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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.
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 alternative 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
0278-2391/13/01311-6$36.00/0
http://dx.doi.org/10.1016/j.joms.2013.10.002
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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.
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KHIABANI ET AL
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FIGURE 1 (contd).
Khiabani et al. Buccal Fat Pad Lifting. J Oral Maxillofac Surg 2014.
photographic views with minimal errors, all photographs were taken in a similar fashion by 1 photographer 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 comparing 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 neurosensory deficit and intense pain, were assessed using a
questionnaire modified from the extensively tested
McGill Pain Inventory.11
Infection, parotid duct injury, and massive hematoma also were subjectively evaluated based on clinical evaluations. This research was approved by the
local institutional review board and was in compliance
with the World Medical Association and the Declara-
KHIABANI ET AL
403.e5
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 anterior lobe also envelopes the infraorbital vessels and nerve and together enter the infraorbital canal. The branches of the facial nerve are on the outer
surface of its capsule. The intermediate lobe is situated 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 temporalis 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
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The Bichat fat pad can be extracted by 3 approaches: 1) an incision of the buccal mucosal membrane 1 cm below the opening of the parotid duct
(Matarasso method), 2) an incision behind the opening of the parotid duct (Stuzin method), and 3) an incision 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-
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 determine the ideal location for malar augmentation and are used before injection to mark the site of procedure and to aid the evaluations after surgery. 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 augmentation 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 surrounding tissues. Intra- and extraoral incisions are sutured. 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 unilateral 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.
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Variables
Body mass index (kg/m2)
Time after trauma
Amount of depression (mm)
Amount of augmentation (mm)
Age (yr)
Gender
Maximum
Minimum
Average
27.8
3 yr (old) (n = 10)
5
3
24
male (n = 8)
19.4
10 days (recent) (n = 3)
3
5.5
57
female (n = 5)
24.6
3.9
4.21
39
Discussion
The purpose of this study was to evaluate the BFP
flap technique for malar augmentation surgery. The authors 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 longterm results and complications of the technique. According to the facial analysis and clinical evaluation,
the degree of augmentation was significant; there
was no massive resorption requiring a secondary procedure. 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 subcutaneous 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 patients lifetime. The volume in adults ranges from 8.3 to
11.9 mL. The mean volume in men is 10.2 mL and
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 performed 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 technique 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
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KHIABANI ET AL
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procedure, blunt dissection at the end point of the inner 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 authors suggestion is that surgeons use a transconjunctival incision with or without lateral canthotomy, which
provides good access with an invisible scar, because
scars can be an especially challenging problem for esthetics. In the present series of patients, a transconjunctival 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 fascia covering the Bichat fat pad is maintained intact
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KHIABANI ET AL
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.
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FIGURE 6. A, Preoperative and B, postoperative views. A 29-year-old man underwent zigzag genioplasty, open rhinoplasty, malar and paranasal 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.
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 mechanisms. 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 undesirable 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 suggest that BFP lifting should not be performed in patients with a thin face, and it should be limited to
patients with sufficient subcutaneous buccal and no
presurgical hollowing (Fig 7C).
Hollowing Effect
BFP extraction has been an accepted method for many
years to decrease buccal fullness, especially in obese pa-
Indications
In the present series of patients, almost all BFP lifting
procedures were performed in patients with esthetic
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.
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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.
fractures or esthetic reasons, but it should be considered 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 repositioning 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 resonance 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 evaluation method is the only method that has been
reported in published articles that allows a quantitative 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.
the authors believe that this new open access technique should be considered an alternative method
for the management of mild to moderate malar depression in patients undergoing surgery for esthetic reasons and after trauma.
Acknowledgment
The authors offer special thanks to Ms Shahrzad Zojaji.
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