Fat removal, primarily by liposuction, is a well known and effective procedure for many body areas. But when it comes to the face there are obviously much smaller volumes of fat to be removed. And there is one additional issue that the rest of the body does not have…motor nerves that can be injured. The face is full of branches of the facial nerve whose injury could have devastating facial consequences.
Thus facial sculpting by fat reduction, by its own anatomy, is a limited procedure. The size and location of the fat in the face provides limited opportunity for any significant external reduction in the shape of the face. While it is limited that does not mean it is impossible.
The facial locations by which fat can be removed are the buccal fat pads and the subcutaneous fat in the perioral mound area.They are safe removal sites because they lie either underneath (buccal fat pads) or below (perioral mound area) the buccal branches of the facial nerve.
These two facial fat removal sites are often confused as to their location and what facial reduction effects they may have. The perioral mound area is often perceived as to the location of the buccal fat pads…or at least as to where its lower extent of that fat pad lies. These are completely different fat locations as well as have different fat cell characteristics.
The buccal fat pad is a large well encapsulated ball of fat that lies deep under the cheekbone. Its removal, while substantial, impacts the submalar region directly under the cheekbone. Its effect does not go any further south than that upper midface location in most patients. Conversely perioral mound fat is a much thinner subcutaneous fat layer whose location is south of the buccal fat pad and more at a horizontal level of the mouth.
To maximize facial fat reduction it is necessary to perform both buccal lipectomies and perioral mound liposuction.
Dr. Barry Eppley
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The buccal fat pad is a well known reservoir of facial fat that can be removed in selective patients for a cheek thinning effect. The buccal lipectomy is an impressive procedure when one looks at the size of the fat pad as it is being extracted.
But beyond its potential aesthetic facial benefits, the uniqueness of buccal fat is that it is an encapsulated fat collection and it has a large lobules of fat within it. This suggests that this unique collection of facial fat may be metabolically different than other types of face or body fat. The role the buccal fat pad plays has never been precisely defined but it is not one of being a primary depot (collection) site for excess calories. This raises the question of whether buccal fat may offer advantages in fat transfer. (are the fat cells more hardy if transferred?)
Buccal fat can be processed into an injectable form. The fat pads can be cut into small pieces and then passed slowly back and forth between syringes until it is in more of an emulsified form. It is then placed into one cc syringes for injection. One unique feature of this emulsified fat injectate is that it has a very linear smooth flow as it comes out of the syringe.
The quantity of fat that both buccal fat pads can provide is 10cc to 12ccs. This is more than adequate for many facial augmentation needs such as the lips and cheeks. Whether it may survive better than other fat is speculative. But because it does not require a liposuction harvest suggests that it might have a higher survival rate.
The main drawback to the use of buccal fat for fat injections is that the buccal lipectomy procedure must be concurrently done for an aesthetic purpose. Because it creates its own aesthetic effect buccal fat is not harvested only for convenience.
The buccal fat pad is the only completely encapsulated fat collection in the face. Besides its capsule it is a unique piece of fat anatomy as it is a distinct pad that has a well identified vascular pedicle providing its main blood supply. Because it is an easily found and removed piece of facial anatomy with little consequence in doing so, it is a common aesthetic procedure. Removal of the main body of the buccal fat pad (buccal lipectomy) can a visible external facial change by reducing the fullness of the cheeks which can create better cheekbone highlights.
But in facial derounding procedures the buccal lipectomy procedure is often misunderstood for where it creates it facial effects. Of the three aesthetic cheek zones influenced by fat (buccal, perioral mound and medial cheek), removal of buccal fad creates its effect just under the cheekbones. It does not go lower down to the mouth level and does not extend closer to the nose. Those are different fat zones which can also be treated. (perioral mound liposuction, medial cheek liposuction)
The best way to know what effect a buccal lipectomy will have on the face is by drawing specific horizontal and vertical lines. If a vertical line is drawn from the corner of the eye down the mouth corner and a horizontal line is drawn from the tragus of the ear to the mouth corner, the northwests section above the intersection of the lines is the buccal zone. This is where the fullness of the face will be reduced by a buccal lipectomy.
There are numerous fat compartments on the face that can be surgically reduced. The most recognized and easily removed is the buccal fat pads. (aka buccal lipectomy) Located just under the cheekbones, it is a very discrete collection of fat that has its own pedicled blood supply and a surrounding capsule. It is removed from an intraoral approach through a small incision just opposite the molar teeth.
While the buccal fat is a large collection of fat compared to the rest of the face, it is frequently given more credit that it is due. Its removal affects the fullness of convexity of the cheek just under the cheekbones. It does not extend very low onto the face and its thinning effect will be relegated to the upper cheek area. If you drew a line from the tragus of the ear to the corner of the mouth, a buccal lipectomy has its effect above this line.
Below this drawn line sits another smaller collection of facial fat known as the perioral fat or, when bulging, the perioral mounds. This is a subcutaneous non-encapsulated fat collection that sits between the skin and the buccinator muscle. It is located at the southern end of the cheeks or its lower half. It has no anatomic connection to the buccal fat pad. In rare cases the buccal fat pad has been known to fall or prolapse into the perioral mound area.
Removal of perioral mound fat is done by very small liposuction cannulas. It is never an impressive amount of fat that is removed but a little fat reduction does make for a visible external effect. It is a good companion to buccal lipectomies for a more complete cheek reduction effect.
Background: Faces are well known to come in a wide variety of shapes. One of the well known facial shapes is the square one. The square facial shape is created mainly by the influence of the facial bones. One has to have strong cheek and jawline bones to make such a facial shape….at least in younger and weight appropriate patients. The cheeks and their zygomatic arch extensions must match the width of a strong jawline and jaw angles to create a facial ‘box’ appearance
In women the square facial shape can be very attractive and there are numerous examples of famous women who have such a facial shape. It is undoubtably the strong jawline that adds to this attraction. But the one soft tissue feature that they all share is that there is a concavity between the cheeks and the jawline. This is caused by a relative lack of substantial fat in the subcutaneous and deeper tissue planes. In essence the face has a fairly skeletonized appearance.
The aesthetics of the square facial shape can be marred if it has an intervening convexity between the cheeks and the jawline. Such ‘fullness’ can make the square face look less attractive than if there was a convexity present.
Case Study: This 23 year-old female requested fat removal from her face to give a more contoured look. She had a square facial shape with a straight line profile between her cheeks and jawline. She was very weight appropriate for her height.
Under general anesthesia a combination of buccal lipectomies and perioral mound liposuction were done through two separate intraoral incisions. A subtotal buccal lipectomy removed 3 cm diameter fat pads. The microcannula liposuction removed just over 1cc of fat per each side.
At 6 weeks after surgery, her square facial shape shows the desired concavity between the cheeks and jawline. This can her face a more sculpted look. It really takes the combination of both facial fat sites to be removed to create the full effect over the vertical distance between the cheeks and jawline.
1) Thinning of the more square facial shape can be done by decreasing soft tissue volume between the convex skeletal shapes.
2) Creating a facial concavity can be done by buccal lipectomies and perioral mound liposuction.
3) Such facial thinning effects creates a subtle but noticeable facial shape improvement.
The buccal fat pad has a unique role in facial contouring surgery, It is a unique encapsulated fat pad and the only one that exists outside of the orbit on the face. This makes it a prime target for removal for several reasons. It is relatively easy to remove through a small intraoral incision. Once located beyond the buccinator muscle opening its capsule allows it to be extracted quite easily. Given the size of the fat pad, a buccal lipectomy procedure would also seem to create a substantial facial thinning effect.
The influence of removal of the buccal fat pad can be substantial on the face but in different ways that most people think. Its thinning effect is much higher that is often envisioned. It affects the area right under the prominence of the cheekbone and not all the way down to the jawline. While the immediate intraoperative effect of its removal is apparent, that effects will become greater with time as the overlying tissues shrink and contract around the voided buccal space.
While the buccal lipectomy procedure has been around for decades, it is fallen into a condemned procedure by some surgeons. With the acknowledgement that the face loses fat with aging, long-term sequelae from a buccal lipectomy may create a scenario where fat grafting restoration may be needed much later in life. In other words there may be a price to paid when one is older for what was done when one was younger.
While these long-term facial volume loss with aging (and other conditions) are real, this done not mean that a buccal lipectomy should never be performed. In the right full face which is genetically prone to roundness and thicker tissues, a buccal lipectomy has a valid facial contouring role. These are the type of faces that have a low risk of ever becoming too thin or developing a gaunt facial appearance.
The other approach for this type of facial fat removal is a subtotal buccal lipectomy. The buccal fat pad has multiple lobes and extensions. While large amounts of buccal fat can be teased out through an intraoral incision, this does not mean that the maximum amount of fat needs to be removed. In a subtotal buccal lipectomy the extraction is stopped after the first large lobe has been delivered. This will preserve a portion of the facial fat pad and prevent pulling down its temporal extensions.
To get a good facial contouriong effect, a subtotal buccal lipectomy must be combined with perioral liposuction to get a more complete effect below the cheek bones.
One of the techniques to help create a thinner face is that of a buccal lipectomy procedure. Because it is the largest collection of encapsulated fat on the face and its extraction is a straightforward and uncomplicated procedure, it is an easy target when it comes to facial slimming efforts.
Despite that the buccal lipectomy procedure has been around for a long time, the effects if its removal are frequently misunderstood. The first misconception is what effect it has on slimming the face. The main portion of the buccal fat pad adds volume primarily to the submalar region of the face. This lies right under the cheekbone where one would put their thumb under the cheekbone prominence. It should not be confused with the malar fat pad, which is directly below the skin of the cheek. It also does not extend all the way down to the side of the mouth or even down to the jowls.
Given its anatomy, this is why a buccal lipectomy will NOT slim the face from the cheeks down to the jawline. By itself it can not make a round face into more of a V-shape. It simply is not that powerful. This is why a buccal lipectomy is often combined with perioral liposuction to extend its effect further down on the face.
Another more recent misconception is that a buccal lipectomy will eventually lead to gauntness of the face or a prematurely aged look. While this belief does have some partial truth to it, such a facial effect depends on what type of face on which it is performed. Thinner faces that are genetically prone to eventual facial lipoatrophy would be prematurely and adversely affected by removing the buccal fat pads. But in fuller and more round faces (aka heavy face) there is no reason to believe that excessive facial thinning will eventually occur.
The last misconception is that the buccal lipectomy is an all or none procedure. While large amounts of the buccal fat pad can be removed, that does not mean it has to be. A subtotal or incomplete buccal lipectomy can be done when there are concerns about too much fat removal. There are three lobes or extensions of the buccal fat pad and in a subtotal technique only a portion or just the anterior lobe can be removed.
Lip augmentation is a popular facial filling procedure that has been done by a wide variety of materials. Synthetic fillers, fat injection and implants have all be done with well known advantages and disadvantages. The perfect lip augmentation material, however, remains elusive
Of all the known injectable fillers, fat has a high appeal but is the most vexing. Fat is a natural material that is unique to each patient and everyone has enough to harvest to do lip augmentation. But even in small volume placements like the lips, its retention and survival is far from assured. In fact, substantial clinical experience has shown that the lips actually have one of the lower rates of fat grafting success on the face. Whether that is due to high motion activity of the lips or their lack of much native fat tissue is unknown.
The donor site for lip fat injections has been harvested from just about every body donor site imaginable. No one knows if the donor source of fat grafting affects how well the fat graft takes although it is hard to imagine that it does not play some role albeit even if it is a minor one.
One donor source for injectable fat grafting that has not been previously described is that of the buccal fat pad. There is more than enough fat in the buccal fat pads for transfer into the lips. But buccal fat pad harvesting should not be routinuely done due to potential undesired aesthetic tradeoffs of facial hollowing that could occur in many patients. But for those patients with rounder faces that desire facial slimming, a buccal lipectomy can be aesthetically beneficial.
Harvested buccal fat pads can be pass back and forth to create an injectate that can easily be injected through a small blunt-tipped cannula. And for the buccal lipectomy patient who also desires lip augmentation this can be a superb method of fat recycling/redistribution.
Does fat from the buccal fat pads survive better than other donor sites. The fat is clearly different in being encapsulated and with much larger globules. It is tempting to hypothesize that it survives better than subcutaneous fat, and I suspect that it does, but it remains to be scientifically proven.
The buccal fat pad is most commonly known because of the aesthetic buccal lipectomy procedure. Its historic significance is in what it creates when it is removed…a facial thinning effect. It is the one facial defatting procedure that is easy to do, effective and permanent. It is not a facial liposuction procedure, as is commonly perceived, but rather an excisional procedure where the fat is teased out and directly cut off and removed.
Despite its historic use more recent concepts of facial aging have cast doubt on the validity of the procedure. Losing facial volume by fat atrophy is one of the sequelae of aging and its toll on the face is that of a devoluminizing effect leading to a gaunt and more aged facial look in many people. This has let to contemporary efforts to maintain or even add fat volume to the face as a restorative procedure. This has led to many plastic surgeons spurning the buccal lipectomy as a procedure that should be avoided and abandoned.
The reality is that the buccal lipectomy is neither a completely good or bad aesthetic procedure. It all depends on the patient’s facial anatomy, shape and desired effect. Understanding the anatomy of the buccal fat pad will shed light on whether it could be beneficial to any patient’s facial reshaping goal.
While the merits of the buccal lipectomy can be debated, its anatomy can not. It is a large encapsulated fat pad that has a distinct vascular pedicle that sits right below the cheekbone in the appropriately named buccal space. There is no other such fat collection with this specific anatomy in the face. Besides its size and exact anatomic location it is also not appreciated that it has numerous extensions (fingers) that extend outward and beyond its ‘home’ submalar located buccal space. Its biggest extension heads northward where it can be found around the temporalis muscle. Its location here speaks to what is believed to be its role as an interpositional material between the masseter and temporalis muscles. This allows them to have functional movement without interfering with each other or allowing scar adhesions to develop between the two muscles. What is also clear in the anatomy of the buccal fad pad is that it does not extend downward below about the level of the occlusal plane.
This anatomy has several implications as to the merits and potential deleterious effects of the buccal lipectomy procedure. First, its removal results in a very discrete facial thinning location or indentation which sits below below the cheekbone and is about the size of a thumbprint. It does not have a larger facial thinning effect. It will not create any lower cheek thinning effect like down around the side of the mouth as is commonly believed. Secondly, an aggressive removal of the buccal fat pad (which is easy to do) will result in an adverse thinning effect up into the temporal region. This will result in temporal hollows as the remaining fat pad is pulled down and atrophied from the loss of the ‘mother ship’ so to speak. Lastly loss of the buccal fat pad is permanent and is one of the only facial fat collections that can not be restored by secondary weight gain by fat cell uptake of excess lipids. (although fat injections can be a corrective procedure)
The conclusion based on anatomy is that the buccal lipectomy procedure should be reserved for very specific types of facial shapes and should often be performed in a subtotal or incomplete manner. Only in the fullest and roundest of facial shapes should a more complete buccal lipectomy be done. In less round faces who have a very specific fullness isolated to just below the cheekbone, a subtotal buccal lipectomy can be safely performed. For a more complete facial derounding effect, a buccal lipectomy will need to be combined with other procedures to achieve a maximal facial reshaping effect.
The buccal lipectomy is a well known procedure that is done in certain patients for a cheek slimming effect. It is unique amongst most fat removal procedures in plastic surgery because it involves removal of fat within a surrounding capsule. (the only other procedure is the removal of the fad pads in blepharoplasty surgery) The buccal fat is a deep pad that is located between the buccinator muscle and the more superficial muscles including the zygomaticus and masseter muscles in the, appropriately named, buccal space. What is actual function is, large as it is, is not really known. It has been described the functions of aiding sucking in infants to facilitating the movement of the muscles it lies between. None of these explanations, however, are particularly satisfying.
While buccal fat pad removal is controversial today due to the potential long-term risks of excessive thinning and the creation of a gaunt face, the buccal fat pad has an interesting history. It is also often called Bichat’s fat pad and is so named after the famous French anatomist and physiologist Marie Francois Xavier Bichat. While he lived only a short thirty years (1771-1802), he is remembered as the father of modern histology and descriptive anatomy. While he never used a microscope (interestingly he did not trust them) he was able to describe tissues as distinct entities. (muscle, fat etc) Hence the ‘discovery’ of the large buccal fat pad and its four main extensions. (parotid, temporal, buccal and malar) While one could argue some anatomist somewhere would have found it eventually anyway (it is hard to miss when doing facial dissections), in the context of its day over 200 hundred years ago, such anatomic finds were revolutionary.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.