Facial aging is associated with the development of soft tissue laxities and descent. This appears on the face in a variety of ways of which one is the most common and recognized as the development of jowls. As jowls develop the face changes shape often from a heart-shaped to a more square shape in women. This causes a masculinization effect as well as as aged one. In some cases there also develops fullness lateral to the jowls due to descent or ptosis of the buccal fat pad.
While maintaining or adding volume (fat) in the aging face is a recognized rejuvenation strategy, ptosis of the buccal fad represents the one time where fat removal is appropriate. Excising the buccal fat pad is most commonly done through an intraoral approach on its inner side. However during a facelift access can be done on its outer side underneath the facelift skin flap. But under the facelift flap just about everything looks yellow/fatty in color so knowing where to begin the dissection would be very helpful.
In the January 2020 issue of the Aesthetic Surgery Journal an article was published entitled ‘External Approach to Buccal Fat Excision in Facelift: Anatomy and Technique’. In this cadaveric study the authors examined the location of the buccal fad pad through a facelift flap approach. In eighteen (18) specimens measurements from the buccal fat pad to a variety of ear and facial landmarks were determined with the objective of describing a reliable external approach for its removal in facelift surgery.
The buccal fat pad was found to be 4 cms below the zygomatic arch, 7.5cm anterior to the tragus and 4.5cm anterior to the gonial angle. The parotid duct passed superiorly to the fat pad in all specimens. The buccal branches of the facial nerve were found to be superficial to the buccal fat pad capsule. The middle facial artery suppled the fat pad either on its inferolateral side in 2/3s of the specimens and on its inferomedial side in the remaining 1/3.
Buccal fat pad herniation in the aging face is not common but can occur. While intraoral removal is the most direct and easiest approach for buccal lipectomies, even during a facelift, it can also be done from the facelift side. These measurements provide a good guide as to where to begin the search for its location.
Dr. Barry Eppley