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

Goals/Purpose: 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 BFPR for the purposes of aesthetic midface contouring. Most of the available literature concentrates on the clinically-relevant anatomic relationships of the buccal fat pad to the adjacent anatomic structures which are at risk of injury during resection, such as the parotid duct and facial nerve. Although parotid injury is a known occurrence following parotidectomy, penetrating trauma, and other facial operations, this complication in the setting of facial aesthetics is exceedingly rare. To date, the literature is limited to only twenty-three documented cases of iatrogenic injury to the parotid following facelift surgery and only one documented report following intraoral buccal fat pad removal (BFPR). The authors sought to emphasize an underreported and potentially preventable and untoward complication involving iatrogenic parotid duct injury. The purpose of this publication is threefold: (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.

Methods/Technique: 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 is reviewed. The diagnostic criteria and clinical presentation of parotid duct injury following BFPR is comprehensively outlined to help surgeons approach this challenging complication.

Results/Complications: The authors present a clinically actionable algorithm when managing a patient with a suspected or diagnosed parotid duct injury following BFPR. A clinical case example is discussed to highlight this complication, the diagnostic criteria, and systematic and algorithmic approach to management of a parotid duct injury.

Conclusion: Intraoral BFPR is an incredibly valuable and powerful procedure which can improve facial contour in patients with buccal lipodystrophy or buccal fat pad pseudoherniation. Iatrogenic injury to the parotid duct is an exceedingly rare complication following intraoral buccal fat removal. Given the increasing popularity of this procedure over the recent years, aesthetic surgeons should be familiar with the relevant anatomy of the parotid duct and its relationship to the buccal fat pad. Since there remains a gap in the literature with regards to management of iatrogenic parotid duct injury in the setting of intraoral BFPR, the authors propose a proper diagnostic approach and treatment algorithm to manage this untoward complication.