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Buccal Fat Pad Lifting: An Alternative OpenTechnique for Malar Augmentation

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Kazem Khiabani, DDS, OMFS,* Seied Omid Keyhan, DDS, OMFS,yPayam Varedi, DDS,z Seifollah Hemmat, DDS, OMFS,x Roohollah Razmdideh, DDS,k

and Elham Hoseini, DDS{
Purpose: 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.

Materials andMethods: The investigators designed and conducted a prospective clinical trial. Patients

underwent unilateral malar augmentation surgery using buccal fat pad pedicle flaps from June 2011

through June 2012. Patients underwent surgery for esthetic reasons or for trauma with severely commi-

nuted or old zygomaticomaxillary complex fractures that could not be reduced precisely. The primary pre-

dictor variable was the buccal fat pad pedicle flap technique. The primary outcome variables included the

amount of augmentation and resorption (whichwas estimated by comparing pre- with postsurgical photo-

graphic views), pain, edema, bruising, and nerve and parotid duct injuries.

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 alter-

native method for the management of mild to moderate malar depression in patients undergoing estheticand post-trauma surgery.

� 2014 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 72:403.e1-403.e15, 2014

The use of autogenous free fat grafts is a well-known

method to fill in superficial depressions resulting

from traumatic or congenital defects. The major donor

fat for this procedure is subcutaneous fat from the

abdomen or buttocks. The buccal fat pad (BFP) as an

anatomic element was first mentioned by Heister1 in1732 andwas described by Bichat2 in 1802. Scammon3

was the first to describe the anatomy of the BFP. In

1977, Egyedi4 was the first to report the use of the

BFP as a pedicle graft; subsequently, Tideman et al5

nt Professor, Department of Oral and Maxillofacial

ndishapour University of Medical Science, Ahvaz, Iran.

nt Professor, Department of Oral and Maxillofacial

raniomaxillofacial Research Center, Shahid Rahnemoon

azd, Iran.

Resident, Department of Oral and Maxillofacial Surgery,

illofacial Research Center, Shariati Hospital, Tehran

of Medical Sciences, Tehran, Iran.

nt Professor, Department of Oral and Maxillofacial Surgery,

bas University of Medical Science, Bandar Abbas, Iran.

nt, Department of Oral and Maxillofacial Surgery,

our University of Medical Science, Ahvaz, Iran.

403.e

studied its anatomic characteristics and blood supply,

described the surgical technique, and presented the

clinical results of 12 cases of surgical defect recon-

structions of the oral cavity.

Anatomically, the BFP is an encapsulated, rounded,

and biconvex, mainly adipose structure with an excel-lent blood supply from the maxillary, superficial tem-

poral, and facial arteries (Fig 1).5-7 This triple

irrigation system allows the use of this tissue without

significant risk of necrosis. The fat pad is delimited

{Resident, Department of Oral and Maxillofacial Surgery,

Jundishapour University of Medical Science, Ahvaz, Iran.

Address correspondence and reprint requests to Dr Keyhan:

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,

Shahid Saddooghi University of Medical Sciences, Emam Reza BLV,

Yazd, Iran; e-mail: [email protected]

Received July 17 2013

Accepted October 1 2013

� 2014 American Association of Oral and Maxillofacial Surgeons

0278-2391/13/01311-6$36.00/0

http://dx.doi.org/10.1016/j.joms.2013.10.002

1

Delta:1_given name

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mailto:[email protected]

http://dx.doi.org/10.1016/j.joms.2013.10.002

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.

403.e2 BUCCAL FAT PAD LIFTING

by the buccinator muscle, the masseter muscle, and

the ascending mandibular ramus and zygomatic arch.

The BFP flap is an axial flap and can be used to fill in

small- to medium-sized soft tissue and bony defects. It is

often encountered as it bulges into the surgical field

during surgery in the pterygomandibular region. Use

of the BFP for facial esthetic surgery was first described

by Chung et al8 and Ramirez.9 However, the literaturelacks data about the technique, indications, complica-

tions, and long-term results.

The purpose of this study was to introduce a novel

technique for malar augmentation using BFP pedicle

flaps. The authors hypothesized that it would be effec-

tive because of its reported advantages, such as a pres-

ervation of the vascular pedicle, accessibility, and

volume and that the technique should be consideredan alternative technique. The specific aim of the study

was to evaluate the long-term results and complica-

tions of the technique.

Materials and Methods

The authors designed and conducted a prospective

clinical trial. Patients underwent malar augmentation

surgery using BFP pedicle flaps. The study population

was composed entirely of patientswhowere voluntarily

referred to the authors’ department for the evaluation

and management of malar contouring from June 2011

through June 2012. These patients had recent trauma-related comminuted or old zygomaticomaxillary com-

plex fractures that could not be reduced precisely. To

be included in the study sample, the main complaint

had to be an esthetic problem, and the patients had to

FIGURE 1 (cont’d). (Fig 1 continued on next page.)


KHIABANI ET AL 403.e3

undergo unilateral malar augmentation surgery using

BFP pedicle flaps with a 1-year postsurgical follow-up

(Fig 2).

The following patients were excluded as studysubjects: patients with orbital consequences, such as

diplopia, enophthalmos, or limitations in mouth open-

ing (as a result of severe malar bone displacement);

patients unwilling to accept risks; patients requiring

additional procedures, such as a zygomatic bone

reduction or osteotomy; patients requiring a large

amount of augmentation (>5-mm increase in malar

projection compared with the control or unaffectedside; Fig 2A); patients who previously underwent

similar procedures; patients with compromising sys-

temic conditions (eg, platelet dysfunction syndrome,

critical thrombocytopenia, septicemia, history of local

or systemic corticosteroid consumption, platelet

count <100/UI, hemoglobin count <10 g/dL, and

active symptoms of local infection at the site of theprocedure); and patients with a history of addiction

or dramatic weight loss or gain during the previous

month. The primary predictor variable was the BFP

pedicle flap technique. The primary outcome vari-

ables were the amount of augmentation and resorp-

tion, symmetry (which was estimated by comparing

pre- with 1-month and 1-yr postsurgical photographic

views; Fig 2G), pain, edema, bruising, and nerve andparotid duct injuries.

All steps of the technique were performed for all

patients by a single clinician. For the evaluation of

FIGURE 1 (cont’d).



photographic views with minimal errors, all photo-graphs were taken in a similar fashion by 1 photogra-

pher 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 com-paring 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 neurosen-

sory deficit and intense pain, were assessed using aquestionnaire modified from the extensively tested

McGill Pain Inventory.11

Infection, parotid duct injury, and massive hema-

toma also were subjectively evaluated based on clin-

ical evaluations. This research was approved by the

local institutional review board and was in compliance

with the World Medical Association and the Declara-

tion of Helsinki as it relates to medical research proto-cols and ethics.

Statistical evaluation of the findings was performed

with SPSS 16.0 (SPSS, Inc, Chicago, IL). Parametric

tests were used to evaluate treatment efficacy and

complications. The significance level of statistical hy-

potheses was set at .05 (statistically significant).

RELEVANT ANATOMY

The BFP is an encapsulated mass of specialized fatty

tissue, the volume of which varies throughout a pa-tient’s lifetime (approximately 10 cm3). It is distinct

from subcutaneous fat. It fills in deep tissue spaces

and acts as a gliding pad when masticatory and

mimetic muscles contract. In addition, it cushions

important structures from the forces generated by

muscle contraction.5-7,12 It is attached by 6 ligaments

to the maxilla, posterior zygoma, inner and outer

rims of the infraorbital fissure, temporalis tendon,and buccinator membrane.5-7,12 The BFP has a body

and 4 processes. The body is located behind the

zygomatic arch. The body is divided into anterior,

intermediate, and posterior lobes in accordance with

FIGURE 2. Intraoperative views. A, Intraoperative measurement of malar projection. B to F, Intraoperative views of surgical technique. (Fig 2continued on next page.)



the structure of the lobar envelopes, ligaments, and

feeding vessels. The anterior lobe is located below

the zygoma and extends to the front of the

buccinator, maxilla, and deep space of the quadrate

muscle of the upper lip and zygomaticus major

muscle. The canine muscle originates from the

infraorbital foramen and passes through the medial

part of the anterior lobe (Fig 1).5-7,12 The parotidduct passes along the lateral surface or penetrates

through the posterior part of the body fat pad

before traversing the buccinator muscle and

entering the oral cavity (Fig 1C to F). The anterior

facial vein passes through the anteroinferior margin.

The anterior lobe also envelopes the infraorbital ves-

sels and nerve and together enter the infraorbital ca-

nal. The branches of the facial nerve are on the outer

surface of its capsule. The intermediate lobe is situ-

ated 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 inthe masticatory and adjacent spaces. It extends up

to the inferior orbital fissure, surrounds the tempora-

lis 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

FIGURE 2 (cont’d). (Fig 2 continued on next page.)



forms the buccal, pterygopalatine, and temporal pro-cesses.5-7,12

Four processes (buccal, pterygoid, superficial, and

deep temporal) extend from the body into the sur-

rounding spaces, such as the pterygomandibular

space and infratemporal fossa. The BFP flap is an axial

flap. The facial, transverse facial, and internal maxillary

arteries and their anastomosing branches enter the fat

to form a subcapsular vascular plexus.5-7,12

SURGICAL TECHNIQUE

The Bichat fat pad can be extracted by 3 ap-

proaches: 1) an incision of the buccal mucosal mem-

brane 1 cm below the opening of the parotid duct

(Matarasso method), 2) an incision behind the open-

ing of the parotid duct (Stuzin method), and 3) an inci-

sion of the superior gingivobuccal sulcus through the

superomedial wall of the buccal space, which is the

most common type.7 In the third approach (theauthors’ 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-

tion of zygomatic bone is performed. The Bichat fat isalmost always exposed to the extent of the vestibular

incision into the second molar area; if that does not

occur, a small incision in the periosteum and a blunt

dissection can be performed through the muscle,

and the Bichat fat pad can protrude through. The

capsular fascia, covering the Bichat fat pad, is main-

tained intact using blunt instruments, and the attached

fascial layer of the wall of the buccal space is dissectedoff the Bichat fat pad to avoid stretching the nerve

structures that cross the lateral wall of the buccal

space (Fig 1). The Bichat fat pad should be free and

easily movable for repositioning as a pedicle flap (Fig

2B to F). Vessels on the fascia of the Bichat fat pad usu-

ally can be observed.

In the next step, a 1-cm preorbital incision (Fig 2F) or

a transconjunctival incision is planned, a subcutaneousdissection is performed in the marked malar area with

scissors or cannulas, and the skin pocket is created. In

the most inferior portion of the pocket, with a cut to-

ward the bone, the skin pocket is connected to an in-

traoral incision. A 2-0 nylon suture is woven into the

Bichat fat pad (Fig 2F) with a needle, and the ends of

the suture are tunneled to the skin pocket (Fig 2F).

FIGURE 2 (cont’d). G, Schematic view of photographic analysis. For cheekbone area evaluations in profile views, 4 reference lines wereused: oral commissure to lateral cantus, alar to tragus, tangent line with infraorbital rim, and nasion–to the subnasal point. The first 3 lines deter-mine the ideal location for malar augmentation and are used before injection to mark the site of procedure and to aid the evaluations after sur-gery. Then, the most projected point of the cheekbone area in profile views is determined as a reference point. A perpendicular line is drawnfrom 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 profileviews. This amount will increase incrementally after resorption. Themeasurement of this differentiation could indicate that the amount of augmen-tation and resorption (from Keyhan et al10). AL, alar; MP, maximumprojected point; N, nasion;OC, oral commissure;OR, infra orbital rim; RLC,right lateral cantus; SN, subnasal; TR, tragus.



The repositioned pedicle flap is sutured to the sur-

rounding tissues. Intra- and extraoral incisions are su-

tured. 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 unilat-

eral 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.

Table 1. VARIABLE DESCRIPTIONS

Variables Maximum Minimum Average

Body mass index (kg/m2) 27.8 19.4 24.6

Time after trauma 3 yr (old) (n = 10) 10 days (recent) (n = 3) —

Amount of depression (mm) 5 3 3.9

Amount of augmentation (mm) 3 5.5 4.21

Age (yr) 24 57 39

Gender male (n = 8) female (n = 5)

Abbreviation: mm, millimeter.



Before surgery, theaverageamountofunder-projectionin affected sites was 3.9 mm (3 to 5 mm; P < .05). One

month after surgery, the average amount of augmentation

was 4.21 mm (3 to 5.5 mm; P < .05) compared with the

unaffected side, which had a value of 0.0 mm. One year

after surgery, the average amount of resorption was

0.376mm(0.0 to 0.6mm;P> .05) comparedwith theun-

affected side, which had a value of 0.0 mm.

Other major complications, such as prolongedbruising, massive hematoma, intense pain, asymmetry,

infection, or parotid duct injury, were not observed.

A mild hollowing lateral effect to the oral commissure

was observed in 1 patient (Fig 7). The total time of sur-

gery varied from 2 hours in the first case to 1 hour in

the last case. No significant difference was observed

in regard to gender or age. Edema was the most

frequent complication.

Discussion

The purpose of this study was to evaluate the BFP

flap technique for malar augmentation surgery. The au-

thors hypothesized that it would be effective becauseof 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 long-

term results and complications of the technique. Ac-

cording to the facial analysis and clinical evaluation,

the degree of augmentation was significant; there

was no massive resorption requiring a secondary pro-cedure. 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 subcutane-

ous 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 pa-

tient’s lifetime. The volume in adults ranges from 8.3 to

11.9 mL. The mean volume in men is 10.2 mL and

ranges from 7.8 to 1.2 mL, whereas the mean volumein women is 8.9 mL and ranges from 7.2 to 10.8 mL.7

The body and buccal extension make up the bulk

(50% to 70%) of the fat pad.13 The BFP was considered

a surgical nuisance for many years because it was com-

mon to accidentally encounter the pad during various

operations in the pterygomandibular area, such as for

tumor, or during orthognathic or trauma surgeries.

Many articles have reported the advantages of thistechnique for the reconstruction of small- to

medium-sized congenital or acquired soft tissue and

bony defects in the oral cavity.14-33 Defects up to 12

to 15 cm2 can be closed using a BFP alone without

compromising the blood supply. Rapidis et al22 stated

that in maxillary defects larger than 4 � 4 � 3 cm, the

possibility of partial dehiscence of the flap is high

because of the impaired vascularity of the stretchedends of the flap. In buccal or retromandibular defects

up to 7 � 5 � 2 cm, reconstruction can be accom-

plished because of the underlying rich vascular bed.

SURGICAL TECHNIQUE

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 per-

formed with endoscope devices that pass through

the temporal hairline incisions. With the present

more recent technique, 2 small incisions (intraoraland 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 tech-

nique 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 performedafter 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

FIGURE 3. Photographic views. A,B, Preoperative views. C,D, Postoperative views.



FIGURE 4. A, Preoperative and B, postoperative views



procedure, blunt dissection at the end point of the in-

ner 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 au-

thors’ suggestion is that surgeons use a transconjuncti-

val incision with or without lateral canthotomy, whichprovides good access with an invisible scar, because

scars can be an especially challenging problem for es-

thetics. In the present series of patients, a transcon-

junctival 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 fas-cia covering the Bichat fat pad is maintained intact

using blunt instruments, which avoids traction of

the nerve structures that cross the lateral wall of the

buccal space. However, injury to the distal end of

the facial nerve branches distal to the line drawn

from the lateral corner of the eye to the angle of the

mandible. Such injuries usually will be repaired by

cross innervation; it can be repaired by primary or sec-ondary microsurgery if indicated. The Bichat fat pad

should be free and easily movable for repositioning

as a pedicle flap, and insufficient dissection of the

flap results in stretching of the pedicle of the flap,

which can compromise blood supply and decrease

the volume of the flap, in addition to dislodging the

flap from the vascular pedicle. If this occurs, augmen-

tation should be continued using avulsed fat pad mate-rial as a free fat graft, and the patient is followed.

Revision surgery can be performed 3 to 6 months later

using other procedures, such as filler injection or free

fat grafting. Flap repositioning can be performed sim-

ply by using the hinge rotation of the flap around the

zygomatic buttress (consisting of the body and buccal

process of the BFP) at the center of rotation under the

zygomatic arch and near the temporal and pterygopa-latine processes of the fat pad.

FIGURE 5. Photographic views. A,B, Preoperative views. C,D, One-year postoperative views.



FIGURE6. A, Preoperative and B, postoperative views. A 29-year-old man underwent zigzag genioplasty, open rhinoplasty, malar and para-nasal prosthesis in combination with left buccal fat pad lifting (from Keyhan et al35).



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 averageamount 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.

Flap Fixation and Incision Closure

The repositioned pedicle flap is sutured to the sur-

rounding preorbital subcutaneous tissues. Superficial

preorbital dimpling may be observed. If this occurs,

it can be resolved with local massage.

Hollowing Effect

BFPextraction has been an acceptedmethod formanyyears to decrease buccal fullness, especially in obese pa-

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 canbe used to augment themalar area using 2mech-

anisms. In addition to the direct effect, it has an indirect

effect, which was discussed earlier. This augmentationcan be considered a useful effect, especially in obese

and normal-weight patients, although it can result in un-

desirable consequences in thin patientswho 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 sug-

gest that BFP lifting should not be performed in pa-

tients with a thin face, and it should be limited to

patients with sufficient subcutaneous buccal and no

presurgical hollowing (Fig 7C).

Indications

In the present series of patients, almost all BFP liftingprocedures were performed in patients with esthetic

FIGURE 7. Comparison of hollowing effect in A, fat, B, normal, and (Fig 7 continued on next page.)



complaints owing to trauma, although a combination of

rhinoplasty, zigzag genioplasty,34,35 bilateral malar and

paranasal augmentation, and unilateral BFP lifting

(left) after prosthetic augmentation in the left malar

area with rigid implants to improve left malar

projection in relation to opposite side was performed

(Fig 6). Based on their experience, the authors recom-

mend that BFP lifting should not be performed as anisolated procedure, but as an adjunct procedure in com-

bination with orthognathic surgery, malar or paranasal

alloplastic augmentation, panfacial fracture surgery,

dimple creation surgery,36 or in combination with con-

ventional or endoscopic midface lift procedures. In

such cases, BFP extraction should be performed after

finishing the other procedures, as was discussed earlier.

After extraction of the flap, it can be fixed to the adja-cent prosthesis or plated in subperiosteal fashion.

Use of the BFP lifting technique before facial lipo-

structure10,37 should be considered an alternative

technique to decrease the average amount of fat

resorption (authors’ hypothesis).

Time of Surgery

The time of the surgery is not a challenging prob-

lem in patients undergoing surgery for old zygomatic

fractures or esthetic reasons, but it should be consid-

ered 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 re-

positioning surgery are difficult to evaluate completely

and objectively. It is also difficult to evaluate theamount of fat augmentation and resorption without

performing pre- and postoperative magnetic reso-

nance 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 bird’s

eye views or submental views.

Currently, a precise quantitative method doesnot exist when using these views. The present evalu-

ation method is the only method that has been

reported in published articles that allows a quantita-

tive evaluation of such procedures. However, the

FIGURE 7 (cont’d). C, thin facial types. C, Note the hollowing effect (arrow).



present method is 2-dimensional and thus has some

limitations.

Use of the BFP for facial esthetic surgery was first

described by Chung et al.8 However, the literature lacks

data about the technique, indications, complications,

and long-term results.9,32 The authors’ recentexperience in this field has shown acceptable results.

This method can be used as an alternative option for

malar augmentation in patients undergoing surgery

for esthetic reasons or after trauma, especially for

severe comminuted zygomatic fractures, which may

be impossible to reduce precisely.

Although free fat grafts also can be used in this clin-

ical context, fat grafts have always represented a chal-lenge in inducing the necessary neoangiogenesis,

which results in significant resorption. As a result,

the authors believe that this new open access tech-

nique should be considered an alternative method

for the management of mild to moderate malar depres-

sion in patients undergoing surgery for esthetic rea-

sons and after trauma.

Acknowledgment

The authors offer special thanks to Ms Shahrzad Zojaji.

References

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