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The buccal fat pad is a unique facial structure located in the deep midface area  whose exact function remains uncertain. What makes it unique is that it is an encapsulated fat collection that has its own pedicle blood supply. Being a discrete fat mass in the face that can be readily accessed it has long been a target for removal for the effect of reductive cheek contouring. While once widely condemned for fear of its potential adverse long term facial effects it is become more mainstream today and more commonly performed. (although patient selection is critical to avoid creating a gaunt facial appearance)  

In the March 2023 issue of the journal Plastic and Reconstructive Surgery an article in this topic was published entitled ‘The Five Ds for Safe and Effective Buccal Fat Removal’. In this paper the authors review five critical steps in the procedure which include: 1) intraoral incision location with awareness of the location of the parotid duct, 2) the use of blunt dissection to avoid prominent blood vessels that lie anterior to the fat pad, 3) gentle traction delivery of the most easily mobilized part of the fat pad, 4) electrocautery at the base of the stalk removal, and 5) single suture closure.

Having removed over 500 buccal fat pads in the past 30 years I can certainly testify that these are important surgical principles for the buccal lipectomy procedure to which I can add the following observations I have learned. 1) Keep the intraoral vestibular incision small, usually not more than 5mms to start. (more of a puncture site) There is no reason to make it any bigger as the mucosa will stretch as a hemostat is inserted to perform the blunt dissection down to the buccal fat pad. 2) In doing the blunt dissection be aware that there are other smaller fat collections anterior to the buccal fat pad which to the inexperienced may lead them to erroneously believe it is the buccal fat pad. I have seen numerous patients who have had prior buccal lipectomies only to find a completely untouched fat pad present. 3) In opening the capsule of the buccal fat pad by blunt dissection the globular fat will literally herniate out. It can then be gently teased out through the small mucosal incision. Don’t pull, let the herniation do most of the work. What comes out easily is what should be removed. Since it has a vascular pedicle electrocautery at the amputation location is important to avoid a postoperative hematoma.

In this paper the authors recommend what I consider unnecessary postoperative management although they are certainly not harmful. I have never used mouthwashes or dietary restrictions afterward. They may have benefit if one doesn’t close the intraoral incision. But with closure the incision sits high up in the vestibule where it is out of the way from the trauma of mastication.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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