Reconstruction of partial maxillectomy defect with a buccal fat pad flap and application of 4-hexylresorcinol: a case report
Identifieur interne : 001E64 ( Pmc/Corpus ); précédent : 001E63; suivant : 001E65Reconstruction of partial maxillectomy defect with a buccal fat pad flap and application of 4-hexylresorcinol: a case report
Auteurs : Hyun Seok ; Min-Keun Kim ; Seong-Gon KimSource :
- Journal of the Korean Association of Oral and Maxillofacial Surgeons [ 2234-7550 ] ; 2016.
Abstract
Mucoepidermoid carcinoma (MEC) is the most common type of malignant neoplasm in the minor salivary gland. The hard palate is a frequently involved site of MEC. The treatment of low-grade MEC on the hard palate is wide local resection with a tumor-free margin. In the present case, the maxillary defect was reconstructed using a buccal fat pad (BFP) flap, followed by application of 4-hexylresorcinol (4HR) ointment for 2 weeks. The grafted BFP successfully covered the tumor resection defect without tension and demonstrated complete re-epithelialization without any complications.
Url:
DOI: 10.5125/jkaoms.2016.42.6.370
PubMed: 28053908
PubMed Central: 5206243
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Reconstruction of partial maxillectomy defect with a buccal fat pad flap and application of 4-hexylresorcinol: a case report</title><author><name sortKey="Seok, Hyun" sort="Seok, Hyun" uniqKey="Seok H" first="Hyun" last="Seok">Hyun Seok</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Min Keun" sort="Kim, Min Keun" uniqKey="Kim M" first="Min-Keun" last="Kim">Min-Keun Kim</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Seong Gon" sort="Kim, Seong Gon" uniqKey="Kim S" first="Seong-Gon" last="Kim">Seong-Gon Kim</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28053908</idno><idno type="pmc">5206243</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5206243</idno><idno type="RBID">PMC:5206243</idno><idno type="doi">10.5125/jkaoms.2016.42.6.370</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">001E64</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001E64</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Reconstruction of partial maxillectomy defect with a buccal fat pad flap and application of 4-hexylresorcinol: a case report</title><author><name sortKey="Seok, Hyun" sort="Seok, Hyun" uniqKey="Seok H" first="Hyun" last="Seok">Hyun Seok</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Min Keun" sort="Kim, Min Keun" uniqKey="Kim M" first="Min-Keun" last="Kim">Min-Keun Kim</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Seong Gon" sort="Kim, Seong Gon" uniqKey="Kim S" first="Seong-Gon" last="Kim">Seong-Gon Kim</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea.</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of the Korean Association of Oral and Maxillofacial Surgeons</title><idno type="ISSN">2234-7550</idno><idno type="eISSN">2234-5930</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Mucoepidermoid carcinoma (MEC) is the most common type of malignant neoplasm in the minor salivary gland. The hard palate is a frequently involved site of MEC. The treatment of low-grade MEC on the hard palate is wide local resection with a tumor-free margin. In the present case, the maxillary defect was reconstructed using a buccal fat pad (BFP) flap, followed by application of 4-hexylresorcinol (4HR) ointment for 2 weeks. The grafted BFP successfully covered the tumor resection defect without tension and demonstrated complete re-epithelialization without any complications.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Brandwein, Ms" uniqKey="Brandwein M">MS Brandwein</name></author><author><name sortKey="Ivanov, K" uniqKey="Ivanov K">K Ivanov</name></author><author><name sortKey="Wallace, Di" uniqKey="Wallace D">DI Wallace</name></author><author><name sortKey="Hille, Jj" uniqKey="Hille J">JJ Hille</name></author><author><name sortKey="Wang, B" uniqKey="Wang B">B Wang</name></author><author><name sortKey="Fahmy, A" uniqKey="Fahmy A">A Fahmy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Caccamese, Jf" uniqKey="Caccamese J">JF Caccamese</name></author><author><name sortKey="Ord, Ra" uniqKey="Ord R">RA Ord</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Baumgardt, C" uniqKey="Baumgardt C">C Baumgardt</name></author><author><name sortKey="Gunther, L" uniqKey="Gunther L">L Günther</name></author><author><name sortKey="Sari Rieger, A" uniqKey="Sari Rieger A">A Sari-Rieger</name></author><author><name sortKey="Rustemeyer, J" uniqKey="Rustemeyer J">J Rustemeyer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kokemueller, H" uniqKey="Kokemueller H">H Kokemueller</name></author><author><name sortKey="Brueggemann, N" uniqKey="Brueggemann N">N Brueggemann</name></author><author><name sortKey="Swennen, G" uniqKey="Swennen G">G Swennen</name></author><author><name sortKey="Eckardt, A" uniqKey="Eckardt A">A Eckardt</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nabil, S" uniqKey="Nabil S">S Nabil</name></author><author><name sortKey="Lo, Rc" uniqKey="Lo R">RC Lo</name></author><author><name sortKey="Choi, Ws" uniqKey="Choi W">WS Choi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Youn, T" uniqKey="Youn T">T Youn</name></author><author><name sortKey="Lee, Cs" uniqKey="Lee C">CS Lee</name></author><author><name sortKey="Kim, Hs" uniqKey="Kim H">HS Kim</name></author><author><name sortKey="Lim, K" uniqKey="Lim K">K Lim</name></author><author><name sortKey="Lee, Sj" uniqKey="Lee S">SJ Lee</name></author><author><name sortKey="Kim, Bc" uniqKey="Kim B">BC Kim</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Egyedi, P" uniqKey="Egyedi P">P Egyedi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Yeh, Cj" uniqKey="Yeh C">CJ Yeh</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lee, Sw" uniqKey="Lee S">SW Lee</name></author><author><name sortKey="Um, Ic" uniqKey="Um I">IC Um</name></author><author><name sortKey="Kim, Sg" uniqKey="Kim S">SG Kim</name></author><author><name sortKey="Cha, Ms" uniqKey="Cha M">MS Cha</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, Sg" uniqKey="Kim S">SG Kim</name></author><author><name sortKey="Kim, As" uniqKey="Kim A">AS Kim</name></author><author><name sortKey="Jeong, Jh" uniqKey="Jeong J">JH Jeong</name></author><author><name sortKey="Choi, Jy" uniqKey="Choi J">JY Choi</name></author><author><name sortKey="Kweon, H" uniqKey="Kweon H">H Kweon</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rapidis, Ad" uniqKey="Rapidis A">AD Rapidis</name></author><author><name sortKey="Alexandridis, Ca" uniqKey="Alexandridis C">CA Alexandridis</name></author><author><name sortKey="Eleftheriadis, E" uniqKey="Eleftheriadis E">E Eleftheriadis</name></author><author><name sortKey="Angelopoulos, Ap" uniqKey="Angelopoulos A">AP Angelopoulos</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ahn, J" uniqKey="Ahn J">J 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N" uniqKey="Givalos N">N Givalos</name></author><author><name sortKey="Gakiopoulou, H" uniqKey="Gakiopoulou H">H Gakiopoulou</name></author><author><name sortKey="Stavrianos, Sd" uniqKey="Stavrianos S">SD Stavrianos</name></author><author><name sortKey="Faratzis, G" uniqKey="Faratzis G">G Faratzis</name></author><author><name sortKey="Lagogiannis, Ga" uniqKey="Lagogiannis G">GA Lagogiannis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, Bg" uniqKey="Kim B">BG Kim</name></author><author><name sortKey="Kim, Jh" uniqKey="Kim J">JH Kim</name></author><author><name sortKey="Kim, Mi" uniqKey="Kim M">MI Kim</name></author><author><name sortKey="Han, Jj" uniqKey="Han J">JJ Han</name></author><author><name sortKey="Jung, S" uniqKey="Jung S">S Jung</name></author><author><name sortKey="Kook, Ms" uniqKey="Kook M">MS Kook</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, Cm" uniqKey="Kim C">CM 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uniqKey="Tideman H">H Tideman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hanazawa, Y" uniqKey="Hanazawa Y">Y Hanazawa</name></author><author><name sortKey="Itoh, K" uniqKey="Itoh K">K Itoh</name></author><author><name sortKey="Mabashi, T" uniqKey="Mabashi T">T Mabashi</name></author><author><name sortKey="Sato, K" uniqKey="Sato K">K Sato</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kweon, H" uniqKey="Kweon H">H Kweon</name></author><author><name sortKey="Kim, Sg" uniqKey="Kim S">SG Kim</name></author><author><name sortKey="Choi, Jy" uniqKey="Choi J">JY Choi</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Korean Assoc Oral Maxillofac Surg</journal-id><journal-id journal-id-type="iso-abbrev">J Korean Assoc Oral Maxillofac Surg</journal-id><journal-id journal-id-type="publisher-id">JKAOMS</journal-id><journal-title-group><journal-title>Journal of the Korean Association of Oral and Maxillofacial Surgeons</journal-title></journal-title-group><issn pub-type="ppub">2234-7550</issn><issn pub-type="epub">2234-5930</issn><publisher><publisher-name>The Korean Association of Oral and Maxillofacial Surgeons</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28053908</article-id><article-id pub-id-type="pmc">5206243</article-id><article-id pub-id-type="doi">10.5125/jkaoms.2016.42.6.370</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Reconstruction of partial maxillectomy defect with a buccal fat pad flap and application of 4-hexylresorcinol: a case report</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid" authenticated="true">http://orcid.org/0000-0002-5278-3807</contrib-id><name><surname>Seok</surname><given-names>Hyun</given-names></name><xref ref-type="aff" rid="A1"></xref></contrib><contrib contrib-type="author"><contrib-id contrib-id-type="orcid" authenticated="true">http://orcid.org/0000-0002-5481-841X</contrib-id><name><surname>Kim</surname><given-names>Min-Keun</given-names></name><xref ref-type="aff" rid="A1"></xref></contrib><contrib contrib-type="author"><contrib-id contrib-id-type="orcid" authenticated="true">http://orcid.org/0000-0001-5088-2732</contrib-id><name><surname>Kim</surname><given-names>Seong-Gon</given-names></name><xref ref-type="aff" rid="A1"></xref></contrib></contrib-group><aff id="A1">Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea.</aff><author-notes><corresp>Corresponding author: Hyun Seok. Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, 7 Jukheon-gil, Gangneung 25457, Korea. TEL: +82-33-640-3139, FAX: +82-33-640-3113, <email>sok8585@hanmail.net</email></corresp></author-notes><pub-date pub-type="ppub"><month>12</month><year>2016</year></pub-date><pub-date pub-type="epub"><day>27</day><month>12</month><year>2016</year></pub-date><volume>42</volume><issue>6</issue><fpage>370</fpage><lpage>374</lpage><history><date date-type="received"><day>09</day><month>6</month><year>2016</year></date><date date-type="accepted"><day>22</day><month>7</month><year>2016</year></date></history><permissions><copyright-statement>Copyright © 2016 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/">http://creativecommons.org/licenses/by-nc/4.0/</ext-link>) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>Mucoepidermoid carcinoma (MEC) is the most common type of malignant neoplasm in the minor salivary gland. The hard palate is a frequently involved site of MEC. The treatment of low-grade MEC on the hard palate is wide local resection with a tumor-free margin. In the present case, the maxillary defect was reconstructed using a buccal fat pad (BFP) flap, followed by application of 4-hexylresorcinol (4HR) ointment for 2 weeks. The grafted BFP successfully covered the tumor resection defect without tension and demonstrated complete re-epithelialization without any complications.</p></abstract><kwd-group><kwd>Mucoepidermoid carcinoma</kwd><kwd>Minor salivary glands</kwd><kwd>4-Hexylresorcinol</kwd></kwd-group><funding-group><award-group><funding-source country="KR"><institution-wrap><institution>Rural Development Administration</institution><institution-id institution-id-type="CrossRef">http://dx.doi.org/10.13039/501100003627</institution-id></institution-wrap></funding-source><award-id>PJ01121404</award-id></award-group></funding-group></article-meta></front><body><sec><title>I. Introduction</title><p>Mucoepidermoid carcinoma (MEC) is the most common type of malignant tumor in the salivary gland and comprises approximately 12% to 23% of malignant tumors in the minor salivary gland<xref rid="B1" ref-type="bibr">1</xref>. The tumor can occur in the minor salivary gland of the lip, buccal mucosa, retromolar region, or tongue and floor of the mouth, but the most frequently involved site is the hard palate<xref rid="B2" ref-type="bibr">2</xref>. MEC of the hard palate presents as an asymptomatic, fixed, slow-growing swollen area, sometimes appearing red or blue in color, is fluctuant and ulcerative, and invades the underlying bone<xref rid="B3" ref-type="bibr">3</xref>. MEC is categorized as either low, intermediate, or high based on histology<xref rid="B1" ref-type="bibr">1</xref>. MEC has diverse biological features and variable clinical symptoms depending on the grade and stage of the tumor<xref rid="B4" ref-type="bibr">4</xref>. Low-grade MEC is generally slow growing and benign, while high-grade MEC is more aggressive, invades the tissue, and metastasizes <xref rid="B4" ref-type="bibr">4</xref>. Treatment of low-grade MEC is wide local resection with a tumor-free margin<xref rid="B3" ref-type="bibr">3</xref>. When low-grade MEC arises in the hard palate, the tumor is resected along with the involved palate mucosa and any underlying bone<xref rid="B5" ref-type="bibr">5</xref>.</p><p>A posterior maxillary or hard palate defect can be successfully covered with a pedicled buccal fat pad (BFP) flap<xref rid="B6" ref-type="bibr">6</xref>. BFP has been introduced as a pedicled flap for the closure of oroantral communication<xref rid="B7" ref-type="bibr">7</xref> and has been successfully used to cover oral defects in the posterior maxilla, hard and soft palate, and retromolar region after tooth extraction, saucerization, and tumor resection<xref rid="B6" ref-type="bibr">6</xref>. BFP is located in the masseteric space between the buccinator muscle and the mandibular ramus and masseter muscle and receives a rich blood supply from the superficial temporal, internal maxillary, and facial arteries<xref rid="B8" ref-type="bibr">8</xref>. Due to its anatomic location, the BFP can be easily accessed and harvested via an intraoral approach and applied to the posterior oral cavity<xref rid="B6" ref-type="bibr">6</xref>.</p><p>4-Hexylresorcinol (4HR) is a well-known antiseptic used as an ingredient in mouthwash<xref rid="B9" ref-type="bibr">9</xref>. Because the oral cavity is a septic area, 4HR can be used to prevent postoperative infection<xref rid="B9" ref-type="bibr">9</xref>. In addition, 4HR differentiates oral cancer cells by increasing the expression of involucrin and keratin 10<xref rid="B10" ref-type="bibr">10</xref>. The BFP contains abundant stem cells that can differentiate the oral epithelium<xref rid="B11" ref-type="bibr">11</xref>. If 4HR could accelerate the differentiation of BFP-originated stem cells to the oral epithelium, overall healing time would be reduced. Our recent research showed that 4HR ointment suppressed the expression of tumor necrosis factor-α (TNF-α) in burn wounds and increased the epithelialization of skin wounds<xref rid="B12" ref-type="bibr">12</xref>.</p><p>We present a patient diagnosed with low-grade MEC on the left maxillary alveolus and hard palate. The malignant tumor was excised using partial maxillectomy, and the defect was covered with a simple pedicled BFP flap, followed by application of 4HR ointment to heal the wound.</p></sec><sec><title>II. Case Report</title><p>A 61-year-old male was referred from a local clinic for continuous swelling of his left maxillary edentulous area after a tooth extraction. He had asymptomatic swelling on the left hard palate and an ulcerative lesion on the left maxillary alveolus.(<xref ref-type="fig" rid="F1">Fig. 1</xref>) A panoramic view showed generalized bone destruction in the left posterior maxillary area, and incisional biopsy was performed for further evaluation. On histological examination, neoplastic proliferation of the epithelial cells, which contained mucous cells, was observed. Tumor cells showed low-grade cellular malignancy. The biopsy result was low-grade MEC on the left hard palate. Magnetic resonance imaging (MRI) was performed, and the mass was observed with central necrosis in the left hard palate.(<xref ref-type="fig" rid="F2">Fig. 2. A</xref>) The mass had destroyed the alveolar process of the maxilla and extended into the soft palate, left maxillary sinus, and inferior wall of the left nasal cavity.(<xref ref-type="fig" rid="F2">Fig. 2. B</xref>) Multiple nodularshaped lymph nodes were observed around the submandibular gland on contrast-enhanced computed tomography (CT). Metastasis of the lymph nodes was suspected in the submental, submandibular, and upper jugular areas based on positron emission tomography (PET) CT (PET-CT).</p><p>Under general anesthesia, a partial maxillectomy was performed from the left maxilla canine to the posterior maxillary tuberosity. The resected tumor mass was approximately 6×4 ×3 cm.(<xref ref-type="fig" rid="F3">Fig. 3</xref>) An elective neck dissection was performed to remove the left submental, submandibular, and upper jugular lymph nodes. Evidence of nodal metastasis was not observed in the frozen biopsy. After surgical resection, the BFP was harvested and advanced to the defect. The left maxillary sinus and hard palate were successfully covered without tension. (<xref ref-type="fig" rid="F4">Fig. 4</xref>)</p><p>Upon histological examination, mucin-producing cells mixed with epithelioid tumor cells were evident in the main tumor mass. A small microcystic formation was also observed. Histological diagnosis confirmed low-grade MEC. We applied 4HR ointment on the BFP-grafted area 1 day after surgery to promote re-epithelialization. A palatal stent was then applied to prevent the loss of ointment. 4HR ointment was applied once a day for 2 weeks. Re-epithelialization of the grafted BFP was observed 20 days after surgery (<xref ref-type="fig" rid="F5">Fig. 5. A</xref>), and the defect was completely covered without any complication 8 weeks after surgery.(<xref ref-type="fig" rid="F5">Fig. 5. B</xref>) MRI showed that the BFP was located in the left maxillary alveolus and hard palate defect.(<xref ref-type="fig" rid="F6">Fig. 6</xref>) Evidence of recurrence and distant metastasis were not observed on PET-CT at the 5-month follow-up visit.</p></sec><sec><title>III. Discussion</title><p>MECs are classified into low, intermediate, and high grades depending on the relative portion of cell types<xref rid="B4" ref-type="bibr">4</xref>. MEC is composed of various types of cells including mucous-producing, squamous, and intermediate<xref rid="B1" ref-type="bibr">1</xref>. Low-grade MEC has abundant mucous-producing cells, cystic structures, and few squamous cells<xref rid="B3" ref-type="bibr">3</xref>. Intermediate-grade MEC is histologically between low-grade and high-grade MEC and has fewer cysts and more prominent intermediate cells with a minor degree of mitotic activity and cellular atypia<xref rid="B1" ref-type="bibr">1</xref>. High-grade MEC has a relatively high proportion of squamous cells, a greater degree of mitotic activity, and infrequent mucous-producing cells or cysts<xref rid="B1" ref-type="bibr">1</xref>. High-grade MEC has local infiltration and grows aggressively, similar to squamous cell carcinoma<xref rid="B4" ref-type="bibr">4</xref>. Radiologically, high-grade MEC has irregular, poorly-defined margins and infiltrative adjacent tissue, while low-grade MEC demonstrates a well-delineated mass similar to a benign tumor<xref rid="B3" ref-type="bibr">3</xref>.</p><p>The MEC treatment varies based on the tumor location, clinical stage, and histological grade<xref rid="B3" ref-type="bibr">3</xref>. If MEC occurs in the parotid gland, a parotidectomy is performed, and the facial nerve will be excised<xref rid="B4" ref-type="bibr">4</xref><xref rid="B13" ref-type="bibr">13</xref>. MEC of the minor salivary gland in the hard palate is treated with wide local resection<xref rid="B3" ref-type="bibr">3</xref>. Low-grade MEC is surgically excised in a single piece along with the involved underlying mucosa and bone for an adequate tumor-free margin<xref rid="B5" ref-type="bibr">5</xref>. High-grade MEC has local infiltration and regional lymph node metastasis<xref rid="B14" ref-type="bibr">14</xref><xref rid="B15" ref-type="bibr">15</xref>, requiring wider surgical resection with postoperative radiotherapy or chemotherapy<xref rid="B1" ref-type="bibr">1</xref><xref rid="B16" ref-type="bibr">16</xref>. Lymph node metastasis can occur in low-grade MEC<xref rid="B1" ref-type="bibr">1</xref>.</p><p>The biopsy result of the present case was low-grade MEC, and a reactive lymph node was suspected around the left submandibular gland based on contrast CT. Therefore, elective neck dissection was performed along with tumor resection. Low-grade MEC has a favorable prognosis; the 5-year survival rate is 76% to 95%, and recurrence has rarely been reported<xref rid="B17" ref-type="bibr">17</xref>.</p><p>The BFP has been widely used as a pedicled flap in the oral cavity for closure of an oroantral fistula, coverage of a sequestrectomy defect in osteomyelitis, regenerative treatment of peri-implantitis, and treatment of oral submucous fibrosis<xref rid="B6" ref-type="bibr">6</xref><xref rid="B8" ref-type="bibr">8</xref>. Reconstruction using the BFP is considered a reliable technique due to an excellent blood supply, minimal morbidity, easy harvest, and simplicity<xref rid="B18" ref-type="bibr">18</xref>. The posterior maxilla, hard palate, and retromolar trigone are the ideal defects for reconstruction with the BFP due to anatomical proximity to these areas<xref rid="B6" ref-type="bibr">6</xref>. The BFP provides a 7×4×3 cm pedicled tissue when proper dissection and advancement are performed<xref rid="B11" ref-type="bibr">11</xref>. Many authors recommend reconstructive surgery using the BFP with defects smaller than 4×5-cm size<xref rid="B18" ref-type="bibr">18</xref>. Our patient's MEC specimen measured approximately 6×4×3 cm.(<xref ref-type="fig" rid="F3">Fig. 3</xref>) The involved defect area was the left maxillary canine to the tuberosity, the hard palate, and the sinus mucosa floor. We carefully harvested and advanced the BFP flap and successfully covered the defect without tension.(<xref ref-type="fig" rid="F4">Fig. 4</xref>)</p><p>Epithelization of the grafted BFP begins 1 week after surgery, and complete healing is noted within 4 to 6 weeks<xref rid="B6" ref-type="bibr">6</xref>. This is accomplished by migration of the epithelial cells from the surrounding tissue in the flap margin<xref rid="B19" ref-type="bibr">19</xref>. At first, the superficial layer of the BFP is replaced with granulation tissue; however, this eventually turns into stratified squamous epithelium<xref rid="B18" ref-type="bibr">18</xref>. Histologically, parakeratotic squamous epithelium covers the healed site, and dense fibrous connective tissue is present in the subcutaneous stroma<xref rid="B18" ref-type="bibr">18</xref>. To promote re-epithelialization of the large graft area, we applied 4HR ointment on the BFP area due to its antiseptic and broad-spectrum antibacterial properties<xref rid="B10" ref-type="bibr">10</xref>. 4HR inhibits foreign body giant cell formation via the diacylglycerol kinase (DAGK)-mediated pathway<xref rid="B20" ref-type="bibr">20</xref> and suppresses the expression of TNF-α<xref rid="B12" ref-type="bibr">12</xref>. In a recent study, 4HR ointment was applied to a burn wound, and rapid epithelialization and collagen regeneration occurred<xref rid="B12" ref-type="bibr">12</xref>. In the present study, we applied 4HR ointment on the graft area for rapid re-epithelialization. The large graft area was re-epithelialized 20 days after surgery.(<xref ref-type="fig" rid="F5">Fig. 5. A</xref>) During the healing process, minimal complications such as infection, hematoma, or partial necrosis were noted<xref rid="B11" ref-type="bibr">11</xref>. However, these complications have rarely been reported, and as in our previous study, most cases of BFP flap successfully covered the saucerization defect without any complications<xref rid="B14" ref-type="bibr">14</xref>. In the present case, the grafted BFP was completely epithelialized and covered the defect.(<xref ref-type="fig" rid="F5">Fig. 5. B</xref>)</p><p>The hard palate is a frequently involved site of low-grade MEC<xref rid="B14" ref-type="bibr">14</xref>. We surgically resected low-grade MEC on the left maxillary alveolus and hard palate and successfully covered the large defect with a BFP flap. 4HR ointment was applied to the fat graft area for rapid re-epithelialization and wound healing. The grafted BFP was completely re-epithelialized without complication. Based on the results from this case, we confirmed that BFP grafting is a simple, reliable, and minimally complicated technique for reconstruction of posterior palatal defects, and 4HR is a clinically useful ingredient to promote re-epithelialization of fat.</p></sec></body><back><fn-group><fn fn-type="supported-by"><p>This work was performed with the support of “Cooperative Research Program for Agriculture Science and Technology Development (Project No. PJ01121404),” Rural Development Administration, Republic of Korea.</p></fn><fn fn-type="COI-statement"><p><bold>Conflict of Interest:</bold> No potential conflict of interest relevant to this article was reported.</p></fn></fn-group><ref-list><ref id="B1"><label>1</label><element-citation publication-type="journal"><person-group 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A. Tumor mass with central necrosis on the left hard palate. B. Extension of the tumor to the soft palate, left maxillary sinus, and inferior wall of the left-side nasal cavity.</title></caption><graphic xlink:href="jkaoms-42-370-g002"></graphic></fig><fig id="F3" orientation="portrait" position="float"><label>Fig. 3</label><caption><title>Excised specimen was approximately 6×4×3 cm in size. Histological diagnosis was low-grade mucoepidermoid carcinoma.</title></caption><graphic xlink:href="jkaoms-42-370-g003"></graphic></fig><fig id="F4" orientation="portrait" position="float"><label>Fig. 4</label><caption><title>Coverage of the buccal fat pad flap to the tumor resection defect without tension.</title></caption><graphic xlink:href="jkaoms-42-370-g004"></graphic></fig><fig id="F5" orientation="portrait" position="float"><label>Fig. 5</label><caption><title>Re-epithelialization of the grafted buccal fat pad 20 days (A) and 8 weeks (B) after surgery.</title></caption><graphic xlink:href="jkaoms-42-370-g005"></graphic></fig><fig id="F6" orientation="portrait" position="float"><label>Fig. 6</label><caption><title>Axial (A) and coronal (B) views showing the grafted buccal fat pad located in the left maxillary alveolus and hard palate defect (arrows) at the 8-week follow-up.</title></caption><graphic xlink:href="jkaoms-42-370-g006"></graphic></fig></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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