Facial Contouring by Targeted Restoration of Facial Fat Compartment Volume

The Midface

Wenjin Wang, M.D., Ph.D.; Yun Xie, M.D., Ph.D.; Ru-Lin Huang, M.D., Ph.D.; Jia Zhou, M.D., Ph.D.; Herrler Tanja, M.D., Ph.D.; Peijuan Zhao, M.D., Ph.D.; Chen Cheng, M.D., Ph.D.; Sizheng Zhou, M.D., Ph.D.; Lee L. Q. Pu, M.D., Ph.D.; Qingfeng Li, M.D., Ph.D.

Disclosures

Plast Reconstr Surg. 2017;139(3):563-572. 

In This Article

Materials and Methods

Facial Fat Compartment Dissection

Twenty formaldehyde-fixed cadavers were obtained from the Willed Body Program at Shanghai Jiao Tong University School of Medicine. In 40 hemifaces from 20 formaldehyde-fixed cadavers, the ligaments and fascia that constitute boundaries for the superficial and deep fat compartments were identified. The facial artery and angular vein were dissected and measured for their distance to the maxilla.

Clinical Study

Patients. A total of 78 healthy female patients undergoing facial fat grafting from January of 2010 to January of 2014 were included in the present study (Table 1). The study was approved by the institutional review board. Each patient was fully informed regarding the procedure and the aim of the study. (See Figure, Supplemental Digital Content 1, which shows patient data and surgical technique, http://links.lww.com/PRS/C41.)

Surgical Technique. Fat was collected by liposuction performed on the abdomen or thigh region using the superwet technique with a 16-gauge cannula attached to a 20-ml syringe. A paraoral commissure incision was made on the lip mucosa 1 to 2 mm adjacent to the oral commissure to avoid any unwanted scar formation. [See Figure, Supplemental Digital Content 2, which shows the paraoral commissure incision. The incision was made at the oral mucosa, 1 to 2 mm adjacent to but not exactly at the oral commissure to avoid any unwanted scar formation. From here, a cannula was placed beneath the oral mucosa, in the muscle, or subcutaneously in the first place to ensure accurate placement of fat in different layers in subsequent procedures. The schematic drawing indicates the paraoral commissure injection site (red dot), http://links.lww.com/PRS/C42.] From here, an 18-gauge cannula connected to a 1-ml syringe was accurately placed beneath the lip mucosa or subcutaneously in the very beginning as required in subsequent procedures.

Fat Placement in the Deep Fat Compartment: Autologous fat was placed in the medial part of the deep medial cheek fat compartment by advancing the cannula between the mucosa and the orbicularis oris muscle. The root of the canine tooth was used as a bony marker to approach the medial part of the deep medial cheek fat compartment. The lateral part of the deep medial cheek fat compartment was approached by advancing the cannula in the same layer with the guidance of the first molar tooth and was advanced close to the maxilla. The medial part of the suborbicularis orbital fat compartment was also approached by advancing the cannula in this trajectory in a line connecting the first molar and the lateral limbus of the ipsilateral cornea. Special attention was paid to avoid advancing the cannula too close to the maxilla when the cannula was around the level of the nasal ala. From this incision, the cannula was directed laterally to the superior part of the buccal fat pad from the superoanterior quadrant of the medial wall of the buccal fat pad by advancing the cannula close to the maxilla. For fat placement in the deep cheek fat compartments, the following sequence is recommended: (1) medial part of the deep medial cheek fat compartment; (2) medial part of the sub–orbicularis oculi fat compartment; (3) lateral part of the deep medial cheek fat compartment; (4) lateral part of the nasal base; (5) upper lip in the submucosa layer; and (6) superior part of the buccal fat pad (Fig. 1). [See Figure, Supplemental Digital Content 3, which shows a schematic view of compartment-based fat grafting. (Above, left) Incision at the oral commissure; (above, right) defining injection layer; (second row, left) cannula advancement submucosally; (second row, right) fat grafting into the sub–orbicularis oris fat; (third row, left) fat grafting into the lateral part of the deep cheek fat compartment; (third row, right) fat grafting into the upper half of the medial part of the deep cheek fat compartment; (below) fat grafting into the lower half of the medial part of the deep cheek fat compartment, http://links.lww.com/PRS/C43.]

Figure 1.

Trajectory and sequence for deep fat compartment filtration. For fat placement in the deep cheek fat compartments, a specific sequence of fat placement is recommended: 1, medial part of the deep medial cheek fat compartment; 2, medial part of the sub–orbicularis oculi fat compartment; 3, lateral part of the deep medial cheek fat compartment; 4, lateral part of the nasal base; 5, upper lip in the submucosa layer; 6, superior part of the buccal fat pad. (Permission granted for publication from the painter, © Zhou Shuyang.)

Fat Placement in the Superficial Fat Compartment: For fat placement in the superficial fat compartments through the paraoral commissure incision, the following sequence is recommended: (1) superior half of the medial cheek fat compartment below the lid-cheek groove; (2) superior part of the nasolabial fat compartment below the midcheek groove; (3) superior part of the nasolabial fat compartment below the tear trough; and (4) below the nasolabial fold when necessary (Fig. 2).

Figure 2.

Trajectory and sequence for superficial fat compartment infiltration through a paraoral commissure incision and an intraearlobe incision. The following sequence is recommended. First, direct the cannula laterally to approximately 1 cm lateral to the oral commissure, and turn upward toward the most prominent point of the zygoma and inject fat along the trajectory while withdrawing the cannula to create the upper half of the lateral border of the golden triangle (medial cheek fat compartment and nasolabial fat compartment). Second, direct the cannula laterally to approximately 1 cm lateral to the oral commissure and turn upward toward the mental tubercle and inject fat along the trajectory while withdrawing the cannula to create the lower half of the lateral border of the golden triangle. Third, direct the cannula to the nasolabial fat compartment and the medial cheek fat compartment medial and lateral to the lateral border of the golden triangle to create a smooth transition. Fourth, direct the cannula deep and along the nasolabial fold when necessary. For augmentation of the middle and lateral cheek fat compartments, another incision in the sideburn could be used as a complement to avoid any unwanted injury to the blood vessels or nerves in the masseteric ligament. (Permission granted for publication from the painter, © Zhou Shuyang.)

For augmentation of the middle and lateral cheek fat compartments, the fat was placed by directing the cannula to the lower one-third of the masseteric ligament where the fibrous structure is weak. Alternatively, another incision in the sideburn was used to avoid any unwanted injury to the blood vessels or nerves in the masseteric ligament (Fig. 2).

Outcome Assessment

All patients were evaluated for malar lipoatrophy grade (Table 2) before surgery and 12 months after the last procedure. The quantitative cheek correction rate was assessed, and a satisfaction survey was conducted 1 year after the last operation.

Quantitative assessment of the cheek hollowing corrective rate was based on two-dimensional facial analysis using frontal photography. [See Figure, Supplemental Digital Content 4, which shows the two-dimensional facial analysis for the quantitative assessment of the cheek concavity corrective rate. Frontal views on preoperative and postoperative photographs were standardized by Adobe Photoshop software (Adobe Systems, Inc., San Jose, Calif.) to locate the two lateral canthi on the same horizontal line. The x and y axes (green) are horizontal and vertical lines passing through the bilateral medial canthus and the lateral limbus of the pupil. The most projected lines of bilateral cheeks were marked with a curvilinear line (red). The areas formed by the x and y axes and the curvilinear line were measured and adjusted with the inter–medial canthus distance by Image Process Plus (Media Cybernetics, Inc., Rockville, Md.). The adjusted areas before and 1 year after surgery were compared as a reflection of volume change of the cheek area. The cheek hollowing corrective rate was assessed quantitatively by calculating the formula (postoperative area - preoperative area)/preoperative area and is presented as a percentage, http://links.lww.com/PRS/C44.] Three-dimensional laser surface scanning images were collected using a Konica Minolta Vivid 910 (without the rotating stage set) and Polygen Editing Tools version 2.21 (Konica Minolta, Tokyo, Japan) as described previously. Images taken before and 1 year after the procedure were overlapped to compare the profile changes according to several selected reference points that would not be altered because of treatment, such as the medial canthus, lateral canthus, tragus, and oral commissure. The discrepancy between these two images was calculated objectively, and a colored hypsographic image was obtained.

A patient satisfaction survey was completed by the patients, the plastic surgeons, and independent investigators of nonmedical background by comparison of preoperative and postoperative photographs as described previously. The degree of improvement was evaluated by all three groups and was classified as fully satisfactory (facial contour remarkably improved), satisfactory (facial contour noticeably improved), or unsatisfactory (facial contour not noticeably improved).

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