COSMETIC

The Youthful Cheek and the Deep MedialFat Compartment

Rod J. Rohrich, M.D.Joel E. Pessa, M.D.

Brunno Ristow, M.D.

Dallas, Texas, andSan Francisco, Calif.

Purpose: This article introduces the concept of pseudoptosis as a mechanismof midfacial aging: diminished volume of a specific deep fat compartmentleads to an excess skin envelope and the illusion of a more prominentnasolabial fold. Tha anatomy of this deep fat compartment, and of two others,is described.Methods: Fourteen hemifacial cadaver dissections were performed using thedye injection technique to identify deep medial cheek, submentalis, and sub–orbicularis oris fat compartments. Latex injection was used to investigate thearterial supply.Results: The deep medial fat compartment was defined in each subject. Twoseparate areas of deep medial fat exist. The more medial compartment abuts thepyriform membrane. The lateral component lies directly on the maxilla. Theanatomy of submentalis and suborbicularis fat was defined.Conclusions: Loss of volume of deep medial cheek fat leads to pseudoptosis andis an additional determinant of the nasolabial fold. Augmentation of deepmedial fat has four effects: it increases anterior projection (not addressed bylateral redraping alone); it diminishes the nasolabial fold; the V-deformity iscorrected; and a youthful cheek with natural boundaries is recreated. The term“malar fat” is probably a misnomer: this region is composed of both distinctsuperficial and deep fat compartments. Submentalis and sub–orbicularis oris fatplay 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 torejuvenate the aging face. (Plast. Reconstr. Surg. 121: 2107, 2008.)

There have been many techniques and con-cepts described to address the aging mid-face, an excellent review being given by

Little.1 Lambros has proposed the concept of de-flation as an important factor is the cause of facialaging.2 Both of these authors have discussed avolumetric approach to midfacial aging. Ristowhas discussed midface rejuvenation by deep aug-mentation of the face to improve midfacial pro-jection, again highlighting the concept of volumeloss as an important mechanism of facial aging.3

During the study of the superficial fat compart-ments of the face, an adipose compartment wasnoted deep to the superficial fat. This fat was deepto the superficial compartments and was located

medial to the zygomaticus major muscle (Fig. 1).While investigating this anatomy, saline injection ofthis compartment was noted to improve midfaceprojection and to efface the nasolabial fold (Fig. 2).What was as significant as the restoration of adequatemidface projection was the finding that volume aug-mentation of this one compartment recreated a nat-ural appearing cheek (Fig. 2).

This finding has been noted clinically, whenfat is injected deep and medial to the zygomaticusmajor muscle. This technique improves midfaceprojection and recreates a youthful cheek. In ad-dition, the V-deformity of the lower lid is improvedand the prominence of the nasolabial fold isdiminished.

These findings suggest the concept of “pseu-doptosis” as one etiologic mechanism in the for-

From the Department of Plastic Surgery, University of TexasSouthwestern Medical School, and from California PacificMedical Center.Received for publication April 2, 2007; accepted June 23,2007.Copyright ©2008 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31817123c6

Disclosure: The authors have no financial interestin any technology, instruments, or patents related tothe outcome of this research.

www.PRSJournal.com 2107

mation of the nasolabial fold. This is in agree-ment with Lambros’ concept of deflation thatoccurs with aging.2 Because of the clinical im-plications of this anatomy, the following study

was performed to define the anatomy of thedeep medial cheek fat.

MATERIALS AND METHODSFourteen hemifacial cadaver specimens were

dissected in the cadaver laboratory. All specimenswere fresh. Dissection was performed by stainingthe nasolabial compartment with dye before dis-section. Methylene blue was injected and allowedto set for 24 hours. As the study progressed, it wasnoted that more precise boundaries could beidentified if dye was allowed to diffuse for a lesseramount of time, with 4 hours being ideal.

A subcutaneous flap was elevated to reveal thedeep medial fat compartment. The superficialsubcutaneous fat compartments were elevatedaway from the deep medial fat using 4.3� mag-nification. The relationship of this fat to the su-perficial and deep facial muscles was noted, inaddition to the boundaries with other previouslydescribed fat compartments.

The arterial supply to the deep medial fat wasfurther evaluated. Latex was injected into four ofthe above specimens. Washout of the arterio-venous system was achieved by cannulation of thecommon carotid vessels and irrigation with 200 ccof lactated Ringer’s solution. Thirty cubic centi-meters of red latex was injected bilaterally. Dis-

Fig. 2. (Left) Photograph of a deflated midface (arrow). (Right) Saline injected specificallyinto 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 find-ings is the fact that the cheek has a natural appearance, the reason being that the deepmedial fat boundaries determine the anatomical position of the cheek.

Fig. 1. The deep medial cheek fat is stained with methylene blue.This fat lies beneath the superficial subcutaneous fat compart-ments. The zygomaticus major (ZM) and buccal fat (B) representthe lateral boundaries.

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section was performed after allowing the latex toset overnight at room temperature. Three addi-tional fat compartments were identified duringthis study and evaluated with gross anatomical anddye injection techniques.

RESULTSThe deep medial fat was identified in all spec-

imens. The boundaries were found to be predict-able (Fig. 1). Augmentation of deep medial cheekfat recreates a youthful cheek by restoring these nat-ural boundaries (Fig. 2). The most lateral boundaryis the capsule of the buccal fat pad and the zygo-maticus major muscle. The medial boundary is thepyriform ligament surrounding the nasal base. Deepmedial cheek fat lies beneath the orbicularis oculimuscle and has the orbicularis retaining ligament asits superior boundary. The suborbicularis fat of theeye did not stain, indicating that these compart-ments are distinct from one another (Fig. 3). Theinferior boundary of this adipose tissue compart-ment was found to be another deep compartment,the sub–orbicularis oris fat.

Deep medial cheek fat surrounds a lip elevatormuscle, the levator anguli oris. This muscle orig-inates on the face of the maxilla before insertinginto the oral commissure. Cross-sectional anatomyand dye injection have confirmed the position offat relative to the levator muscle and the anatom-ical point that this fat is a distinct compartment.

The superficial border of the deep medialcheek fat is the subcutaneous fat, in particular, themedial and middle fat compartments (Fig. 1). Theposterior border is the periosteum of the maxilla.A potential space exists between the periosteum ofthe maxilla and the deep medial fat, discussed byRistow as a potential site for rejuvenation.3 Ristow’sspace is in contrast to the attachment of the sub-orbicularis fat to its underlying periosteum, withthe suborbicularis fat being more densely adher-ent to the underlying periosteum.

The arterial supply to the deep medial cheekfat was examined in four cadaver hemifaces. Theinfraorbital artery was noted to be the main vesselsupplying this compartment (Fig. 4). The infraor-

Fig. 3. Deep medial cheek fat (DMCF) surrounds the levator an-guli oris muscle (LAO). Buccal fat (B) and suborbicularis fat (SOOF)are distinct from the deep medial cheek fat.

Fig. 4. (Above) The main blood supply to the deep medial cheekfat was noted to be the infraorbital artery (IOF). Although thetransverse facial (TFA) and the angular arteries provided smallbranches to this fat pad, these were minor compared with thecontribution of the infraorbital artery. (Below) Macroscopic pho-tograph of the infraorbital artery (arrow) as it enters the deepmedial fat compartment.

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bital artery sends numerous branches into the deepmedial fat. Other minor branches from the angularvessel were noted, although most of these termi-nated at the border of this adipose tissue.

Other fat compartments were noted duringthis project because of their proximity and ana-tomical relationship to the deep medial cheek fat.Stuzin has pointed out how lateral cheek topog-raphy becomes irregular with age, and uses thesuperficial musculoaponeurotic system to improvelateral cheek contour.5 Because loss of volume ofdeep medial fat may decrease midface projection, itwas thought that there existed a deep lateral com-partment responsible for loss of lateral cheek pro-jection. This compartment, difficult to identify, wasfound using cross-sectional anatomy and dye stain-ing (Fig. 5). This compartment lies above the fasciaof the masseter muscle.

Suborbicularis fat has been described aboutthe orbital aperture.6,7 There is also suborbicularisfat of the oral aperture (Fig. 6). The suborbicularisfat of the lip is composed of several distinct com-partments. Sub–orbicularis oris fat lies immedi-ately posterior to the wet-dry border of the lip, anarea defined by the insertion of the orbicularis orismuscle (Fig. 6, left). This is noted on histologicexamination (Fig. 6, right).

Other deep fat compartments have been noted.A deep chin fat compartment is noted beneath thementalis muscle (Fig. 7). This spans the border ofthe cutaneous lower lip. The suborbicularis fat of thelower lip is distinct on gross dissection from thesubmentalis fat. Augmentation of the submentalisfat has been performed and improves the concavelabiomental area noted with age.

During later dissections, the deep medial cheekfat was further identified as having two components.The first component abuts the pyriform membrane,and the lateral part surrounds the levator angulimuscle and is adjacent to the buccal fat.

DISCUSSIONA major theme that occurs throughout this

project is the concept that deep fat supports theoverlying subcutaneous fat compartments. Becausethe deep fat is compartmentalized in a fashionsimilar to the overlying subcutaneous fat, volumeloss of specific deep fat compartments leads topredictable changes in the topography of the face.

Volume loss of the deep medial fat compart-ment may determine much of what is observed inthe aging “midface.” The recent observation thatsubcutaneous fat is highly compartmentalized byfascial condensations enables the midface to bedefined more precisely. In the aging midface, thenasolabial fold is preserved, whereas there is lossof projection of the medial and middle subcuta-neous fat compartments. This has a characteristicappearance on front view.

These findings suggest the concept that theformation of a prominent nasolabial fold with ag-ing is, in part, a form of pseudoptosis: loss ofprojection of the superficial medial and middlecompartment fat creates the illusion that the na-solabial fold has become more prominent. Thesubcutaneous tissues of the medial, middle, andlateral temporal cheek compartments are unableto flow past their respective septal boundaries anddo not contribute to the nasolabial fold in theaging face. Skin “laxity” is secondary to volumedeflation and an excess skin envelope.

This concept is supported by clinical experience.Skin redraping of the face lift, as advocated byStuzin,5 is performed by some surgeons. When vol-ume augmentation of deep cheek fat is added, an-terior projection of the midface is achieved. Ristowdescribed direct injection of this area with autoge-nous fat.3 It is interesting that a recent article onfillers by Nicolau shows similar improvement of themidfacial hollowing with the use of fillers.8

An important clinical point regarding aug-mentation of the deep medial cheek fat is thatwhen the compartment is injected accurately, theresults are apparent immediately. A smaller vol-ume of fat is also required when this compartmentis injected correctly. One good indicator that thecorrect compartment is being filled is to observethe nasojugal hollow: this region is always effacedas volume is increased.

Fig. 5. Ristow’s space lies directly above the maxilla (RS). This is adistinct region that is a site for augmentation of the midface. Thedeep lateral cheek fat is seen on cross section (red arrow), super-ficial to the fascia of the masseter muscle.

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The arterial supply of this fat compartmentwas noted to be the infraorbital artery (Fig. 6). Theinfraorbital artery may be injured during facialtrauma and orbitomaxillary fractures. Lacerationor occlusion of this artery may not be innocuous,and disruption of the main blood supply to thedeep medial cheek fat may lead to a diminished

anterior cheek projection. Preservation of the in-fraorbital artery may be important to maintainmidface projection, as is proper resuspension ofthe soft tissues after degloving.9

Many other fat compartments were noted dur-ing this research. Deep fat compartments of theorbital aperture have been described by Aiacheand Ramirez, and May et al.6,7 Suborbicularis fat isalso noted around the lips. The orbicularis muscleinsertion defines the wet-dry border, and subor-bicularis fat lies posterior to this boundary. Aug-mentation of the lip is usually performed at thevermilion-cutaneous junction. Overaugmentationat this site creates an unnatural shape with whichall plastic surgeons are familiar. It may be loss ofvolume of the deep lip fat and mucosal glandatrophy that diminish support for the normal con-vex shape of the lips. Rather than injecting directlyinto the muscle, it is possible to specifically aug-ment the suborbicularis fat of the lip by injectingposterior to the wet-dry border. It is interesting tonote that a youthful lip with adequate volumealways has more show of the wet-dry border than anaging lip, in agreement with the clinical applica-tion of restoring suborbicularis fat volume.

Suborbicularis fat of the lower lip is differentfrom the submentalis fat pad. A prominent labi-omental crease is often noted in mature individ-

Fig. 6. (Left) Just as there is suborbicularis fat around the eye, there is suborbicularis fat of theperioral region. Superficial fat (SF) lies above the orbicularis (O), which lies above the subor-bicularis fat [deep fat of the lip (DF)]. This upper lip sample also shows how the orbicularisinsertion defines the wet-dry border (red arrow). (Right) Histologic examination confirms themacroscopic finding that the orbicularis insertion defines the wet-dry border (arrow indicatesthe fibrous insertion).

Fig. 7. Many other fat compartments exist. The submentalis fat(SMF) lies directly beneath the muscle (M). Augmentation of thisfat compartment has been performed clinically to efface the con-cavity of the labiomental region.

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uals and may be related to how this fat compart-ment behaves with age.

A deep lateral cheek fat compartment wasnoted during this study. Stuzin, during his visitingprofessor lecture, pointed out the lateral facialatrophy that occurs with age.5 It is possible that achange in the volume of this compartment maycontribute to lateral cheek atrophy. The easiestway to show the deep lateral cheek fat is by cross-sectional anatomy, where it is noted superficial tothe fascia of the masseter muscle.

The recurring theme throughout this discus-sion has been the concept of deflation as themechanism responsible for changes of the surfacetopography of the aging face. Many other con-cepts of midfacial aging exist, and it is likely thatthere are many contributing factors.10 That vol-ume restoration of the deep medial cheek fat di-minishes the nasolabial fold and improves cheekprojection without lifting is testimony to Lambros’genius in visualizing this process decades beforethe anatomical work. Lambros’ vision has pro-vided the conceptual framework that has enabledmultiple anatomical observations to be formu-lated into a cohesive model.

CONCLUSIONSMany other compartments of fat, both above

and below the superficial fascia, remain to be iden-tified. The adipose tissue of the entire humanbody is highly compartmentalized. That volumerestoration of particular compartments leads tohighly specific and predictable results brings uscloser to approaching facial aging in an algorith-mic manner. Future research will be directed to

the fat compartments of the extremities andtrunk, where additional findings of interest willalmost certainly be found.

Joel E. Pessa, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical School5323 Harry Hines Blvd.

Dallas, Texas 75390-9132joel.pessa@utsouthwestern.edu

REFERENCES1. Little, J. W. Three-dimensional rejuvenation of the midface:

Volumetric resculpture by malar imbrication. Plast. Reconstr.Surg. 105: 267, 2000.

2. Lambros, V. Fat augmentation and facial aging. Presentedat the American Society for Aesthetic Plastic Surgery, April2007.

3. Ristow, B. Personal communication, September 2001.4. Ewart, C. J., Jaworski, N. B., Rekito, A. J., and Gamboa, M. G.

Levator anguli oris: A cadaver study implicating its role itsrole in perioral rejuvenation. Ann. Plast. Surg. 54: 260, 2005.

5. Stuzin, J. M. Visiting Professor Lecture. UT SouthwesternMedical School, September 2006.

6. Aiache, A. E., and Ramirez, O. H. The suborbicularis oculifat pads: An anatomic and clinical study. Plast. Reconstr. Surg.95: 37, 1995.

7. May, J. W., Jr., Fearon, J., and Zingarelli, P. Retro-orbic-ularis oculi fat (ROOF) resection in aesthetic blepharo-plasty: A 6-year study in 63 patients. Plast. Reconstr. Surg. 86:682, 1990.

8. Nicolau, P. J. Long-lasting and permanent fillers: Biomaterialinfluence over host tissue response. Plast. Reconstr. Surg. 119:2271, 2007.

9. Phillips, J. H., Gruss, J. S., Wells, M. D., and Chollet, A.Periosteal resuspension of the lower eyelid and cheek fol-lowing subciliary exposure of facial fractures. Plast. Reconstr.Surg. 88: 145, 1991.

10. Raskin, E., and LaTrenta, G. Why do we age in our face? Aesth.Plast. Surg. 1: 19, 2007.

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