Bichectomy, or Bichat fat pad removal, is a surgical procedure
indicated when there is excess volume on the middle third of the
face (bellow the cheekbones / zygoma) giving it a chubby or round
look. The ideal candidates are men and women who wish to achieve
a slimmer face appearance in this area, and it is also recommended
for patients with chronic cheek biting. Extra-oral photographs are
part of the preoperative clinical assessment and will be compared
with photographs taken postoperative (immediately after the
procedure, after 15 days, 45 days and the final evaluation after 4
months), when the facial contour and volume reduction will be
monitored.
Another important part of the preoperative clinical assessment
is managing the patient expectations in regards to the irreversibility
of the procedure and its final results. Bichat fat pad removal is a
procedure best indicated on round, oval and square face shapes.
Two structures must be evaluated before the procedure: the size
of the zygomatic bone - if too small, a filler might be required
a few months after the bichectomy; and the masseter muscle –
hypertrophied masseter muscles become more evident after the fat
pad removal. Bichat fat pads were first described in 1902 by Marie
François Xavier Bichat, a French Anatomist and Biologist, as an
encapsulated mass of fat in the cheek, located below the zygomatic
bone and above the jawline, with several extensions. On average,
3 to 4 ml of fat is removed during the procedure, with a maximum
volume of 6ml. The buccal fat pad is the largest pad of the group,
containing 40% of its total volume.
Bichat fat pad’s primary function is mechanical. Due to its
location, between the buccinator muscle and the masseter, it
facilitates chewing and suckling in infants. The fat pads are
made of residual fat, which explains why patients, even showing
ideal weight, give the false impression of being overweight, with
excessive face roundness. This condition causes dissatisfaction in
men and women, many of them having suffered from bullying and
low self-esteem, affecting their mental state and happiness. I don’t
believe that having a thinner lower third of the face is a ‘passing
fad’. After all, there has never been a hero or beauty symbol, male or female, with a round face. The best example is Nefertiti, the
Egyptian queen, that is still considered a beauty symbol with her
defined and prominent jaw line.
Also in my opinion, the removal of Bichat fat pads do not
contribute to ageing or future skin slack around the area. These are
the result of the normal ageing process, due to the loss of collagen
and elastin and the shifting of fat tissues under the skin that are
inevitable with age. This procedure changes the contour of the face
with a decrease in bulk, resulting in less weight for the tissues to
support, and, therefore, less sagging. A thorough extra and intraoral
evaluation is important prior to the procedure; any point of dental
or gum infection must be treated before to any intraoral surgery. The
procedure is done under local intraoral anesthesia. The incision,
with scalpel blades or laser beam, measuring between 1 and 1.5
cm between the vestibular fold, starting from the cusp of the third
or second superior molar and in the direction of the opening of the
parotid duct, cuts through the following order: the jugal mucosa,
the buccinator muscle, and the thin capsule of the buccal fat pad.
After delicately divulsing the tissues, the fat pad is carefully
pull out into the oral cavity and scised with the help of specialized
pliers, taking the precaution of not damaging the pad fascia so
it is possible to remove the pad in one single piece. The fat pad
capsule is not removed. The mucosa is sutured. Immediately
after the procedure, therapeutic laser is applied, followed by
cryotherapy and compression band to minimize the risk of edema.
Pain medication can be prescribed, as well as corticosteroids and
antibiotics. Important structures located around the incision, and
that are avoided with proper technique: parotid gland ducts, facial
vein, facial artery and facial nerves. Most common complications
are: bleeding, edema, ecchymosis, hematoma, subcutaneous
emphysema and infections. This procedure is marked by edema;
therefore we should use all management tools available to control
its occurrence.
Good results can be noticed within 15 days of the procedure;
great results within 45 days; and the final result can effectively
be seen after 4 months, when the facial volume reduction can be
observed through photos.
Removing the buccal fat pad will re-accommodate the masseter
and buccinators muscles, increasing friction, specially on patients
suffering from bruxism, however, a prescription of muscle relaxers
on the first days postop are enough to control trismus. In general,
very few complaints are reported. Medical studies are still
establishing medium and long-term results for this procedure on
patients that removed Bichat fat pads when young, but results so
far are promising. Tissue accommodation and cicatrization don’t
affect the connecting tissues, maintaining all functionality and
longevity to the treatment.
The following changes can be observed after a bichectomy:
reduced depth of nasolabial fold, appearance of fuller lips,
noticeable shadow line under the cheek (blush effect) more
defined cheekbone, better teeth exposure when smiling, eyes more
prominent when smiling, jaw line more defined, reduced cheek
volume.
Ideal patients for this procedure are satisfied with its final
outcome, they are happier, more confident, feeling sexier and with
higher self esteem. Therefore it is not only a procedure that brings
physical results, but also psychological ones. A well-defined jaw line
is often considered a sign of sensuality and power, characteristics
that are praised nowadays.
ISSN: 2574 -1241
