47 Buccal Fat Pad Excision

Rod J. Rohrich, Yash J. Avashia, Ira L. Savetsky, and Nikhil A. Agrawal

Abstract

The buccal fat pad can be a cause of excess facial width and can blunt the jaw line. Excision of this fat is a great option for patients who would like a slimmer lower face. If there is excess excision of the fat pad, then premature aging will occur. The fat pad is broken up into lobes and through a small intraoral incision and gentle traction, excision can be limited to the buccal extension of the buccal fat pad. This will lead to nice contour of the lower face without the complication of premature aging.

Fat pad excision – fat compartments – buccal fat – facial analysis – cheek fullness – masseter hypertrophy – mandibular definition

47 Buccal Fat Pad Excision

Key Points

Buccal fat pad excision is an excellent procedure to narrow the width of the lower face.
The fat pad is split into four main lobes that are separated by a thin fibrous layer.
Excess traction or dissection of the fat pad can lead to excision of too many lobes of the fat pad and premature aging.

47.1 Preoperative Steps

47.1.1 Anatomy and Analysis (Fig. 47.1a, b)

The buccal fat pad consists of a main body and four extensions:
- Buccal extension.
- Pterygoid extension.
- Superficial temporal.
- Deep temporal.
Examine the patient and the source of the buccal and mandibular contour:
- Anterior buccal fullness can be treated by buccal fat removal.
- Posterior buccal fullness can be treated by Botox injections to the masseter.
- Mandibular border definition is best augmented by filler.
  
  Fig. 47.1 (a) The lobes of the buccal fat pad are displayed here. The superficial and deep temporal extensions are superior. The body is anterior. The pterygoid extension is seen posteriorly and the buccal extension is seen inferiorly. (b) The body of the buccal fat pad is adjacent to the buccal branches of the facial nerve, which can be injured if excess traction is provided during surgery.

47.1.2 Managing Expectations

Define where the patient would like the width of the face reduced.
Discuss the risk of premature aging and need for fat grafting of the face when the patient is older for facial rejuvenation.
In the right patient, this surgery can be done in the office under local anesthesia.

47.2 Operative Steps

See Video 47.1.

47.2.1 Markings and Anesthesia

The horizontal 2 cm incision is marked 2 cm inferior to Stensen’s duct.
For hemostasis and anesthesia, 4 mL of 1% lidocaine with epinephrine is injected.
Two intraoral Obwegeser retractors are utilized for visualization.
The incision is made with Bovie electrocautery to prevent any bleeding that may obstruct visualization (Fig. 47.2).

Fig. 47.2 Stensen’s duct is identified and a transverse incision is made 2 cm inferior to this.