Aesth Plast Surg (2013) 37:216–221
DOI 10.1007/s00266-013-0080-x
ORIGINAL ARTICLE
A Modified Surgical Method of Lower-Face Recontouring
Jinghong Xu • Yijia Yu
Received: 6 September 2012 / Accepted: 12 January 2013 / Published online: 16 February 2013
 Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013
Abstract
Background In general, the width of the lower face is
determined by four parts: the mandible, the masseter
muscle, the buccal fat pad, and the subcutaneous fat. In this
article, we introduce a modified surgical method to reshape
the outline of round faces that have no significant over-
growth or eversion of the lower jawbone.
Method The procedure includes dissection of the masse-
ter muscle and partial lipectomy of the buccal fat pad
through the same intraoral small incision.
Results The patients were satisfied with the aesthetic
outcome of both the profile and frontal view. Follow-up of
more than 6 months shows no prospective complications.
Conclusion This method yields an optimal aesthetic
result in patients who have a round face without significant
overgrowth or eversion of the lower jawbone.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Masseter muscle
Hypertrophy

Buccal fat pad
Introduction
Masseter muscle hypertrophy was first described by Legg
in 1880 in the case of a 10-year-old girl with bilateral
J. Xu (&)
Y. Yu
Department of Plastic Surgery, The First Affiliated Hospital,
College of Medicine, Zhejiang University, Hangzhou,
Zhejiang 310003, People’s Republic of China
e-mail: xujinghong2008@gmail.com
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AESTHETIC
hypertrophy of the temporalis muscle and masseter muscle.
Since then, many experts have been interested in treatment
for this disharmony. Treatment of masseter muscle
hypertrophy varies from conservative to surgical, and the
latter depends on the surgeon’s skill and experience [1].
Surgical treatment was first proposed by Gurney in 1947
[2]. The procedure consists of a submandibular incision
and the removal of 3/4 to 2/3 of all muscle tissue available
from the muscle upper aponeurosis to the lower mandibular
border [2]. In 1977, Becker [3] reported on a surgical
intraoral approach in treating 17 patients. An internal
muscle band was removed from the hypertrophied masseter
muscle in the upper insertion in the zygomatic arc and the
lower insertion in the mandibular angle, thus reducing the
possibility of injuring branches of the facial nerve and
avoiding a visible scar on the face [3].
This article describes one typical case of idiopathic
masseter muscle hypertrophy and proposes an effective
treatment option for these patients who have benign mas-
seter muscle hypertrophy and buccal fat pad hypertrophy
but no significant overgrowth or eversion of the lower
jawbone. Secondary masseter muscle hypertrophy, such as
parotid tumors and minor salivary gland tumors, are not
considered.
Method
Eight female patients (age range = 24–32 years) under-
went surgery in our department between March 4, 2011 and
June 20, 2012. All of the patients fit the following
conditions:
• The patient had a strong desire to alter her facial lines
on both the profile and the frontal view.
Aesth Plast Surg (2013) 37:216–221 217

Fig. 2 The buccal fat pad will show itself after separating the
Fig. 1 A horizontal intraoral incision is made *1.5 cm in the buccal buccinator
mucosa at the bite level

• The patient’s only complaint was that her round face

generated discomfort and negative cosmetic impact;
there was no complaint of any functional disorder.
• Physical examination from intraoral and extraoral
inspection and palpation revealed the patient had
bilateral masseter muscle hypertrophy and buccal fat
pad overgrowth without further alteration, no signifi-
cant overgrowth or eversion of the mandibular angle,
no mouth opening disorder, and no other functional
disorder.
• The patient did not have any contraindications for
surgery.
Fig. 3 Partial lipectomy of the buccal fat pad
All the surgeries were performed with the patient under
local anesthesia. A horizontal intraoral incision approxi-
mately 1.5 cm in the buccal mucosa of the bite level was
made first (Fig. 1). When the buccinator was carefully and
gently separated through the incision, the buccal fat pad
showed itself (Fig. 2). The body of the buccal fat pad was
located and partial lipectomy of it was performed (Fig. 3).
The masseter muscle was detached with an elevator from
the inferior margin and posterior margin attachment point
of the mandible surface through the same incision (Fig. 4).
The incision was closed in a single plane with a 5-0
absorbable suture at the end of the procedure. A com-
pressive dressing was put in place and elastic compression
for more than 3 days (Fig. 5).
Fig. 4 The masseter muscle was detached with an elevator from the
inferior margin and posterior margin attachment point of mandible
surface
Results

For all eight patients, surgery was offered for cosmetic
reasons and no complications occurred during surgery. All
patients were satisfied with the aesthetic outcome of both
the profile and the frontal view. Follow-up of more than
6 months has revealed no prospective complications
(Figs. 6, 7, 8, 9, 10, 11, 12, 13).
Discussion
According to Poch’s classification, there are ten face types.
Among them the oval face is recognized as the most
beautiful, especially for Asian people. In many Chinese
classics, the face of beauty is always described as an oval

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218
Fig. 5 A compressive dressing was put in place
Fig. 6 Preoperative views of a 29-year-old woman showing obvious
bilateral masseter muscle hypertrophy and buccal fat pad overgrowth,
especially in the right side of the face. Postoperative views at
7 months showing substantial improvement of the lower face
face with a round upper face, small lower face, and pointed
chin. In general, the shape of the lower face is determined
by four parts: the masseter muscle, the buccal fat pad, the
mandible, and the subcutaneous fat.
The masseter muscle plays an important role in facial
aesthetics. The prominent masseter muscle can be consid-
ered cosmetically disfiguring, especially in patients without
significant overgrowth or eversion of the mandibular angle.
Treatment options for masseter muscle hypertrophy range
from simple pharmacotherapy to more invasive surgical
reduction [1].
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Aesth Plast Surg (2013) 37:216–221
Fig. 7 Preoperative views of a 24-year-old woman showing obvious
bilateral masseter muscle hypertrophy and mild buccal fat pad
overgrowth. Postoperative views at 6 months showing substantial
improvement of the lower face
Injection of botulinum toxin type A (BTX-A) into the
masseter muscle was first introduced by Smyth, and Moore
and Wood in 1994. In recent decades, BTX-A injection has
become a very popular way to cosmetically sculpt the
lower face because it is convenient and less invasive.
However, the results of injection can vary from subtle
thinning of the face to an extremely thin, cachectic
appearance. While treating masseter muscle hypertrophy,
BTX-A can also cause muscle weakness. It is reported that
the maximum bite force was significantly lower after
injection of BTX-A into the masseter muscle [5, 6].
The traditional method for treating masseter muscle
hypertrophy is surgical partial excision of the masseter
muscle under general anesthesia. Complications of partial
excision include hematoma formation, facial nerve paral-
ysis, infection, limited ability to open the mouth, and
sequelae from general anesthesia [4].
Dissection of the masseter muscle from the point of
attachment to the bone surface can result in a cosmetic
effect as well. Some animal models have shown that the
masseter muscle will atrophy and the volume of the mas-
seter muscle will decrease after dissection [7]. Reasons for
this effect can be attributed to two main points: (1) the
masseter nerve stem and divisions may be injured during
the dissection, which leads to atrophy of denervated
Aesth Plast Surg (2013) 37:216–221 219

Fig. 9 Preoperative views of a 25-year-old woman showing obvious

Fig. 8 Preoperative views of a 26-year-old woman showing bilateral bilateral masseter muscle hypertrophy and buccal fat pad overgrowth,
masseter muscle hypertrophy and obvious buccal fat pad overgrowth. especially in the left side of the face. Postoperative views at
Postoperative views at 6 months showing substantial improvement of 6.5 months showing substantial improvement of the lower face
the lower face

masseter muscle due to disuse, and (2) the blood supply of

the masseter muscle may be reduced after dissection, which
leads to muscular dystrophy [7]. More animal experiments
and clinical studies are needed to confirm the outcomes of
this method.
Buccal fat pad excision can result in aesthetic
improvement of the middle and lower face. It has been
reported that partial lipectomy of the buccal fat pad results
in an optimal result with few complications [8–10].
Our modified surgical method combines dissection of
the masseter muscle with partial lipectomy of the buccal fat
pad. There are several advantages to this method: (1) Two
procedures are performed through the same intraoral small
incision and there is no scar left on the skin after surgery.
(2) Dissection of the masseter muscle under local anes-
thesia replaces excision of the masseter muscle under
general anesthesia. This could diminish the trauma of the
surgery, avoid injury of the parotid gland, and reduce the
possibility of postoperative hemorrhage or hematoma.
Thus, the cosmetic effect will be achieved with reduced
complications.
Prospective complications of this method include
Fig. 10 Preoperative views of a 30-year-old woman showing obvious
infection, hematoma of the cheek, and asymmetry of the
bilateral masseter muscle hypertrophy and mild buccal fat pad
lower face. An unsightly bulge caused by retraction of the overgrowth. Postoperative views at 8 months showing substantial
masseter muscle was considered before we designed this improvement of the lower face

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220 Aesth Plast Surg (2013) 37:216–221

Fig. 11 Preoperative views of a 29-year-old woman showing obvious Fig. 13 Preoperative views of a 25-year-old woman showing obvious
bilateral masseter muscle hypertrophy and mild buccal fat pad bilateral masseter muscle hypertrophy and buccal fat pad overgrowth,
overgrowth, especially in the left side of the face. Postoperative views especially in the right side of the face. Postoperative views at
at 6 months showing substantial improvement of the lower face 7 months showing substantial improvement of the lower face

method. However, we believe the incidence of this phe-

nomenon will be very low based on a great deal of litera-
ture. First, we dissect the masseter muscle at the attachment
point of the mandibular angle rather than in the main part
of the muscle. Second, 3 days of elastic compression after
surgery not only prevents bleeding, it also puts appropriate
force on the muscle. In addition, as mentioned before, the
muscle will atrophy because of the reduced blood supply
and nerve control. None of our patients experienced this
bulge of the cheek during the follow-up period.

Conclusion

The method presented here can obtain optimal aesthetic

results with few complications in patients under the fol-
lowing physical conditions: bilateral masseter muscle
hypertrophy and buccal fat pad overgrowth without further
alteration, no significant overgrowth or eversion of the
mandibular angle, and no functional disorder.

Conflict of interest The authors have no conflict of interest to

disclose.

Fig. 12 Preoperative views of a 32-year-old woman showing obvious References

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