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The Facial Adipose System: Its Role in Facial Aging and Approaches to Volume Restoration

Sadick, Neil S. MD*; Dorizas, Andrew S. MD; Krueger, Nils PhD; Nassar, Amer H. MD§

doi: 10.1097/DSS.0000000000000494
Review Article
Free

BACKGROUND Volume loss in facial adipose tissue plays a critical role in the aesthetics of facial aging. Furthermore, the facial adipose system is a complex network of distinct compartments, and a detailed understanding of these compartments is essential for optimal facial volume restoration.

OBJECTIVE To review the facial adipose system, age-related changes, and the role of volume restoration products for facial rejuvenation.

METHODS Publications including deceased donors' dissection studies and more recent studies using computed tomography were reviewed to provide an up-to-date understanding of the facial adipose system anatomy and age-related changes. Current volume restoration treatment options including hyaluronic acid, calcium hydroxylapatite, and poly-L-lactic acid are discussed.

RESULTS Facial aging is associated with volume loss in superficial and deep adipose compartments, including those of the forehead, cheek, lip, chin, and jowl areas. Volume restoration products can be used to address the age-related changes of the facial adipose compartments.

CONCLUSION Understanding the complex network of facial adipose compartments and their age-related changes allows for the optimal use of injectable volume restoration products for facial rejuvenation that can be customized to the anatomical needs of each patient.

*Department of Dermatology, Weill Cornell Medical College, New York, New York;

Department of Dermatology, University at Buffalo, Buffalo, New York;

Rosenpark Research, Darmstadt, Germany;

§Department of Surgery, University of Washington Medical Center, Seattle, Washington

Address correspondence and reprint requests to: Neil S. Sadick, MD, Department of Dermatology, Weill Cornell Medical College, Cornell University, 911 Park Avenue, Suite 1A, New York, NY 10075, or e-mail: nssderm@sadickdermatology.com

N. S. Sadick has received research grants from Allergan, Inc. and Valeant Pharmaceuticals North America LLC and is a member of the Advisory Board for Merz Pharmaceuticals and Valeant Pharmaceuticals North America LLC. The other authors have indicated no significant interest with commercial supporters.

Facial aging is a multifactorial process involving complex structural and volumetric changes in the skin, underlying muscle, skeleton, and adipose compartments.1 The paradigm of facial rejuvenation has shifted with better understanding of the aging face.2 Sagging of facial tissues is not just gravity-induced but caused by diminution and repositioning of separate and distinct adipose compartments.2–52–52–52–5 Volume restoration is an important part of any facial rejuvenation treatment plan,3,63,6 and knowledge of facial anatomy, specifically the facial adipose system and its relationship to aesthetically important folds and rhytides,7 is integral to achieving optimal results, customized to individual patient needs.

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Facial Adipose Compartments

Clinical observation, deceased donors' studies, and more recent computed tomographic imaging have advanced our knowledge of facial anatomy, identifying a subcutaneous facial adipose system partitioned into multiple compartments, rather than a confluent mass.5,7–95,7–95,7–95,7–9 A complex network of blood vessels run in the septal boundaries between these compartments. Fibrous membranes partition the subcutaneous tissue, providing support for facial soft tissue and protection of the skin's vasculature.5,105,10 This review describes these adipose compartments and explains how anatomical knowledge informs optimal treatment approaches in the main areas of the face: the forehead and lateral face including temples; tear troughs and periorbital complex; midcheek; preauricular area and proximal jawline; and lower face including the chin, marionette lines, and distal jawline.

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Superficial Adipose Compartments of the Forehead

There are central, located in the midline, and bilateral middle temporal adipose compartments in the forehead. The supraorbital ligamentous adhesion is the inferior border of the middle temporal compartment, its lateral border corresponding to the superior temporal septum.

When considering volume restoration of the superficial adipose compartments of the forehead, it is the opinion of the authors that the use of hyaluronic acid (HA) filler results in a better aesthetic outcome because of its low viscosity and ability to achieve a superficial filling effect without overvolumizing the region. Furthermore, recent studies show a synergistic result when combining botulinum toxins with HA fillers.11–1311–1311–13 Small vessels branching from the supratrochlear and supraorbital arteries provide the blood supply to the glabellar region, and due to their superficial location and near the glabellar crease, their interruption by filler materials is possible to result in tissue necrosis, indicated by immediate blanching in the area of the injection. Special considerations and precautions regarding injection technique can minimize this risk, such as lacing the needle tip superficially and medially to avoid injecting the filler into the supratrochlear vessels and their anastomosing branches. Drawing back on the plunger before injecting can ensure that the needle tip is not located within a vessel, and performing a serial puncture technique with subsequent massaging of the area can prevent high filler volumes to compress adjacent vessels by exceeding the intravascular pressure.14

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Superficial Adipose Compartments of the Lateral Face Including the Temples

The adipose compartments of the lateral face and temples include the lateral temporal cheek, middle cheek, buccal extension of the buccal fat, and inferior jowl. Superiorly, the middle cheek compartment is adherent to the zygomaticus major muscle, but does not extend above the superior margin of the zygomatic arch. Located superficially to the parotid gland, the lateral temporal compartment connects temporal adipose tissue to the cervical subcutaneous adipose tissue with a true septal barrier at its anterior boundary.

Buccal adipose tissue is anatomically distinct from jowl adipose tissue and formation of ligaments and blood vessels help to define distinct enveloped lobes (anterior, intermediate, and posterior), fixed by 6 ligaments.5,155,15 An extension of this compartment with superficial and deep lobes was previously described to be part of the posterior lobe but more recently postulated as a distinct compartment separated by an anatomical boundary in the paramaxillary space.15

Restoration of volume with dermal fillers can transform the temporal region resulting in an overall more balanced and natural youthful appearance. Considerations during filler selection include the products texture, longevity, safety profile, and the onset of the filler's effect.

The preferred use of HA among injectors results from the fact that it provides immediate predictable augmentation of the atrophied fat pads, correcting the volume loss for approximately 12 months.16 Moreover, the safety profile and lack of immunogenicity further increase the desirability of HA fillers.17,1817,18

Poly-L-lactic acid (PLLA) is another filler that once injected induces a subclinical inflammatory response that stimulates fibroblast proliferation and collagen formation. It is important to inform patients that the volumizing effect of PLLA occurs gradually over several months, and thus it might not be an appropriate choice for patients seeking immediate results. Its reconstitution should be at least 9 mL and above,19 injected supraperiostially at the origin of the temporal muscle. Depot injections can be performed using a fanning technique, with rigorous massaging afterward.

Similarly to PLLA, calcium hydroxylapatite (CaHA) also stimulates the production of endogenous collagen20 and has been shown to exhibit greater duration effect than HA.21 Subdermal injection and massage of the treatment site immediately after injection facilitate even distribution of the product.22

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Superficial Adipose Compartments of the Tear Troughs and Periorbital Complex

There are both inferior and superior subcutaneous orbital adipose compartments in the tear troughs and periorbital complex7 bound circumferentially by the orbicularis-retaining ligament, spanning the superior and inferior boundaries of the orbits, blending into the medial and lateral canthi. The inferior orbital adipose compartment is a thin, subcutaneous layer located in the lower half of the orbit after the course of the lower orbital rim. Lateral to the bony orbit, the lateral orbital adipose compartment is bordered superiorly by the inferior temporal septum and inferiorly by the superior cheek septum, adherent to the zygomaticus major muscle.

Patients often seek cosmetic surgery to reduce prominent adipose compartments of the lower eyelids. With age, infraorbital fat pads herniate forward, malar fat pads descend and flatten resulting in puffy lower eyelids and unmasking of the tear trough. This clinically manifests as an excessively tired and sad look, and injectable fillers can be beneficial in this setting by restoring uninterrupted convexity. Because injections of the periorbital area are popular, understanding the anatomy and function of the orbicularis-retaining ligament is important to avoid ocular complications.23 Lower eyelid adipose compartments are separate from the posterior intraorbital adipose compartment with the orbital-retaining and circumferential intraorbital-retaining ligaments as the anterior and posterior boundaries.24

Volume loss of the orbital rim contributes to the development of the nasojugal groove. Because there is no dissectible anatomic region beneath the orbicularis oculi muscle in that area, it is advisable to correct the nasojugal deformity by injecting subdermally or within the orbicularis oculi muscle fibers. In a study by De Pasquale and colleagues,25 it was demonstrated by ultrasound that HA filler lies within the muscle fibers of the orbicularis oculi, and not beneath it, on a preperiosteal plane. Several other techniques have been described,26 and a consensus group of European and North and South American aesthetic experts recommended the linear threading technique for infraorbital hollow augmentation.27,2827,28

Injections with HA that are too superficial can yield the appearance of a bluish tint, which is the phenomenon whereby the particles within a bolus of superficially injected filler scatter light back to the observer's eye known as the Tyndall effect.29 Postinjection purpura and swelling are possible events after injection at periorbital area but can be minimized using blunt-tipped cannulas.30

Some serious complications are of particular concern when HA products are used in the periorbital region. Arterial occlusion of the retinal artery either by direct injection or by compression is a rare but serious risk seen with filler injection in this anatomic area, since even if a tiny amount of the filler enters the arteries, it can cause blockage of retinal artery, which can lead to blindness.31,3231,32

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Superficial and Deep Adipose Compartments of the Mid-Cheek

The mid-cheek consists of medial, lateral, and nasolabial superficial adipose compartments. The medial compartment is lateral to the nasolabial fold and bordered superiorly by the orbicularis-retaining ligament and lateral orbital compartment. The orbicularis oculi muscle comprises part of its posterior border.33 The plane between the medial and middle cheek compartments contains the parotid-masseteric ligaments. The septal boundaries fuse into a dense fascial network (the zygomatic ligament).34

The nasolabial adipose compartment is anterior to the medial cheek, medial to the deeper adipose tissue of the suborbicularis, and overlapping the jowl adipose compartment. The lower border of the zygomaticus major muscle adheres to the nasolabial adipose compartment. The medial cheek and suborbicularis oculi adipose regions border it laterally, whereas the orbicularis-retaining ligament is its superior boundary.8,338,33

The deep medial cheek adipose compartment is distinct from the buccal and suborbicularis adipose compartments. It surrounds the levator anguli oris and lies beneath the orbicularis oculi muscle with the orbicularis-retaining ligament as its superior boundary. The piriform and orbicularis-retaining ligaments surrounding the nasal base are its medial and superior boundaries. Ristow space, between the periosteum of the maxilla and deep medial adipose tissue, is a potential space for facial rejuvenation.9,359,35 There are 2 distinct medial and lateral compartments. Triangular in shape, the medial compartment is located beneath the nasolabial adipose zone, extending medial to but not lying on the periosteum of the maxilla, whereas the lateral component is located beneath the superficial medial cheek adipose zone, directly lying on the periosteum of the maxilla.8,338,33

Several viable options exist to replace atrophic fat pads in midface region, including low–molecular-weight (20 mg/mL) HA, PLLA, and CaHA. Depletion of midfacial fat pads results in evident structural and cosmetic alterations; thus, the establishment of deep structural support is crucial for an aesthetically acceptable result with long-lasting effects. Fillers with inherent biostimulatory properties to induce neo-collagenesis on their own effectively achieve longevity. When choosing non-biostimulatory fillers, the authors of this article recommend using a product with high viscosity (g-prime) to prevent spreading of the filler and to ensure its anatomical placement at the site of the injection. The higher the g-prime, the greater a filler's lifting capacity. By beginning the injection superiorly and working toward inferiomedial region, it allows for the injector to achieve maximal support and natural lift.

When prominent panfacial adipose pad atrophy is present, initial restoration of the malar fat pads could prove beneficial in not only replenishing the midface fat pads but also indirectly reposition adjacent hollow regions, such as the infraorbital region. An injector can then proceed to restoring remaining volume loss in those areas afterward. By following this sequence, overvolumization of the infraorbital region is avoided.36 Common injection techniques for this area include supraperiosteal depot injections, towering technique, and cross-hatching.37

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Adipose Compartments in the Lower Face Including the Chin, Marionette Lines, and Distal Jaw Line

Superficial adipose tissue resides in the cutaneous lip and chin, with additional adipose tissue found immediately deep to the orbicularis muscle beneath both the vermilion and cutaneous lip. The insertion of the orbicularis oris muscle into the dermis at the wet-dry border of the vermilion lip provides the boundary between superficial and deep adipose tissue.33 A submuscular adipose compartment, distinct from the suborbicularis oris adipose tissue, has also been identified. Submentalis adipose tissue can be found just beneath the mentalis muscle in 2 nonconfluent compartments either side of the midline chin. These compartments may contribute to the depth of lip-chin crease noted with aging.

Adherent to the depressor annuli oris muscle, the jowl adipose compartment is distinct from the nasolabial compartment.5 The lip depressor muscle is the medial boundary; a membranous fusion of the platysma muscle and its inferior boundary. Three distinct subcutaneous compartments define this region: superior and inferior compartments lie above and the submandibular jowl compartment below the mandibular border. The superior jowl adipose compartments about the nasolabial cutaneous adipose region appear clinically as an extension of the nasolabial fold.38

The use of HA or CaHA with a linear threading or cross-hatching technique is preferred method of volumization in these areas. Care should be used when using PLLA for marionette line volumization, as there is a higher incidence of nodule formation. A minimum reconstitution with 7 to 9 mL of saline may reduce this adverse effect.

The medial characterization of the aging jawline by the prejowl sulcus, jowl, and postjowl sulcus are other necessary areas of concern with respect to the lower one-third of the face. When choosing a filler for replenishing the volume loss of the jawline, supraperiosteal placement of PLLA, CaHA, or HA can all be used. Depot injections work best in this area, followed by a linear threading technique subcutaneously. The layering effect created by these superimposed techniques ensures that initial volumization occurs over the mandible, followed by a more superficial filling for a more natural look.

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Age-Related Changes in the Facial Adipose System

Loss of volume in these adipose compartments is a major contributing factor to facial aging, with inferior volume shift inside each compartment and in some, migration.5,345,34 This migration is not only gravity-related but a consequence of volume loss.

Characterized by smooth transitions, a youthful face appears full and balanced with an even distribution of facial adipose tissue. With increasing age and progressive volume loss, changes in the position of discrete facial adipose compartments result in abrupt contour changes.39 Distinct superficial and deep adipose compartments (forehead, periorbital area, deep and midcheek, perioral, jowl/chin) and underlying facial structures appear more discernible as separate entities (Figures 1 and 2).

Figure 1

Figure 1

Figure 2

Figure 2

As facial aging progresses, the hollow inferior to the lower edge of the orbicularis oculi muscle and deepening of the nasojugal fold are subsequent to inferior migration and volume loss of the buccal extension of the buccal adipose compartment.1 Volume loss results in lack of support for the medial and middle cheek adipose compartments, contributing to their descent. Inferior volume shift within the midfacial compartments may also be an important consideration. Volume increase of the inferior part of the nasolabial adipose compartment leads to greater prominence of the nasolabial fold and superior jowl. Volume loss of the cephalad part of the nasolabial and medial cheek adipose compartments may also contribute to facial aging by worsening the appearance of tear-trough deformity, nasojugal fold, and palpebromalar groove.7

Changes in the biomechanical properties of facial retaining ligaments may contribute to the natural descent of aging facial structures with midface descent in the infraorbital region and increased prominence of the nasojugal groove; the zygomatic ligament being the strongest (demonstrating the greatest stiffness and resistance to failure) and the buccal maxillary ligament the weakest. The increased midface descent load likely overwhelms the mandibular ligament, resulting in an undefined jawline. The inferiorly directed forces of the periorbital muscles, in conjunction with the laxity of the lateral-most portion of the superficial fascia plane, result in lateral eyebrow descent.40

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