Reply: Facial Contouring by Targeted Restoration of Facial Fat Compartment Volume: The Midface.

Abstract

Sir: We thank Drs. Oranges et al. for their in-depth analysis and comments on our recent article entitled “Facial Contouring by Targeted Restoration of Facial Fat Compartment Volume: The Midface.”1 The concept of facial fat compartments revealed by Drs. Rohrich and Pessa updated our understanding of facial fat distribution,2,3 and the monumental work by Dr. Gierloff further revealed the aging changes of facial fat distribution and volume and explained beautifully the mechanism of facial groove formation in elderly populations.4 These understandings are fundamental for facial rejuvenation by either fat grafting or fillers for both volume restoration and effacement of aesthetically unpleasant grooves. In their letter, Dr. Oranges et al. mention the importance of ethnic consideration during facial rejuvenation when fat grafting or fillers are considered. We concur with this statement. Indeed, in our recent study of masseteric nerve anatomy in Asian populations, we did find ethnic differences in the dissection area for the masseter nerve compared with currently available data from the literature, which are mostly from Caucasian populations (unpublished data). This is because of both the skeletal and the soft-tissue differences between Caucasians and Asians. As already mentioned by Oranges et al. in their article, the Asian individual tends to have a wider but shorter face compared with Caucasian faces.5 What we provided in our article is a general principle of applying the idea of fat compartment–based fat grafting for the midface: to sculpture the facial contour by deep fat compartment restoration and achieve a smooth transition by superficial fat grafting. Fat grafting in the superficial fat compartment can also be very helpful for other cosmetic considerations. To avoid a balloon face, a golden triangle connecting the most prominent point of the zygoma and the mandibular tubercle was also recommended in our article, which concurs with the suggestion by Oranges et al. that fat grafting in Asian individuals should be limited to medial maxilla volumization, to enhance central projection and avoid the creation of facial disharmony by further widening the midface. Indeed, when fat grafting is performed for patients from different ethnicities, the difference of anatomical features should be appreciated. It is also worthwhile to mention that people from different ethnicities and cultural backgrounds possess different views of the aesthetic ideal. Although more Asians tend to appreciate “European beauty” nowadays and want to appear more European, given the anatomical differences stated above, clinicians need be cautious and appreciate the ethnic differences in these scenarios despite the strong desire from the patients, as the improper combination of European and Asian features in one face could appear odd and disharmonious. The “restoration versus augmentation” approach suggested by Dr. Oranges et al. is worthy of taking into consideration when treating patients of different ethnicities. However, a detailed and thorough study might be needed to determine the difference of fat distribution and volume changes in different populations, because both age and body mass index can also be variables affecting the fat grafting plan for each individual, in addition to ethnicity. Before that, either ethnic or individualized appreciation of beauty should be taken into consideration with each individual in the clinic, and thorough analysis and communication are also prerequisite. ACKNOWLEDGMENT This study was supported by the National Science and Technology Pillar Program during the Twelfth Five-Year Plan Period (project no. 2012BA/11B03) and by the State Key Program of the National Natural Science Foundation of China (project no. 81230042). DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. 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.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of China Tanja Herrler, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of ChinaDepartment of General, Trauma, Hand, and Plastic SurgeryLudwig-Maximilian University of MunichMunich, Germany Peijuan Zhao, M.D., Ph.D.Chen Cheng, M.D., Ph.D.Sizheng Zhou, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of China Lee L. Q. Pu, M.D., Ph.D.Division of Plastic SurgeryUniversity of California, DavisSacramento, Calif. Qingfeng Li, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryShanghai Ninth HospitalShanghai, People’s Republic of China