A bichectomy, also known as buccal fat pad extraction or Bichat’s fat pad removal, is a cosmetic plastic surgery procedure to remove fat tissue from the cheek and achieve a slimmer face while also enhancing the cheekbones, overall producing a more finely sculpted face.
What is the buccal fat pad? (Bichat’s fat pad)
The buccal fat pad is a fat structure that lies deep in the cheeks, more precisely in the masticatory space, and separates some of the chewing muscles from each other. It should not be confused with the malar fat pad or other superficial fat deposits. The buccal fat pad does not vary in size regardless of the overall body weight and fat distribution, being about the same size in all individuals. It is more prominent in infants while it gets more subtle in adulthood when all other tissues around it grow. As other fat deposits it shrinks with old age and its ptosis, due to other tissue laxity that allows for buccal fat descent, may contribute to jowl volume.
The buccal fat pad consists of a main central depot (three lobes) with three main extensions: buccal, pterygoid and temporal. The average volume of the fat pad is 10 ml in males and 9 ml in females weighing approximately 8 to 12g.
Indications and purpose of Buccal fat pad removal
Buccal fat pad removal is a cosmetic procedure with subtle results. Not all patients are good candidates and an experienced surgeon will make sure that the expectations of the patient match the likely outcome of the procedure; nonetheless, in the right patient the buccal fat pad removal can have pronounced results and noticeably recontour the face: it can sculpt the mid and low portion of the cheek, while at the same time enhancing the cheekbones.
Patients with a full and round face may have no to extremely subtle results with this procedure and should be offered other options that better suit their expectations.
The purpose of the buccal fat pad removal is not to remove the fat pad lobes and extensions completely, but just to excise part of the main body and buccal extension; sometimes also part of the pterygoid extension is excised, but removing too much fat tissue from the buccal fat pad may have negative effects on the aesthetics of the face and often requires corrective surgery. It is rarely performed in people older than 50 as by that time the fat pad has likely shrunk physiologically due to aging and other procedures may be more appropriate.
Buccal fat pad removal surgery
The surgery is generally performed with local anesthesia or with IV sedation and takes about 30-45 minutes to complete. It is carried out in a treatment room.
The incision is made inside the mouth, on both sides, close to the upper molars. After reaching the buccal fat pad and making an incision in the thin fibrous layer surrounding it, the surgeon pushes it from the external side of the cheek into the oral cavity or sometimes uses a suction device to pull it out; once exposed it is easily excised, commonly by using a electrosurgical device to control bleeding. After removing the appropriate amount of fat tissue, dissolvable sutures are used to close the incisions.
After the surgery there will be some swelling for a couple of days, with more subtle swelling fading away over the course of up to 4 months. There will be some soreness which is easily controlled with pain medications usually taken by patients only for the first 2 days. Numbness is not uncommon and may take a few weeks to subside.
It is very important to choose a surgeon experienced in performing this specific procedure and with good knowledge of facial anatomy to avoid a bad cosmetic outcome as well as other complications. Among the risks of buccal fat pad removal there are:
- Asymmetry. Human faces are often not symmetrical as it may also be the case for the buccal fat pad itself. The surgeon should be careful with the excision in order not to increase or cause an asymmetry and actually address it if present and if possible.
- Gaunt look. Removing too much tissue may cause a gaunt look both in the short term, right after surgery, and in the long term as the patient ages and the fat pad shrinks physiologically. It is not that rare to have patients requesting corrective surgery with fat grafting to address face hollowing due to an aggressive fat pad resection.
- Facial nerve damage. There are facial nerve branches in the area and the surgeon should be careful not to cause any nerve damage.
- Parotid gland and duct damage.
- Bleeding. The area of the face is very vascular and there is risk of bleeding, anyhow this can be easily controlled with cauterization.
- Excessive scarring.
- Reaction to the anesthetic.
- Dissatisfaction with the cosmetic results. As stated previously, buccal fat pad removal should be limited to selected patients and often has subtle results which are hard to appreciate in a before and after picture. Patients looking for a dramatic change, or with excessive expectations, or with excessive roundness of the face may be dissatisfied by the results.
Cost of buccal fat pad reduction surgery
The price for this cosmetic procedure varies depending on the chosen doctor, clinic, surgical technique used and country where you’re undergoing surgery.
In the USA the price is between 2,000 and 6,000 USD.
In Thailand the price is between 20,000 and 80,000 THB (640-2,500 USD)
It is important to book a consultation with an experienced surgeon in order to avoid a surgery that would not meet your expectations. He will guide you and advise you on alternative procedures that may better suit the result you are looking for.
Depending on your age, anatomy and expectations some of the alternative treatment available are:
- Ultrasound Assisted Lipoplasty (VASER)
- Injection lipolysis
- Masseter Botox Injection
- Anatomical structure of the buccal fat pad and its clinical adaptations.
HM Zhang, YP Yan – Plastic and Reconstructive Surgery Journal, Jun 2002
- Gross anatomical, CT and MRI analyses of the buccal fat pad with special emphasis on volumetric variations.
M Loukas, T Kapos – Surgical and Radiologic Anatomy, Jun 2006
- Buccal Fat Pad Excision: Proceed with Caution.
M Benjamin, RG Reish – International Open Access Journal of the American Society of Plastic Surgeons, Oct 2018
- Regenerative potential of the Bichat fat pad determined by the quantification of multilineage differentiating stress enduring cells.
G Conti, D Bertossi – European Journal of Histochemistry, Oct 2018
- Cosmetic Facial Surgery – 2nd Edition
Joe Niamtu – Elsevier, 2018
- Cosmetic Surgery – Art and Techniques
MA Shiffman, A Di Giuseppe – Springer, 2013
- Facial Plastic and Reconstructive Surgery – 4th Edition
ID Papel – Thieme, 2016
- The Art of Aesthetic Surgery – Principles and Techniques, 2nd edition
F Nahai – CRC Press, 2010
- American Society of Plastic Surgeons (ASPS)