J. Maxillofac. Oral Surg.
https://doi.org/10.1007/s12663-022-01707-4
CASE REPORT
Resection of Bilateral Masseter Hypertrophy and Buccal Fat Pad
Associated with Genioplasty to Correct Aesthetic–Functional
Disturbances in the Face
Igor Lerner Hora Ribeiro1 • Marcelo Victor Omena Caldas Costa2
Ingrid Madiany da Silva Santos3 • Clarisse Samara de Andrade4 •
Pedro Henrique da Hora Sales1,5
Received: 20 May 2021 / Accepted: 2 March 2022
Ó The Association of Oral and Maxillofacial Surgeons of India 2022
Abstract Masseter hypertrophy is an uncommon condi-
tion, characterized by an increase in the volume of the
masseter region, with the patient presenting functional and
aesthetic complaints. Several therapeutic modalities have
been suggested for this condition, however, a surgical
approach usually presents consistent results in more com-
plex cases. The objective of this article is to report a
clinical case of masseter hypertrophy associated with class
IV of Kin, treated through partial removal of the masseter
muscle, bichectomy and genioplasty. Surgery was per-
formed under general anesthesia in a hospital setting. The
planning was previously carried out through prototyped
models and radiographs to remove the excess bone shown
in the mandibular angle region. Surgical treatment of
masseter hypertrophy is effective and long-lasting in severe
cases. Additional surgical procedures must be performed in
order to provide the best possible result according to the
facial deformity found.
& Pedro Henrique da Hora Sales
salespedro@gmail.com
1
Oral and Maxillofacial Surgeon, Santa Casa de Misericórdia
Hospital of São Miguel dos Campos, Dr. José Inácio Street,
43, São Miguel dos Campos, Alagoas, Brazil
2
Oral and Maxillofacial Surgeon, Daniel Houly Hospital,
Arapiraca, Alagoas, Brazil
3
Physical therapist, Privace Pratice, Maceió, Alagoas, Brazil
4 spur [2, 3]. Although surgery can be performed through
Oral and Maxillofacial Surgeon, Santa Casa de Misericórdia
Hospital of São Miguel dos Campos,
São Miguel dos Campos, Alagoas, Brazil
5
Oral and Maxillofacial Surgeon, Santa Casa de Misericórdia
Hospital, São Miguel dos Campos, Alagoas, Brazil
•
Keywords Masseter hypertrophy
Buccal fat pad

Genioplasty
Surgical treatment
Introduction
Masseter hypertrophy is a rare, asymptomatic, benign
condition with uncertain etiology, which can result in
functional problems and aesthetic complaints. Most
patients complain of an enlargement in the lower third of
the face, close to the mandibular angles and muscle pain in
that region, which are characteristic of muscle hyperac-
tivity and which, due to the excessive traction force exerted
by the muscle in this region, can result in changes in
morphology normal of the mandibular angle, the most
common being the bone spur, which can be observed
through imaging exams and in some cases through palpa-
tion [1–3].
Several therapeutic modalities have been used over the
years for the treatment of masseter hypertrophy with the
main emphasis on Botulinum Toxin A and surgical treat-
ment, with both showing good results [2–4].
Although botulinum toxin A is a less invasive method, it
has disadvantages such as the need for several applications,
the possibility of inducing changes in muscle structure as
well as recurrences in cases of large hypertrophies [4–6].
Surgical management has been described in the litera-
ture for many years. In this type of treatment, an excess
part of the muscle is surgically removed (approximately
2/3 of the internal face of the muscle), as well as the bone
extra-oral access [1], intra-oral access is undoubtedly the
most recommended today. In many cases, additional pro-
cedures to optimize facial harmonization can be performed
at the same time and even though the same surgical access
123

as in the case of bichectomy, where part of the Bichat’s
adipose body can be removed, aesthetically improving the
contour of the middle third of the face, allowing a better
demarcation between this and the lower third, leaving them
with a more triangular shape [7]. As well as the association
with chin repair for vertical chin augmentation, in order to
minimize the brachycephalic pattern, especially in Kim’s
class IV cases [8].
The aim of this study is, through a case report of mas-
seter hypertrophy and retrogenia, to describe the surgical
steps for the partial removal of the masseter muscle bilat-
erally, the buccal fat pad and the genioplasty, to correct this
clinical condition.
Case Report
In order to carry out this study, the patient’s free and
informed consent was obtained, who authorized the pub-
lication of her images and exams in this journal.
KCL patient, 20 years old, attended an Oral and Max-
illofacial Surgery service, complaining of enlargement of
the lower third of the face in the region of mandibular
angles, the constant bite of the cheek mucosa and mild
myalgia. The clinical examination showed an increase in
the thickness of the masseter muscle bilaterally asymmet-
rically, with greater volume on the right, as well as
hyperfunction (Fig. 1). In addition, he complained of a
protrusion in the middle third of his face and that his chin
was small. Imaging exams revealed the absence of patho-
logical lesion in the mandible, however, it was possible to
observe the bone spur in the region of the mandibular angle
Fig. 1 Preoperative frontal and
lateral clinical view in A and B
123
J. Maxillofac. Oral Surg.
bilaterally, uniform hypodensity in the hypertrophied
masseteric musculature and retrogenia (Fig. 2). During the
initial anamnesis, no parafunctional habits that could
influence the presented muscle hypertrophy were identi-
fied. After clinical and tomographic evaluation with pro-
totyping, the following planning was defined: Myotomy of
approximately 2/3 of the right masseter muscle and 1/3 of
the left one; ostectomy of the bone spurs in the region of
the mandibular angle bilaterally, with quantification of
bone volume removed through previous measurements in
the prototype; bilateral bichectomy and genioplasty for
vertical enlargement and chin advancement, with interpo-
sition of a bone graft in a block from the right mandibular
angle.
Initially, an incision was made in the mucosa of the
retromolar region, in order to visualize and individualize
the masseter muscle in that region. After identifying the
muscle, blunt divulsion was performed in the anteropos-
terior direction, isolating the medial portion to be resected,
thus avoiding injuries to the Stensen’s duct and branches of
the facial nerve (Fig. 3A). Myotomy of this portion was
performed with electrocautery, guaranteeing local
hemostasis (Fig. 3B). The detachment of the fibers of the
masseter was performed laterally to the pterygomasteric
aponeurosis, with exposure of the mandibular angle, to
remove the bone spur, in your full bone thickness. The
execution was performed with a reciprocating saw and
surgical drill 702 (Fig. 3C, D). Through the upper part of
the same access, a blunt dissection was performed to reach
the buccal fat pad, which was identified and removed
bilaterally in a symmetrical way. This removal of the
buccal fat pad was performed after the emergence of the
J. Maxillofac. Oral Surg.

Fig. 2 Preoperative panoramic

radiography showing the large
bone spur in the bilateral
mandibular angle region in A;
side view of rapid prototyping
showing excess bone in the
bilateral mandibular angle
region in B and C

Fig. 3 Initial view of the

masseter muscle after the
intraoral incision in A; excess
masseter muscle being removed
with the aid of electrocautery in
B; Vista clı́nica do esporão
ósseo no ângulo mandibular
direito in C; removal of the
bone spur on the right side of
the mandibular angle in D;
genioplasty for correction of
vertical chin deficiency, with
interposition of an autogenous
bone block removed from the
right mandibular angle in E;
buccal fat pad removed from the
adipose body of the cheek
bilaterally in F

123

parotid papilla in order to avoid damage to the Stensen’s
duct. Genioplasty occurred through intraoral access in the
mandibular vestibule, with a vertical increase of 4 mm and
2 mm advancement, using the spur as an interpositional
bone graft in the chin gap, which was fixed with two
2.0 mm straight plates. and monocortical screws (Fig. 3D,
E). The sutures were performed with 4-0 Monocryl
resorbable thread.
After 3 days postoperatively, the patient was referred for
physiotherapy, for early return of muscle function and this
was maintained for 4 weeks. At the moment, the patient is
in the 16-month postoperative period, with good mastica-
tory function, without palpable bone step at the angle of the
mandible and signs of recurrence, and with a harmonious
and symmetrical facial contour (Fig. 4A, B).
Discussion
Masseter hypertrophy is a rare benign condition that,
however, can bring chewing, psychological and aesthetic
discomfort. The choice of treatment modality must con-
sider the type and magnitude of the deformity, the patient’s
profile and the professional’s experience, with surgical
treatment being a safe option with acceptable morbidity
with low recurrence [1–3].
Partial removal of the masseter muscle was initially
described by Gurney 1947 [9], where the author recom-
mends the removal of 2/3 to 3/4 of the hypertrophied
Fig. 4 Frontal and lateral
postoperative view 18 months
after surgery in A and B
123
J. Maxillofac. Oral Surg.
masseter muscle. This approach is still followed to these
days, with other authors recommending the same amount
of removal in order to minimize the effects of masseter
hypertrophy [1, 3]. It is also important that the removal is
performed on the innermost surface of the muscle, in order
to avoid noble structures such as the Stensen’s duct and the
facial nerve [2]. In this article, we chose to remove 2/3 of
the masseter on the right side and 1/3 of the masseter on the
left side, since there was an asymmetry, with greater vol-
ume on the right side, and this removal in different
amounts of both sides aimed to correct not only the mus-
cular hypertrophy, but also the facial asymmetry presented
by the patient.
The technique of partial removal of the masseter muscle
through intraoral access is undoubtedly the most accepted.
It allows a good visualization of the operative field and less
morbidity when compared to the extra-oral technique. As
for disadvantages, we can mention mainly a greater diffi-
culty to remove the bone spur at the base of the angle of the
mandible, which should be performed with the aid of
special retractors, piezo tips or reciprocating saws [2, 10].
We did not observe any technical difficulties to perform the
surgery by intraoral route when using the instruments
described above.
Due to the surgical procedure leading to a partial
removal of the masseter muscle, some phenomena in the
postoperative period are expected, such as: Pain, trismus,
hematoma, and edema [2]. In order to minimize these
complications, intense postoperative physiotherapy
J. Maxillofac. Oral Surg.
should be instituted as early as possible, so that masti-
catory function and aesthetics can be recovered more
quickly, in addition to greater pain control [11]. This
physiotherapy should be performed initially with com-
pressive bandages to prevent bruising and edema [2, 12]
and later with manual therapy in order to allow an early
function of the muscle [11]. In our routine, postoperative
physiotherapy is always performed by an experienced
and qualified professional, through initial bandages in the
first three days, manual therapy for early jaw movement
and low-level laser therapy, in order to control edema,
and promote rapid tissue healing, small muscle fibrosis
formation and precocious return of normal mandibular
movement. A well-directed and well-conducted physio-
therapy are essential for muscle recovery after partial
removal of the masseter muscle, in order to avoid the
formation of fibrous tissue that can generate excessive
trismus in the postoperative period.
As a result of the excessive traction of the masseter
muscle in the region of the mandibular angle, there is a
stimulus for the formation of new bone in this region, a
phenomenon known as ‘‘Wolff’s law’’, and therefore it is
observed that the action of a muscle directly contributes
to bone morphology, case of masseter hypertrophy, with
the formation of a bone spur in the region of the ‘‘go-
nion’’ [13]. Following the philosophy of this line of
thought, only the removal of the spur would not be
enough to correct the asymmetry, since the muscle
stimulus would still exist, meaning that the partial
removal of the muscle, as well as the spur, would appear
to be adequate for the aesthetic–functional resolution of
these cases.
The prominence of the mandibular angle was well
described by Kim et al. 2001 [8], who established four
classifications based on the prominence of the
mandibular angle. In the most complex (class IV), there
is an excessive prominence of the mandibular angle
associated with retrogenia, generating aesthetic and
functional problems. In these cases, the authors recom-
mend the performance of an osteoplasty in the
mandibular angle region associated with masseter myot-
omy and chin repair to correct the aesthetic problem [8].
This correction of the chin can be performed in con-
junction with bilateral sagittal osteotomy of the
mandibular ramus when the patient has dentofacial dis-
crepancies or just genioplasty, when there is a dentofa-
cial and maxillomandibular balance, as in the present
case.
There is still no consensus in the literature regarding the
removal of the bony prominence together with the partial
removal of the masseter muscle to correct bilateral mas-
seter hypertrophy. It is known that the excessive force
generated by the hypertrophied muscle creates this
prominence [14], and that is why some authors claim that
only the removal of the bone spur at the angle of the
mandible would be enough to correct the problem [2, 15],
however other authors recommend the simultaneous partial
removal of the masseter muscle in order to promote a better
facial contour and improved esthetics, an opinion that is
also followed by the authors of this article [3, 10]. Removal
of the spur in the mandibular angle region generally does
not generate visible or even palpable deformities, due to
the existing tissue and muscle volume in this region that
masks these changes [16].
Another co-adjuvant procedure performed in con-
junction with the circular treatment of masseter hyper-
trophy is the removal of Buccal fat pad (Bichat’s adipose
body), known as a bichectomy. In these patients, it is
common to find a greater projection of the middle third
of the face in the transverse direction and the perfor-
mance of bichectomy can generate greater harmony of
the face making the middle third thinner and propor-
tional to the lower third [2, 7]. This procedure has
become very popular among professionals and patients in
recent years, and although it is technically simple, it can
present important sequelae such as: Hematoma, persistent
hemorrhage, injury to the parotid duct and facial nerve
injuries [17, 18]. We recommend that this procedure be
performed only by experienced facial surgeons, avoiding
complications or bypassing them when they occur.
Although the surgical treatment of masseter hypertrophy
is aesthetically beneficial, some complications can occur,
especially those related to asymmetries. The amount of
hypertrophic muscle to be removed is usually performed
empirically, depending largely on the experience of the
surgical team [1, 7]. This increases the possibility of facial
asymmetries, which can be treated with dermal fillers,
which are minimally invasive techniques with good aes-
thetic results [19].
Conclusion
Bilateral masseter hypertrophy is an uncommon condition
that can trigger aesthetic, functional and psychological
problems. Surgical treatment is effective in correcting this
123

condition, however, prior planning, specific instruments,
and intense and specialized physiotherapy are necessary in
order to guarantee better results and the early return of
patients to their normal functions.
Funding The financial support was provided by the authors and there
was no corporate involvement.
Declarations
Conflict of interest There are no conflicts of interest regarding the
authors listed on the title page.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent The patient in this study signed a free and
informed consent form in which she authorizes the publication of her
images or photographs in any type of media with an educational
purpose, research and dissemination of scientific knowledge.
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