Buccal fat removal

What it is

• The buccal fat pad sits deep in the cheek on the buccinator muscle, under the facial muscles and separate from the fat under the skin (PMID 36595570). It has a main body and extensions that reach into the cheek, the temple and spaces around the jaw, held by small ligaments (PMID 12045584).
• The pad is small: about 9 to 10 ml on average, a little more in men than in women (PMID 16528468).
• The facial nerve branches that move the cheek and upper lip and the saliva duct from the parotid gland both cross the pad (PMID 16077311, PMID 38885157).
• In the usual technique, only the fat that pushes out easily with gentle pressure is removed (PMID 19338917).

Where it came from

• Buccal lipectomy for full cheeks was reported in 1980, alone or with other facial surgery (PMID 7447280).
• In 1991 Matarasso described the look surgeons aim for: prominent cheekbones, a subtle hollow below them and a defined jaw angle. He advised removing only the deep pad and leaving the fat under the skin, because that fat thins with age (PMID 1952712).
• US internet searches for the operation rose after early 2020 (PMID 34581762), and a 2021 paper described social media demand as a "frenzy" while warning of premature aging of the midface (PMID 34398085).

Who it suits

• Adults with a round, heavy lower face and fullness in front of the cheek from a large pad (PMID 36595570, PMID 30084868).
• Ultrasound before surgery can measure the pad; some surgeons operate only when the pad is large and remove only the excess (PMID 30084868, PMID 34351510).
• Middle-aged patients whose lower cheek has filled and sagged from a dropped pad have also been treated (PMID 35757289).
• Facelift patients whose pad has shrunk may need the opposite: fat added to the buccal space (PMID 28538560).

How it is done

• Usually under local anesthesia, a small cut is made inside the cheek (PMID 34398085, PMID 19338917). The surgeon spreads the tissue bluntly and removes the fat that pushes out with gentle pressure, without pulling on the pad; some use suction to draw it out (PMID 19338917, PMID 39492203).
• Injecting fluid into the pad first (hydrodissection) shortened the operation and lowered pain in a randomized trial (PMID 30768121).
• Surgeons differ on how much to remove: a conservative reduction for round faces (PMID 36595570), or an extended removal that includes the cheek and part of the temple extension (PMID 34598850).
• Some surgeons pair removal with adding volume to the cheekbone and contouring the jaw (PMID 36730489).

Results and how long they last

• At 12 months, 3D photos showed a small but measurable drop in lower face volume and width, with body weight unchanged (PMID 35757289).
• In the studies a systematic review could pool, most patients rated their face contour much better (PMID 34023838).
• The evidence is limited and of low quality, and no published series reports long-term results (PMID 34023838, PMID 30534506).
• How the pad changes with age is unsettled: scans have shown deep cheek fat increasing with age (PMID 31251327), buccal fat staying about the same (PMID 33165293), and the pad lengthening downward toward the jowl (PMID 33649752). That uncertainty is why some surgeons worry that removal at a young age may age the face early (PMID 34398085).

Risks and how surgeons lower them

• About 1 in 4 patients has a complication, all after surgery: mostly swelling, jaw stiffness (trismus), pain and uneven cheeks; facial nerve weakness, infection and hematoma were rare. The authors advise caution (PMID 39809616).
• In about 1 in 4 cadaver faces, nerve branches that move the cheek ran through the pad's cheek extension, and in about 1 in 4 the saliva duct ran beneath it (PMID 16077311). Knowing this anatomy and dissecting bluntly and gently are how surgeons keep complications low (PMID 39492203, PMID 19338917).
• Saliva duct injury is underreported and has its own repair plan (PMID 35662908). Temporary facial weakness has been treated with steroids and facial therapy (PMID 39435017).
• The cheek spaces connect to deeper spaces of the face, so an infection can spread, including to the eye socket in one case (PMID 38885157, PMID 37060456).
• Chewing muscle activity at rest was unchanged two months after removal (PMID 38690691).

Recovery

• Pain is highest in the first three days and was mild in a randomized trial (PMID 30768121).
• Some surgeons pack the inside of the cheek and wrap the head after surgery to lower bleeding and infection risk (PMID 40425155).
• Chewing muscles adjust over about two months (PMID 38690691).

With a facelift

• In some facelift patients the pad shows as fullness beside the jowl, and it can be removed through the facelift incision (PMID 31965150, PMID 28698935).
• The pad can also be moved instead of removed: tucked under the SMAS into the hollow below the cheekbone, where it stayed in place on MRI (PMID 31111860). An endoscopic midface lift can move it to add cheek volume (PMID 11786834).
• When the pad has shrunk, fat can be grafted into the buccal space during a facelift, with volume persisting up to two years (PMID 28538560).

Questions to ask a surgeon

• Is my pad large, and can you measure it before surgery? (PMID 30084868)
• How much will you remove, and why that amount? (PMID 36595570)
• How will my face look at 50 or 60 after removal? (PMID 34398085)
• Would moving the fat or a facelift suit me better? (PMID 31111860)
• How often do your patients have jaw stiffness or nerve weakness? (PMID 39809616)

Open questions

• Aging of the pad: scans disagree on whether it grows, stays or descends (PMID 31251327, PMID 33165293, PMID 33649752).
• Long-term effect: no series reports long-term follow-up (PMID 30534506, PMID 34023838), and experts warn of premature midface aging (PMID 34398085).
• Remove or keep: transposition (PMID 31111860) and augmentation (PMID 28538560) treat the same pad as volume to keep.
• Cheekbone surgery: the pad bulged forward after cheekbone reduction (PMID 37735260), and uneven cheekbones came with uneven pads (PMID 40915419).

Terms

• Buccal fat pad (Bichat's fat pad): a deep fat body in the cheek lying on the buccinator muscle (PMID 36595570).
• Buccal extension: the part of the pad that reaches into the cheek below the cheekbone (PMID 12045584).
• Bichectomy / buccal lipectomy: surgical removal of part of the buccal fat pad (PMID 7447280).
• Pseudoherniation: bulging of the pad forward through weakened tissue with age (PMID 14578806).
• Parotid duct: the saliva duct from the parotid gland that crosses the cheek (PMID 16077311).
• Buccal branches: facial nerve branches that move the cheek and upper lip (PMID 16077311).
• Hydrodissection: injecting fluid to separate tissue before removal (PMID 30768121).
• Trismus: limited mouth opening (PMID 39809616).
• Sub-SMAS transposition: moving the pad under the SMAS to fill the midface instead of removing it (PMID 31111860).
• Labiomandibular fold: the line from the mouth corner toward the jaw (PMID 33649752).

Papers