The buccal fat pads, previously known as Bichat’s fat pads, were first described in 1802. Everyone has them and their size is predominantly related to genetics, but similar to other facial fat pockets, they can shrink or shift over time. Buccal fat pads are often resistant to weight loss and stubbornly persist because of a slower lipolytic rate than subcutaneous fat. Some patients with round facial shapes may seek removal of the midface volume to create a more angular cheek and jawline, which enhances the zygomatic prominence and mandibular angle, creating a more contoured face.
The buccal fat pad is a submuscular fat pad surrounded by a capsule that contains three lobes with four extensions. The anterior lobe rests in front of the anterior border of the masseter muscle. The intermediate lobe extends between the masseter and buccinator muscles. The posterior lobe extends between the temporal masticatory space. These pads range from 7-11 mL in volume and grow from ages 10 to 20 years, declining in size after age 20. Given their location in the central face, they contain a rich vascular supply and are surrounded by the facial nerves, salivary glands, the parotid gland, and muscles of mastication.
Dr. Lily Talakoub
The aesthetic contour of the lower face is defined by the mandibular prominence, the masseter muscle, subcutaneous fat, and the buccal fat pad. Surgically, removal is a simple and safe procedure. Complications can include damage to the parotid gland, vessels, salivary duct, or facial nerve. Temporary numbness, swelling, and facial asymmetry are the most common complications.
Increasing popularity, controversy
Removal of the buccal fat pads has become popular because of celebrity media exposure, particularly among young women seeking a slim appearance to their face and jawlines. Although the procedure is relatively simple, there have been no long term studies evaluating the effects of buccal fat pad removal on facial aging.
The shrinking or shifting of fat that occurs with aging makes the removal of these fat pads in young women controversial because when removed, they cannot be effectively replaced. Shrinking of the fat pads with age, loss of midface volume, and solar elastosis can make the cheeks appear gaunt and “sucked in.”
An experienced surgeon will reduce and contour the fat pads – and will not completely remove them – to prevent a complete hollowing of the cheeks over time. Complete removal is not recommended and in men, overzealous removal in men can feminize the face.
In middle-aged men and women, the buccal fat pad can shift to the lower face and often drops below the angle of the mandible giving the appearance of jowls. Complete removal of the shifted buccal fat pad will help align the jawline; however, residual skin laxity is a complication and must be addressed to fully correct the jowls.
In my experience, the best approach to reducing buccal pads as an alternative to surgical removal is “melting” the buccal fat in a systematic, controlled manner over several sessions with either radiofrequency laser or deoxycholic acid injections. This slow, controlled method allows me to contour the cheeks appropriately in concordance with the patient’s anatomy. In younger patients or those with little skin laxity, I choose treatments with deoxycholic acid to remove the pads (which I also use to treat the jowls, as outlined in my 2020 column on treating the jowl overhang with deoxycholic acid).
In patients with more skin laxity, I perform sequential radiofrequency laser treatment over the fat pockets to simultaneously melt the fat pockets and tighten the overlying skin. Both of these methods often require three to six treatments. The controlled, cautious, treatments gradually shrink the fat pockets while preventing the overhollowing of the face.
Dr. Talakoub and Dr. Naissan O. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Dubin B et al. Plast Reconstr Surg. 1989 Feb;83(2):257-64
Jackson IT. Plast Reconstr Surg. 1999 Jun;103(7):2059-60.
Matarasso A. Ann Plast Surg. 1991 May;26(5):413-8.