Episode 48: Friday January 7
What is the secret to "Instagram cheekbones?" The procedure called buccal fat pad excision has been trending on TikTok ever since Chrissy Teigen revealed she underwent the procedure to thin her cheeks.
Drs. Sam Jejurikar @samjejurikar, Salvatore Pacella @sandiegoplasticsurgeon, and Sam Rhee @bergencosmetic discuss what exactly does the procedure entail? What you should know before getting the surgery, who the best candidates are, and the pros and cons of getting the procedure done.
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TRANSCRIPT S03E48 Buccal Fat Pad Excision (Cheek Reduction)
[00:00:00] Dr. Sam Jejurikar: Welcome to yet another episode of Three Plastic Surgeons and a Microphone. I'm Sam Jejurikar in Dallas, joined as always by Dr. Sam Rhee, Paramus New Jersey and Dr. Sal Pacella of LA Jolla, California. Welcome gentlemen. And before we get onto today's topic, which is going to be an exciting topic on cheek contouring and buccal fat pad removal by Dr. Sam Rhee, Dr. Sal Pacella is going to handle our usual legal business.
[00:00:28] Dr. Salvatore Pacella: The show is not a substitute for professional medical advice, diagnosis or treatment. The show is for informational purposes, only treatment and results may vary based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified health provider.
With any questions you may have. I have regarding medical care, never disregard professional medical advice or delay seeking advice because of something in the show. I think next time I do this, disclaimer, I'm going to do it in some sort of Irish brogue or British accent, or maybe an Italian accent. I dunno. What do you guys think?
[00:01:01] Dr. Sam Jejurikar: I think those were how I was going to say. It's not much of a stretch to do Italian. I think all of those are appropriate accents. You just gotta be careful about which accent you choose.
All right, well, doctor retake it away.
[00:01:18] Dr. Sam Rhee: All right. We've talked a little bit about buccal fat excision in the past. It's extremely popular. The social media has really taken a hold of it recently and run with it. And in fact, Our esteemed colleague, Dr. Rod Rohrich commented on this a couple months ago.
And I'll just show a little video of him talking about it, as well as some of the findings that he had in his in his paper, which he recently published about it. So let me just pull that up.
[00:01:47] Dr. Salvatore Pacella: But for our viewers that may not be familiar with the buccal fat pad. It is a piece of fat in the middle of the face, deep into the face, somewhere around the mid cheek area. And it's been a technique popularized to help thin or slim out the face and augment the cheek lines.
[00:02:08] Dr. Sam Jejurikar: Yeah. And it's a, it's a procedure that has been around for a long time removal was popular 20 years ago was the V and the Vogue done with, with many, many facelifts went away for awhile. And that was making a popular resurgence.
[00:02:23] Dr. Sam Rhee: Yes. And in fact it's going to be interesting because I'll show this, which was recently published a couple of months ago and you tell me what's changed about it at that point. So it will be interesting.
[00:02:32] Dr. Rod Rohrich: Have you seen these plastic surgery posts on social media where a baby fat from the cheek is popped out literally through a small incision inside the mouth buccal fat pad removal went viral due to the striking it subtle post-op. Where patients emerge with slimmer, lower faces and a more defined jawline.
Despite the popularity, there are still a lot about the surgicals long-term efficacy. We don't really know about to learn more. The authors of this innovative hot topic performed an in-depth anatomic analysis of the effects of this procedure. Short and longterm, even though the surgery is relatively minor involving a small incision inside the mouth can be done under local and.
And can take only under 30 minutes. It's certainly not without risk. The authors found that excessive traction or aggressive to section can end up removing more than just the fat pit and could also affect the buccal branches of the facial nerve. This could lead to an excessively hollowed out appearance, premature aging, and nerve damage.
They do state that if excision is controlled and limited to the buccal fat pad extension, only the short-term risks are. But still there's no long-term evidence to show what happens to the face without the buccal fat pad over time. Remember all facial fat compartments are important. This fat pet is very different.
It goes from the superficial and the deep fat. Very important. So the key to understanding facial fat is that the loss of facial fat in the. Really predicates, how you age, the more you lose, the more you age, that's why modern facial rejuvenation restores volume actually by targeting deflated fat company.
The author's note that there is indeed evidence that buccal fat pad does diminish naturally as we age, but how much it does. Dissipate is still unknown. More evidence in long-term studies will be needed to determine if removing buckle fat to get that oval beautiful heart shaped face and defined jaw.
When you're younger and does it truly not cause premature aging, but for now the authors conclude that in the hands of a skill plastic surgeon, this procedure can be performed safely. It is best reserved for those patients. With naturally full round faces that have fullness in the front of their lower cheek, above the jaw line.
Even if a procedure is trending on social media, like Instagram, it might not be right for you. That's why we always encourage our patients to do their homework.
[00:05:12] Dr. Sam Rhee: The more you know.
[00:05:12] Dr. Sam Jejurikar: That's a great synopsis. I love how Dr. Rohrich refers to the authors in the third person, even though he's the lead author on that paper, he is the lead author and and and the rest of the authors were, were ones, other ones, one of my partners at present. And another one was a fellow who was with us.
So I know all of these guys and. Great plastic surgeons. I think that's a great review though. W when, when buckle fat pad removal was done a lot in the 1990s, early two thousands, even the late 1980s we were very much in the mindset in plastic surgery that when moving fat was the key, Dr.
Pacella is the eyelid expert amongst the three of us, but he'd certainly. I'm sure it was dealing with many patients who 20 or 30 years ago had lower eyelid surgery where their lower eyelids were totally hollowed out. We would take out fat from the lower eyelids. We would do facelifts where we would do some mastectomies or take out large amounts of facial fat and buccal fat powder move on when as well.
And I gave people a very chiseled look. Which looked awesome in the short term, but as they, as they advanced, 5, 7, 10 years down the road, it made them look prematurely older. And so, it's interesting that this procedure has made a comeback. I will say that I've been doing more of it than I thought.
I would do, and I'll even have this conversation with patients and I'll tell them you're going to look older when we do this. And they all have a very quick retort, which is all good. Or facial fat put back in later on. And so, I think, I feel like patients know that, but they very much in the short term are liking the chisel look that they get from fat pad removal.
[00:06:44] Dr. Salvatore Pacella: Yeah. And I think, it's interesting because I rarely have patients come in specifically asking for this procedure that, it's rare that someone will say, I want my buccal fat pad removed. I read about it, or I saw it on social media, but it is part of a comprehensive kind of assessment of the face and tailoring your, your your treatment.
So for example, in young patients, this can take this technique can work very well. If you have a full face around the. And your jaw is a little while. I usually use this in combination with not only direct excision through the mouth, it can be done under local anesthesia, but I also give patients a bit of Botox, two or three injections of Botox into this, this area here called the masseter muscle.
Many of these patients have hypertrophy of this muscle, which gives their face a much more boxy look. And so I think the combination of adding Botox there and doing the buccal fat pad can really make a huge deal.
[00:07:41] Dr. Sam Rhee: Yeah, I think when I do these cases they're in relatively younger patients I usually do some sort of adjunctive technique, like masseter Botox injection, just like Sal said.
And they usually get a very nice slimming effect. It's funny because Stuzin and Kawamoto wrote about this and I'll if you want, I'll show you the video that they did 30 years ago operatively about how to take this out. Really exactly the same as it is now. And even then Susan was pretty adamant about being pretty conservative about how much fat he took out.
He said, maybe two, four grams, something like that. And everyone knows at that point what the risks were. And like Sam says, it's made a big comeback. I'm, I'm seeing more and more of these. I try to start with something relatively noninvasive, like the Botox to the master first.
If they feel like they need to get some more slimming alternate to the buccal fat pad in addition sometimes. Lipo can be helpful too. And I'll show a case where we did that. But I'll just throw up an operative picture or, and then we'll see
[00:08:42] Dr. Sam Jejurikar: what that looks like. You're saying that, the only thing that I would say is different than my experience in sales is I have lots of people coming and asking specifically for this Dell call it
Nobody calls it the buccal fat pad and they all think I'm pronouncing it wrong when I call it the buccal fat pad. But literally, probably every six weeks, I have a patient, a younger patient, early twenties, mid, mid to late twenties deal who specifically is requesting buccal fat pad removal.
And so, it's rare for me to have. Making this, somebody that I primarily bring up with someone, even though I do it every six or eight weeks on someone. But it's driven by patients in my patient, in my practice. And you're just like, you guys I'll do some Botox into the masseter. I commonly will do some, some submental and neck liposuction, usually using radiofrequency technique as well, just to really tighten the jawline and all in combination, it gives them a much more chiseled look when they're done.
[00:09:37] Dr. Sam Rhee: So let me show you a little bit of a diagram and we can talk about. The actual procedure here. So the buccal or "boocal" in Texas fat pad is actually pretty large and it actually extends all the way up over the temporal muscle. And what we really get is just the little bit of it that extends down into the mouth.
And as Dr. Warick said, it's pretty straightforward. It can be done under 30. You basically find the second maxillary molar. You make the Stensons duct and you just make a small incision. And the key to this is that even though it's a small procedure, there are structures in this area that have profound, functional issue importance and, Stenson's duct is the opening where.
The parotid gland basically empties into the mouth. And if you were to lacerate it or misidentify it or somehow damage it, you're going to have a huge problem. Afterwards, for something that you thought was a really small procedure. In addition as Dr. Rohrich mentioned, there are buckle band branches of the facial nerve, which are very cool.
To the buccal fat pad, you can literally see or not here, but you can, you, they are literally right there. And the facial nerve innervates the muscles of your face. So you can get a facial paralysis if this is improperly done. So what is,
[00:11:02] Dr. Salvatore Pacella: yeah. Can I ask you, is that, would you say that that incision is accurate to what
[00:11:08] Dr. Sam Rhee: no, I make it actually, well away from Stenson, it's probably about.
Closer to the ginger of of the second maxillary
[00:11:14] Dr. Sam Jejurikar: molar. And just in case our viewers are not clear. Can you tell them what the parotid gland is and the parotid duct and what Stenson's ups actually is and what the problems are if you do damage that.
[00:11:25] Dr. Sam Rhee: Right. So it's good. Thanks for reminding me. It's a salivary gland.
So you actually have saliva that's produced in the product land that is being tunneled or piped through this. That goes from the gland that is right around your ear, through the cheek, into your mouth. And if you were to somehow damage it or block it, you would basically block the passage of saliva into your mouth.
You could get a huge collection of saliva, which we've seen, not in these cases, but in trauma where I, we've all dealt with facial trauma before where this duct was lacerated and it's not a joke to have to reconstruct it. And. Did you guys ever encounter that in your travails in facial trauma?
[00:12:07] Dr. Salvatore Pacella: Oh yeah. At at Michigan, I had a gentleman who got into a bar fight with a glass and had a, a nice stellate laceration right over this area. It was about four in the morning. And I figured out pretty quickly that he had lacerated Stenson's duct. And the interesting thing was I, I placed a little Piece of suture on the inside of his mouth through the duct, on the inside of the mouth.
And then it came right out, straight out into the wounds. So I knew immediately that was the duct was, was violated. So
[00:12:36] Dr. Sam Jejurikar: it's interesting. I saw a patient who had had a buckle Fatfat taken out elsewhere and had persistent swelling in the side of their face for two or three months. And wasn't really getting anywhere with their.
Primary surgeon who was not a plastic surgeon. And so they ended up seeing me and they had a persistent salivary collection inside their mouth. By that point, when you're that far out, it's impossible to reconstruct stances doc. So drain was placed. You may need a compression over that area. They needed what we call agents that basically try to suppress salivary production.
It's a big to-do if that actually happens, took from the time that they came into the time that. It was no longer a problem took several weeks. I want to say almost three months to find a resolve. So it can be a huge problem.
[00:13:25] Dr. Salvatore Pacella: Now, Sam, getting back to that incision again. So do you, you make your incision in between Stenson's duct and the second molar or right, right at that same level, but closer to the, to the teeth
[00:13:38] Dr. Sam Rhee: usually make it a little bit closer.
Well, it depends. Yeah. So I will make it a little bit closer to. Well, this is not really that accurate. Honestly, I feel like sentence duck is farther out a little bit, and there's more space between the mucosa of the second maxillary, molar, molar. There's more space there in which to make your incision.
[00:14:01] Dr. Salvatore Pacella: Yeah. How about yourself? I usually go a little bit more posterior than what the shows. And kind of worked my way back a little bit, just, that's the approach I use for, for facial trauma. And I kinda know the exposure
[00:14:15] Dr. Sam Jejurikar: fairly well, so, I, I think they're trying to show up by the second maxillary molar, but the teeth are so crowded together in there.
It doesn't look that posterior, but if you think about where it actually is in the second maximally molar and how much harder is to see relative in this picture, it's it's It's a little bit misleading. But yeah, w what I'll do is I'll, I'll go again. I agree with, I agree with Sam that this Stenson's docs is a little bit, is not so close to the incision, but I think that's just because of the way that the picture was drawn.
You go, I go right in the sulcus, make an incision, dissect using a pair of scissors. So you see the Buck's Nader a muscle, you tease through those fibers and that should just pop out.
[00:14:55] Dr. Sam Rhee: Yeah, it's a little that if you've never done it, I remember the first couple of times, well, I did it all the time in my crane official fellowship, because we would make cuts for our maxillary osteotomies.
And you would always get into it, even though you didn't want to get into it, which was really annoying. But when the first time I intentionally did it, it was where I wanted to get to the buccal fat pad. You actually have to pop through the fascia a little bit and it takes a little bit of doing to make sure.
You're a little bit confident to get through the bucks Nader and then get into that into that fat pad. So it does take a little bit of finesse to be and to be able to know exactly where you are and to make sure that you're in there. And then once you're there, I just I tease out, how do you judge how much to take out for me?
It's more like, I look at the patient, I see how much external fullness there is in the buccal fat. And I always take out just a little bit less than I think I really need in order to achieve, the look that I think the patient wants.
[00:15:50] Dr. Sam Jejurikar: I tried to tease it out and let it fall out naturally.
And whatever naturally extrudes I take out, I try not to pull out and transect at the same time. I just, whatever naturally falls out when you pop the roll. That is what I'll take out less is more, I think.
[00:16:07] Dr. Salvatore Pacella: Yeah, that's a, I do a similar technique and it's very similar to what I would do for removing upper eyelid fat. If somebody is really excessive, I just kind of gently press on the globe and just, let, let gravity kind of dictate what comes out. Same sort of concept here. And I'm always kind of looking at the opposite side to just make sure I'm not creating an excessive indentation or anything like that.
Yeah.
[00:16:29] Dr. Sam Rhee: Again, a lot of it is experienced, as you can tell, listening to salmon Sal, when you do it, it's what you feel based on your feedback on the patient and your experience what's appropriate. So that that's really
[00:16:43] Dr. Salvatore Pacella: important. One other point to make here is, is that not, not certainly not for the faint of heart as a surgeon, but you know, if you're doing a facelift and.
The newer techniques of deep extended facelifts. You're not far away from this plane to tease out the buccal fat. You, but you have to be exceptionally gentle. So, so many times if I'm planning a buccal fat pad removal and I'm doing a deep extended facelift, I'll lift up my tissue, go underneath the smash, take it extended deep into the face, make sure I'm not damaging any of the nerves.
And you really just have to gently spread and you can get, you can get a good handle on this buccal fat pad externally, but again, not for the faint of heart.
[00:17:28] Dr. Sam Rhee: I haven't done a deep plane facelift in like 25 years probably. And I don't plan on doing it anytime soon. You're right. That's it, it takes balls to be able to do that.
That's all I can say.
[00:17:40] Dr. Sam Jejurikar: Yeah. I also don't do deep plane facelift.
[00:17:43] Dr. Sam Rhee: This is a patient who had a buccal fat pad excision. She also had a little bit of S some mental liposuction, and she actually came back. She, this is, she came specifically for buccal fat pad excision and lipo.
And then after this, we also did master muscle injections of Botox, subsequent to that, which I don't have her most recent pictures on, but she was really happy with the results. She felt like she went from looking like a kid to basically like a young adult, which is what she is. And again it just helps to contour, and narrow the face a little.
The jawline. It's not for everybody as we discussed, but for certain patients, it's, it's very powerful.
[00:18:27] Dr. Sam Jejurikar: Yeah, I, I think I think, I think everything you did works in concert you can see that she has a little bit of templating of the lower cheek area. That's the specific effect for viewers of the buccal fat pad and make her look like she has more cheekbone definition than there's slimming of the jawline, which is a combination of the injections of Botox that you did.
And then the side view really shows the effect of the, of the neck liposuction, just how much. How much more acute, what we call the cervical mental angle is she just has a, a much more defined jawline. And even though I'm sure she's the same weight as she was beforehand, she looks much more chiseled.
So really nice resolved.
[00:19:03] Dr. Salvatore Pacella: Great job. Alright,
[00:19:05] Dr. Sam Rhee: thanks. Any other thoughts about buccal fat pad excision or a cheek contouring itself or Dr. Rohrich and his his information
[00:19:14] Dr. Salvatore Pacella: video? Do you do, do either of you ever use the buccal fat pad as a donor for
[00:19:19] Dr. Sam Jejurikar: other facial fat? I'd never have done that.
[00:19:21] Dr. Sam Rhee: When I did crane facial, we use it all the time as a pedicle graft for.
Palatal fistulas for S yeah, small defects and it worked great, especially in younger patients who seem to have a lot of it, obviously, because it seems to be very bulky and children. I need to remember this technique more for facial fat grafting as well, because there are some patients I know that probably would actually benefit from repurposing it and redirecting it to.
Mailer or other areas. I just keep forgetting that that's something that I should, use. Do you use it a lot? So,
[00:19:54] Dr. Salvatore Pacella: no, not at time. I, I think about it much more than I actually do it just because. Majority of mad facial aesthetic patients, I'm doing a larger volume of fat anyway, that I'm harvesting from the abdomen.
And, just, it's a little bit more precise, but I know people do excise it, chop it up, lay it down. You
[00:20:10] Dr. Sam Jejurikar: know, I think with the newer facial fat grafting techniques that are out there that I know you're using, it's just that the quality of fat when you have it in a syringe and you're checking. Yeah, the buccal fat that would be kind of lumpy and irregular tick.
If you think about the eyelids can do so much in and if you're using fractionated fat I I'd be worried about using the buccal fat pad in that scenario. And in terms of Sam's question I think Dr. Warick synopsis. Ms actually. Perfect. I, I think that it is very popular. It has a role in defining the jaw line.
It can definitely help with a chiseled look for younger patients know that there are long-term implications of doing this. So if you're okay, continuing this whole facial rejuvenation process in your forties, fifties, and sixties, Like most of the people we see are in their forties and fifties and sixties know that you will have to reverse the effects of doing this procedure, but there's definitely benefits to doing it as part of a more comprehensive approach now.
Yeah. I like that. Look just like
[00:21:08] Dr. Sam Rhee: Sal. Yeah,
[00:21:09] Dr. Sam Jejurikar: exactly. Exactly.
[00:21:11] Dr. Sam Rhee: Alright. Awesome guys. Thank you so much. Have a great
[00:21:14] Dr. Sam Jejurikar: day guys. You guys do as well.
