What buccal fat removal does, who it suits, and what the evidence shows.

The buccal fat pad is a deep pocket of fat in the cheek, between the chewing muscle and the inner cheek muscle. It is prominent in infants, where it helps with suckling, and usually becomes less noticeable as the face matures.^1,6 In some adults it persists and contributes to a round face, filling the hollow below the cheekbone.¹

The parotid duct, which carries saliva, passes through the fat pad, and branches of the facial nerve run nearby.^1,7 Because it sits between muscles, buccal fat is relatively spared from the fat loss that affects the face with aging.¹

The best candidates have a full, round lower face due to a prominent buccal fat pad. The fullness lies above the jawline and behind the smile line, an area distinct from the jowl.^1,8 A firm, pulsating or discolored mass in the cheek needs imaging before any surgery.¹

The original description of the procedure recommended removing only this deep fat in carefully selected patients, to preserve the fat under the skin that is commonly lost with aging and to avoid late deformities.⁹ Fat that bulges forward through weakened tissue, called pseudoherniation, can be pressed back with gentle pressure, and surgeons are especially cautious about removing it.¹

Buccal fat removal is also used in middle-aged patients with sagging lower cheeks. In 133 patients followed for 12 months, lower face volume decreased in both younger patients with a heavy lower face and older patients with sagging.^10,11

• Anesthesia: Local anesthetic is injected inside the cheek, and the procedure is often combined with other facial surgery.¹
• Incision: A small incision of about 2.5 cm is made inside the mouth near the upper molars, so there is no scar on the face.¹
• Protection: The opening of the parotid duct is kept in view to avoid injuring it.¹
• Removal: Gentle pressure on the cheek guides the fat into the incision, and only fat that comes out easily is removed to avoid hollowing.¹
• Symmetry: The fat from each side is compared, and the incisions are closed with a dissolving stitch.¹

When combined with a facelift, the buccal fat is usually removed first through the mouth to lower the risk of infection and facial nerve injury.¹

In a study of 73 patients, the first day was the hardest, when 71.23% had trouble chewing. Swelling affected 97.26% on days 1 and 3, bruising was most common by day 5, and average worst pain was 3.34 out of 10.⁵ Most symptoms improved significantly by the end of the first week.⁵

Patients rinse the mouth to keep the incisions clean while they heal, and opening and closing the mouth regularly is encouraged.¹

• Overresection: Removing too much fat can leave the cheeks looking hollow.¹
• Firmness: A small blood collection or excessive handling can cause a firm cheek that gradually softens.¹
• Duct Injury: Injury to the parotid duct can cause swelling or a collection of saliva.^7,12
• Nerve Injury: Facial nerve injury, especially to the buccal branch, is possible.^1,12,13
• Other Risks: Bleeding, facial infection and limited mouth opening have been reported.^7,13

In systematic reviews, 7 complications occurred in 134 procedures, and minor complications occurred in 8.45% of 71 patients with no duct or facial nerve injuries.^2,4 Serious complications are rare but have been described in case reports, including an orbital abscess.^7,12

Short-term results are favorable. In the systematic review, 84.6% of patients rated their contour much better and the rest rated it better, and one study measured a 3.10 ml reduction in fat pad volume.² Three-dimensional measurements in middle-aged patients showed a small but significant reduction in lower face volume and width at 12 months.¹¹

The evidence is thin. Reviews found few studies, all of low quality, with none following patients long term.^2,4 A review prompted by the procedure's popularity on social media found no published data on how the face ages after buccal fat removal and called for caution.³

• Facial Aging: Whether removing buccal fat leads to hollowing as the face ages is unknown.^3,4
• Long-Term Satisfaction: Satisfaction has not been reported beyond about a year after surgery.^2,3,11
• Patient Selection: Objective criteria for who benefits most are not well established.^8,10