Preventive Use of the Pedicled Buccal Fat Pad Flap in Minimally Invasive Zygomatic Implant Surgery: A Modification of the Parisi–Fevola Protocol

Introduction

Treatment of patients with severe maxillary atrophy remains one of the greatest challenges in implant dentistry. Over the last decades, zygomatic implants have become a predictable alternative for rehabilitation of the severely resorbed maxilla while avoiding extensive grafting procedures [1]. The Parisi–Fevola Protocol was developed to reduce surgical morbidity through meticulous three-dimensional planning, anatomically guided implant positioning, and minimally invasive intraoral access. The protocol emphasizes preservation of vascular supply, reduction of soft tissue trauma, and immediate prosthetic rehabilitation whenever clinically indicated. Although primary implant stability and bicortical anchorage are fundamental for treatment success, long-term outcomes also depend on the quality of the peri-implant soft tissues. Soft tissue deficiencies remain one of the major causes of implant exposure, mucosal dehiscence, chronic inflammation, and long-term maintenance difficulties. For this reason, the present article proposes incorporating the pedicled buccal fat pad flap into the Parisi–Fevola Protocol as a preventive biological adjunct for selected clinical situations [2-5].

Biological Rationale

The buccal fat pad is a specialized encapsulated adipose structure located within the masticatory space. Because of its abundant vascularization and anatomical proximity to the posterior maxilla, it has become an established reconstructive option for oral defects. Its biological characteristics make it particularly attractive for zygomatic implant surgery [6-8].

• The pedicled flap provides:
• Excellent vascular supply.
• Autogenous tissue with minimal donor-site morbidity.
• Increased peri-implant mucosal thickness.
• Reduced tension during flap closure.
• Rapid spontaneous epithelialization.
• Mechanical protection of implant emergence profiles.
• Improved soft tissue quality surrounding the prosthetic components.

These biological properties may contribute to improved periimplant tissue stability during the critical healing phase.

Surgical Application within the Parisi–Fevola Protocol

The buccal fat pad can be harvested through the same posterior intraoral access already used for placement of zygomatic implants. No additional external incision is required. After implant placement and before definitive wound closure, the buccal fat pad is gently mobilized while preserving its vascular pedicle. The flap is advanced to cover the implant emergence areas and stabilized using resorbable sutures. This additional maneuver requires only a few extra minutes and does not substantially increase surgical morbidity [9-11] (Figures 1-7).

Figure 1: Image showing an unfavorable soft tissue biotype.

Figure 2: Flapless Parisi–Fevola Protocol Approach Through A Minimal Vestibular Ridge Incision.

Figure 3: Pedicled buccal fat pad flap harvested through the same surgical approach used in the Parisi–Fevola Protocol.

Figure 4: Blunt dissection and mobilization of the buccal fat pad extension.

Figure 5: Pedicle Sutured To The Wound Margins.

Figures 6,7: Clinical appearance after 12 months of follow-up.