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

Discussion

Volume restoration by autologous fat grafting has been proven to be a well-accepted and efficient way of rebuilding a youthful face. A successful facial rejuvenation by autologous fat grafting should take into consideration both aesthetic and physiologic characteristics of facial fat distribution to avoid an unexpected and universally augmented balloon-like face after the procedure.

The connection between the most prominent point of the cheek bone and the mental tubercle forms a youthful anterior projection, constituting a characteristic youthful golden facial triangle with smooth transition between different facial subunits. Volume loss in facial fat not only resulted in compartmented facial topography, deepened grooves, and redundancy of facial skin, but also caused a flattened, even concaved facial contour, which made the face appear even wider despite volume loss. Studies on facial fat distribution suggest that the volume ratio of superficial to deep cheek fat is almost 1:1 in the cheek area,[18] and with the evolving understanding of facial fat distribution, we now realize that multiple planes and multiple fat compartments can be identified in the cheek. Volume loss during aging involves both deep and superficial fat compartments, which contribute differently to facial contour.[13,14] Although both deep and superficial fat compartments lose volume during aging, the situation is much more complex with regard to the superficial fat compartments, which involve not only volume loss but also downward migration, resulting in deepened facial grooves such as the nasolabial groove, tear trough groove, and midcheek groove because of volume differences in adjacent superficial fat compartments. Moreover, volume loss in the deep cheek fat compartments will cause skin redundancy and ptosis and aggravate facial grooves. Thus, a comprehensive injection scheme should be tailored to create a youthful facial contour and efface grooves and lines.

Therefore, our fat grafting strategy is designed with the aim of fat placement in a multiplane and compartment-specific manner to achieve a state close to the physiologic fat distribution of a youthful face. The paraoral commissure incision is chosen because of its advantages of hidden location and accessibility to different layers. From here, the cannula can be advanced subcutaneously or submucosally as needed in the first place. Considering the changes of the deep and superficial fat compartments caused by aging and their physiologic function in constructing facial contour, a deep-to-superficial injection sequence is suggested.

The deep fat compartments support the superficial malar fat from beneath, the fullness of which is regarded as characteristic of a youthful cheek. In our study, we found that the lateral part of the deep medial cheek fat compartment is located beneath the zygomaticus major and supports this muscle together with the buccal fat pad from beneath; this explains why filling of this compartment recreates the youthful anterior projection, as the zygomaticus major constitutes the lateral border of the youthful golden triangle. We also found that by adopting the paraoral commissure incision and advancing the cannula submucosally, the medial part of the deep medial cheek fat compartment and lateral part of the deep medial cheek fat compartment were accessed precisely along the upper canine and first molar teeth. These are helpful bony markers enabling the reproducibility of the procedure. In addition, because of the adjacency of the lateral and medial parts of the sub–orbicularis oculi fat compartment, the fat could be placed in both compartments by upward advancement in a vertical line through the first molar tooth. The sequence for deep fat augmentation was designed to first supplement the volume loss in the upper part of the deep fat compartments. This would improve the skin ptosis caused by volume loss and is very likely to be helpful for the effacement of the nasolabial groove and the tear trough groove. Injection into the medial part of the suborbicularis orbital fat compartment helps to rebuild a youthful cheek bone, and the volume gain helps to efface the nasolabial groove and also improve the midcheek groove. Additional fat injections may be performed into the nasal base to create a smooth transition between the two regions and also to allow for improvement of the deepened nasolabial groove. Through deep fat volume augmentation, our 1-year follow-up cases suggested a lasting effect on facial contouring. Meanwhile, deep fat grafting also exerted a long-term effect on the effacement of the nasolabial fold. Cannula advancement should follow a resistance-free or low-resistance principle in the deep fat compartments. The cannula should be advanced with the guidance of the maxilla, but not too close to the bone, because the angular vein travels 1 cm from the maxilla, and the zygomaticofacial vein travels along the periosteum.

A cannula placed through a paraoral commissure incision can be advanced to almost all superficial fat compartments in the middle and lower face because of the great flexibility and mobility of the lip tissue. Therefore, the lateral border of the golden triangle connecting the most prominent point of the zygoma and the mental tubercle can be reinforced by fat placement in the superior half of the medial cheek fat compartment, the lateral part of the nasolabial fat compartment, the medial part of the inferior jowl fat, and the lateral part of the labiomandibular fat compartment. Together with deep fat injection, a youthful and more vivid facial contour can be rebuilt, creating a visually narrower and more delicate facial contour because of the reflection of light, despite the augmented volume in both deep and superficial compartments. This may be desirable in men, but it might result in a masculine facial contour in female patients, who will require additional fat grafting in the superficial fat compartments to create a smoother transition and a softer facial contour. Obstacles have been encountered when approaching the middle and lateral cheek compartments.[19,20] Our anatomical findings suggest that the cannula was blocked by the upper half of the masseteric ligament, where numerous perforating vessels reside. [See Figure, Supplemental Digital Content 8, which shows the masseteric cutaneous ligament. The masseteric cutaneous ligament arises from the anterior border of the masseter (left), presenting a barrier to cannula advancement in the superficial fat compartment. A major hindrance was encountered in the upper part of the ligament, where the fibrous structure is strong and many perforating vessels reside in the ligament (right). The ligament is the weakest in the lower one-third, allowing the passage of the cannula from this area with little force, http://links.lww.com/PRS/C48.] Forced advancement of the cannula through the ligament can be risky. An intrasideburn incision would be a helpful alternative for reaching the middle and lateral cheek fat compartments. The total volume for each injection varies greatly from patient to patient, ranging from 4 to 25 cc per cheek, depending on the age and original facial contour of the patient.

We understand that there are still limitations of this study, as it displays the surgical technique and clinical outcome of only one technique. There are still many unanswered questions with regard to the comparison of injection volume, survival rate, and long-term contour changes between the current technique and other techniques. Longer studies in a larger patient population are needed to draw definitive conclusions about the long-term performance of the compartment-specific technique in facial contouring.

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