Bilateral Buccal Fat Pad Herniation

A 2-month-old infant boy, born at 351/7 weeks of gestation via cesarean delivery with birth weight 2610 g due to preterm premature rupture of membrane, was referred for evaluation of sudden-onset bilateral buccal protrusions. His mother denied any trauma history previously, nor were any congenital disorders found. On initial assessment, there were no breathing restrictions; physical examination revealed bilateral protrusions that were normal in color and texture without bleeding, pus, or ulcer. With crying, the protrusions became more obvious (Figure 1, A and B). Laboratory data showed normal white blood cell count and C-reactive protein. Magnetic resonance imaging showed lesions 2.9 cm in diameter over the left cheek and 2.7 cm over the right cheek with intact bilateral buccinator muscle, presenting high signal in T1-weighted imaging view and low signal in fat-suppression view. These were suspected to have extended from the buccal fat pad (Figure 2, A and B).Figure 2Buccal mass under magnetic resonance imaging cross-section. A, T1-weighted image view (arrow); B, Fat suppression view (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Under clinical observation, the herniations reduced slightly in size during hospitalization, and the patient was discharged. The lesions had decreased markedly when examined 2 months later during an outpatient department visit and measured one-fourth in size at the age of 15 months. The buccal fat pad, an anatomic structure between the buccinator muscle medially and facial expression muscles laterally, plays a large role in cheek prominence of newborns and infants.1Yousuf S. Tubbs R.S. Wartmann C.T. Kapos T. Cohen-Gadol A.A. Loukas M. A review of the gross anatomy, functions, pathology, and clinical uses of the buccal fat pad.Surg Radiol Anat. 2010; 32: 427-436Crossref PubMed Scopus (54) Google Scholar,2Rácz L. Maros T.N. Seres-Sturm L. Structural characteristics and functional significance of the buccal fat pad (corpus adiposum buccae).Morphol Embryol (Bucur). 1989; 35: 73-77PubMed Google Scholar A buccal fat pad mass is rare in newborns; the differential diagnosis includes buccal tumor (fibroma, neuroma, hemangioma, and their malignant counterparts), traumatic herniation, and nontraumatic herniation.1Yousuf S. Tubbs R.S. Wartmann C.T. Kapos T. Cohen-Gadol A.A. Loukas M. A review of the gross anatomy, functions, pathology, and clinical uses of the buccal fat pad.Surg Radiol Anat. 2010; 32: 427-436Crossref PubMed Scopus (54) Google Scholar,3Santiago B.M. Damasceno L.M. Primo L.G. Bilateral protrusion of the buccal fat pad into the mouth of an infant: report of a case.J Clin Pediatr Dent. 2005; 29: 181-184Crossref PubMed Scopus (4) Google Scholar Incomplete maturation of the buccinator muscles induces the buccal fat pad to protrude into the oral cavity, especially during crying and laughing, and these herniations disappear when these actions are stopped.3Santiago B.M. Damasceno L.M. Primo L.G. Bilateral protrusion of the buccal fat pad into the mouth of an infant: report of a case.J Clin Pediatr Dent. 2005; 29: 181-184Crossref PubMed Scopus (4) Google Scholar Following maturation of the muscles, the herniations can resolve. In the absence of red flags, it was reasonable to follow-up instead of performing surgical intervention.3Santiago B.M. Damasceno L.M. Primo L.G. Bilateral protrusion of the buccal fat pad into the mouth of an infant: report of a case.J Clin Pediatr Dent. 2005; 29: 181-184Crossref PubMed Scopus (4) Google Scholar Because the buccal fat pad is intimately related to the masticatory muscles, facial nerve and parotid gland, these functions need to be monitored.1Yousuf S. Tubbs R.S. Wartmann C.T. Kapos T. Cohen-Gadol A.A. Loukas M. A review of the gross anatomy, functions, pathology, and clinical uses of the buccal fat pad.Surg Radiol Anat. 2010; 32: 427-436Crossref PubMed Scopus (54) Google Scholar In conclusion, infant buccal fat pad herniation is uncommon but should be considered as one of the differential diagnoses of oral masses in infants.