Secondary Buccal Fat Prolapse

The buccal fat pad (the fat between the cheekbone and jaw bone), and its involvement in aesthetic surgery of the face have become increasingly prevalent and relevant over the past several years. Dr. Zelken, a trusted Newport Beach plastic and reconstructive surgeon, discusses the intricacies of secondary buccal fat pad prolapse.

BUCCAL FAT PAD BACKGROUND

As the buccal fat pad removal procedure, also referred to as a bichectomy, becomes more mainstream, it too becomes more controversial. Skeptics that include prospective patients and providers of the procedure often identify hollowness, gauntness, and accelerated facial aging as reasons to be judicious or avoid buccal fat pad removal altogether.

Dr. Zelken performs buccal fat pad removal often, and in conjunction with other procedures like facelifts and facial liposuction, or as a standalone procedure at his Newport Beach office. He remains a strong advocate for the procedure in patients with reasonable expectations and features that portend a favorable cosmetic result. Although every patient who has fat pads is a candidate for the operation, the question becomes who is a good candidate? Who will be happy with the procedure?

Dr. Zelken has discussed answers to these questions through videos and blog posts, but there is a new group of patients that also deserve recognition: patients considering a primary or revisionary facelift.

FACIAL VOLUME IS NOT ALWAYS BEAUTIFUL OR YOUTHFUL

In previous posts and videos, Dr. Zelken repeatedly discussed the importance of dissociating subcutaneous facial fat from the buccal fat pad proper. Through various case examples, Dr. Zelken has illustrated an apparent disconnect between buccal fat volume and age, BMI, and gender. Indeed, some of the largest buccal fat pads he has removed were taken from his oldest patients. Moreover, it is difficult to predict buccal fat pad quality and volume based on one’s appearance alone.

As the public becomes increasingly sophisticated through social media and online research, so too becomes our collective understanding of various topics in plastic surgery. “Virtual” feedback through online forums and social media is grittier and less muted than what surgeons encounter in clinics; patients have the freedom to express their feelings anonymously and without social consequence. For example, Dr. Zelken has yet to meet a patient who complains that he or she looks gaunt after bichectomy surgery, yet many patients cite websites and social media accounts that paint a different picture of the procedure.

In response to healthy speculation, Dr. Zelken aims to educate his patients that, indeed, facial fat (as a whole) is inversely related to facial aging. As we age, we lose volume. Easy as that. Volume loss throughout the face can present as temporal hollowness, volume-depleted (“sagging”) cheeks, visible muscles and glands in the neck, or a “double chin” arising from skin excess, not just fat. Perhaps, this explains why Dr. Zelken advocates strongly for the so-called “lift-and-fill facelift” that relies on strategic, targeted, and artistic structural fat grafting to various areas of the face.

Yet, the “fat equals youth” paradigm must not be confused for “volume equals youth”. The most obvious example of this arises when aging patients volumize their faces with injectable fillers to mask folds, and wrinkles, and even to purportedly lift the face.

Sylvester Stallone’s overfilled face is volume replete, but unartistic volumizing of the mid cheeks, and not the malar region (which may be congenitally deficient) does not complement his facelift well.

Dr. Zelken believes President Joe Biden has undergone plastic surgery. While this is seldom discussed, his upper eyelids reveal residual medial fat excess in the upper eyelids. The medial fat pads uniquely become more prominent and grow as we age, and their removal rejuvenates the face. The medial fat pad is fat, but this fat mass is anatomically and developmentally distinct from subcutaneous fat.

There are other examples that illustrate when volume perpetuates aging and detracts from facial beauty. Prominent or swollen salivary glands in the cheeks or neck, hypertrophic muscles in the lower face, thyroid gland enlargement, and excess fat around the eyes are just a few.

BUT WHAT ABOUT THE BUCCAL FAT PAD?

Assuming this mass does not disappear, and may even grow with age, how does its presence or absence influence facial beauty and aging? In other words, does buccal fat pad removal enhance the beauty in the short term at the expense of long-term premature facial aging? Is it possible that bichectomy BOTH enhances beauty and acts against facial aging? To answer this question, Dr. Zelken will revisit a classic fairy tale.

THE “PRINCESS AND THE PEA” PARADIGM

In Hans Christian Andersen’s classic tale, a Princess is identified not by her appearance, but by her ability to feel a pea that is placed 20 mattresses below her. In his paradigm, Dr. Zelken compares the pea to buccal fat, the mattresses to the soft tissue envelope, and the Princess to an outside observer. As we age, the quantity and quality of these mattresses decrease. Weight loss and excessive facial liposculpture, similarly, make each mattress thinner.

All these phenomena invariably increase the likelihood that an outside observer need not be a “Princess” to react unfavorably to said pea. To improve the Princess’ sleep experience, removing that pea should eliminate the need for so many mattresses. More importantly, when the mattresses deflate and develop holes and weaknesses with age, that little pea will become even more bothersome.

THE FACELIFT-BUCCAL FAT RELATIONSHIP

Conventional thinking in facial plastic surgery favors fat preservation and repositioning in facial rejuvenation surgery. Notable exceptions include fat resection of the upper inner eyelids and liposuction of the jowls and neck during facelift surgery and blepharoplasty (eyelid surgery).

Dr. Zelken encourages his colleagues and patients to challenge conventional thinking and consider the benefits of preventative fat pad removal during a primary facelift, and fat pad removal as a treatment for buccal fat pad prolapse and deformity secondary to prior facelift surgery.

As the “Princess and the Pea” paradigm predicts, volume preservation and structural integrity are integral to keeping the Princess happy. Surgeon proponents of facial volume maximization may hesitate or refuse to resect buccal fat. Others may simply lack the skill to safely remove buccal fat during facelift surgery. For these reasons and more, Dr. Zelken imagines that buccal fat removal is seldom performed during primary facelift surgery. But more and more, patients are presenting with unusual bulges after facelift surgery.

PROPHYLACTIC BUCCAL FAT REDUCTION

Preventative buccal fat pad removal at the time of primary facelift will not only enhance mid-facial contour but may eliminate an important mechanical influence on the lower third of the face. This concept draws from Dr. Zelken’s “breast paradigm” for the anterior half of the lower third of the face that likens the front half of your cheek to a pendulous breast.

Although this comparison may seem preposterous at first, volumetric studies and vector mapping suggest that buccal fat pad removal alone may soften marionette lines and even improve premature jowling. Keeping this in mind, bichectomy surgery should be considered in thin patients with adequate skeletal structure and jowls that are “reducible” and not obviously fatty.

As seen in this short video, Dr. Zelken demonstrates the clinical features of a “pseudo-herniating” buccal fat pad that is easily distinguished from subcutaneous fat, which would demonstrate instantaneous recoil. Note: Dr. Zelken has a thin face, and prominent buccal fat pads and this finding is not always so straightforward. In planning his own facelift, Dr. Zelken would reduce the buccal fat which may otherwise become more prominent after the soft tissue envelope is tightened.

In a thin face, soft tissue volume augmentation is imperative, and buccal fat reduction seems counterintuitive. Dr. Zelken identifies the mobile fat fad as a key contributing force for marionette lines, jowls, and down-turning of the corners of the mouth. A comprehensive strategy that included a facelift, buccal fat pad removal, corner lip lift, paranasal augmentation with an implant, fat grafting, and lip filler contributed to a subtle but important enhancement that (perhaps paradoxically) improved pre-existing gaunt features in this beautiful younger woman.

Buccal fat removal may be considered in thin faces with demarcated fat pads that are clinically separate from the skin envelope. This woman underwent a neck lift only. The facelift effect seen here was achieved with bichectomy, perioral liposuction, jowl liposuction, and mechanical disruption of the mandibular cutaneous retaining ligaments.

SECONDARY BUCCAL FAT PROLAPSE AFTER FACELIFT

Dr. Zelken has identified a dependably consistent pattern in patients with buccal fat prolapse either identified after or caused by facial plastic surgery. Hallmarks of secondary buccal fat prolapse include a convexity and shadow below an imaginary line spanning the oral commissure and lobule, anterior to the masseter, and 1-2 cm above the lower border of the mandible. Presentation varies in subtlety.

Hallmarks of secondary buccal fat prolapse include a bulge and shadow, a finger breadth above the mandibular border, and anterior to the masseter.

It is not uncommon to see a patient who previously underwent a facelift concerned about “bulges” on the sides of her cheeks and a primary concern. This middle-aged Hispanic woman had a deep-plane facelift performed elsewhere years prior.

In other cases, patients present for a revisionary facelift to “tighten” or touch-up previous work. In most cases, patients may be unaware of buccal fat pad herniation secondary to mechanical disruption of the SMAS.

CASE STUDY 1

A 60-year-old woman was unhappy with recurrent “jowls” and neck laxity after a deep-plane facelift performed by another surgeon almost 10 years ago. Unbeknownst to her, much of the “jowling” was buccal fat herniation, not true jowling. Hers demonstrates a subtler example of secondary buccal fat prolapse with the hallmark features.

Although there too is skin and fat excess, the buccal fat mass imposes an important downward force on the corners of the mouth, which led to volumizing with filler and neurotoxins to mask the effect. During her facelift surgery, the fat pad was clearly seen herniating through a sizeable defect in the SMAS.

During her facelift revision, a small SMAS readvancement was planned, in addition to subcutaneous undermining and re-draping. The unmistakably identifiable buccal fat pad was seen emerging from a SMAS defect near the corner of the mouth. Judicious reduction of this excess tissue and repair of the hernia is imperative to achieve a softer cheek and sharper jawline.

CASE STUDY 2

Several years ago, Dr. Zelken performed an awake, limited facelift on a woman with a longstanding history of steroid use to manage reactive airway disease. Although the patient was pleased, an unusual bulge/shadow was evident just above the jawline. It was reducible and clinically consistent with buccal fat herniation. A combination of pre-existing fat herniation and enlargement of the fat pad, both possibly related to steroid use became more noticeable after liposculpture of the jowl and tightening of the already weak SMAS and skin layers. This was effectively addressed with buccal fat pad removal.

Buccal fat removal after the facelift (external approach) was satisfying and meaningfully corrected a visible deformity accentuated by the facelift. The defect was sutured and there is no visual remnant of the defect.

WHY DO BUCCAL FAT PADS BECOME PROBLEMATIC AFTER FACELIFT SURGERY?

Dr. Zelken believes that buccal fat pads can become more visible and problematic after facelift surgery for one of two reasons: unmasking versus creating a defect.

1. Pre-existing buccal fat pad ptosis or pseudo-herniation. Buccal fat pad enlargement and/or pseudoherniation may go underappreciated or unrecognized before surgery. Strategies to optimize the facelift result, including perioral liposuction, liposuction of the jowls, and skin redraping may expose or exacerbate a pre-existing issue.

   A subcutaneous (“mini”) facelift effectively rejuvenated and beautified this face. However, buccal fat excess and ptosis seen preoperatively were “unmasked”. In many cases, buccal fat excess and/or ptosis manifests as a shadow or dimple at the anterior masseteric border, 1 cm above the mandible border.

   

2. I atrogenic buccal fat pad pseudo-herniation or true herniation. In Dr. Zelken’s practice, most patients who present with secondary fat pad herniation either underwent awake, minimally invasive facelift surgery or a deep-plane facelift WITHOUT a bichectomy. Both operations rely on SMAS advancement and do not address the buccal fat pad.

Before and after a deep-plane facelift with SMAS resuspension. A visible postoperative shadow is seen at the anterior border of the masseter, 1 cm above the mandibular border. Although the benefits of this operation are plain to see, the patient was distressed by the abnormal contour abnormality.

Dr. Zelken attributed the contour abnormality to the resuspension of the SMAS. The beneficial influence on the nasolabial folds and marionette lines was overshadowed by secondary buccal fat pad herniation. To remedy this, buccal fat pad removal through an intra-oral approach was straightforward, gratifying, and meaningfully softened this contour abnormality. A slight but persistent shadow may result from a persistent defect in the SMAS.

It is understood that the SMAS layer thins and attenuates anteriorly. The anatomic boundaries of the buccal space, that the buccal fat pad occupies, are complex. A more simplified illustration of the buccal space can be thought of as a sandwich between the buccinator muscle and the SMAS. The “crust” or borders of the sandwich include the masseter, zygomaticus muscles, mandible, and lip depressors.

In this context, the SMAS and its investments to surrounding muscles keep the contents of the sandwich in place. When the SMAS weakens with age, medications, or predisposing features, the buccal fat pad may bulge or “pseudo-herniate”. When the SMAS is dissected and mechanically disrupted, for example in a deep-plane facelift, the attenuated anterior edge of this tissue is recruited posteriorly. The buccal fat may either bulge if this mass is weakened (pseudo-herniation) or truly herniate if there is a defect in the SMAS overlying the buccal space.

This illustration is intended to distinguish pseudo-herniation or ptosis of the buccal fat pad (above) from true herniation of the buccal fat pad (below). Undermining of the skin envelope, perioral liposuction, liposuction of the jowls, and skin redraping may expose a bulge where a ptotic buccal fat pad exists because of a weak overlying SMAS. True herniation may occur when the SMAS is undermined and advanced, exposing and exacerbating inherent weaknesses and defects of the SMAS. When the deep-plane dissection is performed with scissors, rents in this layer may become loci of buccal fat pad herniation.

TREATMENT STRATEGY

Secondary buccal fat pad irregularities are both preventable and treatable. Prevention of secondary buccal fat pad herniation or pseudo-herniation may be achievable by resecting bulging buccal fat when it is seen in the deep plane during the facelift. This may be planned when buccal fat ptosis or excess is observed in the preoperative period. Alternatively, this may be a “game-time decision”, wherein buccal fat is judiciously reduced during deep-plane dissection.

Secondary deformities present as either bulging perioral masses or shadows along the anterior border of the masseter and above the mandible. A history of skin-only (“mini”) facelift or facial liposculpture may expose existing pseudo-herniation of the fat pad. A history of a facelift with or without deep-plane dissection and including SMAS advancement and resuspension sitting increase suspicion of secondary (iatrogenic) herniation of the buccal fat pad.

Regardless of etiology, the excess buccal fat can be addressed through an intraoral approach or accessed through pre-existing facelift scars. Dr. Zelken has yet to determine if repair of the SMAS defect is more effective at eliminating versus reducing visible shadows and contour deformity.

CONSULT DR. ZELKEN

If you are considering buccal fat pad removal or facelift surgery in Newport Beach, CA then schedule your consultation with board-certified plastic surgeon, Dr. Zelken at Our clinic. His specialist skills, eye for detail and surgical expertise place him in a unique position to guide you through what you can realistically expect from the procedures.