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Antunes et al. Plast Aesthet Res 2018;5:11 I http://dx.doi.org/10.20517/2347-9264.2018.03 Page 7 of 9

Each imaging exam has a contribution to make in the study of the anatomy of the ABC, and should be
requested after the clinical exam according to the diagnostic hypothesis. CT is more accurate for hard
tissues analysis, while USG and MRI provide more detail for soft tissues. Due to a greater detailing
provided by images, CT and MRI can be useful for the study of face volumetric alterations that occur with
[5]
aging and the identification of pathologies in the hard or soft tissues of the maxillofacial region, such as
masseter hypertrophy and condylar hyperplasias, as was suspected in the first and second reported cases,
respectively.

[10]
Jugal lipectomy also presents applications other than those described in the three clinical cases .
[11]
Bansal et al. (2015) evaluated the viability of ABC as interposition material after arthroplasty
and concluded that the volume of 1.1 mL of fat is efficient and stable as a barrier for preventing
temporomandibular ankylosis. Recently, the literature discusses the ability of ABC to be an important
source of mesenchymal stem cells, promising to produce bone tissue, muscle, cartilage, and fat. However,
such information is not yet accurate and further studies are needed [12,13] .

Correction of oral defects, including closure of buccosinusal fistulae with ABC pedicled graft, is the
[14]
most common indication found in the literature for jugal lipectomy . The success of this grafting can
be attributed to the rich vascularization of adipose tissue, an important condition for the long healing
[15]
period . However, even when a non-pedicled graft was used, as reported in the third clinical case, there
was excellent tissue stability, and local vascularization was also provided by the palatal flap. Satisfactory
results were also found in free grafts for treatment of patients with cleft lip and palate in the anterior region
[16]
of maxilla .
Three surgical accesses for jugal lipectomy are described in the literature: (1) 1 cm below the opening of
parotid duct (Matarasso method), (2) behind the parotid papilla (Stuzin method), and (3) incision superior
[17]
to the gingivobuccal sulcus . In the first and second reported cases, the Matarasso method was used to
provide wide and direct access to the buccal space, allowing the removal of a larger volume of ABC and
its buccal extension, directly related to the contour of the cheek. In the third clinical case, jugal lipectomy
did not present an aesthetic indication. Therefore, the gingivobuccal access was chosen since the aesthetic
repercussion is almost insignificant. Upon performing an intraoral approach carefully to not pull the
ABC and resecting only that which easily protrudes with gentle pressure, complications of excision for
lipodystrophy or a pseudo herniated buccal fat pad are rare. The most likely complication would be over
resection.

[18]
Although complications are infrequent , lesions in the parotid gland, vascular plexus (branches of facial
artery, maxillary artery, and transverse artery of the face), and the buccal branch of facial nerve may
[19]
occur . While the parotid duct presents a more lateral path in relation to the ABC, the vessels and buccal
[20]
branches have a more superficial path and can go through the ABC extension . Lesions of these structures
can cause dry mouth sensation, the formation of large bruises, and even facial paralysis. Treatments
include surgical repair of the duct, drainage of bruises and linking of blood vessels, anastomosis or
grafting of neural tissue, and may be associated with laser therapy and corticosteroids. There were no
hospitalizations, accidents, or complications in the three cases presented, and the procedure was performed
at the dental office under local anesthesia. Superselective microcatheter angiography and embolization has
been shown to be an effective modality for prompt treatment of bleeding from traumatic facial injury and
[21]
refractory epistaxis when local methods fail to achieve hemostasis . Trismus, infection, asymmetries, or
cheek depressions may also occur, resulting from inadequate and lopsided removal of adipose tissue.

Despite these complications, it is important to highlight that jugal lipectomy is a simple technique with
few variations, fast execution, and low morbidity. It is essential to know the ABC anatomy of each patient
through clinical examination and complementary imaging exams.