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

Results

Deep Medial Cheek Fat Compartment

The deep medial cheek fat compartment was separated into medial and lateral parts by a fascia arising from the lateral border of the levator anguli oris (Fig. 3, above, left). The medial part of the deep medial cheek fat compartment and Ristow space were located above the canine and first premolar teeth. The lateral part of the deep medial cheek fat compartment was located between the first premolar and the first molar teeth, adjacent to the medial part of the deep sub–orbicularis oculi fat compartment superiorly (Fig. 3, above, left). [See Figure, Supplemental Digital Content 5, which shows the deep medial cheek fat compartment and nerves traveling in the compartment. The deep medial cheek fat compartment lies between the maxilla and the levator labii superioris and the zygomaticus minor (above, left). It is bounded medially by the lateral wall of the nose, laterally by the zygomaticus major and the medial wall of the buccal fat pad, and superiorly by the oblique line of the maxilla below the orbit where the levator labii superioris arises. Inferiorly, the fat extends beyond the nasolabial fold to below the orbicularis oris. The infraorbital nerve and vessels mainly travel in the deep part of the fat compartment (above, right). The Ristow space was found between the superior part of the medial part of the deep medial cheek fat compartment and the maxilla, immediately below the infraorbital foramen. The buccal branches of the facial nerve subdivide and interweave in the superficial layer of the deep medial cheek fat compartment and innervate adjacent mimic muscle by heading superiorly, inferiorly, medially. and superficially (below), http://links.lww.com/PRS/C45.]

Figure 3.

Boundary between the medial and lateral parts of the deep medial cheek fat compartment and important vessels in the cheek area. The medial and lateral parts of the deep medial cheek fat compartment are separated by a fascia (purple dashed line) arising from the lateral border of the levator anguli oris (above, left). In several cases, the facial artery bifurcates into two branches, with one accompanying the facial vein, which travels 12 mm from the maxilla (above, right). The angular vein collects a major contributing vein at the level of the origin of the levator anguli oris or the nasal ala, the zygomaticofacial vein (below, left), which travels close to the periosteum of the maxilla (below, right). LLS, levator labii superioris; LAO, levator anguli oris; M-DMC, medial part of the deep medial cheek fat compartment; L-DMC, lateral part of the deep medial cheek fat compartment; Z Mi, zygomaticus minor.

Facial Artery and Vein

The facial artery was found to bifurcate into two major branches in eight of the 40 hemifaces, with one traveling along the usual course and the other accompanying the angular vein. In this case, the accompanying facial artery ran superficial to, instead of beneath, the facial vein (Fig. 3, above, right). The angular vein was found to run in the superficial part of the septum separating the lateral part of the deep medial cheek fat compartment and the buccal fat pad, 12 ± 4.3 mm from the maxilla (Fig. 3, above, right). The zygomaticofacial vein drained into the facial vein at around the level of the nasal ala, traveling along the lateral border of the medial part of the suborbicularis orbital fat compartment and close to the periosteum (Fig. 3, below).

Clinical Study

Among the 78 patients included in the study, 32 patients were injected in the cheek area only, and 46 patients received injections in both cheek and temporal areas. One to three procedures were performed per patient, with a mean interval of 3.9 months between the two subsequent procedures and a mean total volume of 29.3 ml for the cheek area (Table 3).

The curvilinear line on the anterior view and the three-quarters view became smoother and less concave 12 months postoperatively (Figs. 4 and 5). A pleasing and elevated anterior projection of the cheek and ameliorated nasolabial groove were still obvious by 12 months after the procedure (Fig. 6). The average cheek hollowing augmentation rate was 27.1 percent at 12 months after the last operation (Table 3). Malar lipoatrophy grading scores decreased from 3.3 preoperatively to 1.0 postoperatively. (See Figure, Supplemental Digital Content 6, which shows malar lipoatrophy grading before and 12 months after the last procedure, http://links.lww.com/PRS/C46.) The patients reported a satisfaction rate of 76.3 percent in this series, with 18.9 percent of the patients reporting mostly satisfactory and 4.8 percent reporting unsatisfactory. The results according to three different groups of evaluators are compared and summarized. (See Figure, Supplemental Digital Content 7, which shows the patient satisfaction rate 12 months after the last operation evaluated by patients, surgeons, and laypersons, http://links.lww.com/PRS/C47.)

Figure 4.

Preoperative (left) and 12-month postoperative (right) photographs after fat grafting in the midface of a 23-year-old woman. The concavity in the anterior and lateral cheek was obvious for her age (red arrows).

Figure 5.

Three-dimensional scans of the facial topography before (blue) and 12 months after (yellow) fat grafting. The colors in the different facial areas represent depth variation. Red arrows highlight the concavity of the anterior and lateral cheek. Fat was placed in the medial and lateral parts of the deep medial cheek fat compartment, with blending in the nasolabial and medial cheek fat compartments for the anterior cheek concavity. The middle and lateral cheek fat compartments were augmented to adjust the lateral cheek concavity. A significant increase in volume was noted on the three-dimensional scanning images in the subzygomatic area of the lateral cheek and the anterior cheek area (green, yellow, and red zones).

Figure 6.

Preoperative (left) and 24-month postoperative (right) photographs after fat grafting in the midface of a 45-year-old woman. A pleasing and elevated anterior projection could be observed 1 year after surgery (center, right). The depth and length of the nasolabial fold was also ameliorated (below, right).

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....