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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘buccal fat pad’

The Role of The Buccal Lipectomy in Facial Reshaping

Wednesday, July 29th, 2015

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.

Buccal Fat Pad AnatomyWhile 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.

Dr. Barry Eppley

Indianapolis, Indiana

Cheek Enhancement – A Missing Part of Facial Rejuvenation

Tuesday, September 2nd, 2008

When one thinks of facial aging, they inevitably look to the jowl and neck area.While this lower facial area is of big concern to many and is the foundation of facial rejuvenation surgery (usually through a facelift-type procedure), the underlooked area is the midface or cheek. As one ages, the cheek area sinks in and sags for many as it loses volume through fat atrophy. This is partly why a heavy person with a full face may still look somewhat youthful as they age. (known as the Santa Claus effect) A gaunter, thinner face, while interesting when one is young, can really show age when one is older.


Adding volume to the cheek has been recently shown to to help make a more youthful face. Based on cadaver work by Dr. Joel Pessa at the University of Texas at Southwestern, a deep fat compartment was identified in the cheek. When this fat compartment was enhanced through implants or fillers, there was an immediate improvement in the hollowing of the face. Not only does restoring volume to this cheek compartment make the cheek/midface area more youthful, it also helps improves the look under the eyes as well as around the nose and upper lip area.


The jury is still out, however, on the best method to do this cheek volume addition. Fat injections would be the simplest and the most versatile, but fat survival remains unpredictable particularly in the older patient. I currently add PRP (platelet-rich plasma extract from the patient) to the injections and isolate the fat through a unique centrifguation method. Early results are encouraging but only one year results count when it comes to fat grafting. Cheek implants are simple to do, remain stable in volume over time, and come in a few styles to add volume to some different areas around the cheek. Unfortunately, the more lateral cheek area, which is not over bone is not affected by the introduction of an implant. And there is always the risk of infection or malpositioning. Injectable fillers are as versatile as fat injections and don’t involve an operating room experience. But their effects are only temporary and, when adding up the cost per volume injected, can potentially rival surgery fees if a large cheek area needs to be treated.
Not every aging face patient needs cheek enhancement nor is it the mainstay treatment of most aging faces. But it can be a good complement to more conventional facelifting procedures and is a ‘missing component’ of some patient’s treatment plans whether they are young or old.
Dr. Barry Eppley

Indianapolis, Indiana

Buccal Lipectomies As A Component of Facial Derounding

Saturday, June 21st, 2008

 Fullness in the midface, or a rounder area beneath the cheek bone, is partially the result of the prominent of the buccal fat pad. Most people do not realize that their is a large ball-like collection of fat under the cheek bone that in some patients can create lack of definition in the midface-cheek area.
The buccal fat pad has many ‘fingers’ that extend out from it to reach up to the temple area as well. Its exact role is not precisely clear and it appears to be similar to the appendix or your wisdom teeth….you can live just fine without it. Removing the buccal fat pad, a procedure known as a buccal lipectomy, is a very simple and uncomplicated procedure to perform. Through a very small incision just opposite the upper second molars, the buccal fat pad is teased out and removed. Portions of it or almost all of it can be removed. A single dissolvable stitch closes the incision. There is nothing special to do after surgery. One can eat or drink whatever and whenever one wants. There may be some mild swelling, and occasionally a small amount of bruising, but this completely clears within a week or so. It may take several weeks to see the results but some patients seek improvement even in the face of early swelling.
I often perform buccal lipectomies in younger patients in an effort to help change a rounder face and reduce cheek fullness. It may be performed alone but is usually done in combination with other adjunctive facial procedures such as neck liposuction, cheek implants, chin implants, or rhinoplasty. Buccal lipectomies create a subtle improvement and for this reason are not usually done alone….although it can be. When performed alone, I can do them in the office under local anesthesia if the patient desires.
The size of many buccal fat pads can be impressive and their removal can be quite substantial. One has to carefully look at the patient’s face and be certain that this procedure would really be helpful as it is easy to create the opposite problem (gaunt sunken-in look) which can develop over time in some patients. This is why I only usually use it in very full round faces with prominent cheeks. It is not a substitute for the patient who really needs a cheek augmentation instead. When done in the cheek-deficient patient, you are only flattening out the midface further.

Dr. Barry Eppley

Indianapolis, Indiana

Buccal Lipectomies – Beware of the Facial Nerve

Monday, November 5th, 2007


In select patients, removal of the buccal fat pad (which lies immediately under the cheekbone and is about the size of a golfball in most patients) can help contour a fuller face. I have performed this procedure, in conjunction with liposuction of the neck andchin implants, many times in patients whose desire is to thin out their fuller faces.

In numerous anatomic studies, dissectors have detailed the known relationship between the facial nerve, buccal fat pad and the parotid duct. Given the frequent proximity to this area during many types during aesthetic and reconstructive facial surgery, it is useful to have a better appreciation of this midfacial crossroads region.

Like most cadaveric studies, there are no absolutes for each person’s anatomy. However, it is clear that several buccal branches of the facial nerve interlace with the multi-lobed buccal fat pad. Most commonly, this is on the superficial (outer) aspect of the buccal lobe, away from intraoral approaches of manipulation. For this reason,
aggressive buccal lipectomies may inadvertently damage these branches. I have never observed facial nerve injury from a buccal lipectomy procedure but this attests to a more limited resection. Complete removal is usually aesthetically undesireable but also places these nerve branches at risk. Since the parotid duct shares a similar pattern of proximity as that of the nerve, injury to it is also theoretically possible. However, it is a much larger structure that is tethered by its attachment to the oral mucosa and, as such, not as easily avulsed from its anatomic bed.

In performing buccal lipectomies, it is important to bear the anatomy of the facial nerve branches in mind and adjust the amount of buccal fat resection accordingly. This is why it is always better to under remove when taking out the buccal fat pad. This is probably better from a long-term cosmetic standpoint anyway.

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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