PAPER Anatomy and Aging of Cheek Fat Compartiments. Salvatore Fundaró
PAPER Anatomy and Aging of Cheek Fat Compartiments. Salvatore Fundaró
PAPER Anatomy and Aging of Cheek Fat Compartiments. Salvatore Fundaró
Abstract
Introduction: The role of the cheek fat compartment in aging of the face is nowadays accepted and well described in a lot of publications, but the anatomy and the
age-related changes of this compartment are less clear and defined. The authors propose a review on the anatomy of face fat compartments and their age-related
changes.
Materials and methods: The authors executed a review of the literature and verified it by the dissection of 14 cadaveric hemifacial specimens. All the main fat
compartments described in literature were found in these cadaver dissections. The anatomical localization and the relationships of the fat compartments are described
as well as the retaining structures that define them. Based on literature review the age-related modifications of fat compartments were analyzed.
Results: Superficial and deep fat compartments of the cheek were identified: infraorbital fat, superficial medial cheek fat, nasolabial fat, middle cheek fat, lateral
temporal-cheek fat, superior and inferior jowl fat, superficially and medial and lateral suborbicular is oculi fat, deep medial cheek fat, buccal fat.
The fat compartments undergo specific modifications due to the aging process. Generally deep compartments undergo hypotrophic changes and whilst superficial
compartments undergo hypertrophic or ptotic.
Conclusion: Comprehension of anatomy and of age-related changes of facial fat compartments is important to improve our capability in assessing the aging of the
face and planning adequate treatments to correct it.
Introduction The role played by the ligaments in facial aging in general has been
described by various authors [5-8] and this is also considered valid
Midface aging has different causes whose role is still not completely for the infraorbital and malar regions where the retaining structures
clear. The changes of the anatomical components effected by the aging are numerous and anatomically well defined [9,10]. Histopathological
processes involve all the tissues of the region: skin, fat, ligaments, studies seem to show a progressive decrease in elastic fibers with aging
muscles and bones. [11] at the dermal and superficial muscular aponeurotic system (SMAS)
In two interesting papers regarding aging of the bony components level. SMAS is a continuous and organized fibrous network connecting
of the face, the periosteum, the facial muscles, and other fascia types (such as the
parotid fascia), to the dermis. The decrease in the elastic component
Pessa et al. [1,2] using computerized tomography, demonstrated could be a cause of the reduction in the retaining capacities of the
a postero-inferior rotation of the skeleton towards the base of the ligaments that are manifested in ptosis of the soft tissues.
skull. This results in a decrease in the supporting capacity of the bony
structures of the overlying soft tissues and consequently a lowering in Other authors [12] question whether ligament slackening effectively
forward projection of the face. occurs in this way or is simply a consequence of the hypotrophy of
the fatty tissue which, through causing a decrease in tension on the
The part played by bone reabsorption in facial aging and the changes ligamentous structures, causes solely an apparent relaxation.
in the facial skeleton have been substantiated and ascertained by other
It is widely agreed that the changes arising in the fat component
authors too [3], and is always to be taken in consideration, especially in
of the midface are among the main causes of visible facial aging. More
the infraorbital and zygomatic-malar regions, when planning treatment
debatable are the ways in which the fatty tissues change with aging
strategies with hyaluronic acid fillers and fat grafting.
and how these changes manifest and alter the appearance of the face.
In the past it was believed that with aging the muscles of the malar We shall now analyze the anatomy and the modifications occurring in
region, in particular the zygomatic muscles, underwent a progressive midface fatty tissue.
slackening. In recent years, in the absence of evidence of real muscle
relaxation this region, it is thought that the age-related changes the
muscle component are of secondary importance and barely relevant. *Correspondence to: Salvatore Fundarò, Plastic Surgeon Modena, Italy, Tel:
Studies with magnetic resonance imaging show how there are no +39335 5862212; E-mail: dr.fundaro@libero.it
significant changes to the length and thickness of the muscles in the Received: August 26, 2018; Accepted: September 28, 2018; Published: October
malar region in relation to aging [4]. 10, 2018
deep plane (SMAS), but it is firmly adherent to the skin (47). The malar
fat pad is supported in its location during youth by multiple fibroelastic
fascial septa that extend through the fatty cheek mass originating
from the underlying superficial fascia that invests the facial expression
muscles to insert into the overlying dermis [11].
Deep fat compartments are: the Medial Suborbicularis Oculi Fat,
the Lateral Suborbicularis Oculi Fat, Deep medial cheek fat and Buccal
fat.
Medial Suborbicularis Oculi Fat (M-SOOF) (Figure 4): this lies
adherent to the periosteum along the orbital rim (Rohrich et al., 2009),
below the orbicularis retaining ligament and under the orbicularis oculi
muscle. It extends from the medial limbus to the outer cantum. The
zygomatic cutaneous ligament separates the M-SOOF from the deep
medial cheek fat.
Lateral Suborbicularis Oculi Fat (L-SOOF) (Figure 4): this is located
at the lateral orbital rim above the prominence of the zygoma but does Figure 4 In this anatomical dissection the middle cheek fat has been removed and the
buccal extension of buccal fat is clearly visible
not reach above the superior margin of the zygomatic arch and it does
not extended above the lateral canthus and the lateral orbital thickening fat. Other authors [13] describe this compartment as divided into two
represents the upper limit of L-SOOF. Its medial half is covered by different parts. One, the medial part, located beneath the nasolabial
the orbicularis oculi muscle. L-SOOF lies above another more deeply fat, does not lie immediately on the periosteum of the maxilla but it
situated fat compartment, therefore it is not in direct contact with the is bordered posteriorly by another small, triangular compartment. The
periosteum [30]. Medial to it is the M-SOOF. lateral part is located under the superficial medial cheek fat and lies
Deep medial cheek fat (DMCF) (Figure 4): this is under the SMAS directly on the maxilla. Probably the Rislow’s space, the premaxillary
plane and its superior part lies under the orbicularis oculi muscle. Its fat and the triangular fat compartment posterior the medial part, are all
superior boundary is the zygomatic-cutaneous ligament that divides the same anatomical structure.
it from M-SOOF and it medially borders the buccal fat and with the Buccal fat (BF): this is located below the zygoma and anteriorly
zygomaticus major muscle. The medial boundary is the pyriform to the ramus of the mandible surrounding the medial pterygoid and
ligament surrounding the nasal base and the inferior boundary is the masseter muscles. This fat compartment has a buccal extension (Figure
sub–orbicularis orris fat. This fat compartment lies on the periosteum 3) that abuts the medial cheek fat, the deep medial cheek fat, the middle
of the maxilla. Between the periosteum and the fat compartment is a cheek fat, the sub–orbicularis oculi fat, the jowl fat, and the fat of the
potential space, defined as Ristow’s space [19]. pre-masseter space. Gierloff et al. [13] in their computed tomography
Pils et al. [26] divided this compartment in two different layers: one study have observed a hypothetical anatomical boundary between the
superficial, named malar fat, and another deeper, named premaxillary buccal extension and the buccal fat pad. They have hypothesized that
the buccal extension can be regarded as a distinct fat compartment.
Other authors share this opinion [27].
Aging of fat compartments
The fat compartments undergo specific changes due to the aging
process [20,21]. In some compartments the main changes are volume
augmentation; in other the volume reduction or ptotis. The capability
to understand these changes is essential in order to make a correct
assessment of facial aging.
The main age-related modifications, as indicated by our cadaver
dissections and clinical experience, are different in superficial fat
compartments compared to the deep ones. This evaluation is confirmed
in recent scientific literature concerning the aging process of the face.
In the superficial medial cheek fat, the aging process causes a
global volume increase with an inferior volume shift within the fat
compartment. The volume increases in the lower two thirds and remains
stable in the upper one [13]. Similar changes are observed in nasolabial
fat that shows an inferior volume shift of fat tissue. In aged patients, the
Figure 3. Deep cheek fat compartments: A) Medial sub-orbicularis oculi fat. B) Lateral
sagittal diameter of the upper third is smaller and the sagittal diameter
sub-orbicularis oculi fat. The sub-orbicularis oculi fat compartments are located below of the lower third is higher [13]. These modifications create an overall
the orbicularis oculi muscle. In this anatomic dissection, the SOOFs are visible thanks to volume augmentation of lower part of malar fat pad due to the ptosis
the separation of the muscular fibers of orbicularis oculi muscle. C) Deep medial cheek
fat. The upper part of DMCF is below the orbicularis oculi muscle. It lies laterally to the
and caudal migration of fat tissue. For this reason the aging of the malar
zygomaticus major muscle fat pad can be described generally as ptotic/“hypertrophic”. The ptosis
and the volume augmentation of these fat compartments contribute to fat pad and a consequent protrusion of the fat tissue especially in their
the increase of the depth of the nasolabial fold [11,18]. inferior portion. The continued stress and lengthening of fibrotic septa
of the SMAS results in their progressive loosening and the reduction
The middle cheek fat, is loosely adherent to SMAS plane just like
of their retentive capability. With aging the inferior migration of fat
the malar fat pad, and its aging is characterized by ptosis, by caudal
tissue becomes permanent and produces a volume augmentation in the
migration of fat and by a whole volume augmentation [13]. These
lower part of malar fat pad and a consequent increase of depth of the
modifications produce an increasing of convexity in the central portion
nasolabial fold.
of the cheek.
The pattern of facial aging is probably produced by the combination
Finally the lateral temporal-cheek fat lies upon and is adherent to
of the different volumetric and morphologic modifications of the
the parotid fascia without any deep fat compartment between them.
various fat compartments. These changes can vary in different patients
Aging results in a hypotrophic involution of this compartment that
and can manifest themselves in different ways. The volumetric
does not usually have any tendency to caudal migration, showing a
reduction of deep fat compartments causes the formation of hollows
different aging process than the other superficial fat compartments
and flattening especially of infraorbital and zygomatic areas;
previously described.
contemporaneously it causes the ptosis of superficial fat compartments
In deep fat compartments we find different aging related due to the loss of support determined by hypotrophy of deep adipose
modifications. The medial and lateral SOOF both lie on periosteum tissue. The compartmental changes secondary to gravity are also
and have an aging characterized by deflation with low tendency to influenced by compartmental changes secondary to deflation. These
ptosis. This is due to the fact that the reduced weight and the stronger synergistic effects may influence the shape and position of adjacent
attachment to underlying tissue makes it less likely to ptosis under the compartments [22,28]. If the superficial fat compartments are also
effects of gravity. The deflation of medial SOOF produces the formation characterized by volume reduction, it creates an evident skin sagging
of the hollow in the infraorbital region. Reduction of the medial SOOF defined by Rohrich as “pseudoptosis” [19]. If the volume reduction of
has been noted to increase the orbit cheek crease and the V deformity superficial fat compartments isn’t accentuated and a sufficient amount
of the lower lid described by Mendelson et al. [9]. The medial SOOF of fat tissue persists, it creates the downward migration and the volume
supports the palpebral tissues of the inferior eyelid, so its reduction in enhancement at the nasolabial region.
volume increases the relaxation of the tissue of inferior eyelid and of the
If, instead, the hypertrophy and ptosis of the superficial fat
intraorbital fat. The volume reduction of the lateral SOOF decreases the
compartments are prevalent, the aging is characterized by volume
forward protrusion of the malar area and of the cheekbone, facilitating
augmentation especially at inferior part of the malar fat pad. This
the ptosis of superficial fat compartments of the cheek.
aspect is combined with the volumetric reduction of infraorbital and
The deep medial cheek fat undergoes a gradual and global decrease zygomatic areas that are mainly caused by the volume reduction of
of volume [15,23] and a caudal migration [13]. The volume reduction is the deep fat compartments (infraorbital fat, deep medial cheek fat and
greater in the upper two thirds and minor in the lower third where the lateral SOOF).
caudal migration of fat compensates the volume loss [13].
The volumetric modifications of superficial and deep fat
The part of buccal fat that influences the aesthetic of the cheek is its compartments appear to be confirmed from the histologic point of view,
buccal extension. It seems to be mainly characterized by a hypotrophic in a recent study [53] that demonstrated in old cadaveric specimens
ageing response. Several authors have observed a lower volume of the (47–101 years, mean 71 years) a smaller adipocyte size in the deep
buccal extension in older cadaver specimens [13,48]. The deflation of medial cheek fat compared to the nasolabial fat; unfortunately in this
this fat compartment leads consequently to a lack of support for the study these findings were not compared to a younger group and nor was
medial cheek and middle cheek fat, aggravating the descent of these whether these size differences of superficial and deep adipocytes are
compartments. Other authors [49,50] have observed an antero-inferior present in younger subjects when the volumetric compartments change
protrusion of buccal fat that increases the convexity of cheek and the have not yet developed. For a truly controlled study of fat pads age-
ptosis of jowl. related changes, it is mandatory to have a younger cohort with which
compare the histologic findings in cadavers of elderly people. Such a
Conclusion cohort may come from those having fat removed during reconstructive
Clinical and anatomical observations suggest that, with age, and cosmetic surgery.
fat compartments could tend to deflation, specifically in the deep Weight modification and weight differences can influence the
compartments, and to volume augmentation and ptosis, especially in volume of fat compartments but it is not well-know to date how
the superficial fat compartments [19,51]. Some scientific support for this occurs. The clinical observation of submental fat hypertrophy
this hypothesis is observed in literature. Gierloff et al. [13] showed concomitant with deep cheek fat atrophy in overweight patients suggests
a relative volume decrease in the deep cheek compartments of older that weight gain may affect mainly the superficial compartments [30].
cadaveric specimens (75–104 years) compared to younger group Meanwhile, a histologic study on cadavers showed the adipocyte size
(54–75 years). These authors introduced in this study the concept of is increased in both the superficial and deep cheek compartments with
an inferior volume shift within the compartments observed especially higher weight [53].
in nasolabial and superficial medial cheek fat. These events create the
“hypertrophy“ of lower parts of superficial fat compartments that Wan et al. [16] suggest that the different mechanical environments
constitute the malar fat pad. A similar hypothesis is proposed by Gosain of the superficial and deep compartments of the midface also contribute
et al. [52], in their MRI study of the malar fat pad and by Owsley and to their morphological difference. This is due to the different anatomical
Roberts [11] in their anatomical analysis of midface aging. They sustain location of the two fat layers: superficial fat compartments are located
that the facial expression muscle movements related to smiling result in adjacent to the muscles of facial expression, while the deep fat pads lies
the shrinkage of the base of superficial fat compartments of the malar directly on the periosteum. The continuous compression of the deep
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