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10. Kilty SJ, Brownrigg PJ, Safar A. Nasal septal perforation repair using an
inferior turbinate flap. J Otolaryngol 2007;36:38–42
11. Hussain A, Murphy P. Modified tragal cartilage-temporoparietaland
deep temporal fascia sandwich graft technique for repair of nasal septal
perforations. J Laryngol Otol 1997;111:435–437
12. Kaya E, Cingi C, Olgun Y, et al. Three layer interlocking: a novel
technique for repairing a nasal septum perforation. Ann Otol Rhinol
Laryngol 2015;124:212–215
13. Kridel RW, Foda H, Lunde KC. Septal perforation repair with acellular
human dermal allograft. Arch Otolaryngol Head Neck Surg
1998;124:73–78
14. Romo T, Sclafani AP, Falk AN, et al. A graduated approach to the repair
of nasal septal perforations. Plant Reconstr Surg 1999;103:66–75
15. Younger R, Blokmanis A. Nasal septal perforations. J Otolaryngol
1985;14:125–131
16. Dommerby H, Rasmussen OR, Rosborg J. Long term results of
septoplastic operations. ORL 1985;47:151–157
17. Chua DY, Tan HK. Repair of nasal septal perforations using auricular
conchal cartilage graft in children: report on three cases and literature
review. Int J Pediatr Otorhinolaryngol 2006;70:1219–1224
18. Ribeiro JS, da Silva GS. Technical advances in the correction of septal
perforation associated with closed rhinoplasty. Arch Facial Plast Surg
2007;9:321–327
19. André RF, Lohuis PJ, Vuyk HD. Nasal septum perforation repair using
differently designed, bilateral intranasal flaps, with nonopposing suture
lines. J Plast Reconstr Aesthet Surg 2006;59:829–834
20. Li F, Liu Q, Yu H, et al. Pedicled local mucosal flap and autogenous
graft for the closure of nasoseptal perforations. Acta Otolaryngol
2011;131:983–988
21. Schultz-Coulon HJ. Three-layer repair of nasoseptal defects.
Otolaryngol Head Neck Surg 2005;132:213–218
22. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for
repair of nasal septal perforation. Laryngoscope 2003;113:1425–1428
23. Pribaz J, Stephens W, Crespo L, et al. New intraoral flap: facial artery
musculomucosal (FAMM) flap. Plast Reconstr Surg 1992;90:421–429
24. Heller JB, Gabbay JS, Trussler A, et al. Repair of large nasal septal
perforations using facial artery musculomucosal (FAMM) flap. Ann
Plast Surg 2005;55:456–459
25. Castelnuovo P, Ferreli F, Khodaei, et al. Anterior ethmoidal artery septal
flap for the management of septal perforation. Arch Facial Plast Surg
2011;13:411–414
26. Mobley SR, Boyd JB, Astor FC. Repair of a large septal perforation with
a radial forearm free flap: brief report of a case. Ear Nose Throat J
2001;80:512
27. Barry C, Eadie PA, Russell J. Radial forearm free flap for repair of a
large nasal septal perforation: a report of a case in a child. J Plast
Reconstr Aesthet Surg 2008;61:996–997
28. Goh AY, Hussain SSM. Different surgical treatments for nasal septal
perforation and their outcomes. J Laryngol Otol 2007;121:419–426
29. Lee HR, Ahn DB, Park JH, et al. Endoscopic repairment of septal
perforation with using a unilateral nasal mucosal flap. Clin Exp
Otorhinolaryngol 2008;1:154–157
30. Kim S-W, Rhee C-S. Nasal septal perforation repair: predictive factors
and systematic review of the literature. Curr Opin Otolaryngol Head
Neck Surg 2012;20:58–65
31. Rokkjaer MS, Barrett TQ, Petersen CG. Good results after endonasal
cartilage closure of nasal septal perforations. Dan Med Bull
2010;57:A4196
32. Moon IJ, Kim SW, Han DH, et al. Predictive factors for the outcome of
nasal septal perforation repair. Auris Nasus Larynx 2011;38:52–57
33. Daneshi A, Mohammadi S, Javadi M, et al. Repair of large nasal septal
perforation with titanium membrane: report of 10 cases. Am J
Otolaryngol 2010;31:387–389
34. Parry JR, Minton TJ, Suryadevara AC, et al. The use of fibrin glue for
fixation of acellular human dermal allograft in septal perforation repair.
Am J Otolaryngol 2008;29:417–422
35. Foda HM. The one-stage rhinoplasty septal perforation repair.
J Laryngol Otol 1999;113:728–733
36. Newton JR, White PS, Lee MS. Nasal septal perforation repair using
open septoplasty and unilateral bipedicled flaps. J Laryngol Otol
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# 2016 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
37. Teymoortash A, Hoch S, Eivazi B, et al. Experiences with a new surgical
technique for closure of large perforations of the nasal septum in 55
patients. Am J Rhinol Allergy 2011;25:193–197
38. Woolford TJ, Jones NS. Repair of nasal septal perforations using local
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The Buccal Fat Pad for Closure
of Oroantral Communication
Stefano Andrea Denes, MD, DMD, Riccardo Tieghi, MD,
and Giovanni Elia, MD
Abstract: The buccal fat pad (BFP) is a well-established tool in oral
and maxillofacial surgery and its use has proved of value for the
closure of oroantral communications. Oroantral communication
may be a common complication after sequestrectomy in ‘‘bispho-
sphonate-related osteonecrosis of the jaws.’’
The authors report a clinical case of a 70-year-old female patient
in bisphosphonate therapy presented with right maxillary sinusitis
and oroantral communication after implants insertion.
The BFP was used to close the defect. The patient had an
uneventful postoperative healing without dehiscence, infection,
and necrosis.
The authors postulate that the primary closure of the site with
BFP may ensure a sufficient blood supply and adequate protection
for an effective bone-healing response to occur.
Key Words: Bisphosphonate-related osteonecrosis of the jaws,
buccal fat pad, oroantral communication
O roantral communication (OAC) represents a common recur-
rence in dentoalveolar and maxillofacial surgery. It may
develop as a complication of dental extractions, as a sequelae of
radiation therapy, as a result of infection, trauma, and removal of
tumors or maxillary cysts.1 The commonest aetiology is a compli-
cation following the removal of posterior maxillary teeth because of
their close relationship to the maxillary sinus.2 The exact diagnosis
and treatment of OAC is indispensable to avoid negative sequelae for
the patient. In fact, if proper treatment is not provided, severe
complications with persistent sinusitis can occur. Usually, an
OAC less than 2 mm in diameter will close spontaneously. However,
when the opening defect is greater than 3 to 4 mm at the time of
From the Unit of Cranio Maxillo Facial Surgery, Reference Center for
Cranio-Facial Rare Anomalies European Association for Cranio
Maxillofacial Surgery, International Teaching Center Network, St.
Anna Hospital and University, Ferrara, Italy.
Received January 12, 2016.
Accepted for publication February 26, 2016.
Address correspondence and reprint requests to Stefano Andrea Denes,
MD, DMD, Unit of Cranio Maxillo Facial Surgery, St. Anna Hospital
and University, Via Aldo Moro N 8, 44121 Cona, Ferrara, Italy;
E-mail: stefanodenes@libero.it
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002579
e327
Brief Clinical Studies The Journal of Craniofacial Surgery
injury, if a sinus disease is present whatever the size of the opening
and if there is an inflammation in the periodontal region, the
communication is persistent and the surgical closure is indicated
Figures 1–5.2,3
Variable methods for the closure of OAC have been reported in
the literature. Treatment modalities include primary closure, local
and distant sliding tissue flaps, autogenous bone grafts, allogenous
materials, xenografts, or synthetic metals. The choice of coverage is
based on the type and size of the defect. First, regardless of the
technique, the sinus must be rendered free of infection with
adequate drainage and the use of appropriate sinus antibiotics in
addition to topical or systemic decongestants.4
However, these procedures have not always provided satisfac-
tory results. Recently, a buccal fat pad (BFP) has been increasingly
used in the repair of OAC. The BFP was mentioned for the first time
by Heister in 1732 and better described by Bichat in 1802. The
procedure and its use as a pedicle graft was first reported by Egyedi5
and its embryology, vascularization, volume, and function being
studied by Tideman et al,6 Marx,7 and other authors.8–10
The BFP consists of a lobulated mass of specialized fatty tissue
lying within the masticatory space. It is located between the
buccinator muscle and the mandibular ramus, separating the mas-
ticator muscles from each other, from the zygomatic arch, and from
the ramus of the mandible, thereby serving to enhance intermus-
cular motion. It is covered by a delicate fascial envelope with septa
that divide it into a series of fibroadipose compartments.11 Anato-
mically, the BFP consists of a central body and 4 extended
processes: buccal, pterygoid, superficial, and deep temporal exten-
sions. The buccal extension, which is the largest and most super-
ficial component, is deep or medial to the masseter muscle and
superficial to the buccinator muscle and buccopharyngeal fascia.12
It is free, unfixed and can be excised easily through an intra oral
incision, whereas the main body is difficult to remove.13 The blood
supply to the BFP is derived from the buccal and deep temporal
branches of the maxillary artery, transverse facial branches of the
superficial temporal artery, and small branches of the facial artery.3
Because of its rich blood supply, it can be considered a pedicled
graft with an axial pattern. It also contains lymphatics and mye-
linated nerves, and the veins are tributaries of the pterygoid venous
plexus.11
During the last years, an increasing number of clinical studies
about BFP can be found in the literature. These studies reported
encouraging results and influenced our use of this technique. In this
clinical report, we describe a case of a 70-year-old female patient in
bisphosphonate therapy presented with right maxillary sinusitis and
oroantral communication (OAC) after implants insertion. Oroantral
communication may be a common complication after sequestrect-
omy in ‘‘Bisphosphonate-related osteonecrosis of the jaws,’’ avoid-
ing spontaneous healing and resulting in chronic fistulas. The BFP
FIGURE 1. Oroantral fistula in the right side of the maxilla.
e328
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 27, Number 3, May 2016
FIGURE 2. Incision and removing of the fistula.
was employed for closure the defect. The effectiveness of this
technique for OAC, advantages, and indications are discussed.
CLINICAL REPORT
A 70-year-old woman presented in the Cranio-Maxillofacial Depart-
ment of our hospital in August 2010 with pain, drainage, and purulent
discharge in the right fornix of the maxilla. The patient presented
history of osteoporosis diagnosed in 1990 and treated with Alen-
dronate (70 mg once everyday) and Bonviva (Ibandronate, 150 mg
once every 1 month) subsequently. She underwent 3 implants inser-
tion in the right side of the maxilla in another centre in April 2009.
However, 2 of the 3 implants placed had already been removed.
Intraoral examination revealed that the alveolar bone of the right
side of the maxilla was exposed and an oroantral communication
was present. The surrounding soft tissue was erythematous and
edematous. A satisfactory oral hygiene was observed. The patient
complained of pain at the maxillary sinus palpation. So, a clinical
diagnosis of sinusitis and oroantral communication bisphospho-
nates related was made.
Panoramic radiograph and cone beam computed tomography
were also taken and confirmed the presence of pansinusitis and bone
sequestrum in the affected right area of the maxilla.
We applied medical prophylaxis therapy before the surgery:
amoxicillin (4 g/day) and clavulanate (250 mg/day) was started and
continued for 15 days. Then, Functional Endoscopic Sinus Surgery
and closure of the opening defect were performed at the same time
under general anaesthesia.
Surgical Technique
When the Functional Endoscopic Sinus Surgery was done,
excision of the fistulous tract and freshening of the wound edges
FIGURE 3. Advancement of buccal fat pad in to the bony defect and suturing to
the palatal gengiva.
# 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 27, Number 3, May 2016
FIGURE 4. Replacement and suturing of mucoperiosteal flap.
were carried out. The upper vestibular horizontal incision was made
posterior to the first premolar and extended to the posterior margin
of the fistula to expose the BFP. Careful manipulation and blunt
dissection through the buccinator and loose surrounding fascia were
carried out to mobilize and advance the pedicled buccal fat pad.
Pressure on the cheek helped to herniate the fat. The flap was closed
in 2 layers using BFP along with buccal advancement flap. Only
resorbable sutures were used. An incisional biopsy specimen of the
maxillary bone was taken to confirm the diagnosis.
Sufficient soft tissue regeneration was achieved and the mar-
ginal soft tissue level was stable and esthetically satisfactory. The
patient was hospitalized for 3 days. A liquid diet was administered
and mouth-washes with chlorexidine were also prescribed several
times a day until full healing. The preoperative antibiotic regimen
was continued for the next 3 days. The analgesic was prescribed for
5 days. Postoperative healing was uneventful and it was complete
after 4 months. No new oroantral communications and oral lesions
were observed after 12-month follow-up.
DISCUSSION
The use of the BFP has increased in popularity in recent years
because of its reliability, ease of harvest, and low complication rate.
It has been used as a pedicled graft for the repair of persistent
oroantral fistulas after dental extractions,14 in facial augmentation
procedures,15 and in the treatment of oral submucous fibrosis.16
There have been several reports of its successful use as a
pedicled graft in closure of OAC. Stajcic14 reported the use of
pedicled BFP in the closure of oronasal and oroantral communi-
cations following extractions in 56 patients with excellent results.
Despite postoperative infection in 1 patient and partial necrosis in 2
patients, all his flaps were reported to be successful.
FIGURE 5. Follow-up after 8 months.
# 2016 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
Dolanmaz et al17 in their series of 75 OAC patients reported a
favorable healing course in all the patients and the wounds were
entirely epithelialized 3 to 4 weeks after surgery. However, because
excessive granulation and hypertrophy were noticed in 9 patients, in
6 of these, the BFP near the mucosal border was reduced with
scissors to prevent the risk of dental trauma while chewing. The
BFP that was left hypertrophic reached an almost normal level by
completing secondary epithelialization. The difference between
levels eventually disappeared completely after few months.
From the clinical findings, the transferred BFP starts to epithe-
lialize in a week and completes its epithelialization within 6 weeks
postoperatively on both the oral and nasal sides. At that time, the
graft is covered with healthy-looking oral mucosa. It seems that the
superficial layer of fat tissue is replaced by granulation tissue and is
finally covered by stratified squamous epithelium migrating from
the regions neighboring the margins of the flap as the gingival. In
addition, it appears that the original components of the active
replacement by granulation tissue come from the highly vascular-
ized fat tissue and from the fresh wound around the OAC.3
The quick epithelialization of the uncovered fat is a character-
istic feature of the pedicled BFP flap and histologically pro-
ven.3,18,19 Samman et al18 examined histologically samples from
healed reconstructions and found that the surface of the healed graft
was formed by parakeratotic stratified squamous epithelium with
flattened ridges. The subepithelial stroma consisted of sparsely
cellular, dense fibrous connective tissue, and there was no lamina
propria or submucosa. No fat cells were identified supporting the
view that the surface of the fat is replaced by fibrous tissue at least to
the depth of a 6 to 8-mm biopsy specimen.20
When using the BFP for closing simple OAC resulting from
tooth extractions, concerns could arise regarding the necessity of
this procedure. A crucial point for surgical success is the careful and
gentle preparation of the BFP. Extensive pulling or fragmenting of
the tissue can result in complete failure owing to a breakdown in the
vascular supply of the flap. Alternatively, several other surgical
methods exist for successful management of OAC. The most used is
the buccal sliding or advancement flap. However, despite the
simplicity and safety of the procedure, this advancement flap
produces a reduction in the depth of the vestibular sulcus in the
postoperative period, complicating the prosthetic rehabilitation.
Moreover, the flap cannot be applied in patients in whom the
gingival region has been severely damaged.21
In authors’ experience the BFP represents a readily accessible
mass of adipose tissue in the oromaxillofacial region. It can be
transposed as a pedicled and vascularized flap to provide coverage
for surgical defects in the oral cavity. It eliminates the need to create
another wound elsewhere in the body, thus decreasing donor site
morbidity. It can be used in association with other flaps as a second
layer. Moreover, the incidence of failure is low and the negative
side effects are rare and temporary.
CONCLUSION
The BFP application is a safe and successful procedure for closing
OAC. This technique could reduce or avoid postsurgical OAC and
promote bone healing in the affected area. However, it must be
considered that the BFP can only be used once and limitations exist
concerning the potential size of the defects to be covered.
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# 2016 Mutaz B. Habal, MD