Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71, 162–170

Updated anatomy of the buccal space and

its implications for plastic, reconstructive
and aesthetic procedures
Thilo L. Schenck a, Konstantin C. Koban a, Alexander Schlattau b,
Konstantin Frank a, Anthony P. Sclafani c, Riccardo E. Giunta a,
Malcolm Z. Roth d, Alexander Gaggl e, Robert H. Gotkin f,
Sebastian Cotofana g,*
a
Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians University, Pettenkoferstraße 8a,
80336 Munich, Germany
b
Department of Radiology, Paracelsus Medical University Salzburg & Nuremberg, Müllner Hauptstraße 48,
5020 Salzburg, Austria
c
Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, 1305 York Avenue,
New York, NY 10021, USA
d
Division of Plastic Surgery, Albany Medical Center, 50 New Scotland Avenue, Albany, NY 12208, USA
e
Department of Oral and Maxillofacial Surgery, Paracelsus Medical University Salzburg & Nuremberg,
Müllner Hauptstraße 48, 5020 Salzburg, Austria
f
Private Practice, 625 Park Avenue, New York, NY 10065, USA
g
Department of Medical Education, Albany Medical College, 47 New Scotland Avenue, Albany, NY 12208, USA

Received 21 June 2017; accepted 7 November 2017

KEYWORDS Summary Background: The buccal space is an integral deep facial space which is involved in
Reconstructive a variety of intra- and extra-oral pathologies and provides a good location for the harvest of the
surgery; facial artery. The age-related anatomy of this space was investigated and compared to previous
Plastic surgery; reports.
Facial fat
Methods: We conducted anatomic dissections in 102 fresh frozen human cephalic specimens
compartments;
Facial nerve; (45 males, 57 females; age range 50–100 years) and performed additional computed tomo-
Facial artery; graphic, magnetic resonance and 3-D surface volumetric imaging studies to visualize the bound-
Facial vein aries and the contents of the buccal space after injection of contrast enhancing material.
Results: The mean vertical extent of contrast agent injected into the buccal space was
25.2 ± 4.3 mm and did not significantly differ between individuals of different age (p = 0.77) or
gender (p = 0.13). The maximal injected volume was 10.02 cc [range: 3.09–10.02] without
significant influence of age (p = 0.13) or gender (p = 0.81). The change in surface volume was
3.64 ± 1.04 cc resulting in a mean surface-volume-coefficient of 0.87 ± 0.12 without being sta-
tistically significant influenced by age (p = 0.53) or gender (p = 0.78).

* Corresponding author. Albany Medical College, 47 New Scotland Avenue MC-135, Albany, NY 12208.
E-mail address: cotofas@mail.amc.edu (S. Cotofana).

https://doi.org/10.1016/j.bjps.2017.11.005
1748-6815/© 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The anatomy of the buccal space 163

Conclusions: The facial artery was constantly identified within the buccal space whereas the
facial vein was found to course within its posterior boundary. The buccal space did not undergo
age-related changes in volume or size which highlights this space is a reliable and predictable
landmark for various plastic, reconstructive and aesthetic procedures.
© 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Introduction Material and Methods

The buccal space, extending from the mandible to the zygo-
matic arch and from the masseter muscle to the corner of
the mouth, is still poorly understood although it plays a
pivotal role for various plastic, reconstructive and aesthetic
procedures. Due to its integral location in the face this space
is affected by various facial tumors, 1–5 adenomas, 6,7
hemangiomas,8 cystic formations,4 and abscesses9,10 emerg-
ing both from intraoral and extra-oral locations. This space
is also crucial for the harvest of donor/recipient vessels
being utilized for free, pedicled, or other transposition
flaps,11,12 for intraoral malformation repairs13 or for recon-
structive procedures of the tongue14 or the alveolar ridge.15
The recent trend towards minimally invasive procedures
to treat the signs of facial aging has gained increasing pop-
ularity. When looking at the period between 2000 and 2016,
there has been an eight-fold increase in the use of
neuromodulators and a three-fold increase in the implanta-
tion of soft tissue fillers.16 The formation of the jowls as well
as the formation of the labiomandibular sulcus has been
shown to be related to the anatomy of the buccal space,
although a complete understanding of the underlying pro-
cesses is still elusive.16
Understanding the anatomy of the buccal space is of
crucial interest as this deep facial space has close relation-
ships to the facial artery, facial vein, buccal and zygomatic
branches of the facial nerve, parotid duct, buccal fat pad
(of Bichat), various muscles of facial expression and the
superficial musculo-aponeurotic system (SMAS). Reports in
the literature however, vary in their descriptions of the
boundaries as well as the contents of this space. Whereas
most authors agree that the medial boundary is formed by
the buccinator muscle and its overlying fascia and the
lateral boundary is formed by the SMAS – including the
platysma muscle and the mid-facial aponeurotic fascia17 –
opinions are divided for the superior, inferior and posterior
boundaries. The posterior boundary is in close proximity to
the masticator space 18 (previously termed as the
buccotemporal space19) and includes the buccal fat pad (of
Bichat), which sometimes is the subject of aesthetic
reduction.20
The aim of the present study is to investigate the bound-
aries and the contents of the buccal space and their rela-
tionships to the adjacent facial compartments, muscles,
ligaments and vessels. This will be accomplished in a rep-
resentative sample using anatomic dissections and com-
puted tomographic, magnetic resonance and 3D surface
volumetric imaging. We will also present anatomic land-
marks and guidance for surgical access to assist in the per-
formance of safe and effective procedures for plastic,
reconstructive, aesthetic, craniomaxillofacial and
otolaryngologic surgeons.
Sample for anatomic dissections
The sample used for the anatomic dissection part of this
study was previously described in detail.21 In brief, 72 fresh
frozen human cephalic specimens (32 males, 40 females)
with a mean age of 75.2 ± 10.9 years and a body mass index
24.2 ± 6.6 kg/m2 were objectively investigated. Of those, 71
cadavers were Caucasian and one (1.4%) was African-
American. None of the investigated specimens had previous
facial surgery nor any relevant disease affecting the integ-
rity of the facial anatomy.
Sample for radiographic imaging
The computed tomographic and magnetic resonance imaging
part of this study was carried out in an additional 30 fresh
frozen human cephalic specimens. This sub-sample con-
sisted of 17 females and 13 males, with a mean age of
78.3 ± 14.2 years [range: 50–100] and a mean body mass
index of 23.1 ± 5.3 kg/m2.
Anatomic dissections
All 102 cephalic specimens were dissected at the Surgical
Course Center, Salzburg, Austria. The dissection procedure
was based on a layer-by-layer identification of facial struc-
tures. The major focus of this study was to identify the
boundaries of the buccal space, its contents and the rela-
tionship with the adjacent deep facial fat compartments,
the muscles of facial expression, motor branches of the facial
nerve and the facial vessels. During the imaging part of this
study, colored dye was injected into the buccal space and
into the neighboring deep facial fat compartments; this facili-
tated delineation of the extent, contents and bordering struc-
tures of the buccal space.
Radiographic imaging
The buccal space and the adjacent deep facial fat compart-
ments (deep lateral cheek fat, deep medial cheek fat and
deep pyriform space)22–24 were injected using a 20G 70 mm
sharp needle with colored radiopaque material. The mate-
rial consisted of VisipaqueTM 320 (Iodixanol, 320 mg/ml, GE
Healthcare, Little Chalfont, United Kingdom) and Resource®
ThickenUp™ Clear (Nestle HealthCare Nutrition GmbH,
Vienna, Austria) and was specifically composed to obtain
similar viscosity as commercially available soft tissue fillers.
The facial fat compartments were injected transcutaneously
164 T.L. Schenck et al.

with slow pressure and in a perpendicular orientation to the Analysis strategy

bone. During the injection procedure, constant contact with
the bone was maintained to prohibit iatrogenic displace-
ment of the material. When injecting into the buccal space,
intra-oral manual control was performed to prevent intra-
oral penetration of the needle.
All computed tomographic (CT) scans were performed in
an upright position to simulate the effects of gravity. The
following CT scan parameters were used: field of view
200 mm, slice thickness 0.6 mm, increment 0.5 mm, voltage
140 kV and 400 mA/s.
Due to magnetic resonance (MR) space limitations of the
head coil, all MR scans were obtained in supine position. We
applied a sagittal T1 Vista (parameter: field of view 270 x
270 x 205 mm, voxel size 0.7 x 0.7 x 0.35 with a voxel recon
size of 0.352 mm, SNR 1.0, TE 18, TR 350, 586 slices per
dataset) and a T2 3D STIR (parameter: field of view 270 x 270
x 204 mm, voxel size 0.9 x 0.9 x 0.45 with a voxel recon size
of 0.422 mm, SNR 1.0, TE 308, TR 3000, 454 slices per
dataset).
3-D surface volumetric analyses
Changes in surface volume were recorded based on the struc-
tured light imaging technology using the mobile, radiation-
free 3-D scanner Eva® (Artec 3D Inc., Luxembourg) with
consecutive 3-D reconstruction. Differences between pre-
and post-injection surfaces were calculated by the commer-
cially available Mirror® digital measurement software
(Canfield Scientific, Inc., Fairfield, NJ, USA) and given as
root-mean-square measurement (RMS in mm), direct volume
subtraction from post- to pre-3-D surface (in mm) and as a
visual colored heat-map (blue = increase in volume;
red = decrease in volume; green = no change in volume).
A surface-volume coefficient was calculated by dividing the
difference between pre- and post-injection surface change
(in cc) by the injected volume as confirmed by the CT scans
(in cc). This coefficient provides information on the surface
effect of a certain amount of injected volume. Imaging based
(CT) measures of the volume injected into the buccal space
were conducted. Age- and gender-dependent changes in the
position and in the extent of the contrast agent were mea-
sured in a vertical axis (i.e. the distance from the root of the
nose) and in a horizontal axis (i.e. the distance from the
midline) using parametric (gender), linear (age) regression
and correlation models using SPSS Statistics 23 (IBM, Armonk,
NY, USA). Results were considered statistically significant at
a probability level of ≤ 0.05 to guide conclusions.
Results
Boundaries of the buccal space
The lateral boundary of the buccal space is formed by the
superficial musculo-aponeurotic system (SMAS) including, in
its inferior part, the platysma muscle and, in its superior
part, the mid-facial aponeurotic layer (Figures 1 and 2).
The medial boundary is formed by the buccinator muscle
and its overlying fascia, which represents the mid-facial
extension of the bucco-pharyngeal fascia (Figure 3).
The posterior boundary is formed by the anterior lamina
of the parotideo-masseteric fascia, which forms (together
with the posterior lamina) the facial vein canal, providing
shelter for the facial vein along its course at the anterior
margin of the masseter muscle (Figures 1A and 2B).

Figure 1 A: Schematic drawing of the left buccal space in view form lateral showing its boundaries and contents. The platysma (PL)
is pulled in caudal and the zygomaticus mayor muscle in cranial direction by the black strings. Note that the aponeurotic part of the
superficial musculo-aponeurotic system (SMAS) has been removed for clarity. The facial vein (running within the facial vein canal) is
depicted in blue, whereas the facial artery is colored in red. The branches of the facial nerve are given in yellow. The modiolus is
marked by the black star. PMF = Parotideo-masseteric fascia. B : Cadaveric dissection of the left midface from a lateral view. The
zygomaticus major muscle (ZMA) is elevated by the pick-up and the transverse facial septum is spanned (*). The modiolus is marked
by the black star and indicates the muscular pillar where the platysma and the buccinators muscle (BM) converge. The facial artery
can be identified with the buccal space (FA).
The anatomy of the buccal space 165

Figure 2 A: Horizontal cross section at the level of the nasal spine of a deep frozen cephalic specimen showing the right buccal from
inferior. Red dye was injected into the buccal space (BS) but not into the masticator space containing the buccal fat pad (of Bichat)
(BFP). Please note the boundary formed the anterior and posterior lamina of the parotideo-masseteric fascia (PMF). The modiolus is
marked by the black star and indicates the muscular pillar where the zygomaticus major muscle (ZMA) and the buccinator muscle
(BM) converge. B: Transverse magnetic resonance image of the head after the buccal space (BS) was injected with radiopaque
material. The facial vein (FV) is enclosed and separated from the contrasting material within the buccal space (BS) by the anterior
and posterior lamina of the parotideo-masseteric fascia (PMF). The modiolus is marked by the white asterisk and indicates the
muscular pillar where the zygomaticus major muscle (ZMA) and the buccinator muscle (BM) converge.

Figure 3 Cadaveric dissection of the right midface exposing the buccal space (posterior to the modiolus). The deep midfacial fat
compartments have been injected with colored dye: blue into the lateral suborbicularis oculi fat (SOOF), red into the medial
suborbicularis oculi fat (SOOF), blue into the deep lateral cheek fat (DLC) and green into the deep medial cheek fat (DMC). The
transverse facial septum expanding from the underside of the zygomaticus major muscle (ZMA) forms the superior boundary of the
buccal space and inhibits colored dye to migrate inferiorly. Note 1: that the ZMA is cut from its bony origin and that a window is cut
into the platysma (PL). Note 2: the orientation of the picture is oblique (orientation on left upper corner of picture) and that the
scalpel and the dissected skin overly the corner of the mouth.

The anterior boundary is formed by the modiolus and the
muscles of facial expression converging into this muscular
pillar: levator anguli oris, zygomaticus major, zygomaticus
minor (if present) buccinator, risorius (if originating from
the SMAS), depressor anguli oris (and its connecting fascia to
the mandible) and platysma (Figures 1B and 3).
The inferior boundary is multipartite: in its anterior half,
it is formed by the bony adhesion of the platysma to the
mandible and by the mandibular ligament; in the posterior
half, the facial artery and the facial vein crossed the man-
dible. There, no strong adhesion of the platysma to the
mandible was observed in the dissected specimens (Figure 4).
166
Figure 4 Cadaveric dissection of the right side of the upper neck and the lower face. The skin and the subcutaneous fatty layer (SC)
have been reflected posteriorly, whereas the platysma (PL) is reflected cranially. The black circle indicates the adipose tissue
located between the mandibular ligament (*) and the masseter muscle (MM) providing shelter for the facial artery and facial vein
when crossing the mandible.
The vessels however, were embedded in a various amount of
fat, which was not directly connected to the fat within the
buccal space but separated by a thin layer of connective
tissue which was ultimately pierced by the facial artery when
entering into the buccal space.
The superior boundary is formed by a connective tissue
sheet extending from the underside of the zygomaticus major
muscle and attaching to the alveolar process of the maxilla
at the same level as the bony origin of the buccinator muscle
(Figure 3). This fascia was observed in 100% of the investi-
gated specimens and can be regarded as a transverse septum
of the face; in its anterior portion, it also includes the levator
anguli oris muscle. This septum formed the inferior bound-
ary of the deep lateral and deep medial cheek fat compart-
ments of the midface (Figure 3) and the levator anguli oris
muscle was found to be incorporated within this septum.
Contents of the buccal space
The buccal space included the facial artery in all our inves-
tigated samples; it was found consistently to run anterior to
the facial vein. The artery continued toward the modiolus
after crossing the mandible and was attached to this mus-
cular pillar via a thin muscular band emerging from the
buccinator muscle (Figure 1). Within the buccal space, the
facial artery gave off the inferior labial and/or horizontal
mental artery and the superior labial artery. Changing its
name from facial to angular (after giving off superior labial)
the artery exited the space at its anterior-superior corner
and pierced the elevators of the lips depending on its vari-
able course.
An inconsistent number (2–7) of buccal and zygomatic
branches of the facial nerve was identified within the buccal
T.L. Schenck et al.
space after crossing superficially over the facial vein within
the roof of the facial vein canal (Figure 1). Between one to
three rami of the buccal and/or zygomatic branches of the
facial nerve pierced the transverse facial septum (connect-
ing the zygomaticus major muscle to the maxilla) to provide
motor supply to the levator labii superioris alaeque nasi and
the nasalis muscle.
The facial vein was not identified within the buccal space;
it was separated by the anterior lamina of the parotideo-
masseteric fascia, but coursed within the posterior bound-
ary of the space formed by the facial vein canal (Figure 2).
Neither the parotid duct, nor the buccal fat pad (Bichat’s fat
pad) was identified within the buccal space. The parotid
duct was identified within the posterior boundary of the
buccal space whereas the buccal fat pad (of Bichat) was
observed in 100% to reside posterior to the posterior bound-
ary (facial vein canal) within the masticator space (Figure 2).
Lymph nodes as well as lymphatic vessels were identified
in inconsistent locations within the space.
CT and MR imaging
A maximum volume of 10.02 cc [range: 3.09–10.02] was
injected into the buccal space without migration of the con-
trast agent into adjacent spaces or compartments (Figure 5A
and 5B). No significant influence of age (p = 0.13) or gender
(p = 0.81) on the injected volume of contrast agent were
observed. The vertical extent was measured to be
25.2 ± 4.3 mm without significant influence of age (p = 0.77)
or gender (p = 0.13) on the measurements. The most inferior
extent of the injected contrast agent (as measured in a
vertical plane from the level of the root of the nose) was in
mean 90.33 ± 6.4 mm but was not significantly correlated to
The anatomy of the buccal space 167

Figure 5 A: 3-D reconstruction of a cranial CT scan after injection of radiopaque material into the deep facial fat compartments.
The buccal space (BS) has been injected bilaterally. B: Fluoroscopic imaging of the injection process of radiopaque volumizing
material into the buccal space (BS). The radiopaque material can be correlated to the surrounding bony structures: mandible, palate
and maxillary sinus. C: Surface heat map of the buccal space after injection of 6.0 cc of volumizing material into the buccal space
(BS). Change in elevation before and after the injection is represented by blue (increase in volume), and green (same volume).

age R2 = 0.27 (p = 0.32). There was a significant difference in
this extent between gender as men had a longer distance
95.3 ± 2.7 mm as compared to women 87.8 ± 1.7 mm
(p = 0.027).
3-D surface volumetry
A mean injected volume of 4.61 ± 2.1 cc was calculated when
using CT based measures (Figure 5C). The change in surface
volume (between before and after the application of the
material) was 3.64 ± 1.04 cc resulting in a mean surface-
volume-coefficient of 0.87 ± 0.12. No significant influences
of age (p = 0.53) or gender (p = 0.78) were observed.
Discussion
The results of the present study are based on anatomic dis-
sections combined with computed tomographic and mag-
netic resonance imaging performed in a total sample of 102
human fresh frozen cadaveric specimens. The facial artery
was found consistently to run within the buccal space
(Figure 1), whereas the facial vein was identified in its pos-
terior wall; the vein was, therefore not considered a struc-
ture of this deep facial compartment (Figure 2). Likewise, the
buccal fat pad (of Bichat) also was not identified within the
buccal space, but was found within the adjacent masticator
space; this space is located posterior to the buccal space and
was separated from the buccal space by the facial vein and its
facial vein canal (Figure 2). The distribution of contrast agent
did not show significant variability in its CT-based measured
volume or in its overall size or extent when compared between
gender and different age groups. These findings identify this
deep facial compartment as a stable, reliable location for
various plastic, reconstructive and aesthetic procedures when
access to the facial artery and vein are needed.
The buccal space is a frequent location for facial tumors,1–5
adenomas, 6,7 hemangiomas, 8 cystic formations, 4 and
abscesses.9,10 Anatomical knowledge of its boundaries and
contents is thus crucial for surgeons when accessing this
deep facial compartment. Previous reports in the literature
have presented the high variability of the course of the
facial artery in the face,25–27 but have increased our under-
standing of the difficulty when trying to use the facial artery
as a donor or recipient vessel for free flaps,11,12 for pedicled
or transposition flaps for intraoral reconstruction13 or for
reconstructive procedures of the tongue14 or the alveolar
ridge.15 Our study provides anatomical evidence that the
facial artery can be found reliably within the buccal space,
and that it has a dependable course deep to the SMAS but
superficial to the buccinator muscle and its overlying fascia
and it is attached to the modiolus located at the angle of the
mouth.
Lateral (occipital) to the buccal space the branches of
the facial nerve can be found within the walls of the
premasseteric spaces16,28 and thus deep to the parotideo-
masseteric fascia after emerging from the parotid gland.
The buccal and the zygomatic branches of the facial nerve
travel superficial to the facial/angular vein within the roof
of the facial vein canal21 and enter the buccal space in its
superficial aspect. This change in planes can be assessed
clinically as it corresponds to the location of the anterior
margin of the masseter muscle. During face-lifting proce-
dures great care has to be taken when dissecting in the
sub-SMAS plane and advancing anterior to the masseter
muscle into the buccal space as here the branches of the
facial nerve are prone to injury.
The tortuous pathway of the artery can be explained, if it
is accepted that the buccal space serves as a “reserve”
space which enables the mandible to move during mastica-
tion; this ultimately stretches all the contents of the space
including the artery. The facial vein, however, was not iden-
tified within the buccal space; it was found to be separated
from the buccal space by the anterior lamina of the parotideo-
masseteric fascia (Figure 2). This has been shown recently to
form (together with the posterior lamina of the parotideo-
masseteric fascia) the facial vein canal.21 As the vein is located
168 T.L. Schenck et al.

Figure 6 A: Intra-oral view of the intra-operative dissections of the right buccal space. The oral mucosa and the buccinator muscle
have been incised and the facial vein (*) within the facial vein canal is visible within the fat of the buccal space (black arrow). B:
Intra-oral view of the intra-operative dissections of the right buccal space. The oral mucosa and the buccinator muscle have been
incised and the facial vein (blue marker) is exposed after the removal of the facial vein canal. C: Intra-oral view of the intra-operative
dissections of the right buccal space. The oral mucosa and the buccinator muscle have been incised and the facial vein (blue marker)
is exposed after the removal of the facial vein canal. The facial artery can be identified anterior to the vein (red marker).

more posteriorly and thus closer to the center of movement
during mastication (temporomandibular joint), less tension
and compression are expected, which could explain the
straighter course of the vein as compared to the artery.
When intraoral access in this area is required, a reliable
surgical approach (based on the cumulative experience of
the authors) is to first identify the facial vein in its fascial
canal and then to move either anteriorly into the buccal
space for the facial artery or posteriorly into the masticator
space for the buccal fat pad (Figure 6). A more posteriorly
located endobuccal incision (without altering the incision
technique as compared to the standard incision site) accom-
panied by manual palpation of the anterior boundary of the
masseter muscle and/or using ultrasonography guidance has
yielded consistent and reliable results.
Previous reports have provided inconsistent information
about the superior boundary of the buccal space. Whereas
some authors described a fascial attachment to the alveolar
process of the maxilla,29–31 others suggested that the space
has either no superior boundary17,18 or that a relationship
with the temporal fossa and its contents is present.32,33 Our
results confirm the presence of a fascial attachment; we
found a membranous connective tissue sheet extending from
the underside of the zygomaticus major muscle to the alveo-
lar process of the maxilla. Previous studies34,35 have pointed
to this structure as a potential new and important facial
supporting ligament whereas others identified this trans-
verse running septum to form the inferior boundary of the
deep lateral cheek fat compartment and of the deep medial
cheek fat compartment28 (Figure 5). It could be hypoth-
esized that an exceeding amount of soft tissue filler injected
cranial to this transverse facial septum might be causative
for the formation of “apple-cheeks”. An explanatory model
behind this unfavorable result could be that contraction of
the zygomaticus major muscle during smiling tenses this
septum and the fat compartments that lie within this fascial
hammock (deep medial cheek fat, deep lateral cheek fat)
are up-lifted. Following this, it might be plausible why “apple-
cheeks” are more prominent during smiling. This provides a
new understanding of the anatomy of the deep facial fat
compartments as injections of soft tissue fillers should be
adapted on an individual basis and the patient should be
asked to smile during procedures in this area in order to
avoid “apple-cheek” formation.
The inferior boundary of the buccal space has been pre-
viously described to be formed by the inferior margin of the
buccinator muscle, 36 by a fascial attachment to the
mandible30,31 or to have no true boundary and thus to be
potentially open into the submandibular triangle.17,18,32,33 Our
results revealed that in the anterior half of the buccal space,
the platysma is firmly attached to the outer margin of the
mandible; this confirms the fascial adhesion theory. We could
additionally identify the mandibular ligament to be included
within the posterior end of this attachment, which confirms
previous publications16,37–39 where the mandibular ligament
has been described to form the anterior margin of the jowl
deformity (Figure 4). In the posterior half of the inferior
margin the facial artery and vein crossed the mandible and a
distinct amount of fat and connective tissue was identified
between the overlying platysma and the mandible which was
not directly connected to the fat located in the buccal space
(Figure 4). It seems plausible that the facial vessels should
be protected during their exposed crossing at the outer side
of the mandible and that a certain degree of mobility needs
to be given to assure gliding during mandibular movement
while speaking and chewing. The loose attachment of the
platysma to the mandible, between the mandibular liga-
ment (anterior margin) and the masseter muscle (posterior
margin) can be potentially confirmed as the cause of the
jowl deformity as here age- and gravity-related gliding of
the subcutaneous fat together with the platysma is possible.
The platysma should be here respected as the floor of the
jowl deformity, whereas the content is the subcutaneous fat
and the roof the skin. Deep injections on the bone however,
or aesthetic surgical procedures in this area must be per-
formed with caution as the facial vessels are deep to the
SMAS, which is of special importance during sub-SMAS dis-
sections of face-lifting procedures.
The contents of the buccal space have been described to
include primarily fat, branches of the facial artery, buccal
The anatomy of the buccal space
and zygomatic branches of the facial nerve and lymphatic
tissue.18,19,29–33,35–40 The fat, however, was previously labeled
as the buccal fat pad17,32,40 we do not support this designa-
tion based on the results of our studies. The buccal fat pad
(of Bichat)41 was easy to visually identify due to its differ-
ences in color and texture when compared to the deep and
superficial facial fat and has been summarized previously to
be of a different type of fat when compared to the fat within
the buccal space.42 We found the buccal fat pad (of Bichat)
to be located posterior to the facial vein and posterior to the
confluence of the parotid duct into the buccinator muscle
and, therefore, do not regard the buccal fat pad as one of
the contents of the buccal space. Additionally, the buccal
fat pad was separated from the buccal space by the facial
vein canal, attached to the overlying fascia of the buccina-
tor muscle5,17 – a clear fascial boundary between the poste-
riorly located masticator space and the anterior located
buccal space. During aging, however, the facial vein canal
can become loose and the buccal fat pad can bulge into the
midface, increasing the clinical impression of jowls and con-
tributing to a more severe appearance of the labiomandibular
sulcus (i.e. marionette line) and the jowls deformity. During
surgical removal of the buccal fat pad, a useful guideline for
safer removal could be ultrasonography-based imaging of
the facial vein; the buccal fat pad can be found posterior to
the vein. Removal of the buccal fat pad can result in damage
to the facial vein canal and in damage to the buccal and
zygomatic branches of the facial nerve as these can be iden-
tified in the roof of the canal and can be affected during
extraction of this substantial fatty tissue.
Conclusion
Based on our anatomic dissections and on our CT and MR
imaging procedures carried out in 102 fresh frozen cephalic
specimens, we have extended the understanding of the
boundaries and contents of the buccal space. The facial
artery was identified consistently within the buccal space
whereas the facial vein was found to run within its posterior
boundary. The buccal fat pad was identified consistently
within the masticator space – located posterior to the buccal
space, posterior to the facial vein and posterior to the con-
fluence of the parotid duct into the buccinator muscle. The
buccal space did not undergo age-related changes in volume
or vertical extent; such information identifies this space as a
reliable space for various plastic, reconstructive and aes-
thetic procedures.
Author disclosure
None of the other authors listed have any commercial asso-
ciations or financial disclosures that might pose or create a
conflict of interest with the methods applied or the results
presented in this article.
Funding
The imaging part of this study was funded by Q-Med AB,
Sweden (Grant Nr: 15092016).
169
Acknowledgements
We would like to thank Katharina Erlbacher, Markus Schlager
and Stefan Targosinski for their support in the imaging part
of this study and Alexa Giammarino for her skilled anatom-
ical illustration.
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