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330 A ESTHETIC S URGERY J OURNAL ~ M AY /J UNE 2006 Operative Strategies Managing the Buccal Fat Pad The author performs buccal fat pad excision to improve facial contour in some patients with buccal lipodystrophy and to treat buccal fat pad pseudoherni- ation. He recommends an intraoral approach, taking care not to pull on the fat pad and resecting only that which protrudes easily with gentle pressure. (Aesthetic Surg J 2006;26:330-336.) A dults with a capacious midface who desire refine- ment, sculpting, or enhancement of their skeletal features, and reduction of facial fullness by dimin- ishing midface volume, are potential candidates for exci- sion of the buccal fat pad. Buccal fat pad excision is also performed in patients who are properly diagnosed with a cheek mass because of displacement of the buccal fat pad (pseudoherniation). The volume of the buccal fat pad is relatively consis- tent. This is true for men and women throughout their lives, despite weight fluctuations, and in people with varying body mass indexes. In fact, the submuscularly located buccal fat pad stubbornly persists (to a point) in spite of loss of weight and loss of subcutaneous fat. Perhaps this is because it has a different lipolytic rate than subcutaneous fat (similar to periorbital fat). Buccal fat pad removal may be considered in any age group to treat buccal lipodystrophy or buccal fat pad pseudoherniation. Either condition can be approached with intraoral buccal fat pad removal with or without concomitant lipoplasty of the jowls and neck. Buccal fat pad removal can be performed in conjunction with other related facial procedures, including liposuction and facialplasty, or with body contouring procedures. Ulti- mately, the goal of buccal fat pad excision is enhanced facial aesthetics—contouring that highlights the angulari- ty of the facial skeletal features. Pseudoherniation of the Buccal Fat Pad The cause postulated for pseudoherniation of the buccal fat pad is weakening of the investing fascia. Most commonly, patients present with a small, round “marble”-size contour irregularity in the cheek that has no reasonable explanation. It can be observed follow- ing earlier facial liposuction or face lift, in patients tak- ing steroids, or be idiopathic in nature. Pseudoherniation of the buccal fat pad involves the presence of a soft mass with the consistency of adi- pose tissue that, in the absence of any associated pathological findings, is easily reducible with upward displacement into the buccal space. The con- dition should be distin- guished from other cheek masses and can be con- firmed by magnetic reso- nance imaging. It is very important to identify and discuss the finding of a herniated buccal fat pad with the patient before facial surgery. This avoids the dilemma of explaining the finding postoperatively, a scenario in which patients may assume you are justifying a less than pleasing result (Figure 1). It is notable that if unexplained bulging is noticed as a new finding following a face lift or facial lipoplasty, pseudoherniation of the buccal fat pad is the probable cause. Operative Technique The buccal fat pad (Bichat’s fat pad) has a complex relationship to the facial structures. It has 4 parts divided by the parotid duct and facial nerve and vein into anterior and posterior portions (Figure 2). It is the buccal extension and main body that are removed intraorally to achieve midfacial contouring. The “lay- ers” dissected in accessing the buccal fat pad, percuta- neously or intraorally, are similar to the layers encoun- tered in a transcutaneous or transconjunctival blepharoplasty, ie, skin mucosa, muscle investing sep- tum, and fat (Figure 3). I prefer to excise the buccal fat pad intraorally prior to surgical scrubbing and preceding any other facial proce- dures. The gingivobuccal space is injected (bilaterally) with a lidocaine and epinephrine-containing solution approximately between the first and second upper molar. The cheek is retracted laterally with Caldwell Luc retrac- tors, and a 2.5-cm mucosal incision is made while pre- serving a cuff of mucosa for closure (Figure 4). The inci- Alan Matarasso, MD, New York, NY, is a board-certified plastic surgeon and an ASAPS member.
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330 A E S T H E T I C S U R G E R Y J O U R N A L ~ M A Y / J U N E 2 0 0 6
O p e r a t i v e S t r a t e g i e s
Managing the Buccal Fat Pad
The author performs buccal fat pad excision toimprove facial contour in some patients with buccallipodystrophy and to treat buccal fat pad pseudoherni-ation. He recommends an intraoral approach, takingcare not to pull on the fat pad and resecting only thatwhich protrudes easily with gentle pressure. (AestheticSurg J 2006;26:330-336.)
Adults with a capacious midface who desire refine-ment, sculpting, or enhancement of their skeletalfeatures, and reduction of facial fullness by dimin-
ishing midface volume, are potential candidates for exci-sion of the buccal fat pad. Buccal fat pad excision is alsoperformed in patients who are properly diagnosed with acheek mass because of displacement of the buccal fat pad(pseudoherniation).
The volume of the buccal fat pad is relatively consis-tent. This is true for men and women throughout theirlives, despite weight fluctuations, and in people withvarying body mass indexes. In fact, the submuscularlylocated buccal fat pad stubbornly persists (to a point) inspite of loss of weight and loss of subcutaneous fat.Perhaps this is because it has a different lipolytic ratethan subcutaneous fat (similar to periorbital fat).
Buccal fat pad removal may be considered in any agegroup to treat buccal lipodystrophy or buccal fat padpseudoherniation. Either condition can be approachedwith intraoral buccal fat pad removal with or withoutconcomitant lipoplasty of the jowls and neck. Buccal fatpad removal can be performed in conjunction with otherrelated facial procedures, including liposuction andfacialplasty, or with body contouring procedures. Ulti-mately, the goal of buccal fat pad excision is enhancedfacial aesthetics—contouring that highlights the angulari-ty of the facial skeletal features.
Pseudoherniation of the Buccal Fat Pad
The cause postulated for pseudoherniation of thebuccal fat pad is weakening of the investing fascia.Most commonly, patients present with a small, round“marble”-size contour irregularity in the cheek that hasno reasonable explanation. It can be observed follow-ing earlier facial liposuction or face lift, in patients tak-
ing steroids, or be idiopathic in nature.Pseudoherniation of the buccal fat pad involves thepresence of a soft masswith the consistency of adi-pose tissue that, in theabsence of any associatedpathological findings, iseasily reducible withupward displacement intothe buccal space. The con-dition should be distin-guished from other cheekmasses and can be con-firmed by magnetic reso-nance imaging.
It is very important to identify and discuss the findingof a herniated buccal fat pad with the patient beforefacial surgery. This avoids the dilemma of explaining thefinding postoperatively, a scenario in which patients mayassume you are justifying a less than pleasing result(Figure 1). It is notable that if unexplained bulging isnoticed as a new finding following a face lift or faciallipoplasty, pseudoherniation of the buccal fat pad is theprobable cause.
Operative Technique
The buccal fat pad (Bichat’s fat pad) has a complexrelationship to the facial structures. It has 4 partsdivided by the parotid duct and facial nerve and veininto anterior and posterior portions (Figure 2). It is thebuccal extension and main body that are removedintraorally to achieve midfacial contouring. The “lay-ers” dissected in accessing the buccal fat pad, percuta-neously or intraorally, are similar to the layers encoun-tered in a transcutaneous or transconjunctivalblepharoplasty, ie, skin mucosa, muscle investing sep-tum, and fat (Figure 3).
I prefer to excise the buccal fat pad intraorally prior tosurgical scrubbing and preceding any other facial proce-dures. The gingivobuccal space is injected (bilaterally)with a lidocaine and epinephrine-containing solutionapproximately between the first and second upper molar.The cheek is retracted laterally with Caldwell Luc retrac-tors, and a 2.5-cm mucosal incision is made while pre-serving a cuff of mucosa for closure (Figure 4). The inci-
Alan Matarasso, MD, NewYork, NY, is a board-certifiedplastic surgeon and an ASAPSmember.
THIAGO DEGANI DUMONT
THIAGO DEGANI DUMONT
THIAGO DEGANI DUMONT
THIAGO DEGANI DUMONT
THIAGO DEGANI DUMONT
A E S T H E T I C S U R G E R Y J O U R N A L ~ M a y / J u n e 2 0 0 6 331Managing the Buccal Fat Pad
O p e r a t i v e S t r a t e g i e sO p e r a t i v e S t r a t e g i e s
Figure 1. This 72-year-old woman is seen following a face lift; several attempts using lipoplasty had been made to ameliorate the residual bulgein her cheek. The bulge was diagnosed as representing a pseudoherniation of the buccal fat pad and was treated with intraoral excision.
Figure 2. Anatomy of the buccal fat pad.
Parotid duct
Skin and subcutaneous fat
SMAS
Branches of facial n.
Masseter
Buccal fat pad
Buccinator m.
Mucosa
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Figure 3. A, B, In performing intraoral excision of the buccal fat pad, the layers encountered are similar to those found in performing transcon-junctival blepharoplasty.
A
B
Extension of fat pad
Parotid gland
SMAS
Buccal fat pad
Parotid duct SMAS
Buccal fat pad
Extension of fat pad
Extension of fat pad
Extension of fat pad
Buccinator m.
Temporalis m.
Zygomatic arch
A E S T H E T I C S U R G E R Y J O U R N A L ~ M a y / J u n e 2 0 0 6 333Managing the Buccal Fat Pad
O p e r a t i v e S t r a t e g i e sO p e r a t i v e S t r a t e g i e s
Figure 4. The cheek is retracted, demonstrating the relationship of the intraoral incision for buccal lipoplasty to surrounding structures.
Figure 5. The buccal fat pad is exteriorized and drawn into the wound.
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Figure 6. A, The buccal fat pad is elevated, clamped, and excised. B, The operator should retract the upper lip to avoid electrocauterizing it inadvertently.
B
A
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Figure 8. A, Preoperative view of a 34-year-old woman with buccal lipodystrophy who desired to improve her facial contour. B, Postoperativeview one year following buccal lipectomy and lipoplasty of the neck and jowls.
Figure 7. A, Preoperative view of a 74-year-old woman with buccal lipodystrophy. B, Postoperative view one year following a short scar face lift,4-lid blepharoplasty, temporal brow lift, perioral laser procedure, and excision of the buccal fat pad.
A B
A B
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sion is carried through the mucosa and muscle whileapplying external pressure on the skin in the region ofthe buccal fat pad. The buccal fat pad is exposed andthe fascia is pierced with scissors. A long hemostat isused to spread the fat while the surgeon continues toplace external pressure on the cheek, manipulating thefat pad into the wound (Figure 5). Without excess trac-tion, the portion of the fat pad that protrudes isgrasped, gently teased into the field, clamped at itsbase, and excised. The stump is electrocoagulated, andthe wound is packed with gauze soaked in lidocaineand epinephrine solution while the opposite side isoperated (Figure 6). When you electrocoagulate, use afinger to displace the lips to avoid inadvertently cauter-izing them. The wound is closed with one absorbablesuture (Figure 6).
It is most important to remove only the fat that pro-trudes and to do so without excessive pulling or trac-tion. Postoperatively, patients can expect to appreciatethe change in facial contour over the course of severalweeks (Figures 7 and 8).
Using the guidelines I have outlined (performing anintraoral approach, being careful not to pull on the fatpad, and resecting only that which easily protrudeswith gentle pressure), complications of buccal fat padexcision for lipodystrophy or a pseudoherniated buccalfat pad are rare indeed. The most likely complicationwould be overresection. Hematomas and infections arepotential problems in any surgery. I have not encoun-tered those problems. In theory, the most significantcomplication with buccal fat pad removal would benerve injury. However, a 7th-nerve injury can be avoid-ed by following the aforementioned guidelines. I wouldthoroughly discuss with all patients the impact thatbuccal fat pad removal can have on current and futurefacial aesthetics, whether the buccal fat pad is “nor-mal” or one that is pseudoherniated. ■
References1. Matarasso A. Pseudoherniation of the buccal fat pad: a new clinical
syndrome. Plast Reconstr Surg 1997;100:723-730.
2. Matarasso A. Pseudoherniation of the buccal fat pad: A new clinicalsyndrome. Plast Reconstr Surg 2003;112:1716-1718.
3. Jackson I. Anatomy of the buccal fat pad and its clinical significance.Plast Reconstr Surg 1999;103:2059-60; discussion 2061-2063(Matarasso A).
4. Matarasso A. Buccal fat pad excision: aesthetic improvement of themidface. Annals Plast Surg 1991;26:413.
Suggested ReadingBagdade JD, Hirsch J. Gestational and dietary influences on the lipid con-tent of the infant buccal fat pad. Proc Soc Exp Biol Med 1966;122:616.
Downey SE, Hugo NE. Periorbital Fat—Different? Presented at the AnnualMeeting of the American Society for Aesthetic Plastic Surgery, Orlando,FL. April 10, 1989.
Dubin B, Jackson IT, Halim A, et al. Anatomy of the buccal fat pad and itsclinical significance. Plast Reconstr Surg 1989;83:257.
Epstein LP. Buccal lipectomy. Ann Plast Surg 1980;5:123.
Ortiz-Monasterio F, Olmedo A. Excision of the buccal fat pad to refine theobese midface. In Kaye BL, Gardinger GP, editors. Symposium on Problemsand Complications in Aesthetic Plastic Surgery of the Face. St. Louis:Mosby, 1984. p. 91-98.
Stuzin JM, Baker TJ, Baker TM. Anatomical structure of the buccal fat padand its clinical adaptations (Discussion). Plast Reconstr Surg2002;109:2519.
Zhang HM, Yan YP, Ai K-M, Wang JQ, and Liu ZF. Anatomical structure ofthe buccal fat pad and its clinical adaptations. Plast Reconstr Surg2002;109:2509.
Reprint requests: Alan Matarasso, MD, 1009 Park Avenue, New York, NY10028.
Copyright © 2006 by The American Society for Aesthetic Plastic Surgery, Inc.
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doi:10.1016/j.asj.2006.03.009
