An Algorithmic Approach to Managing Parotid Duct Injury Following Buccal Fat Pad Removal

Abstract

The principles of achieving an aesthetically pleasing and harmonious facial appearance are influenced by our evolving understanding of the three-dimensional topography of the face coupled with novel approaches to midface volumization and contouring. In parallel with the evolving landscape of facial aesthetic surgery, an increasing number of publications have emerged focusing on the role of intraoral buccal fat pad removal (BFPR) for the purposes of aesthetic midface contouring. The authors sought to emphasize an underreported and potentially preventable and untoward complication involving iatrogenic parotid duct injury following BFPR. The purpose of this publication is 3-fold: (1) to review the relevant anatomy and literature on intraoral BFPR, (2) to present a case example of this complication, and (3) to discuss treatment options as part of a proposed management algorithm. The authors detail the surgical indications for performing BFPR and review the relevant anatomic considerations. Complication prevention strategies are outlined, and details regarding avoidance of parotid duct injury are reviewed. The diagnostic criteria and clinical presentation of parotid duct injuries following BFPR are comprehensively outlined. The authors present a clinically actionable algorithm for managing a suspected or diagnosed parotid duct injury following BFPR. A clinical case example is discussed to highlight this complication, the diagnostic criteria, and the systematic and algorithmic approach to management. Intraoral BFPR is an incredibly valuable and powerful procedure that can improve facial contour in patients with buccal lipodystrophy or buccal fat pad pseudoherniation. The authors propose a proper diagnostic approach and treatment algorithm to manage this untoward complication.

Figure 1.

Representative anteroposterior photograph of a 25-year-old female patient who underwent intraoral buccal fat pad removal surgery. This is a 2-week postoperative photograph taken at the time of initial consultation after a referral from another provider. The photograph illustrates the abnormal and asymmetric swelling of the left hemiface.

Figure 2.

Representative anteroposterior photograph of a 25-year-old female patient 10 days after her first percutaneous aspiration. The photograph was taken after a series of 3 percutaneous aspirations of the left cheek, maintenance in a compression wrap garment, injection of 25 units of Botulinum toxin into the left parotid gland, and initiation of glycopyrronium bromide (Robinul). Following these interventions, the drainage had stopped, and the patient appeared to be healed without further sequelae.

Figure 3.

Proposed clinically actionable algorithm for managing a suspected or diagnosed parotid duct injury following intraoral buccal fat pad removal surgery. CT, computed tomography.