some necrotic features or blood clots and is initially misdiagnosed as a lipoma. In contrast, pseudoherniation, as described by Matarasso is the abnormal positioning of the buccal fat pad, producing an outward protrusion and giving a “chipmunk facies. ” [2, 4]. The former occurs almost exclusively in the pediatric population and is unilateral; while the latter occurs in older people and is usually bilateral. Other pathologies that involve the buccal fat pad are in the realm of Oncology and will not be the subject of this paper. Treatment of traumatic pseudolipoma is always surgical. The protruding mass is excised under general anesthesia and the defect closed. Discussion Figure 1 (above). Yellow tissue on the right buccal cavity projecting outwards and into the pharynx. It did not obstruct the airway or impede suckling. Figure 2 (below). The same mass drawn out with probes. Herniation of the mass was worsened by suckling. In 1996, Zipfel reviewed the literature on traumatic buccal fat pad herniation and found only 12 reported cases from 1968 to 1991 [6]. In addition, he reported two more cases in the same article. A search on Pub. Med using the terms “buccal fat pad herniation, ” “traumatic fat pad herniation, ” “buccal pseudolipoma, ” and “traumatic pseudolipoma, ” shows 19 more cases since 1991, making a total of 33 cases reported in literature. Our case would be the 34 th and the first on a neonate. In the case presented, adipose tissue from the buccal fat pad had been found protruding into the oral cavity. Suckling exaggerated the herniation, but did not obstruct the airway. In contrast to cases reported in literature, our patient only had a small part of the buccal fat pad herniated into the oral cavity. Nevertheless, it was significant enough to alarm the clinicians and generated ample interest to spawn this write-up. Though there was no obvious source of trauma, we postulate it probably occurred during vaginal delivery. Birth trauma was significant enough to have caused a rupture of the buccal mucosa. Alternatively, the defect could have been part of a syndrome or association of anomalies. However, the absence of other abnormalities on physical examination, the uneventful clinical course and spontaneous closure of the defect supports the former theory rather than the latter. Summary Figure 3. Left: Histopathology of the mass showing tissue composed of lobulated adipocytes at 4 X magnification. > The buccal fat pad is a mass of adipose tissue situated between the buccinators and masseter muscles; It is more prominent in the pediatric age group. > It serves to aid in suckling; acts as a cushion between the muscles of mastication; and serves to protect the neurovascular bundle of the cheek. > Trauma may rupture the delicate buccal mucosa with a resultant herniation of all or part of the buccal fat pad into the oral cavity, termed as traumatic pseudolipoma. > The above finding may distress the clinician, but specialist consult with ENT will address the issue. Treatment is always surgical. References Figure 4. Right: Histopathology of the mass showing tissue composed of lobulated adipocytes at 10 X magnification. Normal Anatomy The buccal fat pad is a thinly encapsulated mass of adipose tissue situated between the buccinators and masseter muscles (FIG. 1). The true fatty nature of the buccal fat pad was first defined by Bichat in 1802 [6]. Prior to that, it was thought to be glandular in function. The cheek, mainly the buccal fat is one of the earliest sites of fetal adipose deposition. [4] and in the fetus, the buccal fat pad (Figure 3) is a well-developed mass between [1] Bichat F (1802) Anatomie Generale, Applique a la Physiologie et a la Medecine. Brosson Gabon and Cie, Paris [2] Matarasso A (1997) Pseudoherniation of the buccal fat pad: a new clinical syndrome. Plast Reconstr Surg 100: 723– 730 [3] Rácz L, Maros TN, Seres-Sturm L (1989) Structural characteristics and functional significance of the buccal fat pad (corpus adiposum buccae). Morphol Embryol 35: 73– 77 [4] Yousof S, Tubbs RS, Wartman CT, Kapos T, Cohen-Gadol AA, Loukas M (2010) A review of the gross anatomy, functions, pathology, and clinical uses of the buccal fat pad. Surg Radiol Anat 32: 427– 436 [5] Zhang H-M, Yan Y-P, Qi K-M, Wang J-Q, Liu Z-F (2002) Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg 109: 2509– 2518 [6] Zipfel TE, Street DF, Gibson WS, Wood WE (1996) Traumatic herniation of the buccal fat pad: a report of two cases and a review of the literature. Int J Pediatr Otorhinolaryngol 38: 175– 179 Texas Pediatric Society Electronic Poster Contest