Dr. Zelken is well known in Newport Beach, and perhaps across the nation, for his expertise and comfort with buccal fat pad removal surgery, also known as bichectomy or cheek reduction surgery. This procedure is gaining popularity, and rapidly. For example, buccal fat removal was not addressed in Dr. Zelken’s plastic surgery training. The fat pad was little more than a reconstructive option, if not a nuisance, that occasionally interrupted facial fracture repair and orthognathic surgery. Now, bichectomy is a mainstream cosmetic procedure that is increasingly recognized by the scientific literature.
The buccal fat pad is anatomically and aesthetically distinct from the deep and superficial fat compartments of the face. This is apparent in both bichectomy surgery and on examination. In surgery, the encapsulated, brilliant yellow fat pad has an identifiable pedicle and should never be mistaken for subcutaneous fat. On examination, the prolapsing buccal fat pad can be “reduced” into the temporal fossa while subcutaneous fat cannot.
Although many surgeons hesitate to resect more than a modest amount of buccal fat for fear of collateral injury and premature aging, premature aging is a subjective finding, and most patients who choose to undergo bichectomy prefer midfacial hollows. Furthermore, the procedure may be addressed with autologous fat grafting or fillers, should correction be sought. The buccal fat pad may beneficially conceal prominent perioral mounds and jowls, but its impact is typically seen at or above the superior mandibular border.
Dr. Zelken does so many buccal fat removal procedures, so why are there so few before and after photos? On one hand, few patients consent to allowing their photographs to be broadcast, though we are super gracious when they do. Secondly, buccal fat removal is performed as a standalone procedure in less than 50% of cases and is typically done in conjunction with a facelift, FaceTite, chin augmentation, and rhinoplasty, for example. Therefore, you’ve probably seen more before and afters than meets the eye.
Finally, Dr. Zelken emphasizes that buccal fat removal is best seen in action, and in 3 dimensions. A simple side-by-side photograph is not as likely to present a drastic change as you’d think. However, when you talk, smile, and animate, the results become more manifest. That’s not to say before and after photographs do not show change. It’s just not an in-your-face change. This is why rumors that buccal fat removal makes you look gaunt or prematurely age may be just that: rumors.
Unlike a BBL or breast augmentation, buccal fat pad removal (despite its widespread popularity on social media) is NOT an “Instagrammable” or Tik Tok-worthy procedure. You won’t see surgeons dancing around a face juggling the resected fat. No, it is a gentle procedure that makes people look more sculpted, possibly less juvenile (not to be mistaken with prematurely aged), and thinner. Dr. Zelken considers buccal fat pad removal to be a cosmetically safe procedure that will stand the test of time with facial aging. Amongst other reasons, pictures don’t do the operation much justice, and maybe that’s why you don’t see as many before and after images as with other procedures.
New photos of Demi Moore surfaced in 2021 and shook the world. Ms. Demi Moore has made headlines for alarming photographs on the runway of a fashion show. She looks more gaunt than typical, leading many Internet sleuths and pseudo-experts to offer unfounded and unfiltered opinions about what may have happened. It is always interesting to study others’ opinions, but I am compelled to speak up because nobody seems to have gotten it right.
Ms. Moore appears, at least in a certain light, to have a cross-cheek depression, sometimes called a “Joker” deformity.Watch Video
Many people feel that buccal fat pad removal has caused a noticeable shadow below Demi Moore’s cheekbone and at the corners of her mouth. I disagree. Of course, Ms. Moore may have had buccal fat pad removal years ago or just naturally contoured, because prior to her most recent pictures, she has a noticeable hollow below her cheekbone and above her jawline signifying that she never had buccal fat pad excess.
Indeed, bichectomy is very popular amongst actors and models alike. Whether or not this woman has had previous buccal fat pad removal has yet to be determined and no one needs to know. However, buccal fat pad removal did not cause her most recent appearance on that runway show. But assuming she has had it at some point, it may have predisposed her.
The “Joker deformity”, also known as a cross-cheek depression is a telltale sign of a facelift.
Dr. Lambros and Dr. Stuzin described this years ago, and I wonder why nobody else has mentioned it in discussing Demi Moore’s looks. Of course, it is not really a deformity as many patients go out of their way to achieve this look.
From the looks of it, Demi may have had a solid facelift. It is impossible to say whether she had one, but Dr. Zelken believes she did. Many of the wrinkles that we see in more recent photos have really gone away. She has an uninterrupted, and possibly augmented, jawline. She has the fullness in her cheeks and the excellent cheekbone structure that she is so well known for.
Unfortunately, a lip lift, her existing buccal hollow, and a facelift have conspired with her existing anatomic features to create an alarming set of shadows in a certain light.
Overfilled cheeks and odd-looking lip lift? Maybe. But this is not simply because she had buccal fat pad removal. It is more likely the result of weight loss, aging, bad lighting, and an unfortunately timed snapshot. Even worse, maybe we are studying an image doctored for the sake of a tabloid’s bounty.
If this so-called “joker deformity” looks familiar to you, and your loved one is interested in correcting it, autologous fat transfer or even filler injections are typically enough to correct many of the issues. Of course, a well-designed facelift operation could prevent this from occurring in the first place.
If you are interested in a facelift and are worried that this may occur, an easy way of telling is to put two fingers on your cheek and jawbone and pull them back. If this gives you the appearance of a joker deformity, it is something to mention to your board-certified plastic surgeon. Thoughtful fat injection at the time of surgery in the mid-face can prevent this from happening. If you have had a facelift and wish to have this addressed, we can correct it with hyaluronic acid fillers, Sculptra, or autologous fat. In many cases, you do not need to go back to the operating room to fix this.
This seems like the biggest reason patients and doctors have hesitation about buccal fat removal. Endless online forums and videos discuss the nuances and theoretical risks of bichectomy and share photographs of patients who underwent surgery abroad and look gaunt or even worse, like a “meth addict” as many fear. And even I agree, yes, that indiscriminate and injudicious buccal fat reduction can accentuate a pre-existing facial concavity which, by some accounts, may make you appear older.
Yet, many patients want to look older. These buccal fat reduction candidates tend to be in their late teens and early twenties and feel that chubby cheeks give them a childish appearance that they wish to correct. Many of those patients wish to look as sculpted as possible despite the limitations of the buccal fat pad removal procedure. But for those patients who are in their 30s, 40, and 50s are worried that removal of the buccal fat pad will give them an aged appearance, a more conservative resection may be best.
In other words, if one looks like they’ve already had buccal fat removal, then buccal fat removal is not a great option. For most others, the results of bichectomy will slim and often rejuvenate the midface by offloading the impact of mobile soft tissue mass of the cheek on the jowls and marionette lines (melolabial folds).
To better illustrate this concept of how bichectomy lifts the face and doesn’t deflate it, picture your cheek and jowl like a breast, and the marionette line (or shadow) as the fold under the breast. Dr. Zelken calls this the “breast paradigm”. Fillers to the marionette line or sulcus (yellow) are effective as a first-line therapy in younger patients with milder shadows.
As is done in gynecomastia surgery and breast reduction, debulking and tightening of the mobile mound (cheek) is considered next. In the face, suction lipectomy and energy-based skin tightening of the perioral mound and jowl (blue) and bichectomy (green) are effective. When minimally-invasive strategies are ineffective, and in older patients: rhytidectomy and SMAS manipulation (black arrows) and release of tethering ligaments (red) may be considered.
It depends on your goals and anatomy. The results of the buccal fat pad removal are variable but subtle in most cases. The subtle enhancement is what draws Dr. Zelken to this procedure who believes small three-dimensional changes in the face go a long way. Despite watching videos intended to assuage concerns of hollowing out and prematurely aging the face, patients continue to discuss concerns about whether this will make them look older.
The volume of the buccal fat pad is very hard to quantify because of injected local anesthesia and the soft and squishy nature of the fat pad itself. Dr. Zelken measures the volume of the buccal fat pads by loosely compacting the fat pad itself into a 10-cc syringe and seeing how much volume it occupies. Volume is typically estimated down to the 10th of a cc. Many studies’ estimates range as to how much fat is generally excised with buccal fat pad removal. Really, depending on the article, anywhere from 2.5-7 cc is removed. One thing Dr. Zelken has observed is that there is a striking consistency of the volume removed. Furthermore, when there is facial asymmetry, the fat pad also tends to be larger on one side than the other.
Gender, BMI, hemifacial hypertrophy, ethnicity, and even age does not have as much influence as you would guess on buccal fat pad volume itself. For a moment, assume we all have the same buccal fat pad volume. Therefore, it is not the volume, so much as position and interplay with surrounding tissues that defines your buccal fat pad removal candidacy and predicts your result. Sometimes, smaller buccal fat pad specimens come from patients with the most impressive results, and vice versa. More drastic bichectomy results can be achieved with a simultaneous jawline and cheek enhancement. Or mucosal myectomy.
Schedule your consultation with Dr. Zelken, a board-certified plastic, and reconstructive surgeon, to find out if you are a candidate for buccal fat reduction at his Newport Beach, CA office.
Written by Dr. Jonathan Zelken
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