Why I Refuse to Do Buccal Fat Removal Anymore

I used to remove people's buccal fat pads all the time, but then I stopped because of my own personal experiences.

There are surgeons out there who get consistently good results and have happy patients after doing this procedure, but it didn't really work out that way for me in my practice.

Buccal fat is the deep fat pad that's located on either side of the face. It's between the buccinator muscle, which is the muscle on the inner part of our cheek, and several other more superficial muscles.

It's important to point out that the buccal fat pad is intricately intertwined with certain important structures and that includes the parotid duct. It connects the parotid gland to the inside of the mouth via the parotid duct, which is what actually sends saliva into our mouth. So, the buccal branch of the facial nerve is right in that space.

This area of the face also allows other important muscles to move, such as the risorius facial muscle that's involved in elevating the upper lip.

People do buccal fat removal surgery to reduce the fullness of their faces and to highlight the zygomatic prominence, also known as their cheekbones, but I have chosen to no longer do this.

My first reason is that there is, in my opinion, too much patient discomfort during the surgery, if it's done while the patient is awake. Most patients want to have this surgery under local anesthesia to avoid the risks of general anesthesia while also avoiding some of the extra costs.

During the surgery, I numb the inner part of the cheek, but I cannot numb the deeper structures that are all within the cheek where the actual fat pad is. So, as I tug on this buccal fat pad, and these internal structures where the fat pad is, people actually feel like their faces are being pulled on from the inside. It's very uncomfortable.

I've had patients be very unhappy during surgery. I hate that because I don't enjoy causing someone discomfort with the only other option being having to stop the surgery or offer it to them when they're fully asleep, which will cost more.

There are also important structures where the buccal fat pad lives, such as the facial nerve, the blood vessels, and the parotid duct, which are all at risk during the surgery as they're all intertwined. What happens if the nerve is injured?

Well, that actually happened to one of my patients.

As surgeons, we don't like to talk about our complications, but I think it's important because it obviously influenced me to stop doing this surgery.

For that specific patient, it was tough for me to find the buccal fat pad on one side. So I kept digging very carefully. I knew I didn't cut any nerves, but there were times when she was in some discomfort, and we ended up finding something that was likely the buccal fat pad. But then, in the postoperative setting, after a few days, she detected that there was a bit of difficulty elevating one side of her upper lip.

Essentially, I knew that there was some degree of swelling, or potentially, a little bit of nerve damage. And as it turned out, her nerve was temporarily affected. Luckily, it all went back to normal after three months, which is usually the case, but it's still very unsettling to the patient and to the surgeon.

There's also some data in the literature, although not common, that found that there were some cases of massive blood loss during the buccal fat removal surgery and one person almost died because they lost so much blood.

A friend of mine, who is another surgeon, had a case where his patient's whole cheek became very swollen with blood. So, there's lots of potential for injury and risk.

Another reason why I stopped doing this surgery is because I don't think that it achieves the look that everyone is hoping for. There are patients who have full faces, and they think that if they get this one surgery, all of a sudden, it's going to completely transform the appearance of their face and make everything look sculpted and how they envision it. But that's oftentimes not the case.

There are other fat compartments of the face that are a bit more superficial, meaning closer to the skin surface, and they stay the same, though they may naturally change over time. I've found that some people were dissatisfied because they couldn't really achieve what they were hoping for because they thought that their entire cheek would be reshaped.

Sometimes, it may go to the other extreme and some patients may end up looking too hollow, which is very difficult to reverse because we can't just go and stuff the fat back into the cheek. We could do a fat transfer, but it won't look the same.

When I was doing these operations, there was some anxiety on my part about not knowing if I'd be able to find both fat compartments going into the surgery and whether would I be able to remove an equal amount of fat on either side. Usually, when I'd go into an operation, the fat pads would be easy to find and everything would be fine. But I ran into situations where that wasn't the case, where I had trouble finding the first fat pad.

It got to a point where if I knew I had a buccal fat pad removal surgery on my schedule, I'd have a terrible feeling and I became anxious about things, which isn't worth it for me.

I operate because I enjoy it, not just to make money. I love making people feel better about themselves, but I wasn't enjoying myself while I was preparing for, and doing the buccal fat removal surgery.

There is a lack of knowledge regarding the long-term effects of this procedure and its role in facial aging. There is a risk that if you remove your buccal fat pad early in life, in your 20s or 30s, later on, when you lose the volume in your face, the buccal fat pad that was giving you some volume is now no longer there, which gives the illusion of premature facial aging due to volume depletion.

I found that many other surgeons who've been operating for 30 to 40 years, who I respect in the field and have had a chance to talk to on some occasions, have also stopped doing the buccal fat removal surgery. So, I felt that after the unpleasant experiences that I'd had, it would be best for me to stop.

I'm not trying to discourage people from doing the surgery, but I want you to know my opinion. I aim to be honest, and I felt like it wasn't right for my practice.

Dr. Gary Linkov is a facial plastic and hair surgeon, double board-certified by the American Academy of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology-Head & Neck Surgery. He graduated as a salutatorian from Cornell University and obtained his Medical Degree from Columbia University College of Physicians and Surgeons. His current practice focuses primarily on hair restoration and cosmetic lip surgery. Besides his medical practice, Dr. Linkov shares his expertise through his YouTube channel 'Doctor Gary Linkov', covering diverse topics in plastic surgery and aesthetics.

All views expressed in this article are the author's own.

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