Malar Fat Pad Research Articles

Assessment of deep plane facelift in facial feminization surgery: A prospective pilot study

Facial feminization surgery (FFS) is often the first procedure requested by patients wishing to undergo gender-affirming surgery. This study aims to evaluate the applicability and effectiveness of deep plane facelifts in FFS. The authors conducted a prospective study that included patients who requested a deep plane facelift as a standalone procedure to achieve a more feminine facial appearance as the only procedure of FFS. These patients underwent deep plane facelifts to achieve a more feminine oval face shape and increased tissue projection of the zygomatic-malar region. To assess the effectiveness of the procedure and patient satisfaction, the Face-Q scales, Face and Neck lift Objective Photo-Numerical Assessment Scale, the Satisfaction With Life Scale, and the Subjective Happiness Scale were applied preoperatively and one year after surgery. Thirty-six patients were included in the study. A statistically significant difference (p<0.005) was observed between pre and postoperative scores. The repositioning of the malar fat pads increased the malar volume, providing a more oval overall shape of the face, which is typically feminine. No major complications were observed. Despite our encouraging results, new studies with a larger sample of patients are needed to support the benefits of the deep plane facelift as part of FFS to elevate this technique from an ancillary to a routine procedure for patients undergoing gender affirmation surgery.

Subperiosteal Midface Lift with Sub–Superficial Musculoaponeurotic System Rhytidectomy

The subperiosteal midface lift is a powerful tool that allows the surgeon to reposition the SOOF and malar fat pad in a vertical direction. Additionally, it significantly softens deep nasolabial folds. Its effect, however, is minimal with regards to addressing the jowl, jawline, gonial angle and cervicomental angle. Combining the subperiosteal midface lift with an extended sub-SMAS rhytidectomy addresses the pre-jowl sulcus by releasing the mandibular ligament. The jawline and gonial angle become more defined with the transposition and suspension of the SMAS flap. The SMAS transposition flap along with the suspension of the platysma flap to the mastoid fascia support the submandibular glands and deepen the cervicomental angle. These two approaches are valuable additions to the surgeons armamentarium and can yield excellent results in carefully selected patients.

MODIFIED COMPOSITE PLANE FACELIFT WITH EXTENDED NECK DISSECTION.

The attenuation of retaining ligaments with aging leads to downward displacement of facial fat compartments, and is responsible for many of the stigmata that occur with aging. The zygomatic cutaneous and masseteric cutaneous ligaments prevent the transmission of adequate traction to the malar portion of the dissection during traditional low SMAS facelift techniques which involve plication or imbrication of the exposed surface of the SMAS because they do not include surgical release of these ligaments. Inadequate release of these ligaments, especially the zygomatic cutaneous ligament may lead to an unbalanced, unnatural appearance with unopposed nasolabial folds. In contrast, extended facelift techniques (extended SMAS, High SMAS, deep plane facelift, composite plane facelift) involving the release of these ligaments and can reposition the ptotic malar fat, and diminish the nasolabial folds. Additionally, the composite and modified composite plane facelifts include orbicularis oculi muscle elevation and can achieve a more harmonious rejuvenation. However, due to facial nerve injury risk, many facelift surgeons either inadequately release these ligamentous attachments or prefer less invasive techniques. Modified composite plane facelift allows safe release of the zygomatic cutaneous ligament, and safe entry into the right plane leaving all malar fat pad attached to the skin. Modified composite plane facelift technique also produces combined, balanced, and harmonious rejuvenation of the midface, cheek, lower face, and neck without requiring a separate midface lift procedure or a transblepharoplasty approach. Extending the subSMAS/subplatysmal dissection inferior to the angle of mandible, releasing of the cervical retaining ligaments, and adding a horizontal platysma myotomy below the angle of the mandible significantly improves the cervical contouring and enhances the jawline rejuvenation. This paper explains modified composite-flap facelift with extended neck dissection in a step by step manner, and highlights anatomical details to perform a safe, effective and successful extended face and neck lift surgery.

The Five Ds for Safe and Effective Buccal Fat Removal.

An aesthetically sculpted malar, cheek, and jawline contour is a desirable feature sought out by many adults with central facial adiposity. This fullness, anterior to the masseter, can be attributed to underlying buccal lipodystrophy. An attractive central facial concavity can be delivered by performing buccal fat pad excision in conjunction with malar fat pad augmentation and mandibular contouring if indicated. Appropriate patient selection is critical for preventing an aged or unnatural appearance. The authors present a safe and reliable five-step technique for buccal fat pad excision: the Five Ds.

Enhanced study of facial soft tissues using a novel large scale histology technique.

The safety and effectiveness of facial cosmetic surgery procedures are dependent on detailed 3D understanding of the complex surgical anatomy of the face. Traditional, small sample size anatomical dissection studies have limitations in providing definitive clarification of the fascial layers of the face, and especially in their relationship with the facial nerve, and their reaction to surgical manipulation. The objective study of large tissue areas is required to effectively demonstrate the broader architecture. Conventional histology techniques were modified to handle extraordinarily large tissue samples to fulfill this requirement. Full-thickness soft tissue samples (skin to bone) of maximum length 18 cm, width 4cm, and tissue thickness 1cm, were harvested from 20 hemifaces of 15 fresh human cadavers (mean age at death=81 years). After fixation, the samples were processed with an automated processor using paraffin wax for 156 h, sectioned at 30 μm, collected on gelatin-chromium-coated glass slides, stained with a Masson's Trichrome technique and photographed. Using this technique, excellent visualization was obtained of the fascial connective tissue and its relationship with the facial mimetic muscles, muscles of mastication and salivary glands in 73 large histological slides. The resulting slides improved the study of the platysma and superficial musculo-aponeurotic system (SMAS), the spaces and ligaments, the malar fat pad, and the facial nerve in relations to the deep fascia. Additionally, surgically induced changes in the soft-tissue organization were successfully visualized. This technique enables improved insight into the broad structural architecture and histomorphology of large-scale facial tissues.

Facial skin ageing: Key concepts and overview of processes.

IntroductionThe face is a cosmetically sensitive region where the process of ageing is most clearly manifested. With increased focus on anti‐ageing and longevity, more anti‐senescent treatments are being proposed despite limited evidence. This study outlines the pathways and mechanisms underpinning the biological process of ageing in the face.MethodsComprehensive searches of MEDLINE, EMBASE, Cochrane Library and CINAHL from inception to 2020. Inclusion criteria included all empirical human research studies specific to facial ageing features, written in the English language.ResultsA total of 65 papers met inclusion criteria for analysis. Pathways were subdivided into intrinsic and extrinsic senescence mechanisms. Intrinsic pathways included genetics, generation of reactive oxygen species and hormonal changes. Extrinsic pathways included photoageing and damage to skin layers. The combined intrinsic and extrinsic pathway alterations result in wrinkles, higher laxity, slackness and thinning of the skin. Skin functions such as barrier immune function, wound healing, thermoregulation and sensory function are also impaired.ConclusionThe ageing process is unique to the individual and depends on the interplay between an individual's genetics and external environmental factors. Through understanding the molecular and cellular mechanisms, an appreciation of the consequent structural and functional changes can be achieved. Based on this knowledge, further research can focus on how to slow or impede the ageing process and identify specific targets to develop and evolve new treatment strategies.

System strategy to achieve full-face aesthetic with hyaluronic acid fillers: Yes-lifting and pyramid-volumized approaches

Individualized strategies are becoming critical for full-face aesthetics, especially for rejuvenating the aging face. This study aimed to assess the clinical outcomes following the Yes-lifting and Pyramid-volumized approaches with hyaluronic acid (HA) fillers. The Yes-lifting and Pyramid-volumized approaches represent the author's clinical experience of facial contouring techniques. The Yes-lifting method focuses on lifting the full-face using sharp needles to inject an appropriate volume of HA at 9 different positions, while the Pyramid-volumized method mainly refills the soft tissue with HA through a blunt cannula at 8 areas. These techniques are chosen based on patients' needs. After Yes-lifting treatment, the patient had an appreciable change to the face, which included lateral structural changes of the full-face and the support of deep malar fat pads. The oblique view exhibits improved zygomatic arch, a nicer jaw angle and chin-elongation and a more defined jawline. For another patient treated with the Pyramid-volumized approach, the facial shape improved immediately after treatment, with improvements in the bitemporal, bizygomatic, binasolabial fold, diminished T-troughs and chin. With pyramid-volumizing strategy, the patient looked more confident due to lateral structural changes of the full-face and the support of deep malar fat pads. The oblique view exhibits improved zygomatic arch, a nicer jaw angle, highlighted lips and a more defined jawline. Based on our experiences using the Yes-lifting or Pyramid-volumized technique can effectively improve aesthetic outcomes and provide a platform for user-friendly algorithms to help clinicians perform the facial contouring techniques, particularly for the Asian population.

The Art and Science of Extended Deep Plane Facelifting and Complementary Facial Rejuvenation Procedures

Dr Jacono and the team at Quality Medical Publishing (St. Louis, MO) have produced a handsome volume dedicated to his personal surgical approach to the treatment of facial aging. The book, at 500 pages, closely follows the size, format, and high standard established by previous QMP hardcover books in aesthetic surgery, with plenty of beautiful illustrations and clinical color photos, and easy-to-read text. The first portion of the book focuses on Dr Jacono’s approach to facelifting. Dr Jacono, a respected facial plastic surgeon from New York, has been developing and refining this technique for over a decade. The first 4 chapters add up to nearly one-half of the book and thoroughly discuss the rationale, safety, and effectiveness of the technique; the relevant surgical anatomy; anatomic changes associated with aging; and the facelift technique itself, which is the longest chapter and very comprehensive. For those unfamiliar with the author’s facelift approach, I will try to summarize. First, the “deep plane” portion of the title is a reference to the work of Dr Sam Hamra, who in 1990 published a paper with a then-new technique utilizing that particular title. Like Dr Hamra’s method, Dr Jacono’s dissection into the deep plane starts on a line between lateral canthus and the angle of the mandible, dissecting deep to the malar fat pad and superficial musculo-aponeurotic system (SMAS), and over the mimetic muscles forward to the naso-facial crease. This develops a composite flap, which is not delaminated or separated from the skin, as in most lateral SMAS-based techniques. Jacono’s procedure differs from that discussed in Hamra’s 1990 paper in several key aspects: he performs a sub-platysmal dissection in the neck, beginning laterally and extending 5 cm below the angle of the mandible, and then makes a 4-cm superior platysmal myotomy, approximately 1 cm below the mandibular border, which is employed to contour the neck. Jacono also stresses the need to release the facial retaining ligaments—the zygomatic cutaneous, masseteric cutaneous, mandibular cutaneous, and cervical retaining ligaments—to obtain appropriate tissue mobility. He describes his anatomic approach to do so in detail, because these ligaments are so often in proximity to facial nerve branches. Numerous intra-operative photos are shown, detailing each step of the procedure, with pearls on incision placement, flap elevation, sub-SMAS dissection, fat contouring, and suspension of the flap and skin closure, and multiple cases are shown with long-term follow-up photos. Interested readers can get a flavor for the book by looking at the author’s recent publications in Facial Plastics Clinics of North America and ASJ.

Special Considerations in Chinese Face-Lift Procedure: Insights From a 15-Year Experience of 1026 Cases.

There is extensive literature on different face-lift techniques; however, few articles published in the English language address the particularities of the face-lift for Chinese patients. Because of differences in facial anatomy, facial aging, and patient expectations, facial rejuvenation procedures for Chinese patients can be quite different from those of White patients. The study includes 1026 consecutive primary face-lift cases performed by the senior author (D.Y.) from 2006 to 2019. Of these, 1010 patients were female and 16 were male. The average age of the patient at the time of primary face-lift was 40.5 years. The face-lift procedures included midface lift in 108 cases, midface and lower-face lift in 882 cases, and midface and lower-face lift with brow lift in 36 cases. All patients received superficial musculoaponeurotic system (SMAS) treatment, in the form of lateral SMASectomy in 607 cases, high-SMAS technique in 84 cases, modified high-SMAS short-scar technique in 108 cases, minimal access cranial suspension technique in 38 cases, and modified minimal access cranial suspension technique in 189 cases. Photographs of patients were analyzed to assess persistent features of facial aging. Complications such as hematoma, skin slough, infection, and nerve injury were also reviewed. Most patients obtained consistently good results with minimal risk and complications. All surgical techniques discussed were safe and reproducible, providing various options for surgeons. Special attention should be taken when planning a facial rejuvenation procedure for Chinese patients. Anatomic variations dictate a greater emphasis on the management of tissue ptosis, particularly regarding lateral brow descent and malar fat pad descent. In our practice, various face-lift techniques can produce excellent results. Surgeons must adopt a technique that serves patients well and is, ideally, safe, consistent, easily reproducible, and applicable to various anatomic problems. In addition, every surgery is customized to the patient's anatomy and concerns. Therefore, the surgeon must adopt individualized technique according to the needs and desires of each patient.

A minimally invasive midface suspension

Aim: With the normal aging process, the malar fat pad descends vertically, causing a number of characteristic changes to the face. Various techniques have been used to correct ptosis of the malar fat pad.

[Nasolabial suspension of the malar fat pad: a new, minimally invasive and reversible technique for facial symmetrization in permanent facial paralysis].

Introduction: For the treatment of asymmetry of the midface due to permanent peripheral facial nerve palsy of different etiologies - which means a great psychical burden for the patients - several surgical solutions have been described. Aim: Our goal was to elaborate a minimally invasive surgical technique, that, on one hand, restores an adequate nasolabial fold, which is the most determinative keystone of facial symmetry. On the other hand, our technique can give an appropriate lift for the malar fat pad with shorter operative time and burden, with much lower complication rate and shorter recovery period compared to the classic static sling suspension techniques. Method: Out method is based on the formation of a neo-nasolabial fold, which is then suspended to the temporal fascia by permanent threads thus restoring facial symmetry and giving a lifting effect on the midfacial soft tissues as well. Results: Between 2014 and 2017, six patients had been operated with this nasolabial lifting technique of the malar fat pad without any major complications under local anesthesia on an outpatient basis at our Department. Conclusions: As our surgical exploration is minimal, the postoperative period is shorter, no visible scars remain on the face and the complication rate is negligible. If necessary, suspension could easily be adjusted, and as the technique is reversible, no other possible facial reconstruction methods are excluded. Our method can symmetrize the face in resting position completely on the long term, which is the most important issue for our patients according to their feedback. Orv Hetil. 2019; 160(22): 869-872.

A Preliminary Clinical Trial Comparing Split Treatments to the Face and Hand With Autologous Fat Grafting and Platelet-Rich Plasma (PRP): A 3D, IRB-Approved Study.

Numerous methodologies have been suggested to enhance fat graft survival, but few long-term studies are available. The authors of this institutional review board-approved study investigated the safety and efficacy of utilizing platelet-rich plasma (PRP). Each of 10 patients received equal volumes of syringe-harvested, centrifuged fat to opposing midfaces with a lateral submuscular aponeurotic system-plication or no face lift and hands that were combined with equal volumes of either concentrated PRP or normal saline. Comparable assessments of fat retention/baseline values by 3D Vectra Analysis, VISIA, and Cortex facial skin analyses were performed. Clinical results were judged on a visual analogue scale. The average percent change in mean volume assessments at the fat/PRP sites from baseline values, as profiled by 3D Vectra Analysis, demonstrated a higher, but statistically nonsignificant value over 1 year than the percent value changes at the fat/normal saline sites in the opposing face or hand. Three independent evaluators were able to assess volume restorations to the malar fat pad, naso-jugal groove, and nasolabial fold as well as to intermetacarpal hollowness with reduction of visible veins and tendons in the anterior midface and hands with both treatments. No adverse events were observed over the year-long study. Perioperative edema, erythema, bruising, and tenderness lasted up to 1 to 2 weeks at most. Autologous fat grafting continues to be a safe and effective adjunct in facial and hand aesthetic surgery. This study will require more patients and longer follow-up periods to determine whether PRP has a potential role to increase fat graft retention in aesthetic patients.

Periauricular Purse-String Reinforced with SMAS plication and Malaria Fat Pad Elevation for Mid-and Lower Facial Rejuvenation: FACE-Q Report.

Facial aging is a complex process influencing every layer of the facial structure. Most accepted surgical techniques for facial rejuvenation involve certain manipulation of the superficial musculoaponeurotic system (SMAS). Out of these SMAS-based techniques, SMAS plication or suspension provides excellent outcomes with shorter convalescence and fewer potential complications. Herein, we would like to present our own technique combining SMAS plication, periauricular purse-string, and malar fat pad elevation technique for mid and lower facelift. Through a classical periauricular and temporal incision, a periauricular permanent purse-string suture was woven into the SMAS to suspend sagging soft tissue of the mid and lower face after superficial undermining, then plication of inner and outer SMAS of the purse-string loop was performed to further secure suspension, and at last the malar fat pad was elevated for midface rejuvenation. The shape of the loop varies with patients' age; for younger patients, the loop is more vertical, and for older patients, the loop is more horizontal. Patient-reported outcomes were described using the FACE-Q questionnaire. From January 2010 to June 2015, a total of 138 patients were treated with this technique by a same surgeon. Follow-up duration ranged from 1 to 6 years. Preoperative and postoperative photographs were recorded and analyzed. The complications rates were low, and satisfaction rates were high. Patients felt that they appeared 7.3 years younger than their actual age on average and were most satisfied with the appearance of their lower face and jawline. Periauricular purse-string reinforced with SMAS plication and malar fat pad elevation technique produces esthetically pleasing outcomes, besides being simple, safe, and personalized.

Selecting the Best Eyelid Techniques.

The periorbital region is a focal point on the face. Dermatochalasis, fat herniation, blepharoptosis, brow ptosis, deep tear troughs, and malar fat pad descent are all age-related changes that occur around the eyes, and successful rejuvenation involves addressing all of these changes. Restoring a youthful, vibrant appearance to the eyes and periorbital areas can often only be accomplished with a combination of surgical and nonsurgical interventions. Facial plastic surgeons should have a comprehensive knowledge of all of these options and their applications to ensure good patient outcomes and satisfaction.

Modified Composite-Flap Facelift Combined With Finger-Assisted Malar Elevation (FAME): A Cadaver Study.

Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches. In the authors' surgical practice for modified composite flap rhytidectomy, the authors employed the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. The aim was to evaluate the anatomical basis and safety measures of this technique through a cadaveric dissection study. Modified composite-flap facelift with the FAME technique was carried out in 22 fresh cadaver hemi-faces. All facial nerve subbranches were dissected thoroughly to assess for any evidence of injury during facelift, and to evaluate the safety of the operation. The relations among the facial nerve, zygomatic cutaneous and masseteric ligaments, orbicularis oculi muscle, and malar fat pad were investigated. Finger dissection of the prezygomatic space allows safe release of the zygomatic cutaneous ligaments as well as adequate entry to a proper surgical plane above the zygomatici muscles under direct vision, while leaving the malar fat pad and overlying structures attached to the skin without the need of a transblepharoplasty approach. This study by the authors shows that a modified composite-flap facelift with FAME technique is a safe procedure that allows adequate and effective repositioning of an en-bloc composite flap that produces balanced and harmonious rejuvenation of the midface and lower face without the need of a separate midface lift.

Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution

Sir: In the August of 2017 issue of Plastic and Reconstructive Surgery, Wong and Mendelson published an interesting article in which the authors described in detail their methods of subtotally releasing the tear trough ligament and the orbicularis retaining ligament and redistributing the free orbital fat for the correction of the tear trough (lacrimal groove, nasojugal crease) and palpebromalar groove (lid-cheek junction) through the transconjunctival approach.1 Because the authors and we have similar treatment subjects (mainly Asians), and the periorbital rejuvenation is a subject on which we have worked intensively, we would like to share our thoughts about this technique. Wong and Mendelson have been consistently committed to studies of the anatomy of the periorbital region and midcheek and the antiaging treatments of the middle face.1–4 Their research achievements and surgical techniques of course contribute to better understanding the structures of these regions and choosing the optimum surgical procedure. The tear trough deformity is considered to be directly associated with the tear trough ligament, and the formation of the palpebromalar groove is mainly attributable to the orbicularis retaining ligament.2 It is also well known that the degree of infraorbital groove depends on the status of the tissue above (i.e., eye protrusion, prominence of the orbital fat pads, and looseness of the orbicularis oculi muscle and skin) and below (i.e., atrophy and descent of the malar fat pad and retrusion of maxillary) this furrow. Once the groove is seen, does it have to deal with the region? Everyone has the structure of the tear trough ligament (although it may be fragile and thus invisible), and almost all of the patients with eye bags have different degrees of prominence of the nasojugal crease. With these factors in mind, it is important for us to classify the tear trough deformity according to the morphologic features of the lacrimal groove and the situations of the surrounding tissue (because of the limit of article length, this section is not described here in detail). In other words, a judgment of which factor (i.e., the tear trough ligament, the surrounding tissues, or a combination of them) plays the major role in increasing the prominence of the tear trough must be correctly made preoperatively. In the article by Wong and Mendelson,1 the extended transconjunctival lower eyelid blepharoplasty with ligament release was performed on the patient (shown in Fig. 11) who had a mild eye bag and a slight tear trough even when smiling on the frontal view. According to our experience, we usually attribute the formation of this type of crease to the protruded orbital fat compartment. We do believe that transconjunctival blepharoplasty only with orbital fat removal can achieve a similar effect. The tear trough deformity that is visible in the static condition should be treated by ligament release, as shown in Figures 6 through 10. However, the surgical approach should be appropriately selected based on the laxity of the orbicularis oculi muscle and skin. Thus, we think that a transcutaneous approach may be preferential for the patient shown in Figure 10. Skin removal and tightening/suspending the orbicularis oculi can be performed simultaneously for better cosmetic outcome. It has been widely accepted that lifting is an essential step after releasing the tear trough ligament and orbicularis retaining ligament for treatment of the aging middle face, and that tissue suspension or repositioning seems unnecessary following the release of the two ligaments when aiming at correcting the periorbital groove. Although releasing the ligament does not lead to tissue ptosis in young patients or in short-term follow-up (as most of the cases presented in previously published articles), it is uncertain whether such a release procedure without suspension or repositioning will contribute to tissue ptosis over a long observation period such as 10 or 20 years. After all, a ligament, although it may create a depression or a crease/groove, may play a role in balancing the related tissue and preventing ptosis of tissue. DISCLOSURE The authors declare no potential conflicts of interest with the respect to the research, authorship, or publication. Qianwen Wang, M.D., Ph.D.Jiaqi Wang, M.D.Head & Neck Cosmetic Surgery CenterPlastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing, People’s Republic of China

LCL: (Locked Cheek Lift) Three-Dimensional Cheek Lift and Inferior Palpebral Rejuvenation.

Many recent advances in face lift techniques have been made to reverse the aging process of the mid-face. In this study, we present a new technique by which mid-face rejuvenation can be achieved in double-angle vectors and allows adaption to the underlying bony structure. The locked cheek lift (LCL) allows effective, simple and rapid lifting of the malar fat pad in two planes. Correction of the curvature of the face and reduction of the height of lid cheek junction distance can be achieved without an incision at the lower eyelid. In total, 115 patients (77 females and 38 males) have been operated on using the LCL technique by a single surgeon; patient ages ranged between 37 and 71years old (average=51). Follow-up was performed by the same team for a year postoperatively. The facial expression and lid cheek distance have been evaluated during this period. After a year from the operation, the lid cheek distance correction was maintained in 95.7% of the cases, with stable position of the ascended malar fat pad. Postoperative edema and ecchymosis were limited. LCL is an effective, simple and rapid surgical technique, which is capable of correcting the cheek gravitational migration, reducing the lid cheek distance (LCD), maintaining the ascended stable malar fat pad for a long time with a short recovery period and minimal risk of complications. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Approach to the Thick Nasolabial Folds, Jowls and Heavy Neck-How to Approach and Suspend the Facial Ligaments.

Patients with thick skin typically present with a redundant, baggy, lax skin envelope together with prominent nasolabial folds, jowls, and a heavy neck. Durable and natural-appearing rejuvenation is not possible unless the deformities are addressed adequately and harmoniously in these patients. Traditional superficial musculoaponeurotic system techniques do not include surgical release of the zygomatic cutaneous ligaments and repositioning of descendent malar fat pad, and may lead to an unbalanced, unnatural appearance and the lateral sweep phenomenon. Additional attempts to improve unopposed nasolabial folds such as fat grafting to malar region are more likely to result with a "stuffed" look, far from a natural and rejuvenated appearance, and must therefore be avoided. The facelift techniques including true release of the anchoring ligaments of the midface and allowing adequate repositioning of saggy tissues are ideal for these patients to obtain harmonious, natural result. Despite the extensive dissections, maximal release, and maximal lateral pull, additional maneuvers, e.g., platysmaplasty, subplatysmal fat removal, or partial resection of submandibular glands may be required for satisfying result in patients with heavy neck. In this article, the authors outline the relevant anatomy of the facial retaining ligaments and their implications to surgical management of patients with heavy skin are discussed.

Facial Layers and Facial Fat Compartments: Focus on Midcheek Area.

AbstractFacial cosmetic procedures are doubtless in constant augmentation directly related to fillers and botulinum toxin injections. Many articles are published in the literature to warn about the complications of these aesthetic procedures. The need for a clear anatomic classification and review of deeper ultrastructural studies on adipose tissues in the midface area are obvious. This study aims: (1) To present midface anatomy of clinical relevance in a practical way for surgeons and cosmetologists. (2) To analyze the facial fasciae related to the fat compartments. (3) To show pictures of anatomic dissections of these anatomic structures. (4) To suggest an anatomic classification. The authors analyzed the facial anatomic layers and the facial fat compartments through facial anatomical dissections and experience in the field of facial surgical and cosmetic procedures. The authors propose a dynamic three-dimensional concept of facial layers related to muscle actions and facial fat compartmentalization in the midcheek area. A “lip–lid” superficial system associated with the malar fat pad represents the first layer; two deeper lip levator systems stratification explains the deep fat compartments as an anatomic division related to fasciae extensions. Facial grooves and segments correspond to these systems action. Moreover, the importance of ultrastructural studies has been underlined.

Use the technique of three layers suspension to lift the mid-low face

Objective To explore an ideal surgical method for mid-low face lifting. Methods In this procedure, the first surgical step was subcutaneous undermining that was performed through the incision along temporal hairline, anteriorear, and mastoideae. It extended distally beyond the furthest skin fold and along the mandibular border or the midline of the neck if nacessary. Then three layers suspension were performed, which included three procedures: first, SMAS was purse string sutured in certain direction; secondly, the malar fat pad was suspended to tow directions backward and upward and anchored in the periosteum of zygoma and SMAS too; lastly, through traction suture of reducing tension step-by-step, lots of the tension was relieved from the incision; at the same time, new retaining ligaments between flap and SMAS were reestablished. And redundant skin was removed in incision at the end of the procedure. Results A total of 22 cases received this operation. 16 cases were followed up from 3 months to 24 months after operation. The results of operation were divided into three degrees: excellent, acceptable and poor; and those were evaluated by patients themselves. 14 cases obtained excellent result (87.5%) , 2 cases regarded that their results were acceptable (12.5%). The total satisfactory rate was 100%. None serious complication occurred in those cases except some slight complications, such as local edema, skin numbness and small hematoma which relieved in 3 to 6 months after operation. Scar was inconspicuous. Conclusions This technique can correct the posies of lower tow-third face better, especially for mitigating the nasolabial fold and enhancing the elastic of face skin. Simultaneously, it is an effective, safe and simple technique. Key words: Face lift; Superficial musculoaponeurotic system; Malar fat pad