Buccal Fat Removal (Bichectomy / Cheek Slimming)

1. What Is Buccal Fat Removal (Bichectomy)?

Bichectomy is a surgical procedure that partially removes the so-called “Bichat fat pads” in the cheek area in order to:

• Make the midface appear slimmer,
• Increase the shadowing between the cheekbones and jawline,
• Give the lower face and cheek area a slimmer, more contoured, V-shaped appearance.

The procedure:

• Is performed entirely from inside the mouth,
• Leaves no external skin incision or visible stitches,
• Produces results gradually over time; an instant, sharply defined change should not be expected.

2. In Which Situations Is Bichectomy Preferred?

Bichectomy is generally considered in patients who:

• Have an overall proportionate body but a fuller, more childlike or round face,
• Have cheeks that look “always puffy” in the mid-cheek region,
• Wish to highlight the cheekbones and jawline,
• Want a more permanent reduction of cheek fullness that they currently try to camouflage with contour make-up or fillers,
• Accumulate more volume in the lower face, giving a heavier look from top to bottom due to prominent buccal fat pads.

Bichectomy is not a solution for general weight problems; it specifically targets structurally prominent fat pads in the mid-lower cheek area.

3. Who Is a Suitable Candidate for Bichectomy?

Suitable candidates:

• Are in general good health for surgery,
• Want their face to look “slimmer and more sculpted”,
• Are aesthetically bothered by fullness in the cheek area,
• Have relatively stable weight, with no plans for major weight gain or loss in the short term,
• Understand that this is a subtle contouring procedure and will not completely change the face,
• Have realistic expectations.

In very thin individuals, those whose face is already slim, older patients with significant volume loss, or people with a strong tendency for facial hollowing, bichectomy is usually not recommended; in such cases there is a higher long-term risk of an overly hollowed, aged appearance.

4. Preoperative Evaluation and Planning

Before surgery:

• The patient’s medical history, medications, allergies and any previous facial procedures are reviewed.

Facial proportions are analysed, including:

• Balance between forehead, midface and lower face,
• Cheekbones,
• Jawline,
• Neck region.

The surgeon evaluates how much of the cheek fullness is due to:

• Bichat fat pads,
• General fat distribution or oedema.

The patient is clearly informed that:

• The amount of fat removed will be controlled,
• Removing too much fat can lead to undesired hollowing in the long term.

Existing dental and gum problems, chronic oral infections and smoking are also taken into account.

The aim is to achieve controlled and safe slimming without disturbing the overall facial balance.

5. How Is Bichectomy Performed?

(Intraoral Access and Technique)

Bichectomy is usually performed under local anaesthesia with sedation as a day case procedure.

In summary:

Intraoral incision:

• A small incision of about 1–1.5 cm is made in the inner cheek mucosa, near the level of the upper molar teeth,
• The procedure is repeated symmetrically on both sides.

Accessing the Bichat fat pad:

• The surgeon carefully passes through the muscle layers to reach the Bichat fat pad,
• The fat pad is gently and in a controlled manner brought out.

Partial removal of fat:

• The entire fat pad is not removed,
• Only a portion is removed according to facial proportions and the surgeon’s plan.
• This provides a natural slimming effect and helps reduce the risk of excessive hollowing in later years.

Closure:

• The intraoral incision is closed with dissolvable sutures,
• There is no incision or stitch on the external skin.

After the procedure, the patient is observed for a short period and can be discharged home on the same day.

6. Anaesthesia Options

For bichectomy:

• The inner cheek area is usually numbed with local anaesthesia,
• Light sedation can be added for comfort so that the patient undergoes the procedure more comfortably.

When combined with multiple facial procedures (e.g. nose surgery, jawline surgery, liposuction, etc.), general anaesthesia may be preferred.

The type of anaesthesia is decided together with the surgeon and anaesthesiologist, based on the patient’s health status, anxiety level and the extent of the planned procedures.

7. The First Postoperative Days: Swelling, Pain and Intraoral Comfort

In the first days:

• A feeling of swelling, fullness and mild pressure in the cheeks from inside out is normal,
• There may be mild pain and tenderness when speaking, laughing or chewing during the first few days,
• The dissolvable sutures inside the mouth can be felt; it is important not to irritate this area with the tongue or hard objects.

Typically:

• Pain is mild to moderate and can be controlled with painkillers recommended by the surgeon,
• Swelling is more pronounced in the first 3–5 days,
• It gradually decreases within 1–2 weeks,
• Full settling of the result takes about 3–6 months.

In the very early stage, the face usually does not look dramatically different; a subtle contour change appears gradually as healing progresses.

8. Staying in Istanbul, Follow Ups and Returning Home

For patients coming from abroad or other cities:

• A stay of about 2–3 days in Istanbul is usually sufficient for:
  1. The first check-up,
  2. Evaluation of intraoral sutures and the incision site,
  3. Monitoring swelling and pain,
  4. Providing detailed guidance on nutrition and oral hygiene.

During this period, the patient is informed about:

• Which foods to choose,
• How and how often to use mouth rinses / antiseptic solutions,
• How long to avoid smoking, alcohol and very hot or spicy foods.

Later, if no in-person assessment is needed, the patient can return home; interim follow ups can be supported with photos and online evaluations.

9. Returning to Social Life, Work and Sports

Home activities:

• Even the day after the procedure, most patients can comfortably meet their basic needs,
• Resting during the first 24 hours is helpful due to mild fatigue and tenderness.

Return to work:

• Desk-based workers can generally return to work within 2–3 days,
• As there is no external incision,
• If swelling is mild, people around usually only notice a “slightly puffy / as if gained a little weight” appearance at most.

Return to social settings:

• During the first 3–5 days, chewing can be slightly uncomfortable, so food choices should be made carefully,
• After 5–7 days, as swelling decreases significantly, most patients feel more comfortable in social environments.

Return to sports:

• Light walking can be done from the first day, with the doctor’s approval,
• For intense exercise that shakes the face, raises the heart rate significantly, or involves weights, a waiting period of about 2–3 weeks is usually recommended.

10. Nutrition, Oral Hygiene and Healing Follow Up

Nutrition:

• In the first days, soft, lukewarm foods are preferred (soups, purées, yoghurt, etc.),
• Very hot, very spicy, or hard and sharp foods should be avoided;
• these can irritate the incision line or trigger bleeding.

Oral hygiene:

• The oral cavity is sensitive to infection; therefore:
  1. Mouth rinses / antiseptic solutions prescribed by the doctor should be used regularly,
  2. When brushing teeth, direct pressure on the incision area should be avoided.

Follow up:

• In the first days, if there is fever, bad odour, severe pain or pronounced swelling on one side, the surgeon should be contacted,
• In a normal course, swelling gradually decreases, sutures dissolve spontaneously, and oral tissues show clear healing within 1–2 weeks.

11. Possible Risks and Complications

Although bichectomy seems like a small procedure, it is performed in a functionally and aesthetically critical area of the face and therefore requires care and experience.

Possible risks include:

• Bleeding, haematoma (blood collection within the tissues)
• Infection
• Delayed wound healing inside the mouth
• Rare injury to salivary gland ducts or neighbouring anatomical structures
• Temporary, and rarely permanent, changes in sensation
• Because it is close to branches of the facial nerve, there is a risk of affecting facial expression if planning is wrong or the technique is too aggressive (working in the correct plane aims to minimise this risk)
• Excessive fat removal leading to an overly hollowed and aged appearance over the years
• Asymmetry (a feeling that one cheek has slimmed more than the other)

These risks are reduced by:

• A surgeon who is experienced with facial anatomy and this specific region,
• Correct patient selection (avoiding the procedure in very thin, elderly or hollow-prone faces),
• Adherence to postoperative hygiene and follow up recommendations.

12. Results, Expectation Management and Facial Proportions

With bichectomy, the aims are to:

• Create a subtle slimming and shadowing in the mid-lower cheek region,
• Help the cheekbones and jawline appear more defined,
• Achieve a more sculpted, slightly V-shaped facial silhouette even without make-up.

Points to remember:

• The result is not immediate; it appears gradually,
• In the first weeks, swelling may even create the impression of a “fuller” face,
• It takes 3–6 months for swelling to resolve and tissues to fully adapt to your facial structure.

Bichectomy alone does not completely transform the face;

When it is evaluated together with:

• Chin tip,
• Cheekbone augmentation,
• Jawline contouring,
• Neck / double-chin area,

more comprehensive results can be obtained.

The most satisfying outcomes are seen in patients who:

• Have reasonably balanced facial proportions from the start,
• Have mild to moderate cheek fullness,
• Maintain stable body weight,
• Have realistic and patient expectations.