Dr. Sam Jejurikar: Welcome to yet another episode of Three Plastic Merge, three plastic surgeons on a microphone. I’m Sam Jejurikar in Dallas, joined as always by Dr. Sam Rhee of Paramus, New Jersey, and Dr. Sal Pacella of La Jolla, California. Welcome, gentlemen. Before we get on to today’s topic, which will be an exciting topic on cheek contouring and buccal fat pad removal by Dr. Sam Rhee, Dr. Pacella will handle our usual legal business.
Dr. Salvatore Pacella: This show is not a substitute for professional medical advice, diagnosis, or treatment. The show is for informational purposes only. Treatment and results may vary based on the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care.
Never disregard professional medical advice or delay seeking advice because of something in the show. I think next time I do this disclaimer, I will do it in some sort of Irish brogue or British accent or maybe an Italian accent. I don’t know. What do you guys think?
Dr. Sam Jejurikar: I think those are…
Dr. Sam Rhee: My Italian accent. Be your accent.
Dr. Sam Jejurikar: I was going to say it’s not much of a stretch to do Italian. I think all of those are appropriate accents. You just got to be careful about which accent you choose. Alright. Well, Dr. Rhee, take it away.
Surgical Technique and Considerations for Buccal Fat Pad Excision
Dr. Sam Rhee: We’ve talked a little bit about buccal fat excision in the past. It’s extremely popular. Social media has really taken hold of it recently and run with it. And in fact, our esteemed colleague Dr. Rod Rory commented on this a couple of months ago, and I’ll just show a little video of him talking about it, as well as some of the findings he had in his paper he recently published about it. So let me just pull that up.
Dr. Salvatore Pacella: But for our viewers that may not be familiar with the buccal fat pad, it is a piece of fat in the middle of the face, deep into the face, somewhere around the mid-cheek area, and it’s been a technique popularized to help thin or slim out the face and augment the cheek lines.
Dr. Sam Jejurikar: Yeah, it’s a procedure that has been around for a long time. Removal was popular 20 years ago with the vogue done with many facelifts, went away for a while, and now is making a popular resurgence.
Dr. Sam Rhee: Yes. And in fact, it’s going to be interesting because I’ll show this, which was recently published a couple of months ago, and you tell me what’s changed about it at that point. So it’ll be interesting.
Dr. Rod J. Rohrich, MD: Have you seen these plastic surgery posts on social media where baby fat from the cheek is popped out literally through a small incision inside the mouth? Buccal fat pad removal went viral due to the striking at subtle pussop changes where patients emerge with slimmer lower faces and a more defined jawline. Despite the popularity, there’s still a lot about the surgical’s long-term efficacy we don’t know about.
To learn more, the authors of this innovative Hot Topic performed an in-depth anatomic analysis of the effects of this procedure short and long term. Even though the surgery is relatively minor, involving a small incision inside the mouth, can be done under local anesthesia, and can take only under 30 minutes, it’s certainly not without risk. The authors found that excessive traction or aggressive dissection can remove more than just the fat pad and affect the facial nerve’s buccal branches. This could lead to an excessively hollowed-out appearance, premature aging, and nerve damage.
They do state that if excision is controlled and limited to the buccal fat pad extension, only the short-term risks are minor. But still, there’s no long-term evidence to show what happens to the face without the buccal fat pad over time. Remember, all facial fat compartments are important. This fat pad is very different. It goes from the superficial and the deep fat very important.
So the key to understanding facial fat is that the loss of facial fat in the face really predicates how you age. The more you lose, the more you age. That’s why modern facial rejuvenation restores volume by targeting deflated fat compartments. The authors note that there is evidence that buccal fat pad diminishes naturally as we age. But how much it does dissipate is still unknown.
More evidence and long-term studies will be needed to determine if removing buccal fat to get that oval, beautiful heart-shaped face and defined jawline when you’re younger and does it truly not cause premature aging. But for now, the authors conclude that this procedure can be performed safely in the hands of a skilled plastic surgeon.
It is best reserved for those patients with naturally full round faces that have fullness in the front of their lower cheek, above the jawline. Even if a procedure is trending on social media like Instagram, it might not be right for you. That’s why we always encourage our patients to do their homework.
Dr. Sam Rhee: The more you know.
Buccal fat Removal in 1990’s
Dr. Sam Jejurikar: That’s a great synopsis. I love how Dr. Rod refers to the authors in the third person, even though he’s the lead author on that paper. He is the lead author. And the rest of the authors were another one’s, one of my partners at present, and another was a fellow with us. So I know all of these guys; they’re all great plastic surgeons. I think that’s a great review, though.
When buccal fat pad removal was done a lot in the 1990s, early 2000s, and even the late 1980s, we were very much in the mindset of plastic surgery that removing fat was the key. Dr. Pacella is the eyelid expert among the three of us. Still, he certainly, I’m sure, was dealing with many patients who, 20 or 30 years ago, had lower eyelid surgery where their lower eyelids were totally hollowed out. We would take out fat from the lower eyelids.
We would do facelifts where we would do vasectomies or take out large amounts of facial fat. And buccal fat pattern movement went as well, and it gave people a chiseled look, which looked awesome in the short term, but as they advanced 5, 7, or 10 years down the road, it made them look prematurely older. And so it’s interesting that this procedure has made a comeback.
I will say that I’ve been doing more of it than I thought I would. And I’ll even have this conversation with patients, and I’ll tell them, you’re going to look older when we do this. And they all have a very quick retort, which is I’ll get filler or facial fat put back in later on. I feel like patients know that, but they very much, in the short term, like the chiseled look they get from fat pad removal.
Dr. Salvatore Pacella: Yeah, and I think it’s interesting because I rarely have patients come in specifically asking for this procedure. It’s rare that someone would say, I want my buccal fat pad removed. I read about it, or I saw it on social media. But it is part of a comprehensive face assessment and tailoring your treatment. So, for example, in young patients, this technique can work very well if you have a full face around them and your jaw is a little widened.
I usually use this in combination with not only direct excision through the mouth that can be done under local anesthesia, but I also give patients a bit of Botox, two or three injections of Botox into this area here called the masseter muscle. Many of these patients have hypertrophy of this muscle, which gives their faces a much more boxy look. And so I think the combination of adding Botox there and doing the buccal fat pad can really make a huge difference.
Dr. Sam Rhee: Yeah, I think when I do these cases, they’re in relatively younger patients, I usually do some sort of adjunctive technique like masseter Botox injection, just like Sal said, and they usually get a very nice slimming effect. It’s funny because Susan and Kalamoto wrote about this, and if you want, I’ll show you the video that they did 30 years ago operatively about how to take this out, which was really exactly the same as it is now. And even then, Susan was pretty adamant about being pretty conservative about how much fat he took out. He said maybe 2, 4 grams, something like that.
The Buccal Fat Removal Comeback
And everyone knew at that point what the risks were. And, as Sam says, it’s made a big comeback. I’m seeing more and more of these. I try to start with something relatively non-invasive, like Botox, to the master first. If they feel like they need to get some more slimming, I’ll turn to the buccal fat pad. In addition, sometimes some neck lipo can be helpful, too. And I’ll show a case where we did that, but I’ll just throw up an operative picture, and then we’ll see what that looks like.
Dr. Sam Jejurikar: As you’re saying that, the only thing that I would say is different in my experience than Sal’s is I have lots of people coming in asking specifically for this. They’ll call it a buccal fat pad. Nobody calls it the buccal fat pad. They all think I’m pronouncing it wrong when I call it the buccal fat pad. But literally, probably every six weeks, I have a patient, a younger patient, early 20s, mid to late 20s deal, who specifically is requesting buccal fat pad removal.
And so it’s rare for me to actually make this something that I primarily bring up with someone, even though I do it every six or eight weeks on someone. But it’s driven by patients in my practice. And just like you guys, I’ll do some botox into the masseter. I commonly will do some submental and neck life of suction, usually using a radio frequency technique as well, just to really tighten the jawline and all in combination. It gives them a much more chiseled look when they’re done.
Dr. Sam Rhee: So let me show you a little bit of a diagram, and we can talk about the actual procedure here. So the buccal or buccal in Texas fat pad is actually pretty large, and it actually extends all the way up over the temporal muscle. And what we really get is just a little bit of it that extends down into the mouth. And as Dr. Rod said, it’s pretty straightforward. It can be done in under 30 minutes.
You basically find the second maxillary molar, you make the STENSON’S duct, and you just make a small incision. And the key to this is that even though it’s a small procedure, there are structures in this area that have profound functional importance. And STENSON’S duct is the opening where the parotid gland basically empties into the mouth.
And if you were to lacerate it or misidentify it or somehow damage it, you’re going to have a huge problem afterward for something that you thought was a really small procedure. In addition, as Dr. Rod mentioned, there are buccal branches of the facial nerve which are very close to the buccal fat pad. You can literally see not here, but they are literally right there. And the facial nerve innervates the muscles of your face, so you can get facial paralysis if this is improperly done. So what is…
Dr. Salvatore Pacella: Can I ask you, would you say that the incision is accurate to where you make it?
Dr. Sam Rhee: No, I make it actually well away from stencils, probably about closer to the gingiva of the second maxillary molar, probably.
Surgery and the Parotid Gland
Dr. Sam Jejurikar: And just in case our viewers are not clear, can you tell them what the parotid gland is and the parotid duct and what sense inducts actually are and what the problems are, if you do damage that?
Dr. Sam Rhee: Right. So it’s good. Thanks for reminding me. It’s a salivary gland. So you actually have saliva that’s produced in the parotid gland that is being tunneled or piped through this duct that goes from the gland that is right around your ear, through the cheek, into your mouth. And if you were to somehow damage it or block it, you would basically block the passage of saliva into your mouth.
You could get a huge collection of saliva, which we’ve seen not in these cases but in trauma where we’ve all dealt with facial trauma before, where this duct was lacerated. And it’s not a joke to have to reconstruct it. And did you guys ever encounter that in your travails in facial trauma?
Dr. Salvatore Pacella: Oh, yeah. At Michigan, I had a gentleman who got into a bar fight with a glass and had a nice stellate laceration right over this area. It was about four in the morning, and I figured out pretty quickly that he had lacerated STENSON’S ducts. And the interesting thing was I placed a little piece of suture on the inside of his mouth through the duct on the inside of the mouth, and then it came right out, straight out into the wound. So I knew immediately that the duct was violated.
Dr. Sam Rhee: Interesting.
Dr. Sam Jejurikar: I saw a patient who had a buccal fat, fat is taken out elsewhere, and had persistent swelling in the side of their face for two or three months and wasn’t really getting anywhere with their primary surgeon, who was not a plastic surgeon. And so they ended up seeing me, and they had a persistent salivary collection inside their mouth. By that point, when you’re that far out, it’s impossible to reconstruct STENSON’S duct, so a drain was placed.
They needed compression over that area. They needed what we call agents to basically try to suppress salivary production. It’s a big to do if that actually happens. From the time that they came into the time that it was no longer a problem, it took several weeks; I want to say almost three months, to finally resolve. So it can be a huge problem.
Dr. Salvatore Pacella: Now, Sam, getting back to that incision again, so you make your incision in between Stenton’s duct and the second molar, or right at that same level, but closer to the teeth?
Dr. Sam Rhee: I will usually make it a little bit closer. Well, it depends. Yeah. So I will make it a little bit closer to the well. This is not really that accurate, honestly. I feel like STENSON’S duck is farther out a little bit, and there’s more space between the mucosa of the second maxillary molar. There’s more space there in which to make your incision.
Dr. Salvatore Pacella: How about you? I usually go a little bit more posterior than what this shows and kind of work my way back a little bit. So that’s the approach I use for facial trauma. And I kind of know the exposure fairly well.
Dr. Sam Jejurikar: I think they’re trying to show it by the second maxillary molar, but the teeth are so crowded together in there that it doesn’t look that posterior. But if you think about where it actually is in the second maxillary molar and how much harder it is to see relative in this picture, it’s a little bit misleading.
But yeah, what I’ll do is, again, I agree with Sam. The STENSON’S ducts are not so close to the incision, but I think that’s just because of the way that the picture was drawn. I go right into the sulcus, make an incision dissect using a pair of scissors. So you see the buccinator muscle tease through those fibers, and it should just pop out.
Dr. Sam Rhee: Yeah, if you’ve never done it. I remember the first couple of times well. I did it all the time in my craniofacial fellowship because we would make cuts for our maxillary osteotomies, and you would always get into it even though you didn’t want to get into it, which is really annoying. But when the first time I intentionally did it, it was where I wanted to get to the buccal fat pad. You actually have to pop through the fascia a little bit, and it takes a little bit of doing to make sure you’re a little bit confident to get through that buccinator and then get into that fat pad.
So it does take a little bit of finesse to be able to know exactly where you are and to make sure that you’re in there. And then, once you’re there, I tease out. I mean, how do you judge how much to take out? For me, it’s more like I look at the patient, I see how much external fullness there is in the buccal fat pad, and I always take out just a little bit less than I think I really need in order to achieve the look that I think the patient wants.
Patient Case Study and Results of Buccal Fat Pad Removal
Dr. Sam Jejurikar: I try to tease it out, let it fall out naturally, and whatever naturally extrudes, I take out. I try not to pull out and transact at the same time. Whatever naturally falls out when you pop through all that is what I’ll take out. Less is more, I think.
Dr. Salvatore Pacella: Yeah. I do a similar technique, and it’s very similar to what I would do for removing upper eyelid fat. If somebody’s really excessive, I just kind of gently press on the globe and just let gravity kind of dictate what comes out. Same sort of concept here. And I’m always kind of looking at the opposite side to just make sure I’m not creating an excessive indentation or anything like that.
Dr. Sam Rhee: Again, a lot of it is experienced, as you can tell, listening to Sam and Sal. But when you do it, it’s what you feel based on your feedback on the patient and your experience, what’s appropriate. So that’s really important.
Dr. Salvatore Pacella: One other point to make here is that not certainly not for the faint of heart as a surgeon, but if you’re doing a facelift and the newer techniques of deep extended facelifts, you’re not far away from this plane to tease out the buccal fat pad. But you have to be exceptionally gentle.
So many times, if I’m planning a buccal fat pad removal and I’m doing a deep extended facelift, I’ll lift up my tissue, go underneath the smash, take it extended deep into the face, and make sure I’m not damaging any of the nerves. And you really just have to gently spread. And you can get a good handle on this buccal fat pad externally, but again, not for the faint of heart.
Dr. Sam Rhee: I haven’t done a deep plane facelift in, like, 25 years, probably, and I don’t plan on doing it anytime soon. You’re right. It takes balls to be able to do that. That’s all I can say.
Dr. Sam Jejurikar: Yeah. I also don’t do deeply in faceless.
Dr. Sam Rhee: So this is a patient who had a buccal fat pad excision. She also had a little bit of submental liposuction, and she actually came back. She came specifically for buccal fat pad excision and lipo. And then, after this, we also did massive muscle injections of Botox subsequent to that, which I don’t have her most recent pictures on, but she was really happy with the results. She felt like she went from looking like a kid to basically like a young adult, which is what she is. And again, it just helps to contour and narrow the face a little. The jawline, it’s not for everybody, as we discussed, but for certain patients, it’s very powerful.
Dr. Sam Jejurikar: Looks great! Yeah. I think everything you did works in concert. You can see that she has a little bit of dimpling of the lower cheek area. That’s the specific effect for reviewers of the buccal fat pad. It makes her look like she has more cheekbone definition. Then there’s slimming of the jawline, which is a combination of the injections of Botox that you did, and then the side view really shows the effect of the neck liposuction, just how much more acute what we call the cervical mental angle is. She just has a much more defined jawline. And even though I’m sure she’s the same weight as she was beforehand, she looks much more chiseled. So really nice result!
Dr. Salvatore Pacella: Great job.
Dr. Sam Rhee: All right, thanks. Any other thoughts about buccal fat pad excision or cheek contouring itself? Or Dr. Rod and his informational video?
Dr. Salvatore Pacella: Do either of you ever use the buccal fat pad as a donor for other facial fat?
Dr. Sam Jejurikar: I have never done that.
Dr. Sam Rhee: When I did craniofacial. We use it all the time as a pedicled graft for palatal fistulas, for small defects, and it worked great, especially in younger patients who seem to have a lot of it, obviously, because it seems to be very bulky in children. I need to remember this technique more for facial fat grafting as well because there are some patients I know that probably would actually benefit from repurposing it and redirecting it to Maillar or other areas. I just keep forgetting that’s something that I should use. Do you use it a lot, Sal?
Dr. Salvatore Pacella: Not a ton. I think about it much more than I actually do. It’s just because, in the majority of my facial aesthetic patients, I’m doing a larger volume of fat anyway that I’m harvesting from the abdomen and just a little bit more precise. But I know people do excise it, chop it up, lay it down.
Final Thoughts on Buccal Fat Pad Excision
Dr. Sam Jejurikar: I think with the newer facial fat grafting techniques that are out there that I know you’re using, it’s just that the quality of fat when you have it in a syringe, and you’re dragging it, yeah. The buccal fat pad would be kind of lumpy and irregular. If you think about the eyelid, much more mouth, you do so much.
And if you’re using fractionated fat, I’d be worried about using the buccal fat pad in that scenario. And in terms of Sam’s question, I think Dr. Warwick’s synopsis is actually perfect. I think that it is very popular. It has a role in defining the jawline. It can definitely help with a chiseled look for younger patients. Know that there are long-term implications of doing this.
So if you’re okay continuing this whole facial rejuvenation process in your 40s, 50s, and 60s, like, most of the people we see are in their 40s and 50s and 60s, know that you will have to reverse the effects of doing this procedure. But there are definitely benefits to doing it as part of a more comprehensive approach now. Yeah, I like that!
Dr. Sam Rhee: You’ll look just like Sal.
Dr. Sam Jejurikar: Exactly.
Dr. Sam Rhee: Alright. Awesome, guys. Thank you so much. Have a great day, guys!
Dr. Salvatore Pacella: You guys do as well. Take care. Bye!