Original Articles Buccal Fat Pad Excision: Aesthetic Improvement of the Midface Alan Matarasso, MD, FACS Visual criteria for a harmonious midface depends on (1) a distinction between the anterior border of the parotid gland and cheek hollow, (2) a visible posterior border of the naso- labial fold (chis signifying the most variable criterion), (3) an intervening cheek sof-tissue convexity that does not ex: ceed the plane of a perpendicular from the mideygome to the mandible (subtle submalar depression), (4) prominent ‘zygomatic eminences, and (5) a well-defined mandible, pa- ticularly the angle. The space within the zygomatic arch and the mandible that defines the ideal midfacial “cheek hollow” has been established. This can be achieved through 1 combination of: aesthetic contouring of the facial skele- ton, facial iposcuipture, and cervicofacialplasty. A series of 25 consecutive patients undergoing submuscular fat re- ‘moval by buccal fat pad excision 10 improve aesthetic mld face were eated and are presented. To preserve the subcu- tancous fat commonly lost with aging and to avoid late secondary deformities, only submuscular buccal fat excision 48 recommended in a carefully selected group of patients. ‘The anctomy, indications, and technique for buccal lipec- tomy in midface contouring are discussed. Mataraio A: Sucel fat pad excision: aesthetic improvement of the rmidface: Ana Plast Surg 1991,26:813-418 From the Manhattan Eye, Ear and Throat Hospital and the Albert Einstein College of Medicine, New York, NY. Presented atthe 23rd annual meeting of the American Soci- ety of Aesthetic Plastic Surgery, Chicago, IL, April 3, 1990. ‘Adaress correspondence to Dr Alan Matarasso, 1009 Park ‘Ave, New York, NY 10028, 413. Copyright © 1991 by Little, Brown and Company ‘The preferred, present-day aesthetics of high cheek- bones and angular facial appearance can be achieved by creating the various layers of the face, that i, the skin, muscle, adipose tissue, and bone as indicated ‘These structures must be evaluated alone and in con- cert with the surrounding tissue layers to achieve an aesthetic balance. This is realized through a combina- tion of aesthetic contouring ofthe facial skeleton, cer- vicofacialplasty, and facial iposculpeure. The mid one-third of the face occupies the central position in the lateral facial profile and, as such, has a highly visi- ble and eritical role in portraying an image. “The attainment of a harmonious midface is based on establishing the ideal normal. Visual criteria for this goal depend on I) a distinction between the ante- rior border of the parotid gland and cheek hollow, (2] a visible posterior border of the nasolabial fold (this Signifying the most variable criterion}, (3}an interven- ing cheek, softissue convexity that does not exceed the plane of a perpendicular from the midzygoma to the mandible (subtle submalar depression), (4) promi- nent zygomatic eminences, and (5) a well-defined ‘mandible, particularly the angle. The space within the zygomatic arch and the mandible defines the ideal ‘midfacial “cheek hollow” (Fig 1). This region falls ‘within Leonardo da Vinci's “square,” which is used to assess the relationship of facial structures on lateral Facial contouring by altering the fatty compart: ‘ments of the face can be done subcutaneously or sub- muscularly, Subcutaneous fat is treated by suction- assisted lipectomy (SAL. This is of limited value in the cheek because of the thin subcutaneous layer and, on excessive removal, is aesthetically displeasing in the midface and is not recommended. Submuscular fatty tissue of the face, such as periorbital, subplatys- mal, and the buccal fat pad, probably behaves differ ently and, when indicated, should be treated by direct surgical lipectomy. A series of patients in whom buc- cal fat pads were removed to contour the midface are presented. Anatomy and Physiology ‘The buccal fat pad (BFP) was initially described in 1732 by Heister [1] as glandular and, subsequently, 2s fatty by Bichat [2] in 1802, whose name is attached to it, Ranke [3], in 1884, recognized that the BEP per- sisted during times of severe emaciation, even after subcutaneous fat was lost. Periorbital fat shares characteristic. Both separate muscle surfaces, al- lowing smoother gliding (syssarcosis). Also, the BFP‘Annals of Plastic Surgery Vol 26 No § May 1991 ig 1, Visual enteria for midfacial aesthetics. The “surgical” midjace does not ft nto the routine vertical facial thirds. 11 does liz, however, within Leonardo da Vinc!’s “square,” ‘which describes the relationship of facial points on lateral view. Surgical procedures are almed at creating a subtle submalar hollow. This is achieved by a combination of fa ial iposuetion, aesthetic contouring of midfacial skeleton, ‘and soft-tissue redraping or buccal lpectomy (submuscular fat. assists in infant suckling, which may explain its rela- tively large volume in infants and its diminished zole and size with growth of facial structures. Loss of facial fa is considered a sign of aging. Ortiz- ‘Monasterio and Olmedo [4] demonstrated in a retro- spective photographic study of 46 people, some in the ninth decade of life, that in those individuals with chubby faces to which the BEP contributed, this char- acteristic was maintained throughout the person's en- tire life. Hence, itis expected that removal of the BFP ‘will not result in a prematurely aged appearance. This demonstration is supported by cadaver studies that show a poor correlation between general adiposity and the size of the BFP, suggesting the relatively fixed size of the tissue [5, 6). In their cadaver studies, Stuzin and colleagues (5] have detailed the anatomy of the BFP. The BFP is closely associated with the muscles of the mastica- tion, parotid duct, and facial nerves and vessels. It is tubular in shape and consists of the main body, buccal extensions, pterygoid, and temporal extensions. The ‘buccal portion is the most superficial, and comprises approximately one-third of the volume of the BEP. It is this predominant part of the BFP and the main body that are excised during buccal lipectomy. The BFP is contained in a masseteric facial membrane within the masticatory space and lies generally between the hori- zontal buccinator muscle and vertical masseter mus- cles, The parotid duct, which divides the buccal exten- sion from the main body and facial nerve (inferior), as crosses the anterior surface of the masseter muscle and then the BEP. The BEP then descends into the retromolar area and is accessible between the first and second molars. The parotid duct courses with the buc- cal branches ofthe facial nerve anteriorly (superficial) ‘and on the lateral surface of the BEP, penetrates it ‘and the buceinator muscles, entering the oral cavity through Stensen's duct opposite the second molar (Fig 2.A, B). The facial vessels are in the same plane and ‘mark the anterior extent of the BFP (Fig 3). In those patients with persistent fat pad volume, the aesthetic indications for buccal lipectomy include diminishing midface fullness and highlighting the zy- gomatic prominences and mandibular body, 0 pro- duce a sculpted facial appearance [7—10]. In recon- structive surgery, it has been used to close oronasal fistulas (11, 12] and for malar augmentation in syn- drome patients [13] The BFP may have a similar resis- tant biochemical composition to periorbital fat (14) and may bea suitable donor site for grafts [15] or autol- ogous fat transplantation. Surgical Technique The patient is examined, keeping in mind the ideal normal for this region. The cheek is palpated in the relaxed position with the mouth open and closed. Forcibly clenching the jaw while holding the skin fur ther distinguishes the subcutancous and submuscular fat comparteneus. With the cheek retracted, the gingivobuccal sulcus between the first and second molars infiltrated with lidocaine hydrochloride and epinephrine solution. The procedure can be dane under local or general anesthe- Sia In this position, Stensen’s duct is readily identified superior and appreximately 1 cm lateral to the opera- tive eld. A 2.5m incision is made, preserving a cull of mucosa for wound closure. The exposed buctinator fibers are spread by blunt dissection with the tip of the scissors aimed foward the helix ofthe ear. Herr ated fat protrudes and the overlying membrane is pen- cfrated. Extemal pressure below the aygomatic arc is fpplied, and the BEP is teased out. It is then clamped, ‘excised, and electrocoagulated, carefully avoiding in- jury to the oral mucosa. Only the fat that easily pro- trades, should be removed to avoid injury to vital structures a8 well as overresection. “The cavity is packed with a sponge soaked in lido- caine and epinephrine, whereas the opposite side is symmetrically resected. Usually a consistent volume of 4 to 6 grams is invariably removed in most patients on both sides. Ifa noticeable disparity in cheek size isMatarasto: Aesthetic Surgery of the Midface ‘BUCCAL FAT PAD / x ‘ig 2. A: Antst's rendering of the relationship between Stensen’s duct and the incision showing heriaved buccal fat pad. B: Intraoperative pictur ofthe buccal fat pad being excised. The incision is made between the fist and second ‘molar. Alternatively the incision for intraoral placement of salar implants is anterior and extends from the laveral inci sor to the first premolar. The forceps between the retractors ‘identifies Stensen’s duce, which is 1 com lateral to the inct sion with the cheek in the retracted position. Fig 3. The layers of the cheek. The parotid duct arbitrarily ‘Fig 4, The average volume of fat excised during buccal lipec divides the main body and buccal extension of the buccal tomy, approximately 46 grams. This varies very litle fat pad. These two portions ofthe buccal fat pad are what among patients and between sides of the face. are excised during aesthetic buccal lipectomy. 415‘Annals of Plastic Surgery Vol 26 No § May 1991 ‘ig 5, Similar comparative anatomy ofthe lower eyelids and buccal fat pad. Perhaps submuscalar fat behaves differently than subcutaneous fa. observed preoperatively, an attemptis made to correct this by asymmetric excisions (Fig 4), The wound can be left open or closed with chromic sutures. The pro- cedure may be done before surgical scrubbing or atthe completion ofthe sterile portion of a combined case, to avoid contamination with intraoral flora. The technique of BFP excision is analogous to plac- ing pressure on the globe and removal of periorbital fat. In blepharoplasty surgery, a concavity below the cnbital im is to be avoided. In buccal lipectomay, how- ever, a slight submalar depression can be desirable. Furthermore the tissue layers encountered are simi- lar, that is, Skin (mucosal, muscle, septum, and the {at pads (Fig 5). The correction achieved with buccal lipectomy is and should be subtle Figs 6, 7). Rarely is a dramatic change in cheek fullness achieved. Results ‘Twenty-five patients, 17 women and 8 men, ranging in age from 18 to 60 years, have undergone surgery. Followup ranges from 6 to 48 months, wich an average (of 3 years. The majority of these patients underwent surgery under local anesthesia (19 of 25 patients}. All procedures were done bilaterally (50 sides) for the pur- pose of aesthetic contouring. Buccal lipectomy was performed as a sole procedure in 2 patients and com: bined with other procedures in 23 patients. In facial surgery, buccal lipectomy is most commonly associ- ated with neck and jow! fat removal to contour a full ‘or rounded appearance (Fig 8). ‘The complications of buccal lipectomy include he- ‘matoma, trismus, infection, nerve injury, duct injury, overresection, induration, or contour irregularities. ‘There were no complications in this series of patients and complications are, indeed, uncommon. However, 416 immediate postoperative edema is common and can mimic a hematoma, This can be reconciled by remov- {ng a suture and inspecting the cavity Postoperatively, the patients received broad spectrum antibiotics and oral rinses with hal-strength hhydrogen peroxide, and were encouraged to exercise their jaws, Patient acceptance has been excellent. F- nal results may take months to observe due f0 pro- Jonged localized edema. Most patients report a subtle change Discussion With the advent and increased occurrence of suction- assisted lipectomy, correction of the corpulent mid- face has been addressed. Direct surgical excision of the BEP alone or in conjunction with SAL, tissue re- draping, or alterations in the facial skeleton are meth- ods of defining this area. Previously, surgeons were limited to camouflage with implants, shading makeup techniques, and third-molar removal. An aesthetically acceptable set of standards for lateral midace propor- tions allows proper diagnosis and treatment. In the profile view, adjustments can now be achieved in the mid portion of the face. Similar eriteria have been de- fined for the neck [16] In patients undergoing facialplasty, wide undermin- ing, elevation, and advancement of the skin, and tight- ‘ening of the superficial musculoaponeurotic system {SMAS) improves the midface by addressing the jowls present at the lower boundary of the midface. Tradi- tionally, defatting has and should only be performed after repositioning of the SMAS-platysma flap and only below the border of the mandible, thus preserv- ing the subcutaneous fat of the midface that changes ‘with age, It may be that the expected events of aging at the nasolabial crease and fold are due toa relaxation of the superior suspension of this complex. Elevation and advancement of this restores a youthful appear- ance, softening the fold and properly repositioning the fat. The deep BFP is distinctly different and only in the occasional patient, in whom a disparity may be noticed between a defatted neck and an undefatted cheek, should this be removed. During a thytidec- tomy, the BFP may be visualized by dissection beyond the masseter muscle, deep to the SMAS layer. Termi- nal branches of the buccal branch of the facial nerve, however, are in jeopardy of injury at this level. Hence, an intraoral incision may be more expedient and pre~ ferred. Previous reports [17] have wamed against simulta- neous malar augmentation and buccal lipectomy,‘Matarasso: Aesthetic Surgery of the Midface A Fig 6A: A 28-year-old women with a fll midfactal appear. ‘ance and good bony architecture. B: One year after symmmet- ‘eal buceal lipectomy with a subtle change. A Fig 7. A: A candidate for buccal Bpectomy in a man with ‘adequate bony architecture who desired more cheek hollow. 5: One year after suction-assisted lipectomy of neck and fowls, and buccal lipectomy. a7‘Annals of Plastic Surgery Vol 26 No 5 May 1991 Fig 8, Buccal lipectomy for aesthetic midface contouring can bbe done asa sole or combined surgical procedure, based on the patients intrinsic anatomy or assthetic raquirements ‘Suction liectomy of the neck and jowls isthe mast com ‘mon concomitant procedure performed with it. ‘which can lead to overly angular appearance, The BEP should be removed first, in well-selected individuals, to achieve subtle change. Malar, submalar, or mandib- ular contouring is performed as indicated. The ideal candidates for buccal lipectomy have prominent cheekbones and a well-defined mandible with full cheeks due to the excessive presence of the BEP. Clearly certain individuals will benefit from com- bined procedures. Summary In a properly selected small population of patients, intraoral buccal lipectomy is one modality that is useful adjunct for addressing micfacefuliness (8. Fred- ricks, personal communication], alone or in conjunc- tion with facial liposculpture, aesthetic contouring of the facial skeleton, and soft-tissue redraping, The sub- cutaneous fat must be differentiated from the submus- cular buccal fat pad and assiduously preserved in most instances. Treatment of a capacious lateral midface is ‘based on diagnosing the cause of the problem. Once identified, visual criteria suggested are useful in estab lishing the normal, and determining the appropriate methods of treatment to enhance the facial profile. Based on speculition of previous studies and the efficacy of submuscular facial lipectomy in those pa- tients in whom the BEP persists in a dominant role beyond infancy and contributes to facial fullness, per- hhaps the composition and lipolytic rate of the buceal fat could be inferred as different. Barly reports compat- {ng neonatal ft and the buccal fat indicated that these ‘were more saturated, just as periorbital fat has more 418 saturated fat [18]. Furthermore, unlike subcutaneous fat, the submuscular fat compartments may be rela tively resistant to emaciation and aging, which, osten- sibly, biochemical evaluation and magnetic resonance imaging studies may ultimately elucidate. References 1, Heister L: Compendium Anatomicurs. Nusibergae, 1732. 2. Bichat F: Anatomie generale, appliquee la physiclogie ce It medecine. Panis, Brosson, Gabon, and Cie, 1802 43. Ranke H: Ein Sangpolster in der menschlichen Backe, ‘Wirchows Arch Fr Pathol Anat 1884,43:527 4. Onis Monasterio F, Olmedo A: Excision of the buccal {at pad to refine the obese midface, In Symposium on Problems and Complications in Aesthetic Plastic Sur gery of the Face. St Louis, CV Mosby, 1984, pp 91-98, 5. Stuzin J, Wagstrom L, Kawamoto H, etal: The anatomy nd clinical application of the buccal fat pad. Past Re constr Surg 1990,85:29-37 6. Dubin B, Jackson PT, Halim A, et al: Anstomy of the ‘buceal ft pa and its clinical signifcance. Plast Reconstr Surg 1989,83:257-263, 7. Epstein LP: Buccal lipectomy. Ann Plast Surg 1980,5:123 8. Krupp S: Buccal lipectomy. Reappraisal and ease repo. Eur Plast Surg 1986,9:40 9. Rees TD: Aesthetic Plastic Surgery. Philadelphia, WE Saunders, 1980 10. Balch C: Buccal fat pad excision through the face lift incision: a four year follow-up. Presented at che 22nd ‘Annual Mecting of the American Society for Aesthetic Plastic Surgery, Orlando, FL, April 12, 1989 11, Egyedi P: Uslization ofthe buceal fat pad for closure of oro-antral and/or oromatal communications, } Maxilo fae Surg 1977,5:241 12, Tideman H, Bosanquet A, Scot J: Use of the buccal fat pad as a pedieled graft j Oral Maxillofac Surg 1986, 435 13. Salyer K, Vasconez L: Surgery in Down syndrome, In ‘Mustard, Jackson feds), Plastic Surgery in Infancy and Childhood, London, Churchill Livingstone, 1988, p 159 14, Downey SE, Hugo NE: Periorbital Fat—Different? Pre sented at the 22nd Annual Meeting of the American Society of Aesthetic Plastic Surgery, Orlando, FL, Apel 10, 1989 15. Neder A: Use of the buceal fat pad for grafts. Oral Surg 1983,55:349 16, Ellenbogen R, Karlin JV: Visual criteria for success in restoring the youthful neck Plast Reconstr Surg 1980; 66:86 17, Whitaker LA: Aesthetic augmentation of the malar sidiace structures, Plast Reconstr Surg 1987,80:337 18, Bagdade JD, Hirseh J: Gestational and diecary influences on the lipid content ofthe infant buccal fst pad. In Pro ceedings of the Society for Experimental Biology and Medicine, Vol 122. 1966: pp 616-619