The Fat of Bichat as Additional Source for Head and Face Fat Transfer Procedures

For a number of important reasons, surgeons throughout the world occasionally find themselves short of autologous donor fat (ie, usually limited to what can be obtained from submental liposuction) when performing autologous fat transfer procedures on the face. For example, in some countries, such as my nation of origin, Brazil, facial cosmetic surgeons and/or maxillofacial surgeons are not allowed to obtain donor fat from below the hyoid bone.¹ Perhaps it is not legal restrictions, but rather that less donor fat is found intraoperatively than planned or consented for preoperatively. These procedures may include autologous fat/stem cell transfer to the lips, autologous fat transfer to the tear trough defect, autologous fat transfer to the temporal region, autologous fat transfer to the face, autologous fat transfer to the lower orbit/lower eyelid area, autologous fat transfer to the geniomandibular groove, autologous fat transfer to the nasolabial area, etc.² Autologous fat transfer in the face is increasingly used also for reconstructive purposes, such as for facial atrophy in HIV patients, in the reconstruction of the congenital craniofacial deformities, and in the facial reconstruction of surgical facial deformities status postvascular anomaly surgery.^3–5 In my long and busy practice, I have found an additional ample source of robust and high-quality autologous fat, suitable for transfer: the fat of Bichat.

After 22 years of practicing as a plastic and reconstructive surgeon in Miami, Orlando, and Beverly Hills, I have discovered that Einstein was correct: the best ideas are the simple ones (ie, E = MC²). The dissection and harvest of the fat of Bichat is very simple and reliable. The gingivobuccal space is injected with 5 cc lidocaine and epinephrine, approximately between the first and second upper molar. A 0.5- to 1-cm incision is made, preserving a cuff of mucosa for later simpler closure. This incision is made cranial to Stensen’s duct/orifice, with being careful to protect this structure. After a sharp mucosal incision, a blunt dissection with hemostats is carried through the buccinator muscle. Gentle external pressure on the cheek, at the level of the buccal fat pad, easily produces the egg-like fat of Bichat. A small incision on the very thin septum/fascia produces a very cohesive and robust fat (Fig. 1).⁶ The incision, which bleeds very little in my experience, is simply irrigated with saline/betadine solution and left open. It heals asymptomatically and quite rapidly. Surprisingly, approximately 25 cc of high-quality fat can be harvested from each side of the face. Again, returning to my career-long success with simplicity, I do not process this fat in any way at all (eg, imagine if I centrifuged you at 2000 rpms, there would be nothing left of you). I do not believe centrifuging makes physiologic sense. In fact, I believe it is traumatic to adipocytes and stem cells. Furthermore, I leave this tissue outside the body for the least amount of time possible. My fat graft survival rates have, consequently, been far superior than those recorded in the literature. Drawing from a previous life as a chemist, I believe processing this autologous fat with even harmless sounding saline, is too caustic to the cells. Why else would saline be recognized as bactericidal and bacteriostatic? Salt kills some types of life by effectively sucking water out of them. Therefore, I transfer the autologous fat/stem cells to the target facial area, unprocessed as fast as possible. The only rapid manipulation of the fat that I perform is a “back and forth,” between 2 Monoject 60cc Toomey type syringes (The Kendall Company, Mass.) separated by sterile suction tubing of approximately 8 cm length (the fat passes between the 2 syringes approximately 10 times). This makes this wonderfully robust fat easily transferrable by a simple 2.4-mm Tulip Gold Standard Facial Set Cannula (Tulip Medical Products, San Diego, Calif.). As plastic surgeons, we recognize different parts of the body as having “superior quality” fat for transfer. In my clinical experience, the fat of Bichat is superior to the fat harvested from the flanks or lower abdomen, qualitatively more dense, possessing more structural strength, and less “watery.” With the high resorption rates of autologous fat transfer to the face and lips found in the literature,⁷ I have been pleasantly surprised how the high quality of the fat of Bichat has yielded firmer and lower resorption results in my hands. In this era of fuller lips,⁸ a refreshing bit of news is that there is a new source of plentiful, reliable, robust, and near-by autologous fat for transfer to the face, namely the fat of Bichat (Fig. 2).

Fig. 1.

The technically simple harvest of the fat of Bichat.

Fig. 2.

The fat of Bichat is a high quality of fat in the body. It beautifies with a fat which is mechanically robust, long-lasting, and is located near the site to be injected.