Introduction
Lipomas most commonly occur just beneath the skin (subcutaneous tissue) and grow slowly over time, often remaining small in size.1) Although lipomas can develop anywhere on the body, they are most commonly detected in the armpits, upper thighs, shoulders, trunk, and neck.2) Lipomas are usually confirmed through imaging studies, such as ultrasound or MRI. Surgical excision is the most common treatment for symptomatic lipomas.
Intraoral lipomas are relatively rare compared to lipomas occurring in other parts of the body. They make up a very minor portion of all lipomas; estimates place their number between 1% and 4% of all benign intraoral tumors.3) The tongue, the floor of the mouth, the vestibular area, the lower lip, the hard and soft palates, and, less frequently, the buccal fat pad are the areas of the oral cavity where lipomas are most frequently found.2)
The buccal fat pad is a mass of adipose tissue located within the cheek region of the face. The buccal fat pad is situated deep between the buccinator and other facial muscles, such as the masseter muscle. The buccal fat pad is supplied by branches of the facial artery and buccal artery. It is believed to serve as a reservoir of fat that provides cushioning and support to the structures of the cheek. It may also play a role in facial contouring and maintaining facial fullness.4)
After reviewing the last ten years’ worth of contemporary literature, in which the keywords ‘buccal fat pad lipoma’ and ‘buccal space lipoma’ were used, a variety of intraoral tumors, including lipomas, were identified. However, only three cases of buccal fat pad lipoma were found.4-6) Also, there is no mention of a unilateral lipoma in the literature.
Case report
A 50-year-old male patient came to the plastic surgery clinic, reporting a unilateral swelling mass of the left cheek. The patient had observed the beginning of the swelling one month ago with no signs of pain, but growing and causing asymmetry of the face. The patient had underlying conditions of hypertension and diabetes.
Clinical examination revealed a unilateral, soft, mobile, and painless mass on the left side, thus causing asymmetry. MRI scan showed 3.2cm x 1.9cm x 3.0cm T1 hyperintense mass along the left mandible body, anterior to left masseter muscle (Fig. 1). MRI findings also said prominent asymmetry of subcutaneous fat in the left cheek area, compared with the right side, r/o prominent fat tissue or small lipoma. The clinical examination and MRI results are consistent with the buccal fat pad lipoma diagnosis.
Fig. 1
Photographs of the patient. (A) Preoperative photograph of a 50-year-old male patient showing the left side swelling, causing asymmetry. (B) MRI imaging of the unilateral mass (coronal view). (C) Axial view. (D) Sagittal view.
Under general anesthesia, an intraoral approach technique was used to do the surgery. Using a no. 15 blade, an oblique incision line was made through the left buccal mucosa, starting from the external oblique ridge and going halfway up the mandibular ramus. With extreme caution, the lipoma was extracted and separated from the surrounding tissues (Fig. 2).
Fig. 2
Intraoperative photographs. (A) The left side of the oral cavity during the surgery showing removal of the lipoma. (B) After removal, the facial vessel is identified by kelly. (C) The buccal fat pad lipoma after removal.
After two days of hospitalization and observation, the patient was discharged in good general condition. Two weeks following surgery, post-traumatic swelling and edema completely subsided (Fig. 3).
Histological examination of the removed masses confirmed the common lipoma presenting a well-circumscribed lipomatous lesion.
Discussion
Lipoma in the buccal fat pad is underreported due to its rarity and atypical characteristics. Burns provided the first description of lipoma in the buccal fat pad in 1811,7) and Cameron released the first review paper on the condition in 1921.8) In the literature, few cases of lipomas have been reported linked to the buccal fat pad. And most of the cases occurred bilaterally. In this case, the patient had a 1cm mass that developed in front of the left masseter muscle and gradually grew larger, and no mass was found contralaterally.
The buccal fat pad is a distinct anatomical structure located within the cheek region of the face and serves a variety of functional and aesthetic purposes. Buccal fat pad lipomas are usually asymptomatic and painless. However, they may cause discomfort or functional issues if they grow big enough to push against nearby structures or interfere with oral functions such as chewing or speaking.9) In this case, the small lipoma grew to 3.2 centimeters in a month, causing discomfort in the patient’s daily life, and leading the patient to come to the hospital for surgical removal.
MRI is the preferred method for imaging the buccal space and its contents. When it comes to identifying a liposarcoma, MRI has 100% specificity and 83% sensitivity.10) It is also 100% specific for common lipomas. Based on earlier literature, it was anticipated that a lipoma in the buccal fat pad would occur bilaterally, so we attempted to confirm both sides through imaging tests. The lesion was discovered only on the patient’s left side, as confirmed by MRI imaging.
Considering the low occurrence rate, it is necessary to differentiate it from other tumors that can develop unilaterally on the face, as they can sometimes resemble other oral lesions or tumors. Facial tumors that occur unilaterally include cysts, abscess, swollen lymph nodes, salivary gland tumors, facial nerve tumors, hemangiomas, and neurofibromas. Among them, malignant tumors like squamous cell carcinoma and melanoma must be distinguished.
About the surgical process, it is noteworthy that the intraoral approach has many advantages.11) The absence of a scar following an extraoral incision is the most significant benefit that concerns patients. Given that MRI can pathologically identify a lipoma of the buccal area and explain the benign nature of the mass, the intraoral approach is the preferred method for gaining enough access.
The buccal fat pad lipoma is rare, and even to the best of our knowledge a unilateral buccal fat pad lipoma is a very rare condition of the oral cavity. Surgical removal using an intraoral approach is the preferred treatment, along with intensive care of the anatomical structures such as the buccinator branch of the facial nerve, the vessels, and the parotic duct in the area.
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