Managing the Buccal Fat Pad - Blog Tempo Cirurgia Plástica

Operative Strategies
Managing the Buccal Fat Pad
The author performs buccal fat pad excision to
improve facial contour in some patients with buccal
lipodystrophy and to treat buccal fat pad pseudoherniation. He recommends an intraoral approach, taking
care not to pull on the fat pad and resecting only that
which protrudes easily with gentle pressure. (Aesthetic
Surg J 2006;26:330-336.)
A
dults with a capacious midface who desire refinement, sculpting, or enhancement of their skeletal
features, and reduction of facial fullness by diminishing midface volume, are potential candidates for excision of the buccal fat pad. Buccal fat pad excision is also
performed in patients who are properly diagnosed with a
cheek mass because of displacement of the buccal fat pad
(pseudoherniation).
The volume of the buccal fat pad is relatively consistent. This is true for men and women throughout their
lives, despite weight fluctuations, and in people with
varying body mass indexes. In fact, the submuscularly
located buccal fat pad stubbornly persists (to a point) in
spite of loss of weight and loss of subcutaneous fat.
Perhaps this is because it has a different lipolytic rate
than subcutaneous fat (similar to periorbital fat).
Buccal fat pad removal may be considered in any age
group to treat buccal lipodystrophy or buccal fat pad
pseudoherniation. Either condition can be approached
with intraoral buccal fat pad removal with or without
concomitant lipoplasty of the jowls and neck. Buccal fat
pad removal can be performed in conjunction with other
related facial procedures, including liposuction and
facialplasty, or with body contouring procedures. Ultimately, the goal of buccal fat pad excision is enhanced
facial aesthetics—contouring that highlights the angularity of the facial skeletal features.
Pseudoherniation of the Buccal Fat Pad
The cause postulated for pseudoherniation of the
buccal fat pad is weakening of the investing fascia.
Most commonly, patients present with a small, round
“marble”-size contour irregularity in the cheek that has
no reasonable explanation. It can be observed following earlier facial liposuction or face lift, in patients tak-
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ing steroids, or be idiopathic in nature.
Pseudoherniation of the buccal fat pad involves the
presence of a soft mass
with the consistency of adipose tissue that, in the
absence of any associated
pathological findings, is
easily
reducible
with
upward displacement into
the buccal space. The condition should be distinAlan Matarasso, MD, New
guished from other cheek
York, NY, is a board-certified
masses and can be conplastic surgeon and an ASAPS
member.
firmed by magnetic resonance imaging.
It is very important to identify and discuss the finding
of a herniated buccal fat pad with the patient before
facial surgery. This avoids the dilemma of explaining the
finding postoperatively, a scenario in which patients may
assume you are justifying a less than pleasing result
(Figure 1). It is notable that if unexplained bulging is
noticed as a new finding following a face lift or facial
lipoplasty, pseudoherniation of the buccal fat pad is the
probable cause.
Operative Technique
The buccal fat pad (Bichat’s fat pad) has a complex
relationship to the facial structures. It has 4 parts
divided by the parotid duct and facial nerve and vein
into anterior and posterior portions (Figure 2). It is the
buccal extension and main body that are removed
intraorally to achieve midfacial contouring. The “layers” dissected in accessing the buccal fat pad, percutaneously or intraorally, are similar to the layers encountered in a transcutaneous or transconjunctival
blepharoplasty, ie, skin mucosa, muscle investing septum, and fat (Figure 3).
I prefer to excise the buccal fat pad intraorally prior to
surgical scrubbing and preceding any other facial procedures. The gingivobuccal space is injected (bilaterally)
with a lidocaine and epinephrine-containing solution
approximately between the first and second upper molar.
The cheek is retracted laterally with Caldwell Luc retractors, and a 2.5-cm mucosal incision is made while preserving a cuff of mucosa for closure (Figure 4). The inci-
Operative Strategies
Figure 1. This 72-year-old woman is seen following a face lift; several attempts using lipoplasty had been made to ameliorate the residual bulge
in her cheek. The bulge was diagnosed as representing a pseudoherniation of the buccal fat pad and was treated with intraoral excision.
Parotid duct
Skin and subcutaneous fat
SMAS
Masseter
Branches of facial n.
Buccal fat pad
Buccinator m.
Mucosa
Figure 2. Anatomy of the buccal fat pad.
Managing the Buccal Fat Pad
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Extension of fat pad
Parotid gland
SMAS
Buccal fat pad
Extension of fat pad
A
Temporalis m.
Extension of fat pad
Zygomatic arch
Buccal fat pad
Buccinator m.
SMAS
Parotid duct
Extension of fat pad
B
Figure 3. A, B, In performing intraoral excision of the buccal fat pad, the layers encountered are similar to those found in performing transconjunctival blepharoplasty.
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Operative Strategies
Figure 4. The cheek is retracted, demonstrating the relationship of the intraoral incision for buccal lipoplasty to surrounding structures.
Figure 5. The buccal fat pad is exteriorized and drawn into the wound.
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A
B
Figure 6. A, The buccal fat pad is elevated, clamped, and excised. B, The operator should retract the upper lip to avoid electrocauterizing it inadvertently.
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A
B
Figure 7. A, Preoperative view of a 74-year-old woman with buccal lipodystrophy. B, Postoperative view one year following a short scar face lift,
4-lid blepharoplasty, temporal brow lift, perioral laser procedure, and excision of the buccal fat pad.
A
B
Figure 8. A, Preoperative view of a 34-year-old woman with buccal lipodystrophy who desired to improve her facial contour. B, Postoperative
view one year following buccal lipectomy and lipoplasty of the neck and jowls.
Managing the Buccal Fat Pad
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sion is carried through the mucosa and muscle while
applying external pressure on the skin in the region of
the buccal fat pad. The buccal fat pad is exposed and
the fascia is pierced with scissors. A long hemostat is
used to spread the fat while the surgeon continues to
place external pressure on the cheek, manipulating the
fat pad into the wound (Figure 5). Without excess traction, the portion of the fat pad that protrudes is
grasped, gently teased into the field, clamped at its
base, and excised. The stump is electrocoagulated, and
the wound is packed with gauze soaked in lidocaine
and epinephrine solution while the opposite side is
operated (Figure 6). When you electrocoagulate, use a
finger to displace the lips to avoid inadvertently cauterizing them. The wound is closed with one absorbable
suture (Figure 6).
It is most important to remove only the fat that protrudes and to do so without excessive pulling or traction. Postoperatively, patients can expect to appreciate
the change in facial contour over the course of several
weeks (Figures 7 and 8).
Using the guidelines I have outlined (performing an
intraoral approach, being careful not to pull on the fat
pad, and resecting only that which easily protrudes
with gentle pressure), complications of buccal fat pad
excision for lipodystrophy or a pseudoherniated buccal
fat pad are rare indeed. The most likely complication
would be overresection. Hematomas and infections are
potential problems in any surgery. I have not encountered those problems. In theory, the most significant
complication with buccal fat pad removal would be
nerve injury. However, a 7th-nerve injury can be avoided by following the aforementioned guidelines. I would
thoroughly discuss with all patients the impact that
buccal fat pad removal can have on current and future
facial aesthetics, whether the buccal fat pad is “normal” or one that is pseudoherniated. ■
Downey SE, Hugo NE. Periorbital Fat—Different? Presented at the Annual
Meeting of the American Society for Aesthetic Plastic Surgery, Orlando,
FL. April 10, 1989.
Dubin B, Jackson IT, Halim A, et al. Anatomy of the buccal fat pad and its
clinical significance. Plast Reconstr Surg 1989;83:257.
Epstein LP. Buccal lipectomy. Ann Plast Surg 1980;5:123.
Ortiz-Monasterio F, Olmedo A. Excision of the buccal fat pad to refine the
obese midface. In Kaye BL, Gardinger GP, editors. Symposium on Problems
and Complications in Aesthetic Plastic Surgery of the Face. St. Louis:
Mosby, 1984. p. 91-98.
Stuzin JM, Baker TJ, Baker TM. Anatomical structure of the buccal fat pad
and its clinical adaptations (Discussion). Plast Reconstr Surg
2002;109:2519.
Zhang HM, Yan YP, Ai K-M, Wang JQ, and Liu ZF. Anatomical structure of
the buccal fat pad and its clinical adaptations. Plast Reconstr Surg
2002;109:2509.
Reprint requests: Alan Matarasso, MD, 1009 Park Avenue, New York, NY
10028.
Copyright © 2006 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$32.00
doi:10.1016/j.asj.2006.03.009
References
1. Matarasso A. Pseudoherniation of the buccal fat pad: a new clinical
syndrome. Plast Reconstr Surg 1997;100:723-730.
2. Matarasso A. Pseudoherniation of the buccal fat pad: A new clinical
syndrome. Plast Reconstr Surg 2003;112:1716-1718.
3. Jackson I. Anatomy of the buccal fat pad and its clinical significance.
Plast Reconstr Surg 1999;103:2059-60; discussion 2061-2063
(Matarasso A).
4. Matarasso A. Buccal fat pad excision: aesthetic improvement of the
midface. Annals Plast Surg 1991;26:413.
Suggested Reading
Bagdade JD, Hirsch J. Gestational and dietary influences on the lipid content of the infant buccal fat pad. Proc Soc Exp Biol Med 1966;122:616.
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