Management of Buccal Fat Pad Herniation in Neonates
For neonatal buccal fat pad herniation, immediate surgical relocation is the preferred treatment when identified early, with excision reserved for cases presenting after 24-48 hours or showing signs of necrosis. 1, 2
Clinical Recognition and Diagnosis
Buccal fat pad herniation presents as a yellow, pedunculated soft tissue mass protruding through the buccal mucosa, typically following trauma to the oral cavity. 3, 1 Key diagnostic features include:
- History of recent trauma (fall, foreign object in mouth, or birth trauma) 3
- Sudden appearance of the mass that was not present before injury 3
- Disproportionate size of the herniated mass compared to the mucosal perforation 3
- Specific anatomic location at the occlusal level of the buccal mucosa 4
- Yellow, lobulated appearance consistent with adipose tissue 3, 1
The suckling activity in neonates and infants may encourage herniation following even minor mucosal trauma. 3
Treatment Algorithm
Early Presentation (< 24-48 hours)
Surgical relocation is the treatment of choice when the herniation is identified within the first 24-48 hours and the tissue appears viable. 1, 2
- Perform under general anesthesia with careful repositioning of the fat pad back into its anatomical location 1
- Close the mucosal defect primarily 1
- Provide antibiotic prophylaxis to prevent infection 1
- This approach preserves facial contour and avoids potential long-term aesthetic concerns in the growing child 1
Delayed Presentation (> 48 hours) or Necrotic Tissue
Excision is indicated when: 2
- Presentation is delayed beyond 48 hours 2
- Signs of tissue necrosis are present 2
- The herniated fat pad is large (> 2-3 cm) 2
- Tissue appears non-viable or infected 2
Observation Only
Conservative management with observation alone has been reported in rare cases where spontaneous resolution occurred, but this should only be considered if: 5
- The herniation is very small 5
- The tissue appears completely viable 5
- Close follow-up can be guaranteed 5
- Parents understand the risks of non-intervention 5
However, observation carries risk of infection, continued trauma, and diagnostic uncertainty, making it generally not recommended as first-line management. 1, 2
Perioperative Management
- Anesthesia considerations: Use general anesthesia for all surgical interventions in neonates 1, 4
- Antibiotic coverage: Provide prophylactic antibiotics perioperatively to prevent infection 1
- Wound care: Ensure meticulous closure of the mucosal defect to prevent recurrence 1
- Pain management: Provide appropriate analgesia postoperatively 1
Critical Pitfalls to Avoid
Do not mistake this for a neoplasm - the sudden onset after trauma, specific location, and yellow adipose appearance distinguish this from lipoblastoma or other oral tumors. 5 If diagnostic uncertainty exists, biopsy will show normal adipose tissue. 3
Do not delay treatment - waiting beyond 48 hours increases the likelihood of tissue necrosis, infection, and the need for excision rather than the more conservative relocation approach. 2
Do not perform excision as first-line in early presentations - given the young age and potential for facial contour changes with growth, relocation preserves tissue and is preferred when viable. 1