CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY

Buccal Fat Pad Lifting: An Alternative Open

Technique for Malar Augmentation
Kazem Khiabani, DDS, OMFS,* Seied Omid Keyhan, DDS, OMFS,y
Payam Varedi, DDS,z Seifollah Hemmat, DDS, OMFS,x Roohollah Razmdideh, DDS,k
and Elham Hoseini, DDS{
Purpose: The purpose of the study was to introduce a novel technique for malar augmentation using
buccal fat pad pedicle flaps and to evaluate the long-term results and complications of the technique.
Materials and Methods: The investigators designed and conducted a prospective clinical trial. Patients
underwent unilateral malar augmentation surgery using buccal fat pad pedicle flaps from June 2011
through June 2012. Patients underwent surgery for esthetic reasons or for trauma with severely commi-
nuted or old zygomaticomaxillary complex fractures that could not be reduced precisely. The primary pre-
dictor variable was the buccal fat pad pedicle flap technique. The primary outcome variables included the
amount of augmentation and resorption (which was estimated by comparing pre- with postsurgical photo-
graphic views), pain, edema, bruising, and nerve and parotid duct injuries.
Results: Thirteen patients (8 men and 5 women) underwent malar augmentation in the cheekbone area
using the buccal fat pad pedicle flap technique. One year after surgery, the average amount of resorption
was 0.376 mm. Other major complications, such as prolonged bruising, massive hematoma, intense pain,
asymmetry, and parotid duct injury, were not observed.
Conclusion: These results indicate that this new open-access technique should be considered an alter-
native method for the management of mild to moderate malar depression in patients undergoing esthetic
and post-trauma surgery.
2014 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 72:403.e1-403.e15, 2014

The use of autogenous free fat grafts is a well-known
method to fill in superficial depressions resulting
from traumatic or congenital defects. The major donor
fat for this procedure is subcutaneous fat from the
abdomen or buttocks. The buccal fat pad (BFP) as an
anatomic element was first mentioned by Heister1 in
1732 and was described by Bichat2 in 1802. Scammon3
was the first to describe the anatomy of the BFP. In
1977, Egyedi4 was the first to report the use of the
BFP as a pedicle graft; subsequently, Tideman et al5
studied its anatomic characteristics and blood supply,
described the surgical technique, and presented the
clinical results of 12 cases of surgical defect recon-
structions of the oral cavity.
Anatomically, the BFP is an encapsulated, rounded,
and biconvex, mainly adipose structure with an excel-
lent blood supply from the maxillary, superficial tem-
poral, and facial arteries (Fig 1).5-7 This triple
irrigation system allows the use of this tissue without
significant risk of necrosis. The fat pad is delimited

*Assistant Professor, Department of Oral and Maxillofacial
Surgery, Jundishapour University of Medical Science, Ahvaz, Iran.
yAssistant Professor, Department of Oral and Maxillofacial
Surgery, Craniomaxillofacial Research Center, Shahid Rahnemoon
Hospital, Yazd, Iran.
zChief Resident, Department of Oral and Maxillofacial Surgery,
Craniomaxillofacial Research Center, Shariati Hospital, Tehran
University of Medical Sciences, Tehran, Iran.
xAssistant Professor, Department of Oral and Maxillofacial Surgery,
Bandar Abbas University of Medical Science, Bandar Abbas, Iran.
kResident, Department of Oral and Maxillofacial Surgery,
Jundishapour University of Medical Science, Ahvaz, Iran.
{Resident, Department of Oral and Maxillofacial Surgery,
Jundishapour University of Medical Science, Ahvaz, Iran.
Address correspondence and reprint requests to Dr Keyhan:
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,
Shahid Saddooghi University of Medical Sciences, Emam Reza BLV,
Yazd, Iran; e-mail: keyhanomid@ymail.com
Received July 17 2013
Accepted October 1 2013
2014 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/01311-6$36.00/0
http://dx.doi.org/10.1016/j.joms.2013.10.002

403.e1
403.e2
FIGURE 1. A to F, Schematic views of the relevant anatomy of the buccal fat pad. (Fig 1 continued on next page.)
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
by the buccinator muscle, the masseter muscle, and
the ascending mandibular ramus and zygomatic arch.
The BFP flap is an axial flap and can be used to fill in
small- to medium-sized soft tissue and bony defects. It is
often encountered as it bulges into the surgical field
during surgery in the pterygomandibular region. Use
of the BFP for facial esthetic surgery was first described
by Chung et al8 and Ramirez.9 However, the literature
lacks data about the technique, indications, complica-
tions, and long-term results.
The purpose of this study was to introduce a novel
technique for malar augmentation using BFP pedicle
flaps. The authors hypothesized that it would be effec-
tive because of its reported advantages, such as a pres-
ervation of the vascular pedicle, accessibility, and
volume and that the technique should be considered
an alternative technique. The specific aim of the study
BUCCAL FAT PAD LIFTING
was to evaluate the long-term results and complica-
tions of the technique.
Materials and Methods
The authors designed and conducted a prospective
clinical trial. Patients underwent malar augmentation
surgery using BFP pedicle flaps. The study population
was composed entirely of patients who were voluntarily
referred to the authors department for the evaluation
and management of malar contouring from June 2011
through June 2012. These patients had recent trauma-
related comminuted or old zygomaticomaxillary com-
plex fractures that could not be reduced precisely. To
be included in the study sample, the main complaint
had to be an esthetic problem, and the patients had to
KHIABANI ET AL
FIGURE 1 (contd). (Fig 1 continued on next page.)
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
undergo unilateral malar augmentation surgery using
BFP pedicle flaps with a 1-year postsurgical follow-up
(Fig 2).
The following patients were excluded as study
subjects: patients with orbital consequences, such as
diplopia, enophthalmos, or limitations in mouth open-
ing (as a result of severe malar bone displacement);
patients unwilling to accept risks; patients requiring
additional procedures, such as a zygomatic bone
reduction or osteotomy; patients requiring a large
amount of augmentation (>5-mm increase in malar
projection compared with the control or unaffected
side; Fig 2A); patients who previously underwent
similar procedures; patients with compromising sys-
temic conditions (eg, platelet dysfunction syndrome,
403.e3
critical thrombocytopenia, septicemia, history of local
or systemic corticosteroid consumption, platelet
count <100/UI, hemoglobin count <10 g/dL, and
active symptoms of local infection at the site of the
procedure); and patients with a history of addiction
or dramatic weight loss or gain during the previous
month. The primary predictor variable was the BFP
pedicle flap technique. The primary outcome vari-
ables were the amount of augmentation and resorp-
tion, symmetry (which was estimated by comparing
pre- with 1-month and 1-yr postsurgical photographic
views; Fig 2G), pain, edema, bruising, and nerve and
parotid duct injuries.
All steps of the technique were performed for all
patients by a single clinician. For the evaluation of
403.e4
FIGURE 1 (contd).
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
photographic views with minimal errors, all photo-
graphs were taken in a similar fashion by 1 photogra-
pher and at the same photographic center to identify
changes in the cheekbone area. To decrease the effect
of postoperative edema during facial analysis, the first
photographic views were obtained 1 month after the
operation and the second series of photographic
views was obtained 1 year after the operation.
The amount of resorption was estimated by com-
paring preoperative with postoperative photographic
profile views, as previously described (Fig 2G).10 The
amount of augmentation was determined by
comparing the preoperative with the postoperative
profile views, which were taken 1 month after the
operation.10
Other parameters, including permanent neurosen-
sory deficit and intense pain, were assessed using a
questionnaire modified from the extensively tested
McGill Pain Inventory.11
Infection, parotid duct injury, and massive hema-
toma also were subjectively evaluated based on clin-
ical evaluations. This research was approved by the
local institutional review board and was in compliance
with the World Medical Association and the Declara-
BUCCAL FAT PAD LIFTING
tion of Helsinki as it relates to medical research proto-
cols and ethics.
Statistical evaluation of the findings was performed
with SPSS 16.0 (SPSS, Inc, Chicago, IL). Parametric
tests were used to evaluate treatment efficacy and
complications. The significance level of statistical hy-
potheses was set at .05 (statistically significant).
RELEVANT ANATOMY
The BFP is an encapsulated mass of specialized fatty
tissue, the volume of which varies throughout a pa-
tients lifetime (approximately 10 cm3). It is distinct
from subcutaneous fat. It fills in deep tissue spaces
and acts as a gliding pad when masticatory and
mimetic muscles contract. In addition, it cushions
important structures from the forces generated by
muscle contraction.5-7,12 It is attached by 6 ligaments
to the maxilla, posterior zygoma, inner and outer
rims of the infraorbital fissure, temporalis tendon,
and buccinator membrane.5-7,12 The BFP has a body
and 4 processes. The body is located behind the
zygomatic arch. The body is divided into anterior,
intermediate, and posterior lobes in accordance with
KHIABANI ET AL
FIGURE 2. Intraoperative views. A, Intraoperative measurement of malar projection. B to F, Intraoperative views of surgical technique. (Fig 2
continued on next page.)
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
the structure of the lobar envelopes, ligaments, and
feeding vessels. The anterior lobe is located below
the zygoma and extends to the front of the
buccinator, maxilla, and deep space of the quadrate
muscle of the upper lip and zygomaticus major
muscle. The canine muscle originates from the
infraorbital foramen and passes through the medial
part of the anterior lobe (Fig 1).5-7,12 The parotid
duct passes along the lateral surface or penetrates
through the posterior part of the body fat pad
before traversing the buccinator muscle and
entering the oral cavity (Fig 1C to F). The anterior
facial vein passes through the anteroinferior margin.
403.e5
The anterior lobe also envelopes the infraorbital ves-
sels and nerve and together enter the infraorbital ca-
nal. The branches of the facial nerve are on the outer
surface of its capsule. The intermediate lobe is situ-
ated in and around the posterior lobe, lateral maxilla,
and anterior lobe. It is a membrane-like structure
with thin fatty tissue in adults, but it is a prominent
mass in children. The posterior lobe is situated in
the masticatory and adjacent spaces. It extends up
to the inferior orbital fissure, surrounds the tempora-
lis muscle, and extends down to the superior rim of
the mandibular body and back to the anterior rim of
the temporalis tendon and ramus. In doing so, it
403.e6
FIGURE 2 (contd). (Fig 2 continued on next page.)
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
forms the buccal, pterygopalatine, and temporal pro-
cesses.5-7,12
Four processes (buccal, pterygoid, superficial, and
deep temporal) extend from the body into the sur-
rounding spaces, such as the pterygomandibular
space and infratemporal fossa. The BFP flap is an axial
flap. The facial, transverse facial, and internal maxillary
arteries and their anastomosing branches enter the fat
to form a subcapsular vascular plexus.5-7,12
SURGICAL TECHNIQUE
The Bichat fat pad can be extracted by 3 ap-
proaches: 1) an incision of the buccal mucosal mem-
brane 1 cm below the opening of the parotid duct
(Matarasso method), 2) an incision behind the open-
ing of the parotid duct (Stuzin method), and 3) an inci-
sion of the superior gingivobuccal sulcus through the
superomedial wall of the buccal space, which is the
most common type.7 In the third approach (the
authors preferred approach), the initial incision
(a 2- to 3-cm vestibular incision from the second molar
to the first premolar) spreads the mucosa, buccinator
muscle, and periosteum. Limited subperiosteal dissec-
BUCCAL FAT PAD LIFTING
tion of zygomatic bone is performed. The Bichat fat is
almost always exposed to the extent of the vestibular
incision into the second molar area; if that does not
occur, a small incision in the periosteum and a blunt
dissection can be performed through the muscle,
and the Bichat fat pad can protrude through. The
capsular fascia, covering the Bichat fat pad, is main-
tained intact using blunt instruments, and the attached
fascial layer of the wall of the buccal space is dissected
off the Bichat fat pad to avoid stretching the nerve
structures that cross the lateral wall of the buccal
space (Fig 1). The Bichat fat pad should be free and
easily movable for repositioning as a pedicle flap (Fig
2B to F). Vessels on the fascia of the Bichat fat pad usu-
ally can be observed.
In the next step, a 1-cm preorbital incision (Fig 2F) or
a transconjunctival incision is planned, a subcutaneous
dissection is performed in the marked malar area with
scissors or cannulas, and the skin pocket is created. In
the most inferior portion of the pocket, with a cut to-
ward the bone, the skin pocket is connected to an in-
traoral incision. A 2-0 nylon suture is woven into the
Bichat fat pad (Fig 2F) with a needle, and the ends of
the suture are tunneled to the skin pocket (Fig 2F).
KHIABANI ET AL 403.e7

FIGURE 2 (contd). G, Schematic view of photographic analysis. For cheekbone area evaluations in profile views, 4 reference lines were
used: oral commissure to lateral cantus, alar to tragus, tangent line with infraorbital rim, and nasionto the subnasal point. The first 3 lines deter-
mine the ideal location for malar augmentation and are used before injection to mark the site of procedure and to aid the evaluations after sur-
gery. Then, the most projected point of the cheekbone area in profile views is determined as a reference point. A perpendicular line is drawn
from this point to the line connecting the nasion to the subnasal point in the left and right profile views of each patient. After malar augmentation,
the length of the perpendicular line will decrease because of anterior displacement of the most projected point of the cheekbone area in profile
views. This amount will increase incrementally after resorption. The measurement of this differentiation could indicate that the amount of augmen-
tation and resorption (from Keyhan et al10). AL, alar; MP, maximum projected point; N, nasion; OC, oral commissure; OR, infra orbital rim; RLC,
right lateral cantus; SN, subnasal; TR, tragus.
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.

The repositioned pedicle flap is sutured to the sur-
rounding tissues. Intra- and extraoral incisions are su-
tured. To evaluate the patients and the technique, a
2-dimensional facial analysis technique, which was
described in the authors previous article, was used
before the operation and at 1 year postoperatively.
Results
From June 2011 through June 2012, 13 patients
(8 men and 5 women) underwent malar augmentation
in the cheekbone area (10 patients with old unilateral
zygomatic fracture and 3 patients with recent unilat-
eral zygomatic bone fracture) using the BFP pedicle
flap technique. In all patients, the chief complaint
was an esthetic problem. No patients had ophthalmic
consequences or limitation in mouth opening before
surgery (Table 1).
The patients ages ranged from 24 to 57 years old
(average age, 39 yr). Based on patients questionnaire
responses, all patients were satisfied with the esthetic
results of their surgery (Figs 3 to 6). No patient who
underwent the BFP pedicle flap technique developed
a permanent neurosensory deficit.
403.e8
Table 1. VARIABLE DESCRIPTIONS
Variables Maximum
Body mass index (kg/m2) 27.8
Time after trauma 3 yr (old) (n = 10)
Amount of depression (mm) 5 3
Amount of augmentation (mm) 3 5.5
Age (yr) 24
Gender male (n = 8)
Abbreviation: mm, millimeter.
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
Before surgery, the average amount of under-projection
in affected sites was 3.9 mm (3 to 5 mm; P < .05). One
month after surgery, the average amount of augmentation
was 4.21 mm (3 to 5.5 mm; P < .05) compared with the
unaffected side, which had a value of 0.0 mm. One year
after surgery, the average amount of resorption was
0.376 mm (0.0 to 0.6 mm; P > .05) compared with the un-
affected side, which had a value of 0.0 mm.
Other major complications, such as prolonged
bruising, massive hematoma, intense pain, asymmetry,
infection, or parotid duct injury, were not observed.
A mild hollowing lateral effect to the oral commissure
was observed in 1 patient (Fig 7). The total time of sur-
gery varied from 2 hours in the first case to 1 hour in
the last case. No significant difference was observed
in regard to gender or age. Edema was the most
frequent complication.
Discussion
The purpose of this study was to evaluate the BFP
flap technique for malar augmentation surgery. The au-
thors hypothesized that it would be effective because
of its reported advantages, such as a preservation of
the vascular pedicle, accessibility, and volume, and
should be considered an alternative technique. The
specific aim of the study was to evaluate the long-
term results and complications of the technique. Ac-
cording to the facial analysis and clinical evaluation,
the degree of augmentation was significant; there
was no massive resorption requiring a secondary pro-
cedure. In this study, there was no case of massive
edema, intense pain, prolonged bruising, parotid
duct injury, or permanent neurosensory deficit. Edema
was the most frequent complication.
The BFP is an encapsulated, rounded, biconvex,
specialized fatty tissue that is distinct from subcutane-
ous fat. It is located between the buccinator muscle
medially, the anterior margin of the masseter muscle,
and the mandibular ramus and zygomatic arch laterally.
The volume of the BFP can change throughout a pa-
tients lifetime. The volume in adults ranges from 8.3 to
11.9 mL. The mean volume in men is 10.2 mL and
BUCCAL FAT PAD LIFTING
Minimum Average
19.4 24.6
10 days (recent) (n = 3)
3.9
4.21
57 39
female (n = 5)
ranges from 7.8 to 1.2 mL, whereas the mean volume
in women is 8.9 mL and ranges from 7.2 to 10.8 mL.7
The body and buccal extension make up the bulk
(50% to 70%) of the fat pad.13 The BFP was considered
a surgical nuisance for many years because it was com-
mon to accidentally encounter the pad during various
operations in the pterygomandibular area, such as for
tumor, or during orthognathic or trauma surgeries.
Many articles have reported the advantages of this
technique for the reconstruction of small- to
medium-sized congenital or acquired soft tissue and
bony defects in the oral cavity.14-33 Defects up to 12
to 15 cm2 can be closed using a BFP alone without
compromising the blood supply. Rapidis et al22 stated
that in maxillary defects larger than 4  4  3 cm, the
possibility of partial dehiscence of the flap is high
because of the impaired vascularity of the stretched
ends of the flap. In buccal or retromandibular defects
up to 7  5  2 cm, reconstruction can be accom-
plished because of the underlying rich vascular bed.
SURGICAL TECHNIQUE
Incisions
The BFP lifting technique described in this article is
an inherently open technique, and it is different from
the technique of Ramirez9 (endoscopic midface lift)
in which BFP lifting (as part of the procedure) is per-
formed with endoscope devices that pass through
the temporal hairline incisions. With the present
more recent technique, 2 small incisions (intraoral
and extraoral incisions) provide an open surgical field,
which facilitates more precise handling. The intraoral
incision can be extended beyond the midline or to the
opposite site, especially in cases in which the tech-
nique is used in combination with other procedures,
such as paranasal or malar implantation, orthognathic
surgery, or maxillary Le Fort fracture management. In
such cases, extraction of the BFP should be performed
after completion of those procedures, such that the
posterior extension of the flap does not extend
beyond the second molar because of inadvertent
fat exposure. After completing the concomitant
KHIABANI ET AL 403.e9

FIGURE 3. Photographic views. A,B, Preoperative views. C,D, Postoperative views.

Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
403.e10
FIGURE 4. A, Preoperative and B, postoperative views
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
procedure, blunt dissection at the end point of the in-
ner surface of the flap can expose the Bichat fat pad.
For extraoral incision, a 1-cm preorbital incision or
transconjunctival incision can be used. In cases that
are candidates for esthetic malar augmentation, the au-
thors suggestion is that surgeons use a transconjuncti-
val incision with or without lateral canthotomy, which
provides good access with an invisible scar, because
scars can be an especially challenging problem for es-
thetics. In the present series of patients, a transcon-
junctival incision was used in only 1 patient, but no
visible scars were observed in patients with preorbital
incisions.
BFP Extraction, Plication, and Suspension
Precise dissection should be performed to prevent
parotid duct injury. Although it is a rare complication,
if transection or injury of the parotid duct occurs,
then the injury is usually located at or distal to the
anterior border of the masseter muscle along the
line drawn from the tragus of the ear to the middle
of the upper lip. Such injury should be repaired
rapidly at detection during surgery. The capsular fas-
cia covering the Bichat fat pad is maintained intact
BUCCAL FAT PAD LIFTING
using blunt instruments, which avoids traction of
the nerve structures that cross the lateral wall of the
buccal space. However, injury to the distal end of
the facial nerve branches distal to the line drawn
from the lateral corner of the eye to the angle of the
mandible. Such injuries usually will be repaired by
cross innervation; it can be repaired by primary or sec-
ondary microsurgery if indicated. The Bichat fat pad
should be free and easily movable for repositioning
as a pedicle flap, and insufficient dissection of the
flap results in stretching of the pedicle of the flap,
which can compromise blood supply and decrease
the volume of the flap, in addition to dislodging the
flap from the vascular pedicle. If this occurs, augmen-
tation should be continued using avulsed fat pad mate-
rial as a free fat graft, and the patient is followed.
Revision surgery can be performed 3 to 6 months later
using other procedures, such as filler injection or free
fat grafting. Flap repositioning can be performed sim-
ply by using the hinge rotation of the flap around the
zygomatic buttress (consisting of the body and buccal
process of the BFP) at the center of rotation under the
zygomatic arch and near the temporal and pterygopa-
latine processes of the fat pad.
KHIABANI ET AL 403.e11

FIGURE 5. Photographic views. A,B, Preoperative views. C,D, One-year postoperative views.
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
403.e12
FIGURE 6. A, Preoperative and B, postoperative views. A 29-year-old man underwent zigzag genioplasty, open rhinoplasty, malar and para-
nasal prosthesis in combination with left buccal fat pad lifting (from Keyhan et al35).
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
BFP Volume
Previous studies have indicated that, regardless of
gender, the average BFP volume is 9.5 mL.7,13
Therefore, the average volume of the body and buccal
process (50 to 70%), which are measured during BFP
lifting, is 5 mL. In contrast, in a recent study, the average
amount of augmentation was 4.21 mL, and according to
this study, the average amount of augmentation gained
per milliliter is 0.84 mL.
If less augmentation is needed, partial extraction of
the BFP can be performed. Other options, such as
limited plication of extracted fat, also can be considered,
although it is impossible to titrate the volume precisely.
Flap Fixation and Incision Closure
The repositioned pedicle flap is sutured to the sur-
rounding preorbital subcutaneous tissues. Superficial
preorbital dimpling may be observed. If this occurs,
it can be resolved with local massage.
Hollowing Effect
BFP extraction has been an accepted method for many
years to decrease buccal fullness, especially in obese pa-
BUCCAL FAT PAD LIFTING
tients. After extracting the fat pad, the malar bones can
be projected more indirectly because of the hollowing
effect at the lateral side of the oral commissures. The
BFP can be used to augment the malar area using 2 mech-
anisms. In addition to the direct effect, it has an indirect
effect, which was discussed earlier. This augmentation
can be considered a useful effect, especially in obese
and normal-weight patients, although it can result in un-
desirable consequences in thin patients who have a body
mass index lower than the normal range. In the present
series of patients, an undesirable hollowing effect was
observed in only 1 patient who was thin, although the
effect was mild and did not have any significant effect
clinically or statistically.
Based on the present experience, the authors sug-
gest that BFP lifting should not be performed in pa-
tients with a thin face, and it should be limited to
patients with sufficient subcutaneous buccal and no
presurgical hollowing (Fig 7C).
Indications
In the present series of patients, almost all BFP lifting
procedures were performed in patients with esthetic
KHIABANI ET AL
FIGURE 7. Comparison of hollowing effect in A, fat, B, normal, and (Fig 7 continued on next page.)
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
complaints owing to trauma, although a combination of
rhinoplasty, zigzag genioplasty,34,35 bilateral malar and
paranasal augmentation, and unilateral BFP lifting
(left) after prosthetic augmentation in the left malar
area with rigid implants to improve left malar
projection in relation to opposite side was performed
(Fig 6). Based on their experience, the authors recom-
mend that BFP lifting should not be performed as an
isolated procedure, but as an adjunct procedure in com-
bination with orthognathic surgery, malar or paranasal
alloplastic augmentation, panfacial fracture surgery,
dimple creation surgery,36 or in combination with con-
ventional or endoscopic midface lift procedures. In
such cases, BFP extraction should be performed after
finishing the other procedures, as was discussed earlier.
After extraction of the flap, it can be fixed to the adja-
cent prosthesis or plated in subperiosteal fashion.
Use of the BFP lifting technique before facial lipo-
structure10,37 should be considered an alternative
technique to decrease the average amount of fat
resorption (authors hypothesis).
Time of Surgery
The time of the surgery is not a challenging prob-
lem in patients undergoing surgery for old zygomatic
403.e13
fractures or esthetic reasons, but it should be consid-
ered an important step, especially in patients with
recent fractures with severe hematoma or edema,
which can result in a complex treatment plan. In
such cases, BFP lifting can be performed after a
10-day grace period, and slight overcorrection (0.5
to 1 mL) can be considered in such cases.
DATA COLLECTION
The results of procedures such as fat grafting or re-
positioning surgery are difficult to evaluate completely
and objectively. It is also difficult to evaluate the
amount of fat augmentation and resorption without
performing pre- and postoperative magnetic reso-
nance imaging. Therefore, the authors decided to
use a 2-dimensional facial analysis based on profile
views, which was discussed in their previous article
(Fig 2G).10 Evaluation can be performed using birds
eye views or submental views.
Currently, a precise quantitative method does
not exist when using these views. The present evalu-
ation method is the only method that has been
reported in published articles that allows a quantita-
tive evaluation of such procedures. However, the
403.e14
FIGURE 7 (contd). C, thin facial types. C, Note the hollowing effect (arrow).
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
present method is 2-dimensional and thus has some
limitations.
Use of the BFP for facial esthetic surgery was first
described by Chung et al.8 However, the literature lacks
data about the technique, indications, complications,
and long-term results.9,32 The authors recent
experience in this field has shown acceptable results.
This method can be used as an alternative option for
malar augmentation in patients undergoing surgery
for esthetic reasons or after trauma, especially for
severe comminuted zygomatic fractures, which may
be impossible to reduce precisely.
Although free fat grafts also can be used in this clin-
ical context, fat grafts have always represented a chal-
lenge in inducing the necessary neoangiogenesis,
which results in significant resorption. As a result,
BUCCAL FAT PAD LIFTING
the authors believe that this new open access tech-
nique should be considered an alternative method
for the management of mild to moderate malar depres-
sion in patients undergoing surgery for esthetic rea-
sons and after trauma.
Acknowledgment
The authors offer special thanks to Ms Shahrzad Zojaji.
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