Malar Fat Pad Research Articles

New Insights into the Anatomy of the Midface Musculature and its Implications on the Nasolabial Fold.

The prominent nasolabial fold is a distinct feature of the aging midface. As minimally invasive procedures have become mainstream, chemodenervation is a preferred method for treating dynamic facial rhytids. We therefore sought to identify relevant nasolabial fold and midfacial muscular anatomy to determine the ideal location of neuromodulation to improve the aesthetics of the midface and nasolabial fold without altering the upper lip and smile. Twelve hemifacial cadaveric dissections were performed to identify midface muscle origin, insertion, width, vector of pull, and neighboring structures. Attention was focused on the levator labii superioris alaeque nasi (LLSAN), levator labii superioris (LLS), nasalis, and orbicularis oculi. Measurements were obtained based on surface landmarks including the medial canthus for future neurotoxin injection. The LLSAN inserts into the medial nasolabial fold and alar base, while the LLS inserts into the middle third of the nasolabial fold. The broadest portion of the superior LLSAN was on average 8.4mm inferior and 4.6mm medial to the medial canthus. A separate muscle obliquely oriented between the orbicularis oculi and LLSAN was identified and found to insert into the malar fat pad. This "malar levator" was present in all specimens and has implications on medial periorbital rhytids and the tear trough deformity. This study further defines midfacial and nasolabial fold muscular anatomy and provides new insights into the use of neuromodulators for these areas without affecting upper lip position. The malar levator muscle appears to be a separate midfacial muscle with independent action. 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 .

Abstract: New Insights for Botulinum Neuromodulator Targets for Correction of the Nasolabial Fold and Midface Rhytids: An Anatomic Study and Introduction of the Malar Levator Muscle

BACKGROUND: An acute nasolabial angle and prominent medial nasolabial fold are features of the aging midface.1 The medial nasolabial fold is a difficult area to correct and is not easily addressed by current facelift procedures. As minimally invasive procedures are becoming mainstay in aesthetic surgery2, botulinum toxin has become a preferred method for treating dynamic facial rhytides. We therefore sought to identify relevant nasolabial fold and midfacial musculature anatomy to determine the ideal location of neurotoxin injection for patients with prominent nasolabial folds and midface rhytids. METHODS: Twelve hemifacial cadaveric dissections were performed to expose the midfacial muscles and identify their origin, points of insertion, relationship to surrounding musculature, greatest width, and vector of pull. Particular attention focused on the levator labii superioris alaeque nasi (LLSAN), levator labii superioris (LLS), nasalis, and orbicularis oris. Measurements were obtained based on palpable surface landmarks, including the medial canthus, for future neurotoxin injection. RESULTS: The central portion of the LLSAN was located 8.4 (+/- 0.9) mm inferior and 4.6 (+/- 0.8) mm medial to the medial canthus. Insertion sites included the medial nasolabial fold and alar base. The LLS has a broad insertion into the middle third of the nasolabial fold before extending to meet the obicularis oris at a point 4.5 (+/- 0.4) cm inferior and 5.9 (+/- 0.8) mm lateral to the medial canthus. We also uncovered a tubular muscle, obliquely oriented between the orbital obicularis oculi and the LLSAN, separated by adipose tissue, with its cephalad origin in continuity with the LLSAN and its insertion into the malar fat pad. This so-called “malar levator” was found in all twelve specimens and diverges from the LLSAN 8.7 (+/- 2.1) mm inferior and 2.8 (+/- 0.5) mm lateral to the medial canthus. The effects of this muscle on medial periorbital rhytids and the tear trough deformity were observed in the live patient. CONCLUSION: This cadaveric study further defines the musclular anatomy of the midface and medial nasolabial fold and provides new insights into the use of neuromodulators for midfacial rhytids, tear trough deformity, and the medial nasolabial fold, all of which are challenging areas to correct with current surgical techniques. Neuromodulators may be sufficient to provide a youthful midface and soften the snarl appearance that comes with age, without affecting the upper lip. REFERENCES: 1. Pessa JE: Improving the acute nasolabial angle and medial nasolabial fold by levator alae muscle resection. Ann Plast Surg. 1992; 29:23–30. 2. American Society of Plastic Surgeons. 2015 plastic surgery report. 2000/2014/2015 national cosmetic procedures. Available at: http://www.plasticsurgery.org/Documents/news-resources/statistics/2015-statistics/cosmetic-procedure-trends-2015.pdf. Accessed February 26, 2016.

Combining eyebrow and inferior palpebral margin incision for the facial rejuvenation in the upper eyelid and midface region

To investigate a simple, minimally invasive and effective operative method for the facial rejuvenation in the upper eyelid and midface region. Blepharoplasty was combined with suspending orbicularis oculi muscle flap and fixing it on the periosteum underneath the eyebrow through eyebrow incision. Meanwhile, for midface rejuvenation, inferior palpebral margin incision was performed and prezygomatic interspace was separated completely under the orbicularis oculi muscle. The under-eye puffiness and tear trough deformity were corrected through releasing orbital fat, reposition and fastening orbital septum, and transposition of orbicularis oculi muscle flap. And the deep sulci nasolabialis and cheek anetoderma were relieved by dual lifting of malar fat pad and orbicularis oculi muscle flap. Follow-up was taken at the 1 week,3 months,6 months,1 year,2years and 3 years after operation. Each case was evaluated with postoperative effect, reprocessing time and postoperative complications and underwent photography. From Feb.2010 to Oct.2014,190 patients (9 male,181 female, an average age of 49.03 ± 5.67 years) underwent this operation. Obvious improvement on the upper eyelid and midface region was achieved in all the patients after operation without serious or irreversible complication Combining eyebrow and inferior palpebral margin incision, through suspending the malar fat pad and orbicularis oculi muscle flap at the same time, as a simple, minimally invasive and reliable method, can strengthen the effect of the facial rejuvenation in the upper eyelid and midface region markedly.

Purse-string suture of imbrication of SMAS and malar fat pad technique for midface and lower face lift

To discuss the rhytidectomy technical improvements and clinical efficacy and safety, using the purse-string imbrication suture in midface and lower face lift. The absorbable purse-string suture was used in a pure antigravitational direction for correction of the aging middle and lower parts of the face. The volume of cheeks and jowls was repositioned in a cranial direction with a first, slightly oblique purse-string suture on SMAS. To correct the nasolabial fold, the face-lift was performed by adding a second malar vertical purse-string suture between the paracantbal area and the malar fat pad. From July 2009 to May 2014,52 patients underwent this technique for facial rejuvenation with obvious effect and high satisfactory rate. There was only two minor complication of hematoma. The Purse-string imbrication suture in the rhytidectomy produces a natural face lifting through a better correction of the sagging tissue and restoration of the volume of the face. This is a simple technique with good results, short down-time, and high patient satisfactory rate.

Anatomical Differences in Ethnic Facial Aging – Clinical Implications

INTRODUCTION: Projections to the year 2050 estimate a non-Caucasian ethnic majority in the United States. As per American Society of Plastic Surgeons Statistic Reports from 2005 to 2014, there has been an 111% increase in cosmetic procedures performed on non-Caucasians.1 Since the face is the most immediately discernible sign of aging, we attempt to summarize current available literature pertaining to ethnic facial aging and its impact on current anti-aging therapies. METHODS: A literature search was performed in the PubMed/Medline database for studies linking facial aging and ethnicity using MeSH headings including ‘ethnic’, ‘aging’, ‘face’, ‘African’, ‘African American’, ‘Caucasian’, ‘Asian’, ‘Indian’, ‘Hispanic’, and ‘Middle Eastern’. A total of 23 electronic publications were selected with subsequent manual bibliographic searches. Data on anatomical differences and variations were noted and recorded. Treatment recommendations, in an algorithmic form, were compiled. RESULTS: The majority of available literature compares ethnic groups to a Caucasian standard. Asian skin has thinner stratum corneum and higher levels of melanin that confer a greater risk of post-inflammatory hyperpigmentation. Overall, the combination of thick skin, heavier malar fat pads, and weaker skeletal support of the Asian face makes laxity more severe with aging and greater gains can be achieved with more comprehensive surgical techniques such as cervico-facial rhytidectomy. Less data is available for the Hispanic group, however prominent midface structure and yellow skin coloration create the need for focused techniques targeting prominent nasolabial folds yet minimally invasive to avoid hyperpigmentation and prominent scarring. Africans and African Americans have possibly the highest intervariability of facial dimensions but a thicker skin envelope and superficial melanin granules confer photoprotection but also a higher propensity to form keloids and pigment changes. A hypoplastic midface results in localized periorbital and midface aging in contrast to greater periocular changes and cervicomental blunting. Age-related prevention and treatment is therefore preferentially targeted to those areas using a careful selection of minimally invasive procedures and careful use of chemical and nonalabative laser resurfacing. CONCLUSION: Although limited, current literature strongly suggests discernible and predictable differences in facial aging across ethnic groups. Given the increasing availability and acceptance of aesthetic plastic surgery by various ethnic groups, understanding ethnic anatomical variability and its effect with aging will allow the surgeon to better understand and tailor a safe and effective care plan for each individual patient.

Fat repositioning in lower eyelid blepharoplasty.

Fat preservation and grafting techniques have gained popularity in lower eyelid blepharoplasty because surgeons recognize the failure of fat removal to address the tear trough deformity.1-4 Analogous to addressing brow ptosis when considering upper eyelid blepharoplasty, patients who present with requests for lower eyelid rejuvenation most often have accompanying midface descent. A tear trough deformity usually results from the descent of the suborbicularis oculi fat (SOOF) and malar fat pad, which produces skeletonization of the inferior orbital rim. An additional irregularity, the double convexity deformity, may occur as a result of lower eyelid pseudoherniated orbital-fat convexity above the inferior orbital rim and tear trough followed by the descended SOOF and malar mound convexity.5 We define fat repositioning as the repositioning of the lower eyelid pseudoherniated orbital fat inferiorly over the orbital rim, repositioning the SOOF superiorly over the orbital rim, or a combination of both techniques. We believe that this repositioning is a more physiologic approach to the sequela of the aging lower eyelid–cheek complex.

Malar fat pad suspension through intraoral approach: a personal technique

Background For decades, facelifting has been the gold standard for facial rejuvenation. However, there is a current tendency towards new and less complex procedures. The reposition of the malar fat pad plays a central role to restore a convex mid-face contour, and until now, it has been achieved mainly through large incisions or endoscopic techniques.

Chirurgische Behandlung von Festoons

The well introduced surgical techniques of lower lid blepharoplasty can only repair aesthetic problems between the lid margin and the orbital rim. The neighbouring malar area is located outside the orbit and requires specialised procedures to reposition the sunken malar orbicularis muscle (festoon) and the malar fat pad. A small incision at the lateral canthus provides the access to combine three procedures: transconjunctival lower lid blepharoplasty, lateral canthoplasty and malar lift.

Anatomical studying of the tear trough area

To explore the mechanism of the aging deformity of tear trough through the anatomic study of the tear trough region. 13 adult cadaveric heads (26 sides), including 9 male heads (18 sides) and 4 female heads (8 sides), aged 22-78 years old, were used. Anatomic study was performed around the orbital, especially tear trough region, with microsurgery instrument under microscope( x 10 times). The lower orbicularis retaining ligament was dissected and exposed. The anatomic location was recorded and photographed. (1) The anatomic layers of the tear trough region contains skin, subcutaneous tissue, orbicularis oculi muscle, periosteal membrane. There is no subcutaneous fat above the tear trough, while it exists below the tear trough, called malar fat pad. (2) There is a natural boundary between the septal and the orbital portions of the orbicularis oculi muscle of lower eyelid at surface of the orbital bone. The natural boundary, projected on the body surface corresponds to tear trough. The width of boundary is (2.06 +/- 0.15) mm on the vertical line through inner canthus and (3.25 +/- 0.12) mm on the vertical line through the lateral margin of the ala. The septal portion and the orbital portion of the orbicularis oculi muscle began to merge in (16.56 +/- 0.51) mm to inner canthus. (3) There is ligament attachment in the medial, upper and lower orbital and no ligament attachment in the lateral orbital. Orbicularis retaining ligament of lower eyelid is divided into two layers. (4) The medial of the upper layer of the orbicularis retaining ligament in lower eyelid originates from orbital margin and from preorbital walls laterally in (16.10 +/- 0.43) mm to the medial of lateral orbital margin, through orbicularis oculi muscle and ends at the skin. The lower layer of the orbicularis retaining ligament of lower eyelid originates from preorbital walls through orbicularis oculi muscle and its superficial fat, then ends at the skin. The length of tear trough is (16.56 +/- 0.51) mm, the width of tear trough is (2.06 +/- 0.15) mm and (3.25 +/- 0.12) mm on the vertical line through inner canthus and the lateral margin of the ala nasi respectively. The main reason of the aging deformity of tear trough attributes to the increased distance between the upper and lower layers of the orbicularis retaining ligament in lower eyelid, which is caused by loose of the orbicularis retaining ligament and its underlying fat atrophy or decline.

Tear Trough and Palpebromalar Groove in Young versus Elderly Adults

The tear trough and palpebromalar groove are of increasing interest to plastic surgeons, but their mechanisms of formation remain unclear. This study evaluated the anatomical foundation for tear trough and palpebromalar groove. Sagittal dissection and layered dissection were performed on 20 elderly cadaveric hemifaces with obvious tear troughs and palpebromalar grooves and on 16 young cadaveric hemifaces without obvious tear troughs and palpebromalar grooves. Cross-sectional specimens and tissue sections were compared between the two groups to identify the differences. The malar fat pad becomes atrophic and descends with aging. The orbicularis retaining ligament arose from the inferior orbital rim and ended at the junction of palpebral and orbital portions of the orbicularis oculi muscle. The ligament limited the descent of the orbicularis oculi muscle. The orbicularis retaining ligament continued with the origin of the orbicularis oculi muscle and the dense muscular attachment arose from the maxilla. Histologic evaluation confirmed the ligamentous features of the orbicularis retaining ligament. The orbicularis retaining ligament plays an important role in formation of the tear trough, and atrophy and descent of the malar fat pad make the tear trough and palpebromalar groove more obvious with aging. These findings may be of value in blepharoplasty and midfacial rejuvenation.

Is the malaris muscle the anti-aging missing link of the midface?

BackgroundThe malaris muscle is a superficial and fine facial muscle. It is not well known because of its inconsistency in Caucasians. It could play a role in midface aging prevention as that observed in subjects with prominent cheekbones like Asian people. The purpose of this study was to explain how the malaris muscle is able to produce an anti-aging effect on the midface.MethodsWe first analysed a hundred pictures of human faces of different age sex and race to better comprehend identifying characteristics of aging in particular of the midface. Then anatomical dissections were done on fresh cadavers to identify the malaris muscle associated with radiological studies. Finally, in vivo experiments with botulinum toxin A (Botox) and lidocaine (Xylocaine) permitted to precise the action of the malaris muscle on the midface and principally on the malar fad pad.ResultsThese anatomical and functional studies demonstrated that the malaris muscle acts as a dynamic link between the Superficial Muscular Aponeurotic System (SMAS) of the upper part of the face and the SMAS of the midface, producing a lifting effect of the soft tissues of the cheek particularly the malar fat pad. This action is the due to presence of the dermal terminations of the malaris muscle.ConclusionsThe malaris muscle could be an anti-aging link of the midface. Our findings suggest a new approach for the comprehension of the global facial aging.

An Analysis of Malar Fat Volume in Two Age Groups: Implications for Craniofacial Surgery

Objective To evaluate how malar fat pad (MFP) volumes vary with age, after controlling for gender and body mass index (BMI). Study Design A prospective case-control study evaluating volume of the MFP in women of two age groups. Methods Soft tissue dimensions were measured in eight subjects using magnetic resonance imaging. A multiplanar localizing sequence, followed in sagittal and coronal orientations using a turbo spin echo sequence, was performed to define the MFP. Volumetric calculations were then performed using a 3D image analysis application (Dextroscope, Volume Interactions, Republic of Singapore) to circumscribe areas, orient dimensions, and calculate volumes of the MFP. Results These data reveal no significant difference in the mean (standard deviation) right MFP (p = 0.50), left MFP (p = 0.41), or total MFP (p = 0.45) volumes when comparing the two age groups. In addition, these data indicate that there was no correlation between age and total MFP volume (Pearson correlation coefficient 0.27). Moreover, there was no correlation between age and the ratio of total volume/BMI (Pearson correlation coefficient -0.18). Conclusions Although the sample size of this study was small, these data indicate that ptosis of midfacial fat is more important than volume loss in midfacial aging. These data would suggest repositioning as the primary modality for craniofacial reconstruction.

Design de novo instrumento cirúrgico para ritidoplastia: agulha para suspensão do SMAS

This article describes an alternative surgical instrument that can be used for suspension of the malar fat pad. The needle was created using Kirschner wire to ensure that both tips were blunt. The double tip allows for passage of the wire through the superficial muscular aponeurotic system, ensuring that the suture is sufficiently deep to avoid dermatography. The utility of the new instrument was tested in rhytidoplasties involving minimal dissection. The needle described herein was proven safe, and could easily migrate through the tissues, without creating vascular and nerve lesions, and facilitate the positioning of the fixation points at the intended sites. The use of this needle for rhytidoplasty was quick, simple, and cost-effective, without any resulting dissection or damage to the anatomical structures or tissues.

Thirteen Years of Experience With the Endoscopic Midface Lift

Numerous techniques have been used to rejuvenate the aging midface. The Endotine midface technique involves an endoscopic temporal approach, including midface dissection and malar suspension with fixation. The Endotine device (Microaire, Charlottesville, Virginia) eliminates the intraoral incision and use of sutures, enabling multipoint fixation and fast, simple adjustability for optimal control of midface elevation and volume. The authors describe their preferred technique for the endoscopic midface lift and summarize their 13 years of experience. A retrospective chart review was conducted of 183 patients who underwent endoscopic midface surgery. Patients treated from 1998 to 2003 received direct needle fixation (n = 95). Those treated later underwent fixation with the Endotine device (n = 88). Most (90%) of the patient population was female, and the average age at the time of surgery was 46 years (range, 39-54 years). Needle fixation was used in 95 patients and Endotine fixation in 88. The average follow-up period was 7 years. The authors have observed many improvements in outcomes since the introduction of the Endotine device into their practice. These include reduced swelling and bruising, more symmetric elevation of the malar fat pad, mild improvement of tear trough deformity, softening of the nasolabial folds, and, in some cases, decreased "jowling." The asymmetry often associated with direct needle fixation has decreased, and no skin dimpling has occurred. Through their experience, the authors' preferred technique has become the temporal-only approach with Endotine fixation. The Endotine midface suspension device enhances soft-tissue fixation, provides simple adjustability for optimal elevation and projection, and maintains mechanical fixation until biologic fixation becomes adequate. The 5 tines provide multiple points of contact for secure soft-tissue fixation. Elevation forces are evenly distributed over a wide area, which eliminates skin irregularities. Insertion and deployment are accomplished easily through temporal incision.

Persistent Improvement in Lower Eyelid–Cheek Contour After a Transtemporal Midface Lift

This study aimed to assess quantitative changes in lower-eyelid aesthetics after a transtemporal midface lift concomitant with transconjunctival blepharoplasty and lower-eyelid skin pinch. The study enrolled 55 consecutive patients who underwent a transtemporal midface lift and concurrent transconjunctival blepharoplasty with lower-eyelid skin pinch. All the surgeries were performed over a 2-year period by the senior author (A.A.J.). Patient demographics and surgical details were recorded. Standardized digital photographs were taken at baseline and then 12 months postoperatively. These were analyzed to assess changes in the vertical height of the lower eyelid and compared using within-subject analysis. The study cohort consisted of 50 women with a mean age of 54 years (range, 28-76 years). Five patients were lost to follow-up evaluation. The mean vertical height of the lower eyelid was 11.8 mm preoperatively and 9.3 mm postoperatively, giving an average difference of 2.5 mm at the 12-month follow-up assessment. The changes in lower-eyelid height were statistically significant (p = 0.0002), and the lower eyelid-cheek contour was improved in all cases. No major complications occurred during the study period, and no revision surgery was performed. Lower-eyelid height changes did not vary significantly with patient age. Age-related changes to the midface are marked by increased vertical height of the lower eyelid and a concomitant appearance of infraorbital hollowing. Separation of the lower eyelid-cheek complex causes the typical double-contour deformity. To the authors' knowledge, no study to date has reported the long-term effect of a midface lift on lower-eyelid aesthetics. The transtemporal midface lift not only repositions the malar fat pad but importantly also provides significant shortening of the lower eyelid at 12 months. This results in an improved midface contour. 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 .

Anatomic study of malar fat pad and aging analysis

To discuss the midface aging mechanism through anatomic study of malar fat pad. 10 fresh adult cadaveric heads (20 sides) fixed by vascular perfusion of formalin were used for anatomic study with microsurgery technique under microscope. The midfacial ligament and connective tissue between skin and subcutaneous fat were observed carefully in different parts of midface. The location, shape and extent of malar fat pad was also recorded and photographed. The malar fat pad has a triangle shape. The bottom is a curve along the orbicularis retaining ligament at the lower eyelid. The fat pad is extended internally to the nasolabial fold and labiomandibular fold, externally from the major zygomatic muscle end point at the malar surface to the angulus oris and submandibular edge. (2) The malar fat pad is composed of meshed fibrous tissue, with big fat particles in it. It becomes tight when being stretched in horizontal direction along nasolabial fold and loosen when being stretched in vertical direction. (3) There is tight connection between skin and fat pad, which is divided into four areas as I, II, III, IV. The areas I, II, III are strip-shaped parelled to the nasolabial fold. The area IV is a irregular quadrilateral. (4) There are six fixation ligaments between malar fat pad and deep tissue: orbicularis retaining ligament upper layer of lower eyelid, orbicularis retaining ligament substratum of lower eyelid, zygomaticus ligament, zygomatic cutaneous ligament, zygomatic cutaneous ligament substratum, platysma There are four closely connected areas cutaneous forward ligament, cheek maxilla ligament. between the facial skin and malar fat pad which makes malar fat pad and skin keep relatively consistent. The malar fat pad moving down mainly resulted from slack of ligaments support which is one of the reasons for aging face.

Facial Rejuvenation Surgery: A Retrospective Study of 8788 Cases

Surgical rejuvenation of the aging face is common in aesthetic surgery, and many surgical techniques have been described for accomplishing it. The keys to consistent results are the surgeon's judgment and ability to individualize a treatment plan according to the patient's needs. To obtain natural-appearing results, the surgeon must consider the morphological characteristics of the aging face. The authors describe their approach for "round" facelift technique and strategies for avoiding complications. This retrospective study included 8788 consecutive patients who underwent facelift procedures in a single clinic between 1958 and 2010. All cases involved the round-lifting technique. Patients in this series ranged in age from 28 to 84 years. The percentage of male patients increased in later years (6.3% in 1970-1974 vs 18.6% in 1986-2010), and there was a trend toward increasing age after 1979 (17.7% of patients aged 60 years or older vs 8.3% before 1980). Submental liposuction was the most common facelift procedure performed (92.2% of patients, 1990-2010). Up to 97% of the cases treated after 1999 underwent repositioning of the malar fat pad. The overall complication rate was 4.5%, with the most frequent complications being hematoma (3%) and cutaneous slough or necrosis (1%). Repositioning the vector connecting the tragus with the Darwin tubercle provides more natural correction of aging tissues than do other techniques. The authors' intent was to keep the structures in their natural location, as they had been prior to aging. Superficial musculo-aponeurotic system (SMAS) plication, malar fat pad repositioning, and correct traction of facial tissues showed satisfactory results. This technique is less aggressive than undermining of the SMAS and deep-plane techniques. 4.

Reply

Sir:FigureWe sincerely appreciate Dr. Gradinger's comments and astute observations regarding our study, “The Five Step Lower Blepharoplasty: Blending the Eyelid-Cheek Junction.”1 Dr. Gradinger has raised some interesting points that further underscore the need for enhancing our ability to truly grade our results objectively using evidence-based medicine, and the challenges plastic surgeons face in effective and predictable lower eyelid rejuvenation. Directly correlating quantitative outcomes with clinical improvements in aesthetic surgery continues to be a daunting task. The crux of Dr. Gradinger's comments centers around our computer-generated outcomes. It is important not to distract our readers from the key points of our study with computer-generated data, which only served to confirm the safety of our study. Dr. Gradinger's queries are valid and require clarification. Overall, we saw a cumulative improvement in the aesthetic outcomes and had no complications that required reoperation. This is quite rare in performing lower eyelid rejuvenation surgery. The goal of our study was to delineate a safe and effective method of blending the eyelid-cheek junction without disrupting the orbicularis oculi muscle or performing operative techniques that have excessively high morbidity. The high complication and reoperation rates seen in lower eyelid surgery served as the impetus for the five-step combination and research design. Although our maneuvers may not have had 100 percent desired change in each of the individual data points measured, overall aesthetics were improved. Does a slight increase in pupil-to–eyelid margin distance in 36 of 100 eyelids mean that the technique is ineffective? Is it possible that in many of the same patients who demonstrated an increase in pupil-to–eyelid margin distance there was also a decrease in tear trough width and pupil-to–tear trough distance? If so, then the sum of effects was effective and safe, because the overall improvements did not require further surgical correction. It is the sum of the five steps and the overall combined effect of these individual techniques and their direct morphologic changes that lead to improved eyelid-cheek junction blending. Just as the individual steps should not be isolated, so should the results not be judged on each isolated data point. Rather, these data points were measured to evaluate the spectrum of changes that can be observed, whether it decreased in some respects and increased in others. The orbicularis retaining ligament is a key structure in bringing together the cumulative changes. With that said, we will address all the points raised by Dr. Gradinger. Selective release of the orbicularis retaining ligament is as effective as arcus release because the major significance assigned to the arcus is its translated effects by means of the orbicularis retaining ligament to the overlying skin and soft tissue. Full release is not always necessary. Lateral retinacular support served as prophylaxis against lid malposition during the healing/edema phase and is not meant to be permanent. All eyelids undergo slight to minimal lower lid fat removal, sometimes purely for contour and “smoothing,” not just for debulking purposes. We have not witnessed any posterior and/or middle lamellae contracture with the five-step method. All patients in our study required at least slight skin pinch excision, and no patients demonstrated exophthalmos, which is a contraindication to this technique. The conservative degree of skin removal and avoidance of injury to the septum/orbicularis muscle anteriorly all help to eliminate tension and resultant anterior lamella shortening. Concern regarding exacerbation of tear trough as a result of adjacent augmentation of the deep malar fat pad is valid and is a common source of trepidation. Selective orbicularis retaining ligament release allows migration of native lower lid fat to coalesce with the superficial and deep malar fat compartments. Molding is performed intraoperatively to further blend this region. Reducing skin laxity with pinch removal also helps reduce tear trough appearance. Deep malar fat augmentation also acts to elevate the superficial fat compartments cephalically to meet the now released lower lid fat. We thank Dr. Gradinger for his clear and directed comments on the numerous challenges inherent in lower eyelid rejuvenation. We hope that our five-step technique helps to shed more light on the key principles and techniques in safe and effective lower eyelid-cheek rejuvenation.2–5 Ashkan Ghavami, M.D. Department of Surgery, Division of Plastic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif. Rod J. Rohrich, M.D. Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Midface Rejuvenation: An Innovative Technique to Restore Cheek Volume

A youthful and attractive face is characterized by a well-contoured, anteriorly projected cheek; with aging, this area gradually looses volume, principally because of the reduction of the malar fat pad and to a minor degree because of malar bone reabsorption. We describe an innovative technique to restore lost volume in this area using a highly cohesive, viscous hyaluronic acid volumizing filler created for facial sculpting. The result is a harmonic and natural look, because the technique respects the physiologic alterations occurring during aging. It focuses on restoring the lost volume of the malar fat pad region (Figure 1), recreating the anterior projection of the cheek without changing the lateral diameter of the face.

Malar Augmentation Assessed by Magnetic Resonance Imaging in Patients after Face Lift and Fat Injection

Restoration of cheek volume is recognized as an important part of facial rejuvenation. However, there are no previous studies that have determined whether any soft-tissue technique is effective for achieving lasting malar augmentation. This study prospectively evaluated a subset of five patients who had deep-plane face lifts with fat injection, and other facial cosmetic procedures. The mean volumes of fat injected were 9.1 cc (range, 4 to 12 cc) into the right cheek and 8.5 cc (range, 4 to 11.5 cc) into the left cheek. Magnetic resonance imaging scans were obtained before surgery and at intervals after surgery up to 6 months (and 1 year in one patient) for a total of 22 studies. Axial, coronal, and sagittal images, T1- and T2-weighted, were obtained. Thickness of the malar fat pads was measured. Malar thicknesses showed significant increases at the time of the 1-month follow-up appointments (p < 0.01). This increase was maintained at the next follow-up appointment (p < 0.01). There was no significant difference in thickness between the first postoperative appointment and the second postoperative appointment. The T1- and T2-weighted images revealed that the increase was attributable to tissue with fat density, not fluid. The average increase in malar projection was 0.66 cm for the right cheek and 0.60 cm for the left cheek. Fat injection at the time of face-lift surgery produces an increase in malar volume that is still present up to 6 months after surgery. This study confirms the rationale for injecting fat at the time of face-lift surgery.