Hidden Facial Cheek Fat Compartments Key to Younger Look

[jamesherried]

Here's an article from the American Academy of Anti-Aging Medicine website:

Rejuvenating newly identified fat compartments in the facial cheeks can help reduce the hollowed look of the face as it ages, according to new research by plastic surgeons at UT Southwestern Medical Center.
Researchers used special dyes to identify and map four cheek-fat compartments hidden deep beneath the skin. When these compartments are restored using fat, tissue fillers or artificial implants, the result is a more youthful and less hollow look to the overall face, according to Dr. Joel Pessa, assistant professor of plastic surgery.

Restoring these compartments also improves volume loss under the eyes, helps eliminate lines around the nose and mouth and gives more curve to the upper lip, all of which restore a more youthful appearance to the face, Dr. Pessa said.

“This research breaks new ground by identifying the boundaries of specific fat compartments that are key to facial rejuvenation involving the cheeks, and as a consequence, the overall look of the face,” said Dr. Pessa, a co-author of the study, which appears in the June issue of Plastic and Reconstructive Surgery. “Cheeks are vital to what we consider beautiful — from chubby-cheeked infants to Hollywood stars like Angelina Jolie.”

Plastic surgeons performed nearly 8,000 cheek implants in 2007, according to the American Society of Plastic Surgeons. In addition, nearly 47,000 fat injections and 1.1 million injections with hyaluronic acid fillers were performed last year.

Researchers injected 14 cadavers with dye and latex to identify the boundaries of the deep medial fat compartments and their relationship with adjacent muscles. Volume loss in the compartments resulted in the hollow look associated with aging, the study noted, but is restored immediately by properly filling the compartment. In addition, when the compartments are filled properly, less fat or filler is needed.

“This anatomic fat cheek compartment completely changes how we look at facial aging,” said Dr. Rod Rohrich, chairman of plastic surgery at UT Southwestern and lead author of the study. “The process to correct facial aging is now dramatically changed as well. No longer do we remove fat without pre-op analysis or merely lift the cheek; we must now lift and fill the face to restore a natural youthful, unoperated appearance.”

The research is part of an ongoing project among UT Southwestern plastic surgeons to better map fat compartments in the face and body.

“Research to identify specific fat compartments for surgeons to target helps provide more predictable results in the ongoing fight against facial aging,” Dr. Pessa said.

[drtodorov]

Interesting, and rather plausible. Do you have the reference to the original publication by any chance?

[jands]

All I can find is their news release: w w w .utsouthwestern.edu/utsw/cda/dept353744/files/469299.html

[orangehrzn]

The idea that the principal component of aging is fat volume deflation is well known to all plastic surgeons that do fat grafting and is not news at all. Below is the actual study of which this thread is about. I skipped the more technical part of the article, left only the abstract and the discussion at the end.

The Youthful Cheek and the Deep Medial Fat Compartment
Rohrich, Rod J. M.D.; Pessa, Joel E. M.D.; Ristow, Brunno M.D
Plastic and Reconstructive surgery, Volume 121(6), June 2008, pp 2107-2112

ABSTRACT:
Purpose: This article introduces the concept of pseudoptosis as a mechanism of midfacial aging: diminished volume of a specific deep fat compartment leads to an excess skin envelope and the illusion of a more prominent nasolabial fold. Tha anatomy of this deep fat compartment, and of two others, is described.

Methods: Fourteen hemifacial cadaver dissections were performed using the dye injection technique to identify deep medial cheek, submentalis, and sub–orbicularis oris fat compartments. Latex injection was used to investigate the arterial supply.

Results: The deep medial fat compartment was defined in each subject. Two separate areas of deep medial fat exist. The more medial compartment abuts the pyriform membrane. The lateral component lies directly on the maxilla. The anatomy of submentalis and suborbicularis fat was defined.

Conclusions: Loss of volume of deep medial cheek fat leads to pseudoptosis and is an additional determinant of the nasolabial fold. Augmentation of deep medial fat has four effects: it increases anterior projection (not addressed by lateral redraping alone); it diminishes the nasolabial fold; the V-deformity is corrected; and a youthful cheek with natural boundaries is recreated. The term “malar fat” is probably a misnomer: this region is composed of both distinct superficial and deep fat compartments. Submentalis and sub–orbicularis oris fat play a role is the formation of the labiomental hollow and aging lip respectively. Understanding the anatomy of this area lends greater precision to our ability to rejuvenate the aging face.

There have been many techniques and concepts described to address the aging midface, an excellent review being given by Little.1 Lambros has proposed the concept of deflation as an important factor is the cause of facial aging.2 Both of these authors have discussed a volumetric approach to midfacial aging. Ristow has discussed midface rejuvenation by deep augmentation of the face to improve midfacial projection, again highlighting the concept of volume loss as an important mechanism of facial aging.3

During the study of the superficial fat compartments of the face, an adipose compartment was noted deep to the superficial fat. This fat was deep to the superficial compartments and was located medial to the zygomaticus major muscle (Fig. 1). While investigating this anatomy, saline injection of this compartment was noted to improve midface projection and to efface the nasolabial fold (Fig. 2). What was as significant as the restoration of adequate midface projection was the finding that volume augmentation of this one compartment recreated a natural appearing cheek (Fig. 2).

Graphic
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[Email Jumpstart To Image] Fig. 1. The deep medial cheek fat is stained with methylene blue. This fat lies beneath the superficial subcutaneous fat compartments. The zygomaticus major (ZM) and buccal fat (B) represent the lateral boundaries.

Graphic
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[Email Jumpstart To Image] Fig. 2. (Left) Photograph of a deflated midface (arrow). (Right) Saline injected specifically into the deep medial cheek fat restores anterior projection, diminishes the nasolabial fold, effaces the nasojugal trough, and improves the malar region. As interesting as these findings is the fact that the cheek has a natural appearance, the reason being that the deep medial fat boundaries determine the anatomical position of the cheek.

This finding has been noted clinically, when fat is injected deep and medial to the zygomaticus major muscle. This technique improves midface projection and recreates a youthful cheek. In addition, the V-deformity of the lower lid is improved and the prominence of the nasolabial fold is diminished.

These findings suggest the concept of “pseudoptosis” as one etiologic mechanism in the formation of the nasolabial fold. This is in agreement with Lambros’ concept of deflation that occurs with aging.2 Because of the clinical implications of this anatomy, the following study was performed to define the anatomy of the deep medial cheek fat.


DISCUSSION:

A major theme that occurs throughout this project is the concept that deep fat supports the overlying subcutaneous fat compartments. Because the deep fat is compartmentalized in a fashion similar to the overlying subcutaneous fat, volume loss of specific deep fat compartments leads to predictable changes in the topography of the face.

Volume loss of the deep medial fat compartment may determine much of what is observed in the aging “midface.” The recent observation that subcutaneous fat is highly compartmentalized by fascial condensations enables the midface to be defined more precisely. In the aging midface, the nasolabial fold is preserved, whereas there is loss of projection of the medial and middle subcutaneous fat compartments. This has a characteristic appearance on front view.

These findings suggest the concept that the formation of a prominent nasolabial fold with aging is, in part, a form of pseudoptosis: loss of projection of the superficial medial and middle compartment fat creates the illusion that the nasolabial fold has become more prominent. The subcutaneous tissues of the medial, middle, and lateral temporal cheek compartments are unable to flow past their respective septal boundaries and do not contribute to the nasolabial fold in the aging face. Skin “laxity” is secondary to volume deflation and an excess skin envelope.

This concept is supported by clinical experience. Skin redraping of the face lift, as advocated by Stuzin,5 is performed by some surgeons. When volume augmentation of deep cheek fat is added, anterior projection of the midface is achieved. Ristow described direct injection of this area with autogenous fat.3 It is interesting that a recent article on fillers by Nicolau shows similar improvement of the midfacial hollowing with the use of fillers.8

An important clinical point regarding augmentation of the deep medial cheek fat is that when the compartment is injected accurately, the results are apparent immediately. A smaller volume of fat is also required when this compartment is injected correctly. One good indicator that the correct compartment is being filled is to observe the nasojugal hollow: this region is always effaced as volume is increased.

The arterial supply of this fat compartment was noted to be the infraorbital artery (Fig. 6). The infraorbital artery may be injured during facial trauma and orbitomaxillary fractures. Laceration or occlusion of this artery may not be innocuous, and disruption of the main blood supply to the deep medial cheek fat may lead to a diminished anterior cheek projection. Preservation of the infraorbital artery may be important to maintain midface projection, as is proper resuspension of the soft tissues after degloving.9

Many other fat compartments were noted during this research. Deep fat compartments of the orbital aperture have been described by Aiache and Ramirez, and May et al.6,7 Suborbicularis fat is also noted around the lips. The orbicularis muscle insertion defines the wet-dry border, and suborbicularis fat lies posterior to this boundary. Augmentation of the lip is usually performed at the vermilion-cutaneous junction. Overaugmentation at this site creates an unnatural shape with which all plastic surgeons are familiar. It may be loss of volume of the deep lip fat and mucosal gland atrophy that diminish support for the normal convex shape of the lips. Rather than injecting directly into the muscle, it is possible to specifically augment the suborbicularis fat of the lip by injecting posterior to the wet-dry border. It is interesting to note that a youthful lip with adequate volume always has more show of the wet-dry border than an aging lip, in agreement with the clinical application of restoring suborbicularis fat volume.

Suborbicularis fat of the lower lip is different from the submentalis fat pad. A prominent labiomental crease is often noted in mature individuals and may be related to how this fat compartment behaves with age.

A deep lateral cheek fat compartment was noted during this study. Stuzin, during his visiting professor lecture, pointed out the lateral facial atrophy that occurs with age.5 It is possible that a change in the volume of this compartment may contribute to lateral cheek atrophy. The easiest way to show the deep lateral cheek fat is by cross-sectional anatomy, where it is noted superficial to the fascia of the masseter muscle.

The recurring theme throughout this discussion has been the concept of deflation as the mechanism responsible for changes of the surface topography of the aging face. Many other concepts of midfacial aging exist, and it is likely that there are many contributing factors.10 That volume restoration of the deep medial cheek fat diminishes the nasolabial fold and improves cheek projection without lifting is testimony to Lambros’ genius in visualizing this process decades before the anatomical work. Lambros’ vision has provided the conceptual framework that has enabled multiple anatomical observations to be formulated into a cohesive model.

CONCLUSIONS:

Many other compartments of fat, both above and below the superficial fascia, remain to be identified. The adipose tissue of the entire human body is highly compartmentalized. That volume restoration of particular compartments leads to highly specific and predictable results brings us closer to approaching facial aging in an algorithmic manner. Future research will be directed to the fat compartments of the extremities and trunk, where additional findings of interest will almost certainly be found.

[jamesherried]

[drtodorov]

Thanks for posting. Yes, you're right, the fact that facial fat loss is a major factor in facial aging has been long known. What's potentially new here is the specific anatomical targeting of the key deep fat pads whose restoration could [if they are right] be especially effective in rejuvenating facial shape.

[smitasharma54]

A cheek lift surgery can definitely change your appearance and make you look more youthful, mellows the profound lines extending from the corners of the nose to the corners of the mouth and raises the external piece of the eyebrow, giving the face a more rested and young appearance.