‘Fat in the Face’ has become a topic of great interest in plastic surgery in the past few years. Understanding where the fat compartments and layers are in the face and how they influence the outward shape of the face has undergone a lot of anatomic study and descriptions recently. The main emphasis of these fat studies is to better understand how the face ages and what causes the many classic findings in the aging face. With this knowledge has come innovations in facial aging management such as fat resuspension and volumetric addition by fat injection.
As another anatomic study of facial fat, a recent paper in the January 2012 issue of Plastic and Reconstructive Surgery looked specifically at midfacial fat compartments. While most facial fat studies use injectable dye techniques, this study out of Germany used computed tomographic scanning. From twelve cadaver heads from two different age groups (aging age 54 to 75 and old age 75 to 10 years), CT scans were evaluated of the various midface fat compartments. (nasolabial, medial cheek, middle cheek, deep medial cheek, sub-orbicularis and buccal fat)
The study finds that the midfacial fat is arranged into two and paranasally into three independent anatomical layers. The superficial layer is composed of the nasolabial fat, the medial cheek fat, the middle cheek fat, the lateral temporal cheek compartment and three orbital compartments. The deep midfacial fat compartments is composed of the sub-orbicularis fat and the deep medial cheekfat. Three distinct fat compartments are found laterally to the pyriform aperture including the buccal extension of the buccal fat pad from the paramaxillary space to the subcutaneous plane. This study showed that an inferior migration of all of the midfacial fat compartments and an inferior volume shift within the compartments occurs with aging.
While such anatomic studies can seem overly detailed and one can easily get lost looking for the forest in the trees, there are a few points of good clinical relevance. As is well recognized, loss of the buccal extension of the buccal fat pad can lead to lack of support to the overlying medial cheek and deep cheek fat compartments causing an outward hollowing effect. Augmentation of this area by fat injections can restore support. Another good point is that the best method of nasolabial fold reduction is by augmentation of the deep medial cheek fat and the deep fat compartment known as Ristow space which sits just above the bony pyriform aperture.
The further detailing of the various facial fat compartments furthers the concept of site-specific augmentation by fat injection. It is now becoming more obvious that deeper levels of fat injections are important for not only increased survival but for better outward volume effects as well.
Dr. Barry Eppley
Indianapolis, Indiana