Buccal (Bichat's) Fat Pads and Treatment Options for Prominent Cheek Fullness
The buccal fat pad (BFP), also known as Bichat's fat pad, is an encapsulated fat mass located in the cheek between facial muscles that can be surgically removed (buccal lipectomy/bichectomy) to reduce prominent cheek fullness and create midface contour, though patient selection is critical to avoid premature facial aging. 1
Anatomy of the Buccal Fat Pad
The BFP is a specialized, encapsulated adipose structure positioned in the middle third of the face, anterior to the masseter muscle. 1 It consists of several anatomical extensions:
- Main body (central portion)
- Buccal extension (most accessible)
- Temporal extension
- Pterygoid extension
- Pterygopalatine extension
Key anatomical consideration: BFP volume increases with age and BMI. Studies show that individuals aged 30-49 and ≥50 have significantly higher BFP volumes than those aged 18-29, and females (particularly young females) have lower volumes than males. 2 This age-related increase contradicts the common misconception that facial fat universally atrophies with aging—the BFP actually enlarges while other facial fat compartments (malar, periorbital) atrophy. 3
Treatment Options for Reducing Prominent Cheek Fullness
Surgical Approach: Buccal Fat Pad Excision
Buccal lipectomy is the definitive treatment for reducing BFP-related cheek fullness, performed via intraoral incision with low complication rates (8.45% minor complications in systematic review), though long-term aging effects remain poorly studied. 4, 5
Patient Selection Algorithm (Critical for Outcomes):
Type I patients: Bottom-heavy face with generalized lower facial fullness
- Remove BFP from both upper and lower facial segments
- Expect volume reduction throughout lower face
- Best candidates: younger patients seeking cheek slimming
Type II patients: Ptotic lower cheeks (typically older individuals)
- Limit removal from upper segment to avoid excessive hollowing
- Focus excision on lower segments
- Higher risk of aged appearance if over-resected 6
The "Five Ds" Surgical Technique (2023):
The most recent high-quality evidence recommends a systematic five-step approach for safe BFP excision, emphasizing proper patient selection to prevent aged or unnatural appearance. 7 Patient selection is more critical than surgical technique—inappropriate candidates will have poor outcomes regardless of technical execution.
Extended Bichectomy Approach:
For patients requiring more dramatic contouring who fail conservative approaches, extended bichectomy includes:
- Resection of buccal extension
- Body removal
- Partial temporal extension excision
This provides superior cheek definition but requires experienced surgical judgment. 8
Expected Outcomes:
- Volume reduction: Mean 3.10 mL (95% CI: 2.38-3.80 mL) 4
- Mean excised tissue: 2.74 ± 0.69 mL (range 1.8-4.9 mL) 4
- Patient satisfaction: 84.6% reported "much better" facial contour, 15.4% reported "better" 4
- Complications: 7 complications in 134 procedures (5.2%), including no parotid duct or facial nerve injuries 4, 5
Critical Pitfalls and Contraindications:
Do NOT perform buccal lipectomy in:
- Patients with existing midface volume loss or hollowing
- Thin-faced individuals seeking "more definition"
- Patients over 40-45 without careful assessment (higher risk of accelerated aging appearance)
- Those with unrealistic expectations about facial transformation
Major caveat: The evidence base is weak—no randomized trials exist, and long-term follow-up data (>5 years) are essentially absent. 4, 5 The procedure's effect on facial aging remains unclear, though theoretical concerns exist that removing this fat compartment may worsen age-related midface deflation.
Non-Surgical Alternatives:
While the provided evidence focuses heavily on aesthetic treatments for facial augmentation (PRF, fillers for volume loss), there are no well-established non-surgical methods for reducing BFP volume. The guidelines discuss:
- Platelet-rich fibrin (PRF) and fillers are used for volume restoration in age-related fat atrophy, not reduction 3
- These modalities address the opposite problem (hollowing from malar fat pad atrophy)
Bottom line: If prominent cheek fullness is genuinely BFP-related and bothers the patient, surgical excision is the only evidence-based treatment. Conservative observation is appropriate for borderline cases, especially in younger patients whose facial proportions may naturally improve with skeletal maturation.
Surgical Access and Technique Considerations:
- Intraoral approach: Standard access, minimal visible scarring
- Combined with orthognathic surgery: BFP can be repositioned (rather than removed) for midface augmentation in skeletal surgery patients 9
- Surgical timing: Can be performed as standalone procedure or combined with facelift in older patients
The fundamental principle: BFP excision creates midface concavity by removing the "volumizing cushion" anterior to the masseter. 7 Success depends on matching the degree of removal to the patient's facial structure, age, and aesthetic goals—overcorrection creates a gaunt, prematurely aged appearance that cannot be easily reversed.