Cosmetic Anatomical Structure of the Buccal Fat Pad and Its Clinical Adaptations D., Ke- Hai-Ming Zhang, M.D., Yi-Ping Yan, Beijing, China Before performing plasticand aesthetic surgery around the buccal area, the authors reviewed the anatomical structures of the buceal fat pad in 11 head specimens (i 22 sides of the face). The enveloping, fixed tissues and the source of the nutritional vessels to the buecal fat pad and its relationship with surrounding structures were observed in detail, with the dissection procedure described step by step. The dissection showed that the buceal fat pad can be divided into three lobes—anterior, intermediate, and pos- terior—according to the structure of the lobar envelopes, the formation of the ligaments, and the source of the nutritional vessels. The buccal, pterygoid, pterygopal tine, and temporal extensions (superficial and profound) are derived from the posterior lobe. The buccal fat pa fixed by six ligaments to the maxilla, posterior zygo and inner and outer rim of the infraotbital fissure, t poralis tendon, or buccinator membrane. Several nut: tional vessels exist in each lobe and in the subeaps vascular plexus forms. The buceal fat pads funetion to fill the deep tissue spaces, to act as gliding pads when mas. ticatory and mimetic muscles contract, and 10 cushion important structures from the extrusion of muscle cor traction or outer force impulsion, The volume of the buccal fat pad may change throughout a person's life Based on the findings of the dissections, the authors pro- vide several clinical applications for the buceal fat pad, the nasolabial fold such as the mechanisin of deepeni and possible rhytidectomy to suspend the anterior lobe upward and backward. They suggest that relaxation, poor development of the ligaments, or rupture of the buccal ft pad capsules can make the buccal extension drop or pro: lapse to the mouth or subcutaneous layer. As such, the authors refined their methods and heightened their focus, when using the buccal fat pad to perform a random or pedicled buccal fat pad fat flap oF to correct a buccal skin, protrusion or hollow, (Plast. Reconstr. Surg. 109: 2508, 2002 Since Heister first described the buccal fat pad 300 years ago," substantial data!“!" have been obtained about it, including its anatomi- cal structures, physiological functions, embry- ology, and relationship to the masticatory space. From the Departmentof Plastic Surgery, the Department of Cini and Peking Union Medical College, Received for publication Septe i, M.D., Jia-Qi Wang, M.D., and Zhi: Liu, M.D. The buccal fat pad is the fat tissue that stays in the profound facial spaces. Its body lies be- hind the zygomatic arch. There are four pro- cesses, including the buccal process, the pter goid process, the superficial process, and the deep temporal process, that extend from the body to surrounding tissue spaces such as the pterygomandibular space and the infra- temporal space.'” Chinese scientists* intro- duced an additional process—the pterygopala tine process—which stays in the space of the pterygopalatine fossa. The volume of the buc- cal fat pad remains relatively stable throughout a person's Ii We focused this study on the clinical appli- cations of the buccal fat pad in plastic and aesthetic surgery in recent years.!!""! For ex- ample, traumatic injury can cause the pad to escape from its ordinary location to the mouth or to the facial subcutaneous layer.""! As a result of aging, deep fascia laxity allows the pad to herniate into the subcutaneous layer; the skin process is shown and should be resected. The buccal fat pad could be used for free* or pedicled fat tissue grafts!” to repair the local tissue defects. If the buccal fat pad is too small, however, it would cause a shadow around the infrazygomatic area, and augmentation to serta suitable volume of silicone capsule would be necessary.® Before performing aesthetic surgery around the buccal area, we finished a revised dissec tion of the buccal fat pad some different op ions on the structures of the buccal fat pad have been put forth. MATERIALS AND MerHoDs Our study was based on 11 full-head speci- mens fixed in formalin liquid. Three of the omy, Plastic Surgery Hi 1; revised Now2510 heads were from children, three were from younger adults, and five were from older adults. The carotids of all of the specimens were injected with black glue, which stayed in for 24 hours. The study involved step-by-step dissection from the superficial layer to the profound layer, and the results were recorded. Whe: dissecting, we preserved the black vessels to the buccal fat pad and observed their sources, es, position of entry into the buccal fat pad, distribution, and anastomosis in the sub- capsular layer. RESULTS Composition of Three Independent Lobes According to the characteristics of encapsu- lation, ligaments, and source of arteries, our study revealed that the buccal fat pad could be divided into three lobes—anterior, intermed ate, and posterior. Each lobe of the buccal fat pad is encapsulated by an independent mem- brane, fixed by some ligaments, and nourished by different sources of arteries. An indeper dent vascular plexus exists under the lobar capsule, and there is a natural space among the lobes. Reports in the literature have pointed out that the duct of the parotid passes along the lateral surface of the buccal fat pad! or pen trates the body of the buccal fat pad®* before it opens on the buccinator. Our results revealed that, whether in children or adults, there is a lot of fat tissue surrounding the duct, anterior facial vein, and infraorbital vessels and nerve and filling the spaces around the quadrate muscle of the upper lip, zygomatic muscles, maxilla, and buccinator muscle. These fat ti sues are surrounded by one complete lobar capsule. Two arteries nourish them: the supe- rior branch of the anterior lobe from the st- perior posterior alveolar artery and the inferior branch of the anterior lobe from the inferior buceinator artery. We named this mass of fat sue the anterior lobe The anterior lobe of the buccal fat pad is located below the zygoma, extending to the front of the buccinator, maxilla, and the deep space of the quadrate muscle of the upper lip and major zygomatic muscle (Figs. | through 4). The canine muscle originates from the in- fraorbital foramen and passes through the i ner part of the anterior lobe (Fig. 3). The duct of the parotid passes through the posterior PLASTIC AND RECONSTRUCTIVE SURGERY, June 2002 AL-BrP Fic, 1. (Aboow) Afler removal of the superficial dssues| above the buccal fat pad of a child’s specimen, the buccal Dbranches (BB) of the facial nerve cross over the anterior lobe (AL-BEP) and buccal extension (BE). The major zygomatic :muiscle lies on the anterior lobe, The duct ofthe parotid (DP), and anterior facial vein goes through the anterior lobe. The buccal extension stays below the duct of the parotid and lies backward on the surface ofthe masseter, which develops well (Below) The anterior lobe in an adult. The fat tissue packing, the ducts less than thatin children, Inward and upward, the anterior lobe encapsulates the infraorbital vessels and goes into the infraorbital foramen (JOP). P, pavotids IML-BEP, intermediate lobe; SPTE, superticial part of the temporal part, and the anterior facial vein passes through the antero-inferior margin. The ante- jor lobe also packs the infraorbital vessels and nerve and goes into the intraorbital tube with them. The branches of facial nerve lie over the outer surface of the capsule of the anterior lobe (Fig. 2, above) The anterior lobe is triangular. It is com- posed of more connective tissue septa that sep- arate the fat tissue into smaller masses. The anterior lobe joins with the intermediate and posterior lobes by loose connective tissue and with the buccinator membrane by dense con- nective tissue around the opening of the pa- rotid duct, together with the posterior lobe ‘The intermediate lobe of the buccal fat padVol. 109, No. 7 / STRUCTURE OF THE BUCCAL FAT PAD Fic. 2. (Advoe) After removal of the super 2511 ial fascia in the face, the exposed buccal branches (BB) of the facial nerve cross the surface of the anterior lobe (AL-BEP) and the buccal extension (BE). The duct of the parotid (DP) and the anterior facial vein (AFV) pass through the etior lobe. (Bel) As the branches of the facial the anterior lobe were completely exposed. The buecal extension lies below the duct and covers backward the sscter, The buccal extension branch of the middle facial artery goes forward across the surface of the masseter and gets into the buceal extension. The facial artery (Fl) is the front rim of the anterior lobe (Figs. 4 and 5), which was not observed from previous reports,“ lies in the space around the posterior lobe, lateral maxilla, and anterior lobe. It is a membrane-like structure with thin fat tissue in adults (Fig. 4, below) and a large mass in children (Fig. 4, above). Although there is a single membranous septum between the upper parts of the intermediate and posterior lobes, there is no septum between their lower parts (Fig. 5) The posterior lobe of the buccal fat_pad (Figs. 4 through 6) exists throughout life in humans. Xie and Zhang” named the two lobes of the buccal process, but this identification was inaccurate because the lobe above the duct of the parotid is actually a part of the posterior lobe or body.!* This lobe stays in the mastica- tory space and in neighboring spaces. It runs up to the infraorbital fissure and space sur- rounding the temporalis muscle, down to the upper rim of the mandibular body, and back to the anterior rim of the temporalis tendon and ramus, in doing so forming the buccal, ptery- gopalatine, pterygoid, and temporal processes. The buccal process (Figs. | through 7) is the lower part of the posterior lobe below the duct of the parotid.'? It is the most superficial pro- cess; however, its size can affect the buccal appearance. For children, this process often extends backward and lies on the surface of the masseter. The pterygopalatine process (Fig. 7, above) is the fat tissue that extends to the pterygopala- tine fossa, which encapsulates the pterygopala- tine vessels. This process also runs up through the infraorbital fissure into the groove with infraorbital vessels acting as a vascular sheath that fuses to the tissue from the anterior lobe. Although staying below the orbita, the fat tis- sues are segregated from the circumbulbar fat with a dense connective tissue septum (Figs. 3 and 5) The pterygoid process is a posterior exten- sion that generally stays in the pterygomandib- ular space, as previously reported, '~* and packs the neighboring vessels and nerves, such as the mandibular neurovascular bundle and lingual nerve. It often extends back along the deep spaces to the fossa of the submandibular gland in children. The temporal process can be divided into two parts: superficial and profound. The super ficial part (Figs. 1 and 4 through 6) is not the same as the descriptions of the superficial tem- poral extension, which lies in the space be- tween two layers of the profound temporal2512. PLASTIC AND RECONSTRUCTIVE SURGERY, June 2002 Fic, 3. A coronal cut of the head at the level of the canine. The anterior lobe is located in the deep space of the mimetic muscles, BEB, buccal extension branch; P, parotid: 7BB, inferior buccinator branch; SCKT, subcutaneous fat tissue; MZM, major zygomatic muscle; OM, orbicularis muscle; QMUL, quadrate muscle of the upper lip; CM, canine muscle. fascia, as reported by Stuzin et al. Actually, the superficial part stays between the profound temporal fascia, temporalis muscle, and ten- don, The anterior end turns inward along the anterior rim of the temporalis muscle and con- tinues with the profound part. Itis fan-shaped, and the ligament formed by the incrassation of the lateral capsule ends running forward and downward to the posterior zygoma (Fig. 4) The profound part (Figs. 4, below, left and right, and 5) stays outward behind the lateral orbital wall and frontal process of the zygoma and turns backward into the infratemporal space. It also functions as the vessel sheath to pack the anterior profound temporal vessels. Fixation of the Buccal Fat Pad by Ligaments Although we found no documentation in the literature of Ii s being used to fix the buccal fat pad,'""" in our investigation they were shaped by the incrassation of lobar cap- sules in certain directions. Each lobe anchors to the surrounding structures by two to four ligaments (Figs. 4, 6, and 7), which are also the entries of nutritional vessels to the buccal fat pad. The maxillary ligament of the buceal fat pad (Fig. 4, 6, and 7) is the incrassation of the inner face of the anterior lobar capsule and clings upward to the inferior end of adhesion of the aygoma and maxilla. ‘The posterior zygomatic ligament of the buc- cal fat pad (Figs. 4, 6, and 7), which is formed from the lateral capsule of the intermediate lobe, the posterior lobe, and the superficial part of the temporal process, fixes inward to the posterior zygoma. Is width is equal to the height of the zygoma. The medial infra buccal fat pad (Figs. 4, 6, and 7) is the structure of the medial capsule of the ate lobe and the upper part of the posterior lobe. It clings to the inner rim of the infraorbital pital fissure ligament of the incrassate ntermedi- fissure, The lateral infraorbital fissure ligament of the buccal fat pad (Fig. 7, below) is the ineras-Vol. 109, No. 7 / STRUCTURE OF THE BUC FAT PAD Fic. 4. (Above) The child’s intermediate lobe (I-BEP) stays in the space between the late posterior lobe (PL-BEP), which develops well. The medial infraorbital fissure 1 wall of the maxilla and the ment (MIFL) hangs down to the end of the intermediate lobe. The lower end of the posterior sygomatic ligament (PZL) grasps the upper margin of the buccal extension (BE). (Below) The posterior rygomatic lig buccal extension (BE), the superficial pa of sation of the medial capsule tissue of the posterior lobe. It clings upward to the outer rim of the infr 1 fissure ‘The temporalis tendon ligament of the buc- cal fat pad (Figs. 6, below, and 7, below) is formed by the posterior capsule tissue of the posterior lobe and secures backward to the surface of the temporalis tendon at the level of the coracoid process. ‘The buccinator ligament of the buccal fat pad (Fig. 6, below) is the incrassation and amal- gamation of the inferior capsule tissues of the anterior and posterior lobes and anchors to the buccinator membrane. The tissues, which are packed by the buccal ypsules of the posterior lobe (PL-BEP), th \¢ temporal extension (SPTE), and the intermediate lobe (/1-BF?). Ie fixes them to the back of the zygoma, AFV, anterior facial vein; DP, duct of the parotid: FA, facial artery fat pad, also support the buceal fat pad. For example, the profound part of the temporal process holds the anterior profound temporal vessels and fixes to them. However, because of the ligaments, displacement of the buccal fat pad does not occur normally Multisourcing Nutritional Vessels of the Buccal Fat Pad Although Stuzin et al.' and Li et al.’ consid- ered that the facial artery, the transverse f vessels, and the internal maxillary artery their anastomosing branches were the nutri- tional vessels of the buccal fat pad, they did not provide any further descriptions. The buccalcFr PPE. SPTE ™ PL-BFP BE AL-BEP PLASTIC AND RECONSTRUCTIVE SURGERY, June 2002 PPTE IOF ZA MM 1L-BFP BM Fic, 5. This coronal cut of the head shows part of the prerygopalatine extension (PPE) into the orbita, Note the existence of a septum berween the circumbulbar fat tissue (CET) and the buecal fat pad, The atrophic intermediate lobe (JL-BEP) stays between the lateral wall and the posterior lobe (PI-BFP). The temporal extensic ‘occupies the space around the temporalis muscle (TM), which divides into super ficial and profound parts, The buccal extension (BE) runs along the anterior rim lof the masseterie muscle (MM) to its superficial layer. The tissue below the buceal extension inward is the anterior lobe UL-BIP), which is composed of fat tissue separated by alot of connective septa, 108, infraorbital fissure; SPTE, superficial part of the temporal extension; PPTE, profound part of the temporal extension: ZA, fat pad is supplied by vessels from different sources that enter into the fat tissues along the surface of the ligaments and that form’ the lobar subcapsular vascular plexus by anasto- mosing to each other The posterior superior alveolar artery (Figs. 4, 6, and 7) begins at the third segment of the internal maxillary artery and divides one superior branch of the intermediate lobe. This branch goes behind the posterior zygomatic ligament and enters the lobe. Its distal end connects th ygomatie arch; BM, buccinator muscle inferior branch of the intermediate lobe from the buccinator artery. The posterior superior al veolar artery runs down behind the end of the posterior zygomatic ligament. When rounding the inner termination of the maxillary ligament, it sends out several branches—the superior branches of the anterior lobe, which run along this ligament to this lobe After originating from the second segmei of the internal maxillary artery, the anteri profound temporal artery pierces the deepVol. 109, No. 7 / STRUCTURE OF THE BUCCAL FAT PAD Fic. 6. (Abowe) The ligaments that fix the buceal f mawilla and the zygoma to the back of the anterior lobe (AL-BEP). T LA) enter the anterior lobe by this ligament. On its right side, a white bundle—the lower part of the posterior zygomatic ML TTL, PPA TEP BML BE illary ligament (ML) hangs from the connection of the small branches of the posterior superior alveolar artery Tigament (PZL)—from the back of the zygoma goes down to the superior rim ofthe buccal extension (). (Beli) The temporalis tendon ligament (TTL) goes from the temporalis tendon (TT) to the middle back of the posterior lobe, tery (PMA) enters the fat tissue, The buccinator muscle pterygoid long which a small snt (BML) is the entry of the ig posterior branch from the inferior buceinatorartery (JB) tothe posterior labe—the inferior branch ofthe posterior lobe (/BPL) part of the temporal process, runs upward, divides several smaller vessels to nourish the fat tissue, and ends in the temporalis muscle. ‘The anterosuperior branch of the posterior lobe from the second segment of the internal maxillary artery extends downward in the lobar septum, in the front of the medial infraorbital fissure ligament (Fig. 7, above) and connects the branches from the inferior buccinator ar tery and pterygoid muscle artery The superior buceinator branch begins at the internal maxillary artery and terminates at the upper part of the buccinator. On its course, it sends out a posterior-superior branch of the posterior lobe, which goes downward behind the lateral infraorbital fissure ligament along the back of the posterior lobe. Its end links up with the ascending branch from the pterygoid muscle artery The middle branch of the posterior lobe from the pterygoid muscle artery (Fig. 6, below) divides into two branches—ascending and de- scending—after it goes into the middle back of posterior lobe. The ascending branch goes up- ward and connects the posterior-superior branch of the posterior lobe. The descending branch goes downward and connects to the inferior branch of the posterior lobe from the buccinator artery. nferior buccinator artery of the facial2516 PLASTIC AND RECONSTRUCTIVE SURGERY, June 2002 Fic. 7. (Alu) The medial infraorbital fissure ligament (MIFL) ling inward to the posterior zygomatic li rim of the infraorbital fissure. (Below) The lateral infraorbital fissure ment (LIFL) isthe incrassate structure of the posterior lobar capsule. attaches upward to the oute posterior lobe and intermediate lobe upward to the in liga fissure. DP, duct of the parotid; MA, masseteric muscle; AFV, anterior facial vein: buceal extension braneh of the middle Facial 3 inferior alveolar nerve artery (Figs. 2 through 4 and 6, below) divides into the anterior and posterior branches on the surface of the buccinator. The anterior branch turns backward and sends out the rior branches to the anterior or intermediate lobe. The posterior branch goes backward and sends out one inferior branch to the posterior lobe near the anterior rim of the ramus. The buccal extension branch from the mid- dle facial artery (Fig. 2) extends forward from the space between the parotid and the masse- ter and enters the buccal extension. It links up with the branch from the pterygoid muscle artery. A, facial artery; MR, ery; PMFand PPE, plerygomandibnilar fissure and plerygopalatine fossa; JAN, Discusston Functions of the Buccal Fat Pad Other reports!" considered that the buccal fat pad filled the masticatory spaces, which was good for mastication and sucking, but we sug- gest that the buccal fat pad actually holds the following functions. Filling and slippage. ‘The lobes of the buccal fat pad fill the deep facial spaces such as the space, infratemporal space, pter fossa, anteparotid space, subman- dibular gland fossa, and the spaces among the mimetic muscles. When the masticatory and mi-Vol. 109, No. 7 / STRUCTURE OF THE BUCCAL FAT P metic muscles contract, these lobes function as gliding pads (Figs. 2 and 5) Protection and cushion. ‘To protect the deep facial neurovascular bundles from injury caused by the extrusion of muscle contraction or the ‘outer force impulsion, part of the anterior lobe and the extensions of the posterior lobe pack them and function as a cushion (Figs. | and 5 through 7) Changing of the Buccal Fat Pad Volume in Different Periods of Life Our dissection results revealed that the inter- mediate lobe developed well in children but poorly in adults. The anterior lobe is rich in fat tissue in children, less rich in adults, and rich again in the aged (Fig. 4) ‘The size of the protrusions of the posterior lobe is also related to age. The posterior lobe is smaller and the pterygoid and buccal protru- sions are larger in children, and the reverse occurs in adults (Figs. 4, 6, and 7) Mechanism of Deepening the Nasolabial Fold We discovered that the anterior lobes in six aged specimens were plump and that their lateral spines of the nasolabial fold were higher than normal. The tissue slides made by Yousi etal.’ illustrated that the antero-inferior part of the anterior lobe stayed just below the lateral spine, suggesting that the chubbiness of the anterior lobe may be one cause of simulta neous deepening of the nasolabial fold skin tissue and relaxation of mimetic muscles, Mechanism of Buccal Chubbiness Usually, the cause of buccal chubbiness is the antero-inferior protrusion. of the buci extension of the buceal fat pad.' Our re revealed that the relaxation of the mimetic muscles, the poor development of the Ii ments, and the rupture of the buccal fat pad capsules were also causes, making the buccal extension drop or prolapse into the mouth ot the facial subcutaneous layer Free or Islanded Buccal Fat Pad Flaps The lobes of the buccal fat pad have been used clinically for several decades.!-" These lobes and four extensions lie in one capsule. ‘The aseptic working and antibiotic m: ment must be carried on as the buccal fat flap to fill the local tissue defect is formed or as the traumatic prolapse of the buccal fat pad" is 2517 managed, to diminish the occurrence of tissue space cellulitis. ‘The lobes and extensions are fixed in the tis sue spaces by means of the ligaments formed by the incrassation of the lobar capsule. However, the buccal fat tissue flaps without any capsular tissue (which were reported previously) should be considered as random fat flaps,” because there is no subcapsular vascular plexus in the fat flap. The fat flap carrying the capsule should be landed, as one pole of the buccal fat pad is the pedicle of the fat flap and the vessels and the ligaments to the other pole must be ligated carefully Riiytidectomy of the Nasolabial Fold When suspending the subcutaneous fat ti sue in the infraorbital region, we obtained more satisfactory aesthetic results if the ante- rior lobe were located along the parotid tube and suspended simultaneously up and back to the ygoma, Partial Resection of the Buccal Process Other authors resected the buccal extension by incising the buccal mucosal membrane | cm, below (Matarasso’s method!) or behind (S method!) the opening of the parotid duct. We dissected it bluntly, and the buccal process was found. The capsule of the buccal process was incised, and a certain volume of fat tissue was removed. The inferior buccinator branches of the facial artery are possibly injured, so the space hematoma should be excised because the vessel route runs around the incision, Another possible complication is the inadequate tissue adhesion, which causes the hollow of the local skin tissue. Our results suggest another possible ops tion route (Fig. 5) in which the membrane incision lies in the superior gingivobuccal groove above the first molar, The maxillary bone membrane is raised and incised on the lateral wall of the maxilla. The entry into the tissue space, in which the buccal fat pad lies, is formed. Partial resection of the buccal protr sion and management of the ligaments, such the maxillary ligament, posterior zygomatic lig ament, or inner infraorbital fissure ligament, should be done simultaneously to relax the posterior lobe. The buccal augmen- tation’ to fill an implant should also be done through this routCoxe USIONS This anatomical study clearly demonstrated that the buccal fat pad can be divided into three lobes, anterior, intermediate, and poste- rior, according to the structure of the lobar envelopes, the formation of ligaments, and the sources of the nutritional vessels. The buccal, pterygoid, pterygopalatine, and temporal ex- tensions are derived from the posterior lobe. ‘The buceal fat pad is fixed by six ligaments and nourished by several nutritional vessels. The buccal fat pad functions to fill the deep tissue spaces and to perform as a gliding pad and a cushion in the muscle contraction and outer force impulsion. We examined several clinical applications of the results, such as the mecha- nism of deepening the nasolabial fold and pos- sible rhytidectomy to suspend the anterior lobe. The relaxation, poor development of the ligaments, or rupture of the capsules could make the buccal extension drop or prolapse. Also, we improved the methods and paid more attention when using the buccal fat pad flaps or resections. HaiMing Zhang, M.D. Plastic Surgery Hospital of the Chinese Academy of Medical Science and Peking Union Medical College BaDa-Chu Road ShisfingShan District Beijing, 100041, People’s Republic of China hexm@edm.imicams.dc.cn ACKNOWLEDGMENT We gratefully acknowledge the contribution of Director ‘Cynthia Chen for the English writing, PLASTIC AND RECONSTRUCTIVE SURGERY, June 2002 REFERENCES 1. Suuzin, J. M., Wagstrom, L., Kawamoto, H. K,etal, The anatomy and clinical applications of the buccal pad. Plast. Reconstr. Surg. 85: 29, 1990, 2. Xie, W-¥., and Zhang, K-Q. ‘The anatomical study of the buccal fat pad. Chin. J. Stomat. 16: 199, 1981 3. Li, WeT.,Xu,D-C.,Zhong,$-Z.,etal. 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Clawson, J R. Kline, K.K.,and Armbrecht, F.C. ‘Traut mainduced avulsion of the buccal fat pad into the mouth: Report of a ease, f. Oral Surg. 26: 546, 1968, 12 Browne, W.G. Herniation of buccal fat pd, Oral Surg Oral Med. Oral Pathol, 29: 181, 1970. 13, Marano, P. D., Smart, E. A. and Kolodny, S. C. Taw ‘matic herniation of buccal fat pad into maxillary sinus Report of a case. J. Oral Surg. 28: 581, 1970, 14, Epstein, LL Buccal lipectomy. An, Plast, Surg. 5: 123, 1980,