Lower facial fullness

Our face is part of our identity and bears the marks of our life history. The lower face is a visible determinant of an individual’s perceived age. The youthful lower face is characterized by an indistinct transition from the midface, well-defined lower jaw border, smooth facial skin devoid of redundant wrinkles and folds, and proportionate upper and lower lips and chin.
 The attractive face is one in which the cheekbones are the widest part of the face, which taper smoothly into the chin. Lower facial rejuvenation is an important complement to midface rejuvenation and brings harmony to the aesthetic outcome. It restores the individual’s body image and self-confidence and improves social functioning.

How Does It Manifest?

Lower facial fullness may manifest as excess cheek or lower jaw volume. Disproportionately full cheeks impart the image of apparent obesity. Excess lower jaw volume causes squaring of the lower face and loss of the usual tapered contour that occurs from the cheeks to the chin, and loss of the normally well-defined lower jaw borders. This appearance is masculinizing and runs contrary to the ideal aesthetic of an Oriental face. Both conditions tend to manifest in individuals in their teens to thirties.


How does it arise?

There are two causes of lower facial fullness: excess cheek fat and overgrowth of the masseter (chewing) muscle. Excess fat in the buccal fat compartment is developmental (“born with it”). Enlarged masseters often occur in Orientals due to a genetic predisposition or as a result of teeth grinding when asleep, a condition known as bruxism.



How are men and women different?

In females, it is often aesthetically pleasing to have a gradual tapering of the facial width towards the chin, giving the appearance of a V-shaped face. In males, the chin is often broader and a U-shaped face is often considered desirable.


Attaining an elegant and bespoke result is frequently possible and requires a combination of accurate assessment, precise technical execution and an experienced practitioner. Cases of excess buccal fat respond well to buccal fat excision; cases of enlarged masseter muscles are treated with botulinum toxin injection.

Both treatments are effective and attain high satisfaction rates. Successful outcomes help to improve body image, self-esteem and social functioning.

Buccal fat excision

Buccal fat excision removes the excess cheek fat and slims the lower face to create pleasing facial proportions. It utilizes an intraoral incision (inside the oral cavity) and has no external scars. It is performed as an ambulatory procedure performed under local anesthesia.

Young individuals with excess buccal fat volume and without skin laxity benefit most from this surgery. These are typically individuals in their twenties and early thirties. In individuals who are in their late thirties and beyond, this procedure needs to be carefully tailored as excessive reduction of facial fat volume may result in a more aged appearance.

Buccal fat excision is an effective and long-lasting method of reduction of excess cheek fat. It reduces the lower facial bulge and recreates a smooth, tapered contour joining the midface and the lower face and improves the overall aesthetic appearance. It reduces the perception of the facial appearance of an overweight person. The incisions are performed inside the oral cavity and there are no external scars.

Local anesthesia is infused into the surgical site for optimal intra- and post- operative analgesia. A 2 to 3 cm incision is performed inside the mouth and the fat compartment is exposed. The fat is gently mobilized and removed. There are critical nerves that run alongside this fat pad and careful technique is required to avoid injury to these nerves. The optimal amount of fat to be removed is a fine art and strikes a delicate balance between removing sufficient fat for optimal result whilst avoiding excessive removal that may lead to hollowing and an aged appearance.

Individuals are advised to stop herbal supplements and traditional medicine 7 days prior to surgery to minimize bruising and swelling.

Many individuals are able to return to work on the day after the surgery. Mild bruising and swelling is expected after surgery, and most of it will resolve by the 5th postoperative day. The stitches do not need to be removed, as they are self-dissolving.

Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed with extra pillows when asleep at night. Bruising may be minimized by avoidance of strenuous activity for the first 2 weeks.


Botulinum toxin injection

Overgrowth of the masseter (chewing) muscles is a common cause of lower facial fullness especially in Orientals and in individuals with bruxism (involuntary teeth grinding when asleep). Botulinum toxin injection is a safe and effective treatment and attains a high degree of satisfaction in most cases. 

Individuals with bulky masseter muscles and minimal skin laxity respond best to botulinum toxin injection.

Botulinum toxin causes partial weakening and shrinkage of the masseter muscles. Treatment is tailored to the individual and is determined by the degree of the muscle bulk and gender. Females generally desire a greater degree of reduction and require higher doses of botulinum toxin. Injection of the masseter muscle is a delicate procedure and strikes a balance between achieving effective and aesthetic muscle reduction whilst avoiding unintended paralysis to the adjacent smile muscles. Individuals with bruxism are co-managed with partnering dental colleagues. They often require the use of teeth guards at night to prevent premature wearing down of their teeth.

Individuals are advised to avoid vigorous massage to the treatment area for 2 hours following the injection. This is to prevent spread of the botulinum toxin, which may result in potential unintended smile muscle paralysis. Individuals may resume their usual activities immediately following the procedure.

An incision is usually made behind the hairline, and the forehead skin and muscle is elevated from the underlying forehead bone. The eyebrows are fixed in the correct position, and the excess skin and muscle removed. Skin closure is also performed in a meticulous manner to optimize wound healing and camouflage its final appearance.