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The buccal lipectomy is a well known cheek reduction contouring procedure. Its effectiveness is based on the removal of a distinct fat pad of significant volume that lies between the masseter and the pterygoid muscles. It is anatomically different from almost all other facial fat sites which are more diffuse and spread out in the more subcutaneous tissue location. Thus buccal fat offers a more complete area of fat removal than what liposuction accomplishes in other parts of the face and is less traumatic to do so as well.

What is very unique about buccal fat pad anatomy, and it bears great similarity to that of eyelid fat, is that it is encapsulated. Encapsulated fat is in many ways under ‘pressure’, meaning once its surrounding capsule is opened the fat comes ‘spilling out’ in large lobule form. This anatomic feature is useful when it comes to its extraction and enables it to be done through a much smaller intraoral incision than the diameter of the fat pad.

The intraoral incision is a small one, made initially as just a stab incision with electrocautery in the vestibule opposite the 1st/2nd maxillary molars. A hemostat is used to spread through the buccinator muscle and past what some erroneously assume is the buccal pad. This is a small submuscular fat collection that has small lobules and provides little fat for any significant volume reduction. Spreading deeper the white capsule of the buccal fat pad is encountered between the two masticatory muscles. Once the capsule is spread open the very large and bright yellow fat of the buccal fat pad is seen. The fat pad is then grabbed and gently pulled out through the incision.

By continued gentle traction the fat pad is pulled out in a linear fashion through the small incision. The buccal fat pad is really a vascularized fat flap so it has a vascular pedicle. What is being pulled out is the distal end of the fat flap. Once the fat flap comes under tension and no more fat easily comes out, the amount of fat pad that can be safely removed is reached. The base of the fat flap is then cauterized for its removal and to prevent any postoperative bleeding.

The small intraoral incision is then closed with one resorbable suture. Since inntraoral mucosa is very elastic it can easily be spread open by stretching for deeper access. Thus deliberately making a long incision is not necessary.

By making a small incision combined with the anatomy of the buccal fat pad, its removal can be done by converting a round madd of fat into a linear form that permits its passage through an incision much smaller than its diameter.     

Dr. Barry Eppley

Indianapolis, Indiana

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