Studies and reports have been written on the role of

José Guerrerosantos, MD Dr. Guerrerosantos, Guadalajara, Mexico, is Chairman and Professor, Graduate School of the University Center of Health Sciences, University of Guadalajara; and a member of the Mexican ssociation of Plastic, esthetic and Reconstructive Surgery. The author contends that to obtain the best contour in the cheek, mandibular border, and upper neck in older patients, it is advantageous to extirpate one or two portions of oral mucosa in addition to removing the buccal fat pad. These combined procedures will effectively lift the sagging oral soft tissues. (esthetic Surg J 2007;27:329 335) Studies and reports have been written on the role of flaccidity and excess oral mucosa combined with hypertrophy and buccal fat pad ptosis in the development of facial bulk in the inferior lateral area of the face at the level of, and below, the mandibular border. Likewise, surgical techniques have been reported on correction of the jowl. However, some surgeons do not address the issue of facial bulk in primary rhytidoplasty and, frequently, jowling may persist after a face lift. Removal of the buccal fat pad to improve contour of the cheeks, mandibular border, and neck has been reported in multiple articles. 1-8 Some surgeons, when combining extirpation of the buccal fat pad and rhytidoplasty, prefer to remove the buccal fat pad through a cheek incision in the SMS near the buccinator muscle after the cheek flap has been undermined. Other surgeons prefer intraoral removal through an incision in the oral mucosa. I am convinced that to obtain the best contour in the cheek, mandibular border, and upper neck in older patients, it is advantageous to extirpate one or two portions of oral mucosa at the same time as buccal fat pad removal. 9 Here, I will present surgical techniques that I have used successfully for the past 27 years in primary and secondary rhytidoplasty to correct the jowl and avoid its recurrence. Surgical Technique uccal fat removal can be performed alone or in combination with rhytidoplasty. If the procedures are performed simultaneously, perform the intraoral procedure after the rhytidoplasty has been completed to prevent infection from oral contamination. First, locate the parotid duct papilla protruding from the mucosa of the cheek, facing the maxillary second molar. Using brightly colored ink, mark the circular edges of the parotid duct papilla. Then draw two semicircles on the oral mucosa, ranging from 3 to 7 2 cm, around the parotid duct papilla (Figure 1). The measurements of the semicircles will vary, depending on the deformity of the jowl. efore surgery, evaluate the amount of oral mucosa to be. nesthesia may be local or general; I prefer combining local infiltration with intravenous sedation. Perform the incisions after infiltrating the local anesthetic, anesthetizing external areas of the upper and lower lips so you can move them easily, and have a clear view of the operating field inside the patient s open mouth. Ten minutes after infiltration of the oral mucosa, with the epinephrine acting as a vasopressor, excise both semicircles of oral mucosa, including some buccal glands and fibers of the buccinator muscle, which may be hypertrophic. With a hypertrophic buccinator muscle, the buccal fat pad herniates into the oral cavity through the upper semicircle; you can then remove it by gentle maneuvers (Figure 2). Usually, I extirpate two thirds of the buccal fat pad, taking great care to control the amount of excision. I use magnification as an aid in extirpating the oral mucosa, buccal fat pad, and some buccinator muscle fibers to prevent damaging branches of the buccal nerve that have motor action. I use electrocoagulation to achieve hemostasis. fter visualizing the ligament of the buccal fat pad that is attached to the subcutaneous layer of the mandibular border, apply a plication, taking a bite in the ligament and another bite in the buccinator muscle, which is located in the upper part of the semicircle (Figure 3). When you make the knot to tie the, raise the subcutaneous layer of the mandibular border. 4 Consequently, this raises the jowl. fter checking for hemostasis, close the wounds on each side, using 4-0 absorbable interrupted s. To achieve the best aesthetic result when the jowl is very bulky, suction the subcutaneous fat layer of the mandibular border and upper neck, using an extraoral esthetic Surgery Journal ~ May/June 2007 329

Figure 1. One or two portions of oral mucosa are marked for removal. (Illustrations by drian Lay, Guadalajara, Jalisco, Mexico). uccal fat pad Upper oral mucosa Lower oral mucosa Figure 2.,, fter infiltrating the oral mucosa with local anesthetic with vasopressor, portions of the oral mucosa and the appropriate amount of buccal fat pad are. Upper oral wound d Paratid duct patilla Lower oral wound d Figure 3., Removal of the buccal fat pad., fter careful hemostasis, the intraoral is executed. 330 esthetic Surgery Journal ~ May/June 2007 Volume 27, Number 3

C uccal fat pad Upper oral mucosa to be Parotid duct patilla Lower oral mucosa to be D Intraoral Rein plication Medial corset E F Figure 4., C, Preoperative views of a 55-year-old woman with a senile face and neck, remarkably chubby cheeks, hypertrophy of the buccal fat pads, and flaccidity and excess of the oral mucosa., D, Postoperative views 2 years after a primary face and neck lift with supra SMS and platysma plication, neck lipoplasty, and intraoral meloplasty. Two semicircle segments were, each 6 2 cm; this included bilateral removal of the buccal fat pad. Ligaments of the remaining buccal fat pad were lifted and d at the superior border of the buccinator muscle. The patient demonstrates a favorable aesthetic result with great improvement in cheek contour. E, Illustrates surgical planning to remove two pieces of oral mucosa and buccal fat pad. F, Intraoral and plication s of the neck. esthetic Surgery Journal ~ May/June 2007 331

C uccal fat pad Upper oral mucosato be Parotid duct patilla Lower oral mucosa to be D Intraoral Rein plication Medial corset E F G Figure 5., C, Preoperative views of a 54-year-old woman with remarkable adiposity in the face and neck, facial and cervical flaccidity, noticeably chubby cheeks, extreme excess and flaccidity of the oral mucosa, and hypertrophy of the buccal fat pad., D, Postoperative views 1 year after face and neck lift with plication and imbrication of the SMS and platysma muscle, forehead lift, blepharoplasty, rein plication, corset plication in the neck, cervical lipoplasty, and intraoral meloplasty. The patient demonstrates aesthetic improvement with dramatic slenderness of the cheek and neck and lifting and correction of the jowl deformity. Cervical lipoplasty resulted in marked cervical contour improvement. E, F, G, Two wide horizontal semicircles, each 7 2.5 cm, of oral mucosa around the parotid duct papilla were. Simultaneously, the buccal fat pad, which showed a remarkable hypertrophy, was also. 332 esthetic Surgery Journal ~ May/June 2007 Volume 27, Number 3

C Intraoral D Chin implant SMS-platsyma plication Intraoral Rein plication E Chin implant Medial corset Corset medial F Figure 6., C, Preoperative views of a 55-year-old woman who had challenging aesthetic problems when she first underwent primary rhytidoplasty some years ago. fter primary rhytidoplasty, she presented with neck flaccidity, protruded buccal and jowl areas, and ptotic chin., D, Postoperative views 1.5 years after a secondary procedure. E, F, The patient underwent face and neck lift with plication suspension s, cervical lipoplasty, correction of the ptotic chin, and partial extirpation of the buccal fat pad and two pieces of oral mucosa. esthetic Surgery Journal ~ May/June 2007 333

Figure 7. Specimen of cadaver shows buccal fat pad at the right, subcutaneous fat layer at left, and the ligament (arrow) between both tissues. approach. t the end of the operation, place a compressive and occlusive dressing over the cheeks to reduce bleeding. The dressing also diminishes local postoperative pain and provides an agreeable sensation of comfort and security. Discussion Plastic surgeons have demonstrated interest in the surgical treatment of cervicofacial deformities caused by senility, describing their treatment of cutaneous skin and fat tissues, muscles, fascia, and bone. 10-15,17-20 In 1997, Manjarrez and I reported on an alternative method for rejuvenating and recontouring the cheek and jowl, involving removal and lifting of the oral mucosa. 4 efore using intraoral meloplasty with simultaneous resection of the oral mucosa and buccal fat pad, we only the buccal fat pad in some patients. lthough we reduced cheek volume with buccal fat pad removal, we could not rejuvenate and raise the cheeks or jowl. It is important to consider the anatomic relationship of the buccal fat pad to the subcutaneous fat of the lower cheek and jowl. These areas are united by the buccal fat pad ligament described by Guerrerosantos and Manjarrez and Cortes, in 1989 4 and by Stuzin et al 5 in 1992 who refer to these as the masseter ligaments (Figure 7). In the senile cheek or protruded oral mucosa, these structures push out the buccal fat pad, which in turn pushes out the subcutaneous fat layer of the lower cheek and jowl, forming an undesirable bulkiness. 334 esthetic Surgery Journal ~ May/June 2007 Volume 27, Number 3

I began to think about removing oral mucosa when I observed (at presurgical evaluations) the improved contour and cheek appearance in some patients when I asked them to compress the oral tissues within their teeth. y removing the oral mucosa and buccal fat pad simultaneously, this pressure is released, and the bulkiness disappears from the cheek and jowl, aesthetically improving the cheek and mandibular border. Freeman 20 reported that patients with unilateral facial paralysis have recurrent buccal infection and necrosis after chronic mucosal biting. He suggested excising the redundant, hypertrophic, and frequently edematous oral mucosa in a spindle and leaf shape to correct mucosal and buccinator muscle sagging. This procedure, used for reconstructive surgery, has the same purpose as the intraoral meloplasty: lifting of sagging oral soft tissues. Conclusion Removal of excess and flaccid oral mucosa can be performed alone or in combination with buccal fat pad removal and rhytidoplasty. These combined procedures provide an excellent opportunity for rejuvenating, recontouring, making the cheeks thinner, and lifting the jowl. I have treated 123 patients with this procedure, including 77 older patients and 36 younger patients (Figures 4 to 6). In young people with chubby cheeks, I remove the buccal fat pad only; it is not necessary to remove the oral mucosa because it is not flaccid. References 1. Epstein LI. uccal lipectomy. nn Plast Surg 1980;5:123-130. 2. Ortiz-Monasterio F, Olmedo. Excision of the buccal fat pad, refine the obese mid face. In: Grandinger G, Kaye, editors. Symposium of problems and complications of facial surgery. St. Louis: Mosby; 1983. p. 126. 3. Ortiz-Monasterio F. Obese cheeks. In: Stark R, editor. Plastic surgery of the head and neck. Vol 2. New York: Churchill Livingstone; 1987. p. 907. 4. Guerrerosantos J, Manjarrez Cortes. Cheek and neck sculpturing: simultaneous buccal fat pad removal and subcutaneous cheek and neck lipoplasty. Clin Plast Surg 1989;16:343 353. 5. Stuzin JM, aker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441 449. 6. Matarasso. Pseudoherniation of the buccal fat pad: a new clinical syndrome. Plast Reconst Surg 1997;100:723 730. 7. Jackson IT. uccal fat pad removal. esthetic Surg J 2003;23; 484 485. 8. Matarasso. Managing the buccal fat pad. esthetic Surg J 2006;26:330 336. 9. Guerrerosantos J. Pseudoherniation of the buccal fat pad: a new clinical syndrome. Plast Reconstr Surg 1997;100:731 736. 10. Johnson J, Hadley RC. The aging face. In: Converse JM, editor. Reconstructive plastic surgery. Philadelphia: W Saunders; 1964. p. 1328 1329. 11. Gonzalez-Ulloa M, Simoni F, Stevens F. The anatomy of the aging face. In: Hueston JT, editor. Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery. Sydney: utterworth; 1971. p.1959. 12. ufricht G. Surgery of excess skin of the face. In: Transactions of the Second International Congress of Plastic Surgeons. Edinburgh: Livingstone; 1960. 13. Pangman WJ, Wallace RM. Cosmetic surgery of the face and neck. Plast Reconstr Surg 1961;27:544 550. 14. Millard DR, Garst WP, eck RL. Submental and submandibular lipectomy in conjunction with a facelift in the male or female. Plast Reconstr Surg 1972;49:385 391. 15. Guerrerosantos J. Ritidoplastia cervicofacial. Rev Lat m Cir Plast 1972;14:31 37. 16. Guerrerosantos J, Morales F, Spaillat L. Muscular lift in cervical rhytidoplasty. Plast Reconstr Surg 1974;54:127 131. 17. Mitz V, Peyronien M. The superficial musculoaponeurotic system (SMS) in the parotid and cheek area. Plast Reconstr Surg 1976:58:80 88. 18. Connell F. Contouring the neck in rhytidectomy by lipectomy and a muscle sling. Plast Reconstr Surg 1978;61:376 383. 19. Guerrerosantos J. Surgical correction of the fatty fallen neck. nn Plast Surg 1979;2:389 396. 20. Freeman S. Late reconstruction of the lax oral sphincter in facial paralysis. Plast Reconstr Surg 1973;51:144 148. Reprint requests: José Guerrerosantos, MD, Garibalde 1793, Guadalajara, Jalisco 44680 Mexico. Copyright 2007 by The merican Society for esthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2007.04.011 esthetic Surgery Journal ~ May/June 2007 335