YIJOM-1505; No of Pages 3

Int. J. Oral Maxillofac. Surg. 2009; xxx: xxx–xxx

doi:10.1016/j.ijom.2008.12.017, available online at http://www.sciencedirect.com

Case report
Trauma

Traumatic pseudolipoma: K. Gadhia, K. Rehman,

R. W. Williams, I. Sharp
Birmingham Children’s Hospital, Steelhouse

herniation of buccal fat pad,

Lane, Birmingham, B4 6NH, United Kingdom

a report of two cases

K. Gadhia, K. Rehman, R. W. Williams, I. Sharp: Traumatic pseudolipoma: herniation
of buccal fat pad, a report of two cases. Int. J. Oral Maxillofac. Surg. 2008; xxx: xxx–
xxx. # 2008 International Association of Oral and Maxillofacial Surgeons. Published
by Elsevier Ltd. All rights reserved.

Abstract. Traumatic pseudolipoma is a term used to describe intra-oral herniation of

the buccal fat pad. A tear of the buccinator muscle and buccal mucosa allows the
buccal fat pad to extrude into the oral cavity. Initially, the lesion can suggest a more
sinister cause, but a history of trauma, an absence of mass before the accident, Keywords: pseudolipoma; buccal fat pad;
anatomical site and fatty appearance should suggest a diagnosis of traumatic trauma.
herniation of buccal fat pad. This injury is rare, but two cases presented to the
authors’ hospital over a period of 3 months. Accepted for publication 22 December 2008

The buccal fat pad, sometimes called the
‘suckling pad’ or ‘buccal fat pad of
Bichat’ is found in the cheek between
the buccinator and masseter muscles. It
is relatively large in young children and is
an anatomical factor of great relevance to
this area.6 A tear of the buccal mucosa and
buccinator muscle allows the buccal fat
pad to extrude into the oral cavity. The
term ‘traumatic pseudolipoma’ was pro-
posed by Brooke and MacGregor in their
report of a case involving adipose tissue in
a swelling of the buccal mucosa.3 Several
cases reported following trauma provide
evidence for this lesion.4,5,10,11
The aetiology and pathogenetic link
between soft tissue trauma and adipose
tissue growth is discussed in the literature.
The first possibility is the herniation of the
buccal fat pad with subsequent epitheliali-
sation, termed ‘traumatic pseudolipoma’.
This usually results from direct impact, has
a relatively short natural history of presen-
tation and commonly occurs in young chil-
dren.8 The second possibility suggests
lipoma formation due to deposition and
differentiation of adipocytes, mediated by
cytokine release, secondary to the trauma
and haematoma formation.1,2 These lesions
are termed ‘posttraumatic lipomas’. The
average time between soft tissue trauma
and lipoma formation is almost 3 years
and occurs more commonly in the fourth
to sixth decades.1,2 Some patients who
present with posttraumatic lipoma have
an elevated thromboplastin time.1,2
This paper discusses 2 cases presenting
as ‘traumatic pseudolipomas’ to the oral
and maxillofacial department of the
authors’ hospital.
Case reports
Case 1
A 5-year-old boy presented to the Acci-
dent and Emergency Department follow-
ing a fall from his bicycle. His presenting
complaint was right cheek swelling and a
laceration of his lower lip.
General examination revealed a fit
and well child, with a haematoma
of the right cheek that was tender to
palpation. Intra-orally a pink, sessile,
smooth and non-tender mass was seen
extruding from a laceration of the right
cheek mucosa. There was no associated
bleeding from the lump. A provisional
diagnosis of herniating buccal fat pad
with a haematoma of right cheek was
made. The lip laceration was sutured
under local anesthesia. A course of

0901-5027/000001+03 $30.00/0 # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: K.. Gadhia, et al., Traumatic pseudolipoma: herniation of buccal fat pad, a report of two cases, Int J
Oral Maxillofac Surg (2009), doi:10.1016/j.ijom.2008.12.017
YIJOM-1505; No of Pages 3
2 Gadhia et al.
Fig. 1. Soft tissue mass on left buccal mucosa diagnosed as traumatic pseudolipoma.
amoxicillin antibiotics was prescribed
for 5 days.
The patient was reviewed weekly for a
month. The cheek haematoma gradually
resolved, but the intra-oral mass continued
to enlarge and protruded between the right
primary molars. The mass was excised
under general anaesthesia without compli-
cations.
Histological examination revealed adi-
pose tissue with denudation and ulceration
of the overlying epithelium. There was
marked oedema and diffuse proliferation
of capillary sized vessels along with the
formation of granulation tissue, composed
of moderately dense lymphoplasmacytic
infiltrate with numerous polymorphonuc-
lear cells. These features are consistent
with ulceration and granulation tissue for-
mation in the buccal fat pad.
Case 2
A healthy 22-month-old boy was referred
to the Maxillofacial Department for eva-
luation of an intra-oral mass, following a
fall on the left side of the cheek 6 days
previously; it was not present before the
injury.
Intra-oral examination revealed a soli-
tary, pink, lobulated, pedunculated,
smooth surfaced, non-tender soft tissue
mass on the left buccal mucosa, approxi-
mately 4 X 2 cm in size with no evidence
of ulceration or haemorrhage (Fig. 1). The
patient was unable to bite teeth his
together. A differential diagnosis of
traumatic fibroma or granuloma was
considered.
Please cite this article in press as: K.. Gadhia, et al., Traumatic pseudolipoma: herniation of buccal fat pad, a report of two cases, Int J
Oral Maxillofac Surg (2009), doi:10.1016/j.ijom.2008.12.017
The protruded mass was excised under
general anaesthesia. The base of the mass
was deeply attached to the buccal fat pad
but excised with minimal bleeding. The
excised mass was pink and homogenous
(Fig. 2). The wound was closed primarily.
Postoperative recovery was uneventful
and at the 6-week follow-up there was
no cosmetic deformity.
Histological examination of the excised
mass revealed adipose tissue with lobules,
septal inflammation and fat necrosis. The
fat appeared to be demarcated by acute
inflammation and granulation tissue along
the periphery. The overall histopathologi-
cal features were compatible with trau-
Fig. 2. Mass excised from left buccal mucosa.
matic herniation of the buccal fat pad
(traumatic pseudolipoma).
Discussion
The buccal fat pad lines the masticatory
space and facilitates masticatory move-
ments. It is closely associated with the
muscles of mastication, the parotid duct
and the facial nerve. It is located between
the buccinator and masseter muscles.
Anteriorly, it extends medial to the mass-
eter muscle. It has many uses in oral and
maxillofacial and cosmetic surgical pro-
cedures.12
The buccal fat pad is contained under
pressure by a fibrous capsule and septa,7,10
and in cases of penetrating trauma to the
cheek the capsule can rupture causing the
fatty tissue to herniate intra-orally; termed
‘traumatic pseudolipoma’. The authors
were surprised to see two cases in 3
months, because of the apparent rarity
of the injury.
Traumatic herniation of the buccal fat
pad occurs more frequently in infants and
young children following a fall with a
sharp object in the mouth or a laceration
of the buccal tissues from occlusal
trauma.8 The mass is pedunculated and
originates from the buccal mucosa near
the parotid duct. It is generally painless,
initially soft, smooth surfaced and non-
blanching. Differential diagnoses include
a pyogenic granuloma, inflammatory
pseudotumour, foreign body granuloma,
traumatic neuroma, lipoma, haemangioma
and salivary neoplasm.8 Initially a yellow
or red colour it progressively darkens to
purple or deep blue as thrombosis and
YIJOM-1505; No of Pages 3
necrosis occurs. At this stage, the mass is
firm to palpation and can be mistaken for a
more sinister lesion. A history of trauma,
an absence of mass before the accident, the
anatomical site and fatty appearance sug-
gest a diagnosis of traumatic herniation of
the buccal fat pad.
Histologically, this lesion is not capsu-
lated and is composed of mature adipose
tissue with a varying degree of inflamma-
tory cell infiltration.9 The interstitial
spaces are often occupied with extrava-
sated red cells. Focal thrombosis and
necrosis within the lesion have also been
described where there has been a delay in
treatment.
Treatment of traumatic pseudolipoma
consists of either replacement of the buc-
cal fat pad or excision. With either
method, precautions should be taken to
avoid injury to the parotid duct and its
orifice. In situations where an early diag-
nosis is made before inflammatory
changes have occurred, tissue replacement
and primary wound closure achieve good
results. In situations where there is a delay
before diagnosis or treatment, excision is
Please cite this article in press as: K.. Gadhia, et al., Traumatic pseudolipoma: herniation of buccal fat pad, a report of two cases, Int J
Oral Maxillofac Surg (2009), doi:10.1016/j.ijom.2008.12.017
Traumatic pseudolipoma: herniation of buccal fat pad, a report of two cases
preferred because of contamination and
necrosis of the tissue.
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Address:
Kushal Gadhia
Fax: +44 121 333 8131.
E-mail: kushalgadhia@nhs.net