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Archive for the ‘buccal lipectomy’ Category

Plastic Surgery’s Did You Know? Bichat’s Fat Pad and Buccal Lipectomy Surgery

Tuesday, February 18th, 2014


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.

Bichat Buccal Fat pad Dr Barry Eppley IndianapolisWhile 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

Indianapolis, Indiana

Shaping The Male Face

Monday, October 17th, 2011

Superman has been an American cultural icon since he first appeared in comic books back in 1938. His appearance is absolutely distinctive, most notably that of his red, white and blue colors and the stylized S shield on his chest. The shield is so symbolic of his character than its appearance alone immediately brings image of the comic character.

But beyond the colors and the symbol, many of his other features are particularly iconic of what masculinity and attractiveness is supposed to be. His face is absolutely chiseled and proportioned and exudes strength and power. Such Man of Steel facial features appear to have galvanized one male fan to undergo numerous plastic surgery procedures to try and look like this popular superhero.

Hebert Chavez, a superfan of Superman from the Phillipines, has dramatically altered his face to look more like Superman. New agencies have reported that he has undergone a series of operations since 1995. These have included a chin implant to get a strong chin with a cleft, nose reshaping, injections for fuller lips, cheek and jaw implants and eyelid surgery. As bizarre as this sounds, his surgical results actually look pretty good and not as unnatural as one would think.

Such a plastic surgery story brings to mind another face changer, Michael Jackson, and there is no doubt that they both share the similar malady of Body Dysmorphic Disorder. In this mental illness, a person can’t stop thinking about how their appearance is flawed and that perfection is just a surgery away.

But beneath these extreme cases of facial plastic surgery lies some basic truths about what makes a male face more appealing. It starts with an overall facial shape that has more definition and a square to inverted triangular shape. The three bony highlights of the male face are the chin, cheeks and jaw angles. Some degree of prominence in all of them is important to create a sense of overall angularity. Therein lies the frequent use of chin, cheek and jaw angle implants to create those prominences if they are weak, flat or recessed.

In the more lean male face, creating these prominences with implants alone may be adequate. As the chin, cheek and jaw angles become more visible, the non-bony supported areas (submalar and lateral face and neck) will appear more concave as the amount of subcutaneous facial fat in these areas is thin. In the rounder or fuller face, however, some fat removal will need to be considered. This could include procedures such as buccal lipectomies, lateral face and neck liposuction to try and change a convex shape in these areas to at least one that is flat or ideally a little bit concave.

Not every male face can be made more ‘super’. These facial plastic surgery techniques work best in a face that is not too overly round or thick. Such facial shapes are the kryptonite for obtaining the well defined male face that is deemed in both comic books and in real life as desireable.

Dr. Barry Eppley

Indianapolis, Indiana

Jawline Surgery and Facial Derounding

Saturday, June 11th, 2011

One recent high profile facial change reported in the media is that of Bristol Palin. At a dinner in Washington in late April, she was reported to be unrecognizeable. Something was very different about her face. She had a distinctly more angled jaw and sharpened chin. It was speculated that she had a facelift, fillers or even implants in her cheeks.

What did she have done? According to the 20 year-old reality star, she had corrective jaw surgery. While she acknowledged that it changed her look, the surgery was done for medical necessary reasons. She underwent the procedure so her lower jaw and teeth could align properly. In essence she had a pre-existing malocclusion (underbite) that was treated by a mandibular (jaw) advancement. (sagittal split ramus osteotomy, SSRO) It is impossible to know how big of a jaw advancement she had done, but judging by her preoperative profile pictures, probably in the range of 4 or 5mms at best. But this procedure alone would not account for her new profile and jawline.

She likely may have had the additional cosmetic procedures of neck/submental liposuction and a chin or genioplasty procedure. What type of chin reshaping she had can only be speculated, but it likely was a chin osteotomy as opposed to a chin implant. It is very common to do a chin osteotomy as a complementary procedure to a jaw advancement osteotomy. This is because the same equipment is used for both procedures and if you are asleep for one bone cutting procedure, it makes sense to cut and move the chin bone as well. This is also a good opportunity to perform a natural bone moving procedure that will heal and never pose any problems in the future in a very young patient, unlike the risks (albeit very low) of having a synthetic chin implant.

The other giveaway that it might be a chin osteotomy is the shape of the new chin. The chin is more narrowed, almost a bit pointy, and there is a slight inward indentation as the chin moves around into the side of the jaw. This is a look that a chin osteotomy (osteoplastic genioplasty) can create as the end of the chin bone moves forward. It frequently will create a more narrow chin as the u-shape of the chin bone moves ahead of the rest of the arc of the lower jaw. A chin implant usually does not create as much chin narrowing and makes the sides of the chin wider not more narrow, unless a central chin button style implant is used.

Because she had jaw surgery, she may well have lost some significant weight in the 6 week recovery phase. As one can not eat or chew normally for this period of time, all patients will lose some weight. A 10 or 15 weight loss could account for her overall thinner face, regardless of whether neck liposuction was done.

This conversion of her round face to one that is more oval occurs because of the triple effect of three changes; a more prominent chin, a trimmer neck profile and a more narrow submalar (below the cheeks) area. While Bristol Palin achieved this result by jaw and chin bony advancement and neck liposuction and/or surgically-induced weight loss, the more common ‘facial derounding’ surgery uses a slightly different approach. The more traditional approach uses chin implant augmentation, neck liposuction and buccal lipectomies.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Thinning the Round Face

Sunday, May 15th, 2011

Background:  The shape of one’s face is influenced by many bony and soft tissue elements. The size of the facial bones and the prominence or deficiency of the lower jaw provides a support framework that serves as a foundation. The soft tissue that drapes over the bones also plays a major role in its shape with much coming from the thickness of the facial muscles and how much fat lies under the facial skin.

There are numerous facial shapes, some of which are flattering and others which are not. The one facial shape that is disliked by many people is a round face and, if big enough, may be called fat. Not only is the shape round but it usually lacks distinct facial highlights. Most round faces include fullness in the neck tissues as well. One of the anatomic features of the round face is that it has more fat beneath the skin creating a thicker subcutaneous layer that masks the prominence of the underlying facial bones.

Facial and neck fat is not just one uniform layer underneath the skin. There are numerous fat compartments that make up certain prominences or collections that are accessible to surgical removal. While fat exists underneath all areas of the facial skin, much of it is thinner and not easily removed. Unlike the abdomen or the thighs where broad areas can be treated by liposuction, facial fat can not be treated the same way or so effectively.

Case Study: This 25 year-old female did not like the shape of her face. She felt it was too round and never liked it. Despite her perception of a round fuller face, she was not overweight and had a thin to moderate body build. She felt that if she could just get rid of some facial fat she would be much improved. She was otherwise happy with her facial bone structure.

She underwent a three compartment facial fat removal approach under sedation anesthesia. Her submental and neck area was treated by small cannula liposuction. A large amount of cheek fat was removed by buccal lipectomies done from inside the mouth. Through small incision under the earlobe, the side of the fat over the parotid gland and into the jowl area was also liposuctioned.  

She wore a neck and jowl compression garment to help with swelling for the first 48 hours. She was able to shower and wash her hair the next day. By one week after surgery, she looked ‘non-surgical’ and was able to see the results of the surgery after three weeks. The final results could be fully seen by six weeks after surgery. She was pleased with the results of the surgery and achieved a facial shape that was less round and more distinct

Case Highlights:

1)     The round face has greater amounts of compartmentalized fat in the cheeks, neck and side of the face which may be surgically treated. Much of the round facial fat has extensive subcutaneous fat which can not removed.


2)     The round face can be improved by cheek, neck and lateral facial fat removal using a combination of liposuction and direct lipectomy.


3)     The amount of ‘derounding’ that a face can achieve by fat removal alone can be minimal to moderate improvement. If combined with facial bone augmentation , if needed, the results can be more significant.

Dr. Barry Eppley

Indianapolis, Indiana

Contemporary Cheek Enhancement – Malar and Submalar Zone Considerations

Sunday, March 21st, 2010

The cheek or the midface region plays an important role in facial appearance. As one of the five facial bony prominences (brow, nose, chin, and jaw angles are the others), it is actually the most complex. It lacks any sharp angles, is made up of several bones that intersect together and is surrounded by three distinctly different soft tissue regions. While everyone appreciates that a high and strong cheekbone is desireable, it is not easy to quantitate what that should look like unlike chin projection or jaw angle width which can be actually be measured.

Rather than some absolute number, the cheek region is better recognized for what it does for facial shape and width. As part of understanding cheek morphology, one should not forget how the soft tissue below it affects how the bone looks above. Known as the submalar (below the cheek) region, it is affected by the size and prominence of the buccal fat pad. This golf ball-sized fat collection can be surprisingly large and it helps make for a rounder and fuller cheek region appearance. If the buccal fat pad is very large, it can make this area protrude or be quite ‘cheeky’. If this and other facial areas are small or atrophic, the facial shape may assume a more gaunt appearance.

Therefore when assessing the cheek area, the consideration of both bone (malar) and buccal fat (submalar) areas should be done. Implant manufacturers have recently showed an appreciation for this concept by expanding traditional cheek implants to include either (malar and submalar) or both. (combined submalar shells) Combinations of malar and submalar changes can often make for a better cheek result than just a ‘simple cheek’ implant alone. In some cases, cheek bone enhancement and some submalar reduction (buccal fat removal) may produce better cheek highlights. In other cases, submalar augmentation or a combined malar-submalar augmentation may be aesthetically better.

The uniqueness of  each person’s face and their desired cosmetic outcome must be taken into consideration when planning changes in this area. Removal, or more accurately, reduction of the buccal fat pad (buccal lipectomy) is a surgically simple procedure but it’s decision to do so is more aesthetically complex. Through a very small incision inside the mouth opposite the maxillary first or second molars, the buccal fat pad can be gently teased out. When doing at the same time as some type of midfacial implant, it can be done through the same incision. How much one removes is a matter of judgment. As a general rule, it is not a good idea to try and remove all of it. Not only may that be undesireable in facial appearance in the long-term, but there are several buccal branches of the facial nerve which interlace with the multi-lobed buccal fat pad. They exist most commonly on the superficial (outer) aspect of the buccal lobe, away from the area of intraoral manipulation. For this reason, aggressive buccal lipectomies may inadvertently damage these branches. I have never observedfacial nerve injury from a buccal lipectomy procedure but this attests to a more conservative resection philosophy. In uncommon cases with a very full and ‘fat’ face, a more complete buccal lipectomy may be justified. Such an approach works well when ‘fat-reducing or facial thinning’ procedures are being done such as neck liposuction and/or chin or cheek implants.

Conversely, submalar augmentation rather than reduction may be needed to help fill out a thin or gaunt facial appearance. While initially developed for lifting sagging cheek tissues over ten years ago, the submalar implant is much more commonly used to add soft tissue fullness rather than a lifting effect. If the cheek prominence is adequate but the underlying submalar region is thin or ‘sucked inward’ (indented), than an isolated submalar implant may suffice. If the overall cheek (malar and submalar) is too flat or deficient, then a combined malar-submalar implant may be needed.

When considering cheek augmentation as part of an overall facial improvement plan, both the malar and submalar regions must be considered together. Between expanded submalar implant designs and buccal lipectomies,  a more comprehensive approach with satisfying surgical results is now available.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Options for the Chubby Face (Fat Face)

Monday, February 15th, 2010

It is not uncommon to hear a patient’s concern about their chubby or ‘fat face’. For some of these patients their face matches their body habitus and some significant weight loss will do wonders for those concerns. But there are people who do have a chubby face that are not necessarily significantly overweight and they may seek a plastic surgery consult to see what their options are.

 The chubby face differs from other facial types in that the entire face appears full. From the cheeks down to the neck, the face assumes a definite round shape. Patients with a chubby face will often complain that the shape of their face makes them appear heavier than their body really is.

There are numerous non-surgical facial fat reduction methods that are marketed and sold. I can not comment on whether these work or are effective as they are not used in my Indianapolis plastic surgery practice. But should you try them and find them unsatisfactory, you can consider the following surgical options.

Almost all chubby face patients have thicker and elastic skin. This is a double-edged anatomic consideration. Such skin has the ability to shrink and contract (snapback if you will) which is good for getting better contours, particularly in the neck. Conversely, thick skin is also heavy and is prone to prolonged swelling.

The strategy for the chubby face is not one of overall fat reduction through liposuction. This is not possible in the face contrary to the perception of many. Select or spot fat reduction must be done instead. This would include submental and neck liposuction and buccal (cheek) lipectomies. These are very consistent procedures that are effective but patients should not expect them alone to produce a dramatic facial change. Fat pockets around the eyes and excessive skin can also be helpful if they exist but these are complementary procedures, not a primary modification maneuver.

There are no other fat areas of the face that can be effectively reduced. While significant changes can be made, for example, through a superficial parotidectomy and submandibular gland removals, these are extreme procedures which are not justifiable for cosmetic changes. Attention must be turned to bringing out facial prominences to aesthetically work in the opposite direction.

The cheeks, chin and nose must be carefully look at to see if their accentuation would be beneficial. The chin is the easiest one to assess as a weak chin is readily seen. Chin augmentation, even if it is only a minor amount, can complement the contour pullback from the neck liposuction. Cheek augmentation is more difficult to determine its potential benefits as it is not a profile structure. Unlike the chin, cheek augmentation in some patients may actually make their face look fuller or heavier. A cheek implant to help make a face look thinner must be placed high on the cheekbone and not be overdone in amount and location of projection. Too much anterior or too much lateral projection creates undesired midfacial fullness.

A rhinoplasty with dorsal augmentation and tip narrowing can help make the face look thinner by an optical illusion effect. Thinning of the nose is the one procedure that affects the central face whose appearance is not based on how much fat is present. Patients with chubby faces rarely have a narrow nose or a nose with a high dorsum. Usually they have a broader dorsum with a wider tip to their noses.

To change the appearance of the chubby face, multiple soft and hard tissues procedures are needed. These can include neck and cheek fat removal, blepharoplasty, and facial bone prominence highlighting. Piecing together these procedures into an effective facial surgery plan is as much an art form as any definitive science.   

Dr. Barry Eppley

Indianapolis, Indiana

The Anatomy of the Buccal Lipectomy

Saturday, November 15th, 2008

I frequently get asked by patients in consultation or online what they can do to make their face look thinner. Besides the obvious answer of weight loss for some patients, they are specifically asking about facial fat removal either through liposuction or removal of the buccal fat pads. While liposuction can make a great difference in the neck, it is not a good method for removal of fat in the face. This has been tried a lot in the past and all that usually happens is a lot of swelling with little to no results. So that leaves the buccal lipectomy procedure as the only true fat removal procedure of the face.

What is a buccal lipectomy and what can it really do? The term, buccal, means cheek and we are talking about a very distinct collection of fat that sits right under the cheek bones in the appropriately named buccal space. It is situated between the cheek skin and the cheek lining inside the mouth. It is a very large fat collection, about the size of a golf ball, and actually has fingers of fat that go beyond the cheek into other areas such as the temples. It does provide fullness to the cheek area but is not responsible for fullness at the level of the corner of the mouth or beyond. The exact reason we have this buccal fat is not really known but most believe it serves as cushioning between the chewing muscles.

Removal of the buccal fat pad is really quite easy through a small incision inside the mouth. The fat is easily teased out and a surprising amount can actually be removed. How much to remove is a matter of judgment. If the patient has a really full round face, I will try and remove as much as possible to create an effect that can be seen through their thick overlying skin. You have no worries that you will make them too ‘thin’. In thinner people one has to be careful to not remove too much for it is possible to give someone a very gaunt or hollowed look months or years after surgery. Certainly in a very thin face, this procedure should not be done.

The results from a buccal lipectomy is to create a flattening or indentation of the area beneath the cheek bones. This effect is mimicked by the application of makeup that women use to contour the cheeks. (darker makeup underneath the cheek bone) While this helps thin out or narrow this part of the face, other procedures are usually needed to create an overall facial change that makes it appear thinner, such as liposuction of the neck and chin augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Improving the Shape of the Face by Bony Augmentation and Fat Reduction

Thursday, October 9th, 2008

Making a face more square or angular can be done through bone augmentation, fat reduction, or both. I have found that there are two types of patients who come because they want a more defined facial look. First is the male patient (usually younger)who does not necessarily have a full or fat face but wants more definition at the defining points of the face. In some cases, I call this seeking the ‘male model look’. The second type of patient is male or female who does have a fuller face and simply wants to be ‘less round’. Their goals are not quite so precise as the first patient. Usually they are younger as well but can be middle-aged also.

The defining bony points of the face are the cheeks, chin, and jaw angles. Facial fat points are the cheeks and neck. Those searching for the ‘male model look’ are usually looking at the trio or combination of cheek, chin and jaw angle implants.  The thinner the face is, the more profound the result will be with this triple implant approach. When you are placing three implants, or simultaneously changing three facial prominences, it is always best to not to overdo it. Large implants in all three places can create a very unnatural or artificial look. Cheek implants never look too good if they are too large.  Subtle cheek changes are more natural.The proper size of a chin implant is easier to know because the amount of chin deficiency can be measured in profile. Most men should consider a more square chin implant style as that is often what this type of patient is trying to achieve. Jaw angle implants can rarely be too large as they are manufactured small anyway and the jaw muscles and thickness of tissue over the jaw angles can camouflage a great deal of the implant.

Those trying to deround a face must use a different approach. Fat removal in the neck (liposuction) and in the cheeks (buccal lipectomies) are an important element of derounding and is often done with a chin implant. In rare cases, cheek implants may be considered but they should be small as buccal fat removal will create the visual impression of some minor cheek augmentation as the area below the cheek moves inward. This type of facial derounding is more subtle than squaring a face with the most dramatic changes occurring in the neck and less in the cheek and side areas of the face.

Careful analysis of the face prior to surgery through computer imaging can be invaluable in this type of surgery. Changing multiple areas of the face at one time, with the objective of changing one’s facial look, requires good insight and understanding between the patient and their plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana






Facial Reshaping Techniques for Improving The Round Face

Thursday, July 10th, 2008

Not infrequently I get requests from patients for the desire to transform a round face into a more shapelier one. One cause of a round face is that the patient is overweight. A full neck, round cheeks, and a lot of subcutaneous fat throughout the face creates a generalized fullness that creates a fat and round face. These patients know full well that they are overweight and some liposuction of the neck and buccal lipectomies may make some difference. But weight loss will probably make the most difference in these cases. And these procedures should not be performed until some weight loss has been achieved.
But the overweight patient is not what usually makes up the ’round face’ patient. Most commonly these are younger patients that are not significantly overweight and are usually closer to being more height and weight porportionate. They may have some mild fullness in the cheeks and neck but often their bony prominences (cheeks, chin, or jaw angles) may be somewhat deficient. The approach to these patients must deal with both hard and soft tissues issues to be effective at improving the face’s angularity and definition.
In addition to the fullness of the cheeks and neck, the next most important consideration in facial shape improvement should look at the chin. Often it may only be midly short in the horizontal dimension but the width of the chin is also important, particularly in the male patient. Chin implants today can provide more projection as well as width in many different sizes. Placed through a small incision under the chin bone, a chin implant can lend more definition and squareness to the lower face from subtle to dramatic results.
Upper facial fullness, more specifically midfacial fullness, can be achieved through cheek implants. Placed into position by incisions inside the mouth under the upper lip, cheek implants can provide good highlights through three-dimensional enhancement of the bone as it wraps around the area below the eye. An amazing aray of cheek and midface implants is available to provide a lot of enhancements around this important facial landmark. When paired cheek implants are combined with a chin implant, an upside down triangle of change is created that directly opposes a more round or oval facial shape.
Jaw angle implants are always a possibility but these are rarely needed in most really round faces. They can produce some lateral facial fullness but this is not usually helpful in ‘de-rounding’ the face.
The procedures of buccal lipectomies, neck and jowl liposuction, chin and cheek implants make up the usual plastic surgery tools for facial rehaping. Which one or combination of procedures is most helpful for improving facial definition is best determined by careful computer imaging study between the patient and their plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

The Six Zones of Change for Improved Facial Definition

Monday, June 23rd, 2008

I frequently see patients who desire greater facial definition. Usually these are younger men and women and much of their desire comes from having a fuller or fatter type face. Most of the time they have lost some weight but can’t lose it in the face. Others have never had a weight problem but want to have a more ‘chiseled’ facial appearance….this type of patient is almost exclusively a younger male patient. Regardless of their age, sex, and weight background, their objectives is to make their face appear less full with better accentuated facial features.
When looking at such patients, it is important to realize that their are only six facial landmarks which can be surgically altered to achieve these goals. They are (from top to bottom): cheeks, subcheeks (submalar), nose, chin, jaw angles, and neck. Four of these are more hard tissue (bone and hard tissue) and two of them are soft tissue or fat only. In the heavy or once heavy patient, the foundation of treatment is usually neck liposuction and buccal lipectomies. Reducing full areas by fat removal is always the first step and, for many, may be all that is really needed.They may benefit from cheek or chin augmentation as well and a good pre-surgical digital computer analysis and predictions will make this clear. A chin augmentation through an implant with fat removals in the cheek and neck is not an uncommon combination that can be highly successful.
In the ‘non-heavy’ or non-weight loss facial patient, fat removals may not be necessary at all. If needed, it is only in the buccal (cheek) areas only. This type of facial definition patient requires bony enhancement mainly. This may be chin, cheeks, or jaw angle implants and a computer analysis can tell which combination may be best. The order of facial implantation is chin implants are done the most, jaw angle implants next, and cheek implants the least. For the young male patient that is looking for what I call the ‘male model’ look, all three facial implants may be necessary.
I would be remiss in this discussion if the concept of rhinoplasty is not brought up as part of the surgical options. A broad, wide, or long nose can also be a source of facial disharmony. Rhinoplasty surgery helps put the nose into better balance with the rest of the face and a well-proptioned nose in some patients can make a dramatic difference. While it is not the most common facial change in facial definition surgery, it must always be considered in diagnosing what makes a patient’s face unbalanced.
Enhancing and redefining facial contours is a combination of fat removals and bony prominence enhancements. While none of these surgeries are difficult and all can be accomplished without facial scars, the most important part lies in the pre-surgical discussion and planning. These patients are highly self-conscious and, as a result, will be extremely critical of their surgical result. Thorough computer imaging and realistic goal-setting is the key in making the facial definition patient satisfied.
Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

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.

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