Hi, Your concern with adding back volume after buccal fat reduction/removal is the main reason, I don’t offer it in my practice. This doesn’t stop people from finding surgeons who will offer it for the promise of chiseled features, which can make a 21 year old look more mature maybe 25-28 with less volume on the lower cheeks which makes the cheekbones pop more. The buccal fat pad is different from the subcutaneous fat (fat directly under the skin.). Fat transfer/grafting is injected so each “pin-head sized” fat graft is injected into existing fat or tissue which will allow some of these fat grafts to gain a blood supply and ultimately survive. In general the yield of fat grafting, meaning how much of the fat actually survives is around 30% +/-. This means if the surgeon injects 10 cc of fat, only 3 cc of fat will survive. Or they can inject 33 cc of fat hoping that only 10 cc survives, but not more than that. Tricky situation. If you inject what looks good on the table, it will not be enough, if you anticipate and try to inject 3 times as much then the risk is maybe too much fat survives or the fat placement suffers because the face is too blown out with volume that the actual placement of the fat will not look good when it completely settled down. The buccal fat pocket is a space where a different type of spongy fat that can be “plucked” out of the space in the buccal fat removal procedure. This is a pocket which is not filled with fat. In the textbook for Facial Fat transfer, Dr. Sydney Coleman explains how he was able to get the fat to survive, by injecting the fat grafts into multiple tunnels in the subcutaneous fat so each “pinehead of fat” is surrounded by existing fat. He also diagrams when lumps form, too much fat is injected into a spot, but only the peripheral pieces of fat gain a blood supply while the central pieces of fat are not touching any live tissue since it is surrounded by other fat grafts which are getting in the way of the blood vessels reaching them. With time, the central part of the fat grafts die off and only the some of the outside fat grafts actually survive. If we inject the liposuctioned fat into the buccal fat pocket, the chances of the fat surviving is low, since it is an empty space and there may be bits of the residual buccal fat in the space, but the fat grafts are most likely not being injected into the remaining fat, but into the space itself, which doesn’t have tissue or blood vessels. By logic, this fat will not survive. Another option would be to inject the fat grafts into the subcutaneous skin where the buccal hollow now exists and try to make the skin thicker by having the subcutaneous fat injected with fat grafts. This can also be accomplished with Sculptra to build some volume in the submalar area. However, this type of volumization is to really attempting to reverse the volume loss in the surgically reduced area. So what can be done. Currently, the only logical option that I use in my practice is to use hyaluronic acid (HA) based fillers (Restylane/Juvederm Brands). The “loop hole” for this type of deeper pocket filling is that the filler in the buccal fat pocket does not dissolve the same way as intradermal injections which is how these fillers were originally designed. The original Restylane was supposed to only last 4-6 months. Original Juvederm only lasts “up to a year.” We now know that these fillers can last much longer than what the manufacturer can market, depending on the locations/depths that the filler was injected. While waiting for a better technological solution, the buccal fat hollow can be refilled using HA using WYSIWYG (What you see is what you get) and not overfill. The yield of the HA filler is 1 to 1, so if you inject 1 cc you will see 1 cc and there is no need to over inject. Since it is off the shelf, I recommend that my patients “under fill” and let the swelling guide them to see if they really want more syringes, this way they don’t have to pay for more syringes than they really want or need. Since it is off the shelf, a second session is not different than going to the doctor to get a routine botox injection as opposed to getting another surgical fat grafting session a second or third time. One example of how long it lasted, one patient who received 1.5 cc of HA filler per buccal hollow in 2015 had the filler last very long. In fact during the 2020 COVID lockdown, she gained some weight and wanted to see if her buccal fat area could be reduced a bit, since she felt “cheeky.” Some hyaluronidase was used to inject into the buccal fat space and the filler was reduced cautiously over 3 sessions to her satisfaction. I pointed out that if she does lose weight again, she may then want the filler back in, so I was hesitant to dissolve, but she did not want to wait. Since she understood the risk and would cross that bridge in the future, we proceeded. Lastly, you should know, if the same situation occurred with the fat transfer, meaning if int 2015, I fat grafted the patient to her satisfaction, if she did gain weight, the final result of fat grafts (2-3 sessions?) would also grow along with her existing facial fat. For my patient her HA filler did not grow, it stayed the same, but the fat around the HA did grow, and she actually wanted to reduce the buccal fat a touch. Just some food for thought. Hope this response provided some value to you. Good Luck. Best, Dr. Yang
