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Dr Bitik1 claims that transposition of the buccal fat pad increases inframalar volume in facelift patients, creating an “implant-like effect.” 1 Although the abstract indicates 22 patients, only 9 nonconsecutive patients were included in the study because the other patients had simultaneous facial fat grafting or implants. Two patients had postoperative magnetic resonance imaging (MRI) studies. It would have been interesting to see preoperative images for comparison. T1-weighted MRI images are a useful way to quantitate maintenance of fat volume.2

The anatomy of the buccal fat pad has been well described by Stuzin et al.3 Its total volume is typically less than 10 cc and is composed of a superficial body component and a buccal extension (which affect cheek contour) plus deeply situated temporal and pterygoid extensions.3 The buccal extension accounts for 30% to 40% of the total. When resected through an intraoral approach, this fat globule typically weighs less than 5 g.3 Dissection at the time of a facelift places the fine facial nerve branches anterior to the masseter at risk.1,3 Sutures compress the fat and apply traction. Large 2-0 sutures may cause cheese wiring and fragmentation of this delicate structure.1 Postoperative atrophy from strangulation can be a problem,1 making such efforts counterproductive to volume maintenance. In a superficial-musculo-aponeurotic-system facelift, tension is applied to this dense fascial layer, flattening any transposed subfascial fat.2 All fat transposition methods essentially “borrow from Peter to pay Paul.” 2

Issue Section:
Letters to the Editor
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