Fat is one of the essential components of youth and cervicofacial rejuvenation. The “grape to raisin” analogy used many times in this text is a metaphor for deflational volume loss in aging and the restoration thereof in rejuvenation ( Fig. 15.1 ).
As we know, the youthful face has plentiful midfacial fat volume and tapers to a youthful jaw and neck profile, whereas the aging face becomes deflated, allowing fat deposits to accumulate on the jawline and neck. This deflational shift, coupled with other hard and soft tissue changes is, in short, what produces aging changes.
Numerous intrinsic and extrinsic factors influence the hard and soft tissue changes throughout life. The main goal of rejuvenation is to reestablish the tapered face of youth and the treatment varies depending on the age of the patient. Younger patients may benefit from simple volume inflation with facial fillers and implants, while older patients will require fat removal and sculpting as well as skin tightening. Injectable fillers, facial implants, and fat transfer have been detailed in previous chapters and this chapter deals with fat reduction and recontouring (sculpting) in the face and neck. Unlike the previous chapters on adding volume, I focus here on removing or reshaping volume.
The malar fat pad supplies the majority of youthful midfacial volume and has been detailed elsewhere. The buccal fat pad (BFP), also called “Bichat’s fat pad” is a distinct and separate structure from the malar fat and also provides facial volume. Teleologically, the function of the buccal fat pad is not singularly defined. Theories include the buccal fat aiding in nursing and also forming a gliding plane to facilitate movement of the masticatory muscles, as well as to cushion and protect the muscles.
Anatomy
The buccal fat pad sits between the buccinator muscle and the masseter muscle and should never be confused with the malar fat pad. The buccal fat pad is an encapsulated adipose mass that spans the lateral face from the temporal region to the mandibular region and has three lobes and four extensions. The temporal extension envelopes the temporalis muscle on both sides, the body of the pad occupies the space under the zygoma, the pterygoid extension is in the region of the posterior maxilla, and the buccal extension sits inferiorly over the mandible ( Figs. 15.2–15.5 ). The parotid duct pierces the buccal fat pad on its intraoral entry. The buccal fat pad can herniate with aging and can be approached intraorally or through the facelift incision during rhytidectomy.
Diagnosis
Buccal fat reduction is a procedure that can assist in reducing facial fat in selected patients. The procedure can assist to trim and taper the cheek area but is not a procedure that will make a fat face skinny. This is an important point, as there are many young patients that seek this procedure with the intent to slim their entire face. Buccal fat reduction (BFR) is more of a precision procedure used to sculpt the cheek area in selected patients. It is requisite for the surgeon and patient to understand the point of change with BFR. The surgical result is related to the size and volume of the BFP. The area of reduction is in the mid to lower cheek ( Figs. 15.6–15.8 ).
The importance of what this procedure will do and what areas will be affected is paramount in patient communication, as many patients have inflated ideas of what this procedure does. Patients that cannot understand that this procedure is conservative are not operative candidates. This is one of those procedures where I always under-promise the result. Sometimes the results are very noticeable and sometimes they are very subtle and that is influenced by the amount of buccal fat the specific patient possesses.
Contrary to the belief of many patients, the entire BFP is never removed. It is generally the buccal extension and body that is reduced and sometimes a portion of the pterygoid extension. The goal with this procedure is reduction and not ablation. This adipose mass is important in providing youthful facial volume and overzealous excision will skeletonize the patient. BFR is a popular request from online patients seeking consultation and another popular request is for BFP revision surgery to help to fill in cheeks that have been overtreated. This should be a conservative procedure. BFP reduction is a trendy topic with online cosmetic bulletin boards and groups. Many young patients, normally not in the cosmetic surgery spectrum, request this procedure. Although some of them are candidates, many of them do not need any cosmetic surgery and the surgeon needs to watch for signs of body dysmorphic tendencies.
Surgical Procedure
BFR can easily be performed with local anesthesia or intravenous (IV) sedation. The first step is to infiltrate the proposed incision site with local anesthesia. Approximately 2 mL of 2% lidocaine with 1 : 100,000 epinephrine is infiltrated just under the parotid duct (Stenson’s duct) into the mucosa. The duct is located opposite the first molar region on the cheek mucosa. On some patients, it is very easy to see and on others, the orifice is more hidden. Several more milliliters are infiltrated into the buccinator muscle and into the generalized region of the region to be reduced. Some surgeons make the mucosal incision above and below the parotid duct and use both. I personally use an infraductal incision, which has worked well. Regardless of the incision position, the surgeon must always protect the parotid duct and orifice from inadvertent injury.
In general, the BFP is easily located and reduced but in some patients, location can be difficult. My first approach is always through an in incision inferior to the parotid duct. If the fat cannot be located through this incision, my secondary mucosal approach is more superior and lateral to the last molars in the sulcus.
The incision is made with a radiowave microneedle just through the mucosa, several millimeters under the parotid duct ( Fig. 15.9 ). This area is very vascular and a coagulative incision modality is preferred. After the incision is made through the mucosa, a long, thin tonsil clamp is used to bluntly puncture through the buccinator muscle. This is a perfect instrument for atraumatic entry through the muscle and the delicate curved tips are efficient to spread and grasp the fat pad. After the hemostat punctures the buccinator, the tips are spread within the buccal space and the fat will frequently billow out of the incision ( Fig. 15.10 ). Placing finger pressure on the cheek skin and manipulating the fat pat to the incision is helpful to capture the fat if it does not present. If the fat does not present itself, the hemostat is repositioned supero-laterally and spreading is continued. The tips can be lightly approximated to capture the fat pat and pull it through the incision. If the fat pad mass is still not located, a 3-mm suction tip can be inserted and will frequently engage the fat pad. If the surgeon cannot locate the fat pad through the parotid duct incision, a more superior incision is made in the sulcus lateral to the most posterior maxillary molar and the hemostat is introduced and guided postero-medially ( Fig. 15.11 ).
The buccal fat is encapsulated and once the capsule is incised, it frees the fat lobules, which enables more fat to be delivered ( Figs. 15.12 , 15.13 ). Once the fat is delivered into the oral cavity, it is reduced with bipolar forceps, radiowave, or electrosurgical microneedle ( Fig. 15.14 ). It is important to use a coagulative modality, as vessels penetrate the fat pad in the same manner as blepharoplasty.
As stated, judicious dissection and grasping needs to be performed due to related anatomic structures, including the parotid duct and large vessels that can traverse the cheek ( Figs. 15.15 , 15.16 ). Minor punctures or lacerations can be treated with simple suture closure. In the case of severe laceration or transection of the parotid duct, cannulating the parotid duct orifice with an IV cannula assists in stabilizing the sutured repair, maintaining patency of the duct. The cannula is sutured to the cheek mucosa and left in place for several days.
Performing BFR is very similar to blepharoplasty in that over-resection can produce a skeletonized appearance. Facial fat is a friend and not an enemy and reduction should be judicious.
After sufficient fat is removed the surgical site is checked for hemostasis. The buccinator muscle at the incision site is a frequent source of bleeding and can contribute to hematoma. If active bleeding is encountered deeper in the wound, cauterization must be carefully addressed, as facial nerve branches can be in the proximity as they traverse the masseter muscle. Packing the wound with gauze can also assist in hemostasis.
Post-surgically, gauze packs are placed between the cheeks and a compressive dressing is placed for 24 h. This dual layer compression assists in eliminating dead space and may assist in control of bleeding and swelling ( Fig. 15.17 ).
Figs. 15.18–15.23 show before and after cases of BFR. Although plentiful fat can be removed bilaterally, the clinical result is subtle and sometimes it is difficult to see a big difference in before and after images. Most frequently, the patient can appreciate a change regardless of pictures and is happy. Patients must be informed preoperatively that the changes with average BFR are small to moderate. Patients with inflated presurgical expectations are not good candidates.
Surgical Procedure
BFR can easily be performed with local anesthesia or intravenous (IV) sedation. The first step is to infiltrate the proposed incision site with local anesthesia. Approximately 2 mL of 2% lidocaine with 1 : 100,000 epinephrine is infiltrated just under the parotid duct (Stenson’s duct) into the mucosa. The duct is located opposite the first molar region on the cheek mucosa. On some patients, it is very easy to see and on others, the orifice is more hidden. Several more milliliters are infiltrated into the buccinator muscle and into the generalized region of the region to be reduced. Some surgeons make the mucosal incision above and below the parotid duct and use both. I personally use an infraductal incision, which has worked well. Regardless of the incision position, the surgeon must always protect the parotid duct and orifice from inadvertent injury.
In general, the BFP is easily located and reduced but in some patients, location can be difficult. My first approach is always through an in incision inferior to the parotid duct. If the fat cannot be located through this incision, my secondary mucosal approach is more superior and lateral to the last molars in the sulcus.
The incision is made with a radiowave microneedle just through the mucosa, several millimeters under the parotid duct ( Fig. 15.9 ). This area is very vascular and a coagulative incision modality is preferred. After the incision is made through the mucosa, a long, thin tonsil clamp is used to bluntly puncture through the buccinator muscle. This is a perfect instrument for atraumatic entry through the muscle and the delicate curved tips are efficient to spread and grasp the fat pad. After the hemostat punctures the buccinator, the tips are spread within the buccal space and the fat will frequently billow out of the incision ( Fig. 15.10 ). Placing finger pressure on the cheek skin and manipulating the fat pat to the incision is helpful to capture the fat if it does not present. If the fat does not present itself, the hemostat is repositioned supero-laterally and spreading is continued. The tips can be lightly approximated to capture the fat pat and pull it through the incision. If the fat pad mass is still not located, a 3-mm suction tip can be inserted and will frequently engage the fat pad. If the surgeon cannot locate the fat pad through the parotid duct incision, a more superior incision is made in the sulcus lateral to the most posterior maxillary molar and the hemostat is introduced and guided postero-medially ( Fig. 15.11 ).
The buccal fat is encapsulated and once the capsule is incised, it frees the fat lobules, which enables more fat to be delivered ( Figs. 15.12 , 15.13 ). Once the fat is delivered into the oral cavity, it is reduced with bipolar forceps, radiowave, or electrosurgical microneedle ( Fig. 15.14 ). It is important to use a coagulative modality, as vessels penetrate the fat pad in the same manner as blepharoplasty.
As stated, judicious dissection and grasping needs to be performed due to related anatomic structures, including the parotid duct and large vessels that can traverse the cheek ( Figs. 15.15 , 15.16 ). Minor punctures or lacerations can be treated with simple suture closure. In the case of severe laceration or transection of the parotid duct, cannulating the parotid duct orifice with an IV cannula assists in stabilizing the sutured repair, maintaining patency of the duct. The cannula is sutured to the cheek mucosa and left in place for several days.
Performing BFR is very similar to blepharoplasty in that over-resection can produce a skeletonized appearance. Facial fat is a friend and not an enemy and reduction should be judicious.
After sufficient fat is removed the surgical site is checked for hemostasis. The buccinator muscle at the incision site is a frequent source of bleeding and can contribute to hematoma. If active bleeding is encountered deeper in the wound, cauterization must be carefully addressed, as facial nerve branches can be in the proximity as they traverse the masseter muscle. Packing the wound with gauze can also assist in hemostasis.
Post-surgically, gauze packs are placed between the cheeks and a compressive dressing is placed for 24 h. This dual layer compression assists in eliminating dead space and may assist in control of bleeding and swelling ( Fig. 15.17 ).
Figs. 15.18–15.23 show before and after cases of BFR. Although plentiful fat can be removed bilaterally, the clinical result is subtle and sometimes it is difficult to see a big difference in before and after images. Most frequently, the patient can appreciate a change regardless of pictures and is happy. Patients must be informed preoperatively that the changes with average BFR are small to moderate. Patients with inflated presurgical expectations are not good candidates.
Cervicofacial Liposuction
The subcutaneous planes in the face and neck have a distinct layer of fat in young and fit individuals. Deeper fat deposits such as the buccal fat pads and the subplatysmal submental fat also contribute to youthful facial volume ( Fig. 15.24 ). With aging and weight gain, patients can accrue large amounts of subcutaneous and deep fat ( Fig. 15.25 ).
Liposuction is an effective procedure and one of the most commonly requested cosmetic surgeries. Although it can be very effective in the face and neck, it is not a treatment for obesity. Liposuction is more indicated for sculpting of specific areas such as the neck, jowls, and jawline. It is important that patients understand the limitations of isolated cervicofacial liposuction and all of my consents detail not only the expected results, but also “what the procedure will not do.”
Anatomy of Liposuction
Lobules of fat are separated by fibrous septae, which contain neurovascular structures and lymphatics. The individual fat cells contain triglyceride and in weight gain, the fat cell increases in size. Weight loss from diet and exercise can decrease the quality of the fat cells (decrease in intracellular fat) but not the quantity (number of fat cells). Liposuction removes the actual fat cells and these cells will no longer contribute to fat increase, so in this context the results are permanent. When the fat cells are removed with the cannula, the septae remain intact giving the region a “Swiss cheese” appearance ( Fig. 15.26 ).
Skin tightening can occur with tumescent liposuction by unknown means, although it is believed to relate to post-traumatic fibrosis and collagen ratcheting and/or shrinkage. Younger patients have a better skin tightening response to liposuction than older patients. It is important for patients to understand that removing fat can lead to skin excess. Many patients present with submental fat and cervical skin excess and request liposuction. By removing the fat in this region, a volume reduction occurs which can create more skin excess. While submental liposuction may be very effective in a younger patient with increased fat and minimal skin excess, it could be problematic in an older patient with excess skin. In these cases, facelift surgery is necessary to address the skin.
Tumescent Anesthesia
Tumescent liposuction was a true paradigm shift in cosmetic surgery and enabled safe and predictable fat sculpting with local anesthesia. The basic functions of tumescent anesthesia are hydrodissection of tissue planes, allowing for more accurate treatment, hemostasis from the epinephrine and local anesthesia from the lidocaine. Body liposuction patients may receive up to 6 L of tumescent solution and there are much more significant fluid balance considerations than in the face and neck, where much smaller volumes are used. Typical Klein’s solution consists of 1 L of saline or lactated Ringer’s solution with 1 g of lidocaine and 1 mg of epinephrine 1 : 1000. Since an entire liter of solution is usually not necessary for facial procedures, the components can be halved for a 500 mL volume ( Fig. 15.27 ).
The areas of intended liposuction are marked with the patient in the upright position before surgery or administration of tumescent anesthesia. Commonly treated areas are the submental regions, jowls, jawline, and lateral neck.
After the patient is prepped, tumescent anesthesia is infiltrated. I prefer a Klein pump with a 22-gauge spinal needle ( Fig. e15.1 
). Alternatively, a dedicated blunt infiltration cannula may be used. Hypodermic syringes can be used in place of a peristaltic pump. The tumescent solution is injected in the subcutaneous plane.
Approximately 100 mL of tumescent solution is infiltrated into the submental region, about 50 mL on each submandibular region and about 30 mL over each jowl ( Figs. 15.28 , 15.29 ). The tumescent solution is injected and the patient is prepped and draped, which gives the tumescent time to percolate through the tissue planes in a process known as detumescence. When the surrounding skin is blanched, the patient is ready for the procedure ( Fig. 15.30 ).
Liposuction Instrumentation
As opposed to body liposuction, the relatively small volumes of fat removed during cervicofacial liposuction only require basic instrumentation. While a dedicated liposuction aspirator is generally used for body lipo, standard wall suction will suffice for face and neck lipo as the fat accumulations are much less ( Fig. 15.31 ).
Liposuction cannulas (cannulae) are available in a vast array of sizes, shapes, and configurations. In large-volume body liposuction, the selection is more varied but in the face and neck, instrumentation is simpler ( Fig. 15.32 ). If liposuction is performed in a “closed” manner, i.e. from a puncture, then the entire region is under negative pressure and more efficient. This means that small cannulas of 1–2 mm can be used to sculpt isolated regions of fat and 2- to 4-mm cannulas can be used for larger collections. When “open” liposuction is performed, this is generally through a larger incision or flap under direct vision. This means that the area to be treated is not under negative pressure and that the fat removal is directly visualized ( Fig. 15.33 ). Larger cannulas can be used in these situations if large fat deposits exist. I frequently use a 6-mm cannula for open submental liposuction with generous fat deposition.
The basis of the liposuction procedure is to place the correct cannula in the correct tissue plane to reduce the correct fat deposit ( Fig. 15.34 ). This basically means that most facial liposuction is performed in the subcutaneous plane and the hydrodissection from the tumescent injection helps define this plane. Small deposits warrant smaller cannulas and vice versa. It is always important to keep the orifice of the liposuction cannula facing away from the dermal surface. Failure to do so can create contour irregularities and grooves from dermal damage. It is also important for the operator to keep in mind relevant anatomy as facial nerve branches and vessels can be injured with liposuction.
The suction hose is pinched (or aspirator turned off) during entry into the puncture site, so as not to damage the skin. Once the cannula is inserted into the puncture site in the subcutaneous plane, the suction is activated and the cannula is kept in continual motion. A rapid, reciprocal, to-and-fro motion is performed while observing how much fat is exiting the suction tubing and the clinical improvement of the treated site. This is best thought of as a sweeping motion, similar to sweeping a carpet with an electric vacuum. The operator should cover a single area with multiple strokes trying not to repetitively overlap the same area. Several strokes over the same area are acceptable but the goal remains a homogenous sculpting treatment over the entire region. With small fat deposition, a single series of strokes may be all that is required, whereas large depositions may require several “passes” of strokes. This means that the area is treated in full with one series of strokes and additional series are made over the same areas. Some surgeons advocate right angle intersections of the cannula to create a cross-hatch pattern for liposuction. This may allow better removal and contour but is probably more relevant in large-volume body liposuction than in the face. Liposuction is best thought of and referred to as liposculpture because it is important to gently sculpt and reshape the treated regions, as opposed to simply emptying them. In areas of deeper fat, the bottom layers can be treated first and treatment proceeds superficially.
It is important (especially for novice surgeons) to be able to judge the endpoint of treatment. Part of this judgment is a learned tactile experience. Pinching the skin and fat between the finger and thumb before, during, and after the cannula strokes can help judge the amount of fat present and remaining ( Fig. 15.35 ). This also allows the surgeon to make sure that the skin thickness is homogenous over the entire treatment region. It also helps to guide the fat to the cannula tip and allows the surgeon to feel the fat going up through the cannula. Careful observation of the suction tubing is also important. If generous yellow fat is coming through the tubing, the target and removal is effective. When the fat stops coming out or when blood-tinged fat is seen (or blood without fat), then the endpoint is present or near.
Submental Liposuction
The submental and anterior cervical regions are the most common areas of the face for liposuction treatment. Many patients have generous fat in this region and the results can be striking in selected patients. The most important patient screening factor is the age of the patient and amount of skin laxity present. Younger patients with isolated fat deposits and no excess skin are optimal candidates. Although liposuction can produce skin tightening, the larger the amount of skin excess and the older the patient, the less dramatic the result will be. Fig. 15.36 shows optimum anatomy for successful submental liposuction and Fig. 15.37 shows poor candidates for submental treatment. Also relevant to the final result are patients with large subplatysmal fat deposits. Although some surgeons advocate deep liposuction of this area, it is less effective in my experience. Open submentoplasty is much more dramatic.
Submental liposuction is generally performed between the sternocleidomastoid muscles from the mandibular border to the thyroid cartilage region ( Fig. 15.38 ). The intended region of treatment must be marked in the upright position prior to surgery and tumescent infiltration. When performing liposculpture on the submental area, the cannula is navigated as previously described with rapid reciprocal motions across the regions of fat deposition ( Fig. 15.39 ). Using the palm of the nonsurgical hand to stretch the tissues in the cephlad facilitates the procedure. A forked skin retractor at the submental incision can also be used to assist in pulling the skin in the opposite direction of the cannula motion ( Fig. 15.40 ). Feathering the treatment by treating heavier fat more aggressively and tapering the removal as the depositions thin out towards the periphery provide a homogenous treatment. This is, of course, different for each patient but as a rule, the larger deposits are in the midline between the mandibular border and the thyroid cartilage region ( Fig. 15.41 ).
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