We read with extreme interest the article by Wang et al. entitled “Facial Contouring by Targeted Restoration of Facial Fat Compartment Volume: The Midface,” published in the March of 2017 issue of the Journal.1 This remarkable work has further extended our knowledge of facial fat distribution, and, in doing so, has followed the path initially set by Drs. Rohrich and Pessa with their pioneering research that first demonstrated that subcutaneous fat of the face is partitioned into discrete anatomical compartments.2 This understanding has indeed become essential to ensure greater precision in the preoperative analysis and surgical treatment of the aging face.2
With their anatomical and clinical study on 40 cadaveric hemifaces and 78 patients, Wang et al. have characterized the fat compartments and neurovascular structures in the midface area, and have successfully treated cheek atrophy using a targeted restoration technique of midface fat compartment volume. With this procedure, the authors have obtained a natural and youthful facial contour, close to the physiologic state, with a high satisfaction rate at 12-month follow-up.
However, we believe that this topic could be further explored, incorporating some relevant considerations regarding the ethnic differences of Asian female patients, which we recently analyzed to discuss facial rejuvenation with injectables.3 The interest in ethnic cosmetic surgery has indeed increased tremendously over recent decades, as documented by a growing number of publications aiming at recognizing and properly analyzing the ethnic differences of body characteristics to maintain the patient’s ethnic harmony.3–5
Compared with patients of European descent, Asians tend to present a shorter face, with wider bitemporal, bizygomatic, and bigonial width and structural low projection of the central third of the face, as a consequence of underlying skeletal and morphologic features.3 Therefore, adequate treatment with injectables of Asian patients should be limited to medial maxilla volumization, to enhance central projection and avoid the creation of facial disharmony by further widening the midface.
With this knowledge in mind, we believe that a different fat grafting approach should be similarly adopted for the different compartments of the midface, with some compartments requiring to be simply restored, and others requiring a proper augmentation. Although the medial part of the deep medial cheek fat compartment and the medial part of the sub–orbicularis oculi fat compartment should indeed be augmented, as specifically required for Asian patients, the lateral part of the deep medial cheek fat compartment should be simply restored, and caution should be observed to avoid overgrafting of this area. Analogously, in the superficial layer, augmentation should be performed in the nasolabial fat compartment, and the medial, middle, and lateral cheek fat compartments should only be restored.
We believe that this “restoration versus augmentation” approach can be considered as particularly appropriate in Asian female patients to avoid the undesired outcome of a “balloon-like face” which, because of their ethnic-specific facial features, may occur as a consequence of excessive volume enhancement of the lateral aspects of the midface.
The authors have no financial interest to declare in relation to the content of this communication. No external funding was received.
Carlo M. Oranges, M.D.Mathias Tremp, M.D.Martin Haug, M.D.Daniel F. Kalbermatten, M.D., Ph.D.Dirk J. Schaefer, M.D.Department of Plastic, Reconstructive, Aesthetic, and Hand SurgeryBasel University HospitalBasel, Switzerland
1. Wang W, Xie Y, Huang RL, et al. Facial contouring by targeted restoration of facial fat compartment volume: The midface. Plast Reconstr Surg. 2017;139:563572.
2. Rohrich RJ, Pessa JE. The fat compartments of the face: Anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:22192227; discussion 2228–2231.
3. Oranges CM, Gohritz A, Haug M, Harder Y, Schaefer DJ. Universal and ethnic-specific considerations on facial rejuvenation: Where do you inject your fillers? Plast Reconstr Surg Glob Open 2016;4:e842.
4. Oranges CM, Gohritz A, Kalbermatten DF, Schaefer DJ. Ethnic gluteoplasty. Plast Reconstr Surg. 2016;138:783e784e.
5. Rohrich RJ, Bolden K. Ethnic rhinoplasty. Clin Plast Surg. 2010;37:353370.