Facial Surgery
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Commentary
Commentary on: Buccal Fat Pad Excision:
Hydrodissection Technique
Alan Matarasso, MD, FACS
Editorial Decision date: March 13, 2019; online publish-ahead-of-print May 10, 2019.
In a well-designed and reported study, the authors have
described a subtle technical variation for buccal lipec-
tomy employing hydrodissection.1 They confirm it to be
faster and less painful than with smaller volumes of local
anesthesia.
Some minor points about the manuscript include: there
is no mention of the period of time during which the 54
patients were compiled, if there was any other (systemic)
anesthesia utilized, at what point local anesthesia falls into
the hydrodissection realm, and how many of these cases
were performed in conjunction with other procedures.
Also, I believe that the operation is commonly requested
not for the reasons necessarily mentioned at the outset of
the discussion, but because it is indicated for facial con-
tour improvement, less facial fullness, and accentuation of
skeletal features—particularly in view of an ever-increas-
ing world of obesity and that its removal does not neces-
sarily confer youthfulness.
In my practice, buccal lipectomy is most often an
adjunctive procedure to operations such as liposuction of
the neck and jowls or facial rejuvenation. From a technique
perspective, I always perform the operation intraorally and
prior to the sterile portion of a facial procedure. In contrast
to what they report, I find that hyper-extending the neck
facilitates visualization and Caldwell Luk retractors with
rubber tip guards provide good exposure. Also, retracting
the upper lip with the nondominant ring finger prevents an
inadvertent cautery burn to this area. I am also cognizant
of the fire risk in this procedure from circulating anesthesia
gases in the confined space of the intraoral cavity, in the
presence of oxygen, and with use of an electrocautery, so
Aesthetic Surgery Journal
2019, 1–2
© 2019 The American Society
for Aesthetic Plastic Surgery, Inc.
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DOI: 10.1093/asj/sjz086
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I keep suction on to diminish the anesthesia gases and the
cautery on the lowest effective setting to avoid sparks.
Removal of the buccal fat to improve facial contour is
not a new procedure. However, it has recently received
renewed interest as indicated by this article and that by
Sezgin et  al2 as well as my commentary on that arti-
cle.3 Interestingly, this is in the context of the numerous
observations that have been published concerning the
importance of facial fat compartment loss with aging
and the benefits of adding facial volume. I vividly recall
in my earliest presentations on this subject, well before
we recognized the importance of facial fat, plastic sur-
geons’ concerns about removing the buccal fat pad; this
despite photographic studies that indicated the buccal
fat pad persisted in patients with full faces into their
ninth decade of life. My own experience with hundreds
of cases during more than 25  years confirms that in
properly selected faces the benefits achieved with buc-
cal lipectomy are not adversely impacted by aging or
weight loss.
Which leads me to perhaps the most important point,
albeit not the purpose of the manuscript, which is the
author’s reference in the introduction section to the
unusual histology of the buccal fat pad and its metabo-
lism. An important point to discuss with patients is its
consistent size in most people despite variations in their
Dr Matarasso is a Clinical Professor of Surgery, Northwell Health
System/Hofstra University, Zuckerman School of Medicine, New
York, NY.
Corresponding Author:
Dr Alan Matarasso, 1009 Park Avenue, New York, NY 10028, USA.
E-mail: amatarasso@drmatarasso.com
2
size and weight, leading to similar volumes being removed
in most patients. Once properly removed, no more can be
excised. In earlier reports, I stated that the buccal fat pad
is embryologically and metabolically similar to eyelid fat.
Indeed, I would further submit that eyelid fat pads, buc-
cal fat pads, mid-line subplatysmal fat, and intra-abdomi-
nal fat are seemingly “aesthetically” analogous structures.
Perhaps physiologically they are different, but all have an
important impact on aesthetics.
Consequently, I would consider that in terms of facial
appearance, the presence of facial fat compartments is
what confers youthfulness and it is the buccal fat pad
that provides the supporting foundation to them. Buccal
lipectomy, therefore, is indicated when too much of a good
thing is detrimental. Hence, the indication for removal for
improvement in facial aesthetics.
On a related topic, it bears mentioning that buc-
cal lipodystrophy is a subjective assessment, whereas
a “herniated” buccal fat pad is incontrovertible and
can be a diagnostic dilemma that creates an abnormal
appearance.
Aesthetic Surgery Journal
Disclosures
The author declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
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Funding
The author received no financial support for the research,
authorship, and publication of this article.
REFERENCES
1. Valencia LC, Pérez GF, Kaplan J, Fernández-Riera R. Buccal
fat pad excision: hydrodissection technique. Aesthet Surg
J. 2019;pii:sjz040. doi: 10.1093/asj/sjz040. [Epub ahead
of print]
2. Sezgin  B, Tatar  S, Boge  M, Ozmen  S, Yavuzer  R. The
excision of the buccal fat pad for cheek refinement:
volumetric considerations. Aesthet Surg J. 2018. doi:
10.1093/asj/sjy188. [Epub ahead of print]
3. Matarasso A. Commentary on: the excision of the buccal
fat pad for cheek refinement: volumetric considerations.
Aesthet Surg J. 2018. doi: 10.1093/asj/sjy260. [Epub ahead
of print]