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I made the mistake of having my buccal fat pad removed and looking to have them refilled like it used to look before. I understand that my pockets collapsed after removing the fat and fillers cannot reinflate deep in the pockets. Is there any other substance that can achieve this, perhaps gore tex, alloderm, etc?
I understand that my pockets collapsed after removing the fat and fillers cannot reinflate deep in the pockets. Is there any other substance that can achieve this, perhaps gore tex, alloderm, etc?
I think I need to go over the anatomy before I answer the question. As you understand the anatomy better, it will become more apparent why it is difficult to fill deep into the pockets, and why using another substance would also be difficult. Here we go with the anatomy lesson:
Normal aging also reduces the buccal fat pad volume. If you follow a person through their life from infant, child, teenager, 20's, through the decades into their 50's and 60's, you can see the person's cheeks start off very full of "baby fat" and convex in contour. As this baby fat naturally "burns off" the cheeks flatten until they are relatively flat in their 20's to early 30's, when it is neither full or hollow. These are the best years when a woman can have children. As the person enter's the late 30's to 40's the cheekbones become more prominent as the lower cheek sucks in (hollowing). During this whole time, the buccal fat pad is slowly shrinking.
Since my main focus is facial rejuvenation, my general feeling about buccal fat removal is that it can prematurely age a person's face. It is true that some people's faces are fuller than their peers of the same age, but this same fullness will be to their advantage with regards to looking youthful. Patients coming in for consultation are looking for a change in the present, but because they are not in the medical field, I feel that they may not truly understand the impact it will have to their facial aging. If a surgeon performs a very conservative buccal fat pad reduction, there may be so little reduction, that the patient will not be happy with the improvement. If an aggressive removal or complete removal is performed then it may please the patient in the short term, but some time in the future (maybe immediately or 5-10 years from the surgery,) I worry that they will regret it. If the pocket that the buccal fat pad resides in could be "reinflated" with fat or filler easily, then I would not feel as strongly about reducing it. There is a YouTube video showing the actual buccal fat pad surgery (caution graphic images of the fat removal are shown), titled: "Thin Face in Fifteen Minutes." Easy way to make few thousand dollars in less than half an hour.
Let's take a look at the anatomy:
Cross section through the Atlas and occipital condyles:
If you look at the location of the buccal fat pad at location #4, you can see that the fat pad is located under the masseter muscle (#7). If this pocket is completely collapsed, it would be difficult to relocate this potential pocket to reinflate it. The second issue would be what material to reinflate the buccal fat pocket with. I think fat would make the most sense. If the cheek were like a barrel of dirt and the buccal fat pad was a plastic bag filled with fiberglass insulation, by removing the buccal fat pad, it would be like removing the insulation filling the plastic bad and leaving this deflated plastic bag. To try to find that collapsed plastic bag and reinflate it after all of the dirt has compressed it completely flat would be nearly impossible using a needle from the surface. When doctors and surgeons who inject fillers, we perform this in the office without benefit of ultrasound or radiologic imaging. Therefore, we fill the "indented area" just under the surface of the skin. Let's say this barrel of dirt collapse on the surface after the removal of the insulation from the plastic bag (buccal fat removal) and creates an indentation on the center surface of the barrel of dirt which was originally flat. Instead of trying to relocate the actual plastic bag and fill it back up with insulation, it is much simpler to just inject some filler under just under the surface until dirt until it looks flat again.
If we take a look at the diagram again, natural aging also causes the same kind of cheek hollowing, yet no one seems to try to reinflate the buccal fat pocket when treating cheek hollowing. Instead the typical treatment for facial fat atrophy is fillers (Restylane, Perlane, Juvederm, Radiesse) or collagen stimulators (Sculptra) or fat transfer (fat injections). The location of these injections are placed directly under the skin, but above zygomaticus major muscle (#6). The overall effect is that the cheek hollow is filled, but as you can see the #4 buccal fat pocket is not the same as the fat under the skin.
For natural facial aging, patients seem happy enough with revolumizing the cheek hollows by filling directly under the skin, and patients who regret having buccal fat removal essentially are in the same boat as older patients. Even though they regret the surgery, most likely the same thing would have eventually happened when they became older.
Here is a before and after photo of Sculptra for facial hollowing (this patient has buccal hollowing below her cheek bones) performed by Dr. Danny Vleggaar in Europe. I watched him demonstrate his sculptra injection technique a few years ago when he was visiting New York and giving lectures. He gave the NYC doctors tips on avoiding lumps and volumizing the whole face and not just the cheeks.
Is there any other substance that can achieve this, perhaps gore tex, alloderm, etc?
The thing that is appealing to me regarding the buccal fat pad, is that the fat is able to slide within the pocket, similar to how the intestines sit in our abdominal cavity, but the intestines can slide around. This mobility is also why it is easy to extract this teaspoon of baby fat from the inside of the mouth. If I simply create a random pocket in the general area of the buccal fat pad pocket and insert a firm piece of gortex or a folded piece of alloderm, my main concern is that it will scar into place and may not slide around as it would with a normal buccal fat pad anatomy. The worse case scenario would be the chunk of gortex or folded alloderm may be felt on the inside of your mouth or give an unusual sensation to the patient. A safer way to do this would actually be a submalar cheek implant which is designed for this purpose. Sub- means under and malar means cheek (bone), so a submalar implant fills the area under the cheek bone, and can give patient fullness in the buccal hollow. This give the patient a deeper filling affect than the fillers and fat grafting. The drawback is that this is a foreign object and potentially could shift or get infected over time. One positive is that if it doesn't look good, or as the patient ages, the implant no longer looks good, the implant can be removed or exchanged for different sizes and shapes.
Filler injection just under the surface of the skin can camouflage the hollowing that is occurring deeper in the facial tissues, but since there is no technique or method to "regenerate" or "replace" the original buccal fat pad, this is the best we can do at this point in time.
Now that you know my views on the buccal fat pad, you can see why I would be reluctant to reduce or removal something that is natural and so difficult to replace. I hope this makes some sense.
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