Surgical Technique of the Transoral Approach to Remove a Lipoma of the Buccal Fat Pad

Background: In 1727, Heister (Compendium anatomicum. Altdorf, Guill, Koleshii: editio tertia 1727: 134, table VIII and figs. 36-37) described the buccal fat pad (BFP) as an independent anatomic structure of the face; in 1801, Bichat (Anatomie generale appliquee a la physiologie et a la medecine. Paris, France: Brosson, Gabon et Cie Libraires, 1801: 60) reported his fatty histologic finding. According to the literature, several pathologic tumorous conditions can arise from BFP, such as lipoma, lipoblastomatosis, liposarcoma, hemangioma, arteriovenous malformation, and nodular fasciitis; all of which are rare. After a revision of the English literature performed through PubMed between 1948 and 2008, we found 10 cases of lipomas arising from the BFP (7 cases are simple subtype, 2 are spindle cell lipoma, and 1 is fibrolipoma). The aims of this study were to introduce our clinical report of this rare pathologic entity, describe the surgical technique of the transoral approach, and discuss the potential pitfalls regarding the preoperative diagnosis and the close interrelation among the BFP, the facial buccal branches (FBBs), and the parotid duct (PD). Clinical Report: A 43-year-old man was referred to the Maxillofacial Unit of the Novara Major Hospital with a 6-month history of a painless swelling in the right cheek. Clinical examination revealed a clearly visible, tender, slightly fluctuant mass, situated anterior to the masseter muscle and extended to the submandibular region. The patient underwent an ultrasound, a computed tomography, and a magnetic resonance imaging. Under general anesthesia with nasotracheal intubation, the patient underwent intraoral resection of BFP lipoma. Discussion: The 2 major areas of discussion are the potential pitfall regarding the preoperative diagnosis and the close anatomic interrelation among the BFP, the FBB, and the PD. First, the spindle cell lipoma, one of the most common BFP lipoma variant, can be histologically and clinically similar to a well-differentiated liposarcoma, which can be recurrent and metastatic. This issue warrants that a careful workup of the tumorous mass of the buccal space and a BFP origin must be considered in every situation. Finally, according to the recent literature, the anatomic variations of the interrelation between the FBB and the BFP are classified into 2 groups: (1) FBB passing lateral to the BFP and (2) branches crossing inside the BFP. The anatomic variations of the interrelation between the PD and the BFP are classified into 3 groups: (1) PD passing lateral to the BFP, (2) PD crossing deep to the BFP, and (3) PD running along the superior border of the BFP.