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Background Since 2007, when the anatomy of facial fat compartment was described, an increasing number of studies on the aging process of the compartment of cadavers has emerged. Objectives The authors evaluated the aging changes of lateral facial fat compartments on the same person. Methods Sixty-three patients were included in this retrospective study. All patients had magnetic resonance imaging scans with at least 4 years apart. The authors targeted the fat compartments of the superficial temporal, subcutaneous temporal, and buccal fat pad, comparing the data on different time points. Results The thickness of the subcutaneous temporal fat did not change significantly. The 3 diameters of the superficial temporal fat compartment all became thinner on the axial view (P < 0.05). On the sagittal view, the superficial temporal fat elongated from 38.89 mm to 43.74 mm (P < 0.05). The buccal fat compartment also lengthened from 68.73 mm to 74.39 mm (P < 0.05) and had a positive correlation with follow-up duration only. Conclusions The study revealed the fat compartment change on the same person with time. The temporal hollow mainly originates from the thinner part of the superficial temporal fat. The descending of the buccal fat pad aggravates the labiomandibular fold. By understanding the aging process more fully, we can rejuvenate our patients more naturally.

Background Current techniques for temple volumization primarily focus on deep or superficial targets. Further anatomical exploration of intermediate injection targets is warranted. Objectives The purpose of this study was to examine the anatomy of the intermediate temporal fat pad (ITFP) as it relates to filler injection procedures and to explore the utilization of ultrasound technology for clinical localization. Methods Ultrasound technology was utilized to identify and inject red dyed hyaluronic acid filler into the ITFP in 20 hemifacial fresh cadavers. Cross-sectional dissection was performed to confirm injection accuracy and document pertinent anatomical relationships. The same technique was performed in a single clinical patient case employing ultrasound guidance and injectable saline. Results The ITFP is a quadrangular structure located in the anterior-inferior bony trough. The ITFP is supplied by a middle temporal artery branch and encased between the superficial and deep layers of deep temporal fascia. In 18 of 20 (90%) injections performed under ultrasound guidance, the injected product was accurately delivered to the substance of the ITFP, and in 2 of 20 (10%), the product was found immediately below the deep layer of deep temporal fascia within the temporalis muscle. In the single clinical case, saline was successfully injected in the ITFP under ultrasound guidance. Conclusions The ITFP is a consistent anatomical structure in the anterior-inferior trough of the temporal fossa. Ultrasound technology can be utilized to identify and inject the fat pad. Further clinical evaluation will determine the role of this fat pad as a potential intermediate injection target for temple volumization procedures.

Background The shock-absorbing soft tissues of the heel are composed of dermis and specialized fat pads. Heel fat pad atrophy is common and can be painful and debilitating. In our previous work, autologous fat grafting was effective for treating pain from forefoot fat pad atrophy. Objectives The authors hypothesized that autologous fat grafting to the heel would relieve pain and improve function in patients with heel fat pad atrophy. Methods Patients with heel fat pad atrophy and associated pain were recruited and randomized into 2 groups. Group 1 received autologous fat grafting on enrollment and was followed for 2 years. Group 2 received offloading and activity modification for 1 year, then crossed over, underwent autologous fat grafting, and was followed for 1 year afterward. Outcome measures included ultrasound-measured fat pad and dermal thickness; pedobarograph-measured foot pressures and forces; and patient-reported outcomes as measured by the Manchester Foot Pain and Disability Index. Results Thirteen patients met the inclusion criteria and completed the study. Seven (12 affected feet) were randomized into Group 1; and 6 (9 affected feet) were randomized into Group 2. The average age was 55 years and BMI was 30.5 kg/m2. Demographics did not significantly differ between groups. Heel fat pad thickness increased after autologous fat grafting but returned to baseline at 6 months. However, autologous fat grafting increased dermal thickness significantly and also increased fat pad thickness under a compressive load compared with controls at 6 and 12 months. Foot pain, function, and appearance were also significantly improved compared with controls at 6 and 12 months. Conclusions Autologous fat grafting improved patient-reported foot pain, function, and appearance and may rejuvenate local soft tissues in patients with heel fat pad atrophy. Level of Evidence: 3

Background In patients with mild superior sulcus deformity, pseudoptosis, or multiple eyelid folds, several bulky fibers can be found anterior to the orbital septum. These fibers, called preorbital septum fibers, may constrict protrusion of the fat pad and movement of the levator palpebrae muscle. Objectives In this study, the authors illustrated the anatomy of these fibers and described the double-eyelid procedure to correct pseudoptosis, mild superior sulcus deformity, and multiple eyelid folds, which may be caused by these fibers. Methods The bulky preorbital septum fibers were dissected and severed during upper blepharoplasty to release the orbital septum fat pad and levator palpebrae muscle. This procedure was performed between January 2016 and January 2018 in 56 patients with distinct preorbital septum fibers. Results Of the 56 patients, 38 displayed mild to moderate upper eyelid depression and multiple eyelids, and 18 displayed pseudoptosis. Bulky fibers that existed in the superficial layer of the orbital septum were all dissected and removed. After 6 months’ recovery, the superior sulcus deformity improved in all patients. No recurrence of multiple eyelids was observed. Patients with pseudoptosis showed a notable release of their upper eyelids. Conclusions This is the first time to our knowledge that the preorbital septum fibers are described as a distinct anatomical structure. They are clinically important in upper eyelid anatomy and the improvement of sunken upper eyelids or pseudoptosis. The combination of blepharoplasty with release of these fibers is easy to perform and promote. Level of Evidence: 4

Background Regardless of the technique chosen to treat the aging midface, the isolated lateral approach facelift has a limited impact on the midface volume deficit. In an effort to overcome this limitation, modern facial rejuvenation procedures incorporate an additional modality for replenishing the midface volume. Some of the author’s facelift patients present with bulging buccal fat pads despite volume deficiency in the inframalar region. The author’s technique is designed to utilize the buccal fat pad to replenish the inframalar volume deficit. Objectives The author sought to present the fat pad transposition surgical technique along with objective outcome data. Methods This study was a retrospective review of nonconsecutive cases where the sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad was performed. A total of 22 patients underwent the fat pad transposition technique by the author (O.B.) between July 2013 and December 2017. Patient data were obtained from patient records, 3-dimensional models, magnetic resonance images, and standardized photography. Preoperative differences in midface volume were assessed utilizing curvilinear surface measurements on 3-dimensional models and the Allergan midface volume deficit scale on standardized photography. Results The average midface volume deficit score significantly improved, and the average midfacial curvilinear surface measurement significantly increased after surgery. Magnetic resonance imaging confirmed a stable position of the buccal fat pad after surgery. Conclusions The sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad is an effective technique that can be safely employed for autologous inframalar augmentation in patients with a favorable facial morphology. Level of Evidence: 4

Background Buccal fat pad (BFP) excision is a procedure in which the fat pad is extracted in order to achieve a more youthful appearance. Objectives The aim of this study was to describe an alternative technique that utilizes hydrodissection to extract the BFP. Methods This is a controlled, prospective, randomized clinical study involving 2 groups. Group A (n = 27) underwent BFP excision with hydrodissection, during which 15 mL of a vasoconstricting anesthetic solution was injected into the BFP. Group B (n = 27) underwent BFP excision, during which 3 mL of lidocaine 2% with epinephrine was injected. All procedures were performed by the same surgeon. Variables analyzed were surgical time, intraoperative bleeding, and postoperative pain directly following surgery 2 hours after the procedure, as well as maximum pain within 72 hours of surgery and complications. Postoperative care was standardized, and patient follow-up extended over a 6-month period. Results Pain scores for 54 patients were recorded on a visual analog scale (0–10). Mean ± standard deviation transoperative pain scores were 0.5 ± 0.8 for Group A and 1.3 ± 1.3 for Group B (P = 0.01); 2 hours postoperation the scores were 1.2 ± 0.7 for Group A and 2.6 ± 1 for Group B (P < 0.0001). Maximum pain occurred within 72 hours, and scored 1.6 ± 0.6 for Group A and 3.1 ± 1 for Group B (P < 0.0001). Mean operative time was 8:18 ± 0:47 minutes for Group A and 14:08 ± 2:28 minutes for Group B (P < 0.0001). There was a positive correlation between operative time and pain. Overall, 5.5% of patients suffered postoperative complications. Conclusions BFP excision by hydrodissection is an effective procedure that decreases surgical times by facilitating extraction of the BFP with less manipulation, thereby resulting in decreased postoperative pain and a more tolerable recovery. Level of Evidence: 2

Background During the course of performing abdominoplasties, a plastic surgeon will encounter a certain body habitus characterized by a thick, tethered, and excessively redundant upper skin flap. Often these patients also demonstrate diffuse and substantial fascial laxity. One approach to this problem involves direct thinning and release of the flap by resection of the sub-Scarpa’s fat pad. In theory, this resection should be safe from a flap perfusion standpoint. However, the safety of the sub-Scarpa’s resection has not been completely documented. Objectives The author sought to assess the safety and efficacy of sub-Scarpa’s lipectomy in abdominoplasty. Methods A total 723 patients were retrospectively examined and divided into 2 groups: those with (Group B) and those without (Group A) a sub-Scarpa’s lipectomy component to the abdominoplasty. Because of differences in the baseline characteristics between the 2 groups, data analysis was performed with a logistic regression model and with propensity score matching. Results The sub-Scarpa’s lipectomy technique allowed for substantial thinning of the flap: the average weight of the resected fat pad was 411 g. Wide undermining allowed for substantial fascial correction, and excellent results were obtainable even in challenging cases. The sub-Scarpa’s lipectomy group did not demonstrate an increase in either minor (5 cm2) flap necrosis. However, there was a statistically significant increase in fat necrosis and seroma formation in Group B compared with Group A. In both groups, an increasing body mass index was a risk factor for fat necrosis and major flap necrosis. Conclusions The implementation of a sub-Scarpa’s lipectomy during abdominoplasty is a useful technique to consider for selected abdominoplasty candidates. The risks of minor and major flap loss do not seem to be increased compared to the standard abdominoplasty, but the risks of fat necrosis and seroma formation may be greater. Level of Evidence: 4

Background Although the excision of the buccal fat pad has become very popular for achieving a slimmer midface, not all patients are good candidates for this procedure. Unfortunately, studies that provide guidelines by emphasizing volumetric and technical details are limited. Objectives The study compared preoperative and postoperative volumetric data to identify the amount of tissue that can safely be removed and important technical concepts involved in lower cheek contouring with buccal fat pad excision. Methods Patients complaining of cheek fullness were evaluated to determine if they were good candidates for the procedure. Eligible patients were screened with transbuccal ultrasound to determine tissue volumes and anatomical details. Intraoperative and postoperative, 6th-month volume measurements were undertaken and residual tissues and vascular pedicles reevaluated. Results Ultrasound imaging showed that the mean preoperative volume of the fat pads was 11.67 ± 1.44 mL, and the mean postoperative volume was 8.58 ± 1.07 mL. The mean volume of the excised tissues was 2.74 ± 0.69 mL. Postoperative buccal fat pad volume values correlated with the reported average in the literature for the same age group. Conclusions Buccal fat pad removal is an effective technique for refining the facial silhouette that should be reserved for patients with increased buccal fat pad volume. Removal of only the excessive portion of the fat pad is important because this structure provides significant volume in the midface that can be difficult to restore once aging affects the surrounding soft and bony tissue. Level of Evidence: 4

BACKGROUND Pedal fat grafting is a cosmetic procedure to treat the functional and aesthetic sequelae of pedal fat pad atrophy. Fat grafting has been found to mitigate these symptoms, but the exact mechanism is unknown. OBJECTIVES The authors hypothesized that pedal fat grafting may improve skin quality, accounting for prolonged symptomatic improvement despite loss of grafted fat. METHODS Patients with pedal atrophy were enrolled in a randomized crossover clinical trial. Group 1 underwent fat grafting upon enrollment with 2-year follow-up. Group 2 was managed conservatively for 1 year then placed into the fat grafting group with 1-year follow-up. Patients underwent pedal ultrasounds to determine thicknesses of the fat pad and dermis, and photographs were taken to assess skin quality. RESULTS Three men and 20 women with an average age of 63 ± 6 years and an average BMI of 26.0 ± 4.6 kg/m2 were enrolled in the study. Twenty-six feet were injected in Group 1 and 17 were injected in Group 2. Group 1 dermal thickness increased at 6 months post-injection (P < 0.05). This increase persisted through 24 months. Group 2 dermal thickness decreased prior to injection (P < 0.05) but returned to baseline after injection and through 12-month follow-up (P < 0.05). Fat pad thickness returned to baseline by study completion in both groups (P < 0.05). CONCLUSIONS Pedal fat grafting yielded a significant, sustained increase in dermal thickness, though grafted fat was not retained. Fat grafting may improve skin quality, which could contribute to improved clinical outcomes despite loss of grafted fat. LEVEL OF EVIDENCE: 2

Zuk et al in 2001 identified stem and regenerative cells within the stromal vascular fraction of fat. In preclinical studies, these cells appeared to stimulate angiogenesis and reduce inflammation, and soon thereafter, clinical use of stromal vascular fraction (SVF) evolved as researchers such as Rigotti, Coleman, Mojallal, our group, and others demonstrated that fat can be used for both therapeutic and aesthetic indications. The regenerative effects of fat and its contents on facial aesthetics have been shown at the histologic and cellular level. Regeneration of elastin and collagen fibers as well as improvement in capillary density and reduction of inflammation have been reported. We review our current approach to the use of regenerative cells and different types of fat grafts in facial surgery. The fat graft is classified, both from a regenerative point of view as well as a tissue product that can be modified into different tissue characteristics, depending on the area and condition treated. Clinical use of SVF enriched fat, millifat, microfat, and nanofat grafts as well as composite fat grafts are reviewed. Based on clinical experience and evidence to date, it appears that the regenerative effects seen with the use of SVF in aesthetic surgery are modest, but there appear to be definite histologic findings of regeneration. These improvements may not be clinically apparent to a patient when cell enriched fat grafts are compared to fat grafts alone. However, the subtle changes seen in histology may be cumulative over time. Three types of fat grafts are defined: millifat (parcel size 2.4

BACKGROUND Although many facelift techniques incorporate fat grafting with tissue repositioning and removal, the intermediate and long-term changes in facial volume after these techniques is unknown. Whereas fillers for facial volume have predictable life spans, we know little about the facial volume changes following fat grafting with facelift surgery. OBJECTIVES The authors sought to track the short-term and long-term effects on midfacial volume change. METHODS We evaluated a subset of patients who were followed by 3-dimensional (3D) photometric imaging 18 to 24 months after facelift with fat grafting to the deep midfacial fat compartments and buccal fat pads. Volume changes were measured preoperatively and postoperatively every 1, 3, 6, 12, 18, and 24 months using the 3D photometry. RESULTS At the 1- to 2-month follow-up period, average facial volume was 49.60% of the initial fat injected. At the 18- to 24-month follow-up period, average facial volume was 73.64% of the initial fat injected, indicating an increase in midfacial volume. Upon graphing available photometric data, dynamic changes in facial volume were observed. In 5 midfacial zones, facial volume appeared to initially decline (average decline, 49.0% of original fat injection), troughing at 10 months (range, 2-15 months), but later inclined (average increase in volume, 95.9% of original fat injection), peaking around 16 months (range, 4-24 months). CONCLUSIONS Progressive improvement in midfacial volume in part may be explained by the graft replacement theory of Suga and Yoshimura, which suggests that grafted adipose tissue immediately dies after transplantation and is replaced by adipose-derived stem or progenitor cells. LEVEL OF EVIDENCE: 4

Background: Many surgeons are reluctant to perform fat grafting in patients with diabetes because soft-tissue healing is impaired, but no previous study has reported data-driven outcomes of fat grafting in subjects with diabetes. Objective: The authors investigate whether diabetes affected survival and complication rates of autologous fat grafting (AFG) in Sprague-Dawley (SD) and Otsuka Long-Evans Tokushima Fatty (OLETF) rats. Methods: In total, 16 male SD and 16 male OLETF rats were prepared for AFG. Fat tissue was harvested from the inguinal fat pad and cut into 1-g (800–1250 mg) sections. Each rat received fat in a subcutaneous pocket in the paraspinal area. The grafted fat tissue was measured by ultrasonography at 30, 60, and 90 days after implantation and evaluated by histological analyses. Results: Ultrasonographic analysis indicated that compared with the SD group, the AFG survival rate was lower in OLETF rats (40.52% vs 53.38%), and the failure rate was higher in OLETF rats (31.25% vs 6.25%). The histological analysis indicated that compared with the OLETF group, adipocytes were more dense (3.18 vs 2.33; P = .025), cyst formation occurred less frequently (3.00 vs 3.61; P = .030), and more capillaries were formed (2.31/field vs 1.61/field; P = .001) in the SD rat group. Conclusions: Diabetes causes marked deterioration in the survival and quality of AFG in the diabetic rat model.

Concavity in the temporal area reflects a deficiency in the bulk of the temporalis muscle or overlying temporal fat pad. It may be a reflection of senescence, low body fat, exaggerated adjacent skeletal or soft-tissue contours, idiopathic progressive atrophy, or postsurgical deformities. The authors describe the application of methyl methacrylate (MMA) to fill depressions in the temporal area. In instances in which no previous surgery has been performed or when the temporal area has served as a dissection plane for surgery in adjacent areas (eg, a subperiosteal facelift), the implant material is placed beneath the temporal muscle through a limited incision in the hair-bearing scalp. When previous reconstructive surgery has been performed in the temporal area, the area of depression is accessed through existing surgical incision scars to place MMA over the temporal muscle. These operative techniques have been reliable, durable, and relatively free of complications.

Background: A great number of studies have reported on the temporal branch anatomy and its relationship to the fascial layers and various fat pads of the temporal region, but no article has included information on the relationship of the temporal nerve to the retro-orbicularis oculi fat (ROOF) and/or the suborbicularis oculi fat (SOOF). Objectives: The authors report the results of a series of human cadaver temporal nerve dissections, with particular attention paid to its relation to the ROOF and the SOOF. The results of a literature review and a subsequent open browlift are also reported to confirm the results of the cadaver study. Methods: Dissection was performed on 15 fresh human cadavers, for a total of 29 hemifaces. The course and relationships of the temporal nerve branch to the fascia, fat pads, and landmarks in the temporal region were noted and detailed. A thorough review was also performed for 23 articles, to compare the author’s anatomical findings with data in the previous literature. Results: During cadaver dissection, the temporal branch was found to lie on the undersurface of the superficial temporal fascia. In the supraorbital area, the ROOF existed in the loose areolar plane or deep layer of the superficial temporal fascia, with the temporal nerve branch directly superficial to it. The temporal branch passed lateral to the SOOF in its superiomedial course at the level of the zygoma. These findings were later confirmed during an in vivo open browlift as well. Conclusions: The ROOF was formerly unrecognized as an important sentinel marker for possible injury to the temporal nerve branch during browlift. However, this cadaver study and its accompanying literature comparisons show that browlift dissection, whether endoscopic or open, should aim to keep the ROOF fat in the superficial plane, ensuring that the nerve branch is safe from iatrogenic injury.

Background: Aging in the malar fat pad is mainly caused by ptosis of the fibroadipose layer. In the lower level of the face, atrophy or osseous rotation may contribute to the signs and symptoms of facial aging. Objectives: The senior author (CYC) describes his simple technique of suspension and fixation of the malar fat pad and the jowl during facial rejuvenation surgery. Methods: Ten patients underwent facial rejuvenation, the technique of which consists of sustaining and elevating the ptotic malar tissue and the jowl with four slings of monofilament nylon suture. The sutures are fixed medially in an artificial orifice dissected on the frontal process of the maxilla, above the alar groove. The sutures are distributed evenly on the face, directly supporting the jowl, the malar fat pad, and the periorbital tissue. Laterally, the loops are fixed under tension on the temporal fascia and the periosteum of the lateral orbital rim. The vector of tissue displacement is upward and concentric, opposing the vector of the aging process, and the fixation is consistent. Results: Postoperative complications included moderate and transitory pain; patients reported no major complications or recidivisms during the follow-up period of two years. Results showed aesthetic improvement for all patients. Conclusions: The present technique has proven simple and effective in a small cohort over two years. A longer follow-up period with more patients would be valuable in further documenting the procedure.

The author contends that to obtain the best contour in the cheek, mandibular border, and upper neck in older patients, it is advantageous to extirpate one or two portions of oral mucosa in addition to removing the buccal fat pad. These combined procedures will effectively lift the sagging oral soft tissues.

The author has modified his original Gore-Tex cable-looped suture system by incorporating a series of knots to centralize the larger-sized pulley and by providing added tissue resistance to slippage through the bidirectionally repositioned malar fat pad. These suture modifications offer a safe and effective technique for longer lasting malar fat pad suspension. Although the technique may be performed as an isolated procedure, for optimum results it is combined with conventional procedures of the lower lid and face to achieve blending of the aging face.

The author performs buccal fat pad excision to improve facial contour in some patients with buccal lipodystrophy and to treat buccal fat pad pseudoherniation. He recommends an intraoral approach, taking care not to pull on the fat pad and resecting only that which protrudes easily with gentle pressure.

Learning objectives The reader is presumed to have a broad understanding of the anatomy of the anterior midface. After reading this article, the participant should be able to: 1. Identify the topographical component signs of aging of the anterior midface. 2. Explain the mechanisms of ptosis affecting these components. 3. Practice the vertical and superolateral repositioning of the malar fat pad. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination on the basis of material covered in this article. The examination begins on page 257. Background We have previously described a technique of anterior midface soft tissue repositioning using 2 cable sutures directed only in a superolateral direction. This technique achieves a more normal distribution of subcutaneous fat laterally over the malar bag prominence but does little to overcome central and medial hollowness in the palpebromalar and tear-trough areas. Objective We describe an alteration of our original technique that introduces a vertical lift of the anterior midface soft tissue utilizing Gore-Tex, (W.L. Gore & Associates, Flagstaff, AZ) cable sutures while elevating the preperiosteal soft tissue. Methods We used a transconjunctival approach to expose the postseptal fat, orbital rim, and arcus marginalis. Subperiosteal dissection over the orbital rim was performed to prepare a pocket for the malar fat pads. Using 6.5-cm Keith needles, we placed a braided suture medially, lateral to the location of the infraorbital nerve and foramen, and maneuvered it through the soft tissue until all signs of dimpling at the nasolabial line or upward distortion of the upper lip were removed. A Gore-Tex graft was introduced and seated in a cupped configuration that anchored the caudal fat pad at the nasolabial line. The medial fat pad and vascular pedicle were transposed over the orbital rim into the predissected pocket; the central fat pad was also fashioned into a pedicle and moved into its pocket. The Gore-Tex sutures were tightened, elevating the supraperiosteal soft tissue vertically. A second set of Gore-Tex sutures elevated the anterior midface soft tissue toward the deep temporal fascia. Results Between 1999 and 2002, 197 patients underwent bidirectional anterior midface lift with Gore-Tex sutures, combined with ancillary procedures. Use of the Gore-Tex cable sutures enabled improvement in the periorbitum, midcheek, and neck, as well as a more harmonious facial appearance in all patients, with few complications. Conclusions The bidirectional cable-suture technique is simple, effective, and safe. It provides secure fixation and filling of the nasojugal hollow and improvement of the malar eminence. It is less effective in the periorbitum and does not seem to correct the recalcitrant nasolabial fold.

Background: The different possibilities for management of excessive or pseudoherniated fatty tissues in the lower eyelid are a subject of lively discussion in the field of aesthetic surgery. Objective: We present a technique that uses the transconjunctival approach for the simultaneous treatment of excessive or pseudoherniated fat and marked periorbital sulci, which is based on the sliding fat pad technique first described by Loeb. Method: Incision of the conjunctiva, inferior tarsal muscle, and capsulopalpebral fascia is performed about 3 mm above the fornix. Dissection is performed following the preseptal-suborbicularis dissection plane, freeing the arcus marginalis, traversing the malar septum, and passing below the palpebromalar and nasojugal sulci. Retraction is performed with a specially designed transconjunctival retractor and lower-lid retractor. The orbital septum is opened and blunt dissection of the inner and central fat bags is performed. The fat flap is secured with transcutaneous stitches tied over small pieces of silicone. A transcutaneous-transconjunctival suture is performed to reduce postoperative discomfort and promote scarring of the transected planes. Results: We have achieved aesthetically satisfactory results with no major complications. Conclusions: The sliding fat pad technique by the transconjunctival approach is a new technique that allows a natural and effective simultaneous correction of the lower eyelid, periorbital sulci, and mild cutaneous excesses with no disruption of the muscular and cutaneous planes, prompt recuperation, and a very low incidence of adverse effects when performed by surgeons experienced in transconjunctival procedures. ( Aesthetic Surg J 2001;21:487-492.)

Andre Camirand, MD, Montreal, Canada, is a plastic surgeon certified by the College of Physicians and Surgeons of the Province of Quebec. By the time we are 5 years old, the bony orbit has a volume of 30 mL that remains constant for the rest of our lives. At the same time, however, the bony orbit contains 10 cc of fat that will gradually resorb with age, a cause of senile enophthalmia. A herniated fat pad almost always results when orbital fat is displaced by lowering of the eyeball. The level of the globe in the orbit is maintained by the Lockwood suspensory ligament, which is attached to the strong and stable medial canthus and the stretchable lateral canthus. With age or because of heredity, the lateral canthus and the Lockwood ligament stretch, causing the globe to descend.1–3 As the space between the globe and the orbital floor is reduced, the orbital fat is pushed anteriorly. No matter how young …

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to: 1. Describe the anatomy of the malar fat pad and the changes it undergoes with the aging process. 2. Comprehend the author’s technique of lifting the malar fat pad to treat the prominent nasolabial fold. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 159.

According to the author, suture elevation of the malar fat pad is a simple, safe, and reliable procedure to reestablish a youthful malar contour, shorten the lower eyelid, and improve the nasolabial crease. Access for incision placement may be prehairline, subciliary, or intraoral, depending on patient characteristics and the goals of surgery.

Background: The eyebrows and eyebrow fat pads, key structures in upper facial aesthetics, are particularly vulnerable to age-related changes. Objectives: In this study, the authors compare the impact of aging on the eyebrows and eyebrow fat pad volume in men and women through three-dimensional (3D) volumetric analysis. Methods: Electronic medical records of patients seen at the Jules Stein Eye Institute in the Division of Orbital and Ophthalmic Plastic Surgery between 2005 and 2010 were reviewed. Patients were included if they had undergone investigative imaging of the orbit for unilateral pathology. Computed tomography (CT) scans of patients with Graves disease diagnosis, extensive orbital trauma, and/or previous eyebrow surgery were excluded. A total of 52 CT scans (24 men and 28 women) were retained for analysis. A 3D reconstruction software was used to analyze the scans and calculate volumes of the retroorbicularis oculi fat (ROOF), galeal fat (ROOF and subcutaneous fat), and soft tissue muscles. Results: Galeal and brow fat volumes showed a significant positive trend toward enlargement in women ( P values of .01 and .05, respectively). Although men showed a tendency toward fat enlargement with age, this was not statistically significant. Soft tissue–muscle volume decreased significantly in aging women (9.32 mm3/y) ( P = .02). Data indicated that soft tissue volume in men tended to increase with age (3.92 mm3/y) but not significantly ( P = .36). Neither total volume nor brow thickness appeared to change significantly in women ( P = .56, P = .73). In men, total volume and brow thickness showed weak evidence of increasing with age ( P = .12, P = .22). Linear regressions of Hertel measurements with and without sex interaction showed no statistically significant trend between the amount of proptosis and the galeal or brow fat. Conclusions: Although overall eyebrow volume does not change with age, the relative contribution of fat and soft tissue to the total volume does seem to change. This pattern also differs between males and females. As women age, the fat volume increases and the soft tissue volume decreases. In men, the shift from soft tissue volume to fat volume is less pronounced. Although many clinicians have been drawn to the concept of fat volume deflation as a key element of facial aging, this study does not support this perspective in the eyebrow fat pad. An increasingly refined understanding of the dynamics of facial aging is mandatory for clinical diagnosis and will likely provide the framework from which to develop more innovative treatment options.

Introduction: The eyelid of a young person can be distinguished by the lateral fullness of the upper eyelid. With aging, lateral fullness decreases. Volume restoration in the periorbital area has been previously addressed by fat draping and grafting. More recently, techniques for regaining lateral fullness of the upper eyelid have focused on fat grafting, although effective graft take, reabsorption, and irregularities have been a concern. To address these issues, the concept of pedicled fat draping in the upper eyelid was explored. Methods: In a retrospective study from June 2006 to August 2008, 31 patients underwent upper blepharoplasty with augmentation of the lateral fullness with a pedicled fat flap from the central fat pad. The fat from the central compartment was elevated, dissected, and then transposed to the lateral upper eyelid below the orbicularis muscle. Results: All patients were women ranging in age from 43 to 68 years. Pre- and postoperative picture comparison demonstrated a more youthful appearance with increased lateral fullness of the upper eyelids. There were no cases of fat necrosis encountered. Increased volume remained stable over an average of one-year follow-up. No complications were recorded. Conclusion: Transposing a pedicled fat pad from the central compartment laterally has proven to be an effective technique for achieving predictable upper lateral eyelid fullness and thus achieving a long-lasting, more youthful appearance.

According to the author, buccal fat pad removal is a minor procedure that adds relative prominence to the cheek area. For optimal results, he suggests augmenting the malar area with hydroxylapatite granules. Here, he describes his technique. (Aesthetic Surg J 2003;23:484-485.).

Background: Elevation of the malar fat pad by use of suture suspension to rejuvenate the central third of the face has been previously described. Objective: The authors evaluated the ability of suture suspension to successfully elevate the malar fat pad. Methods: Four fresh frozen cadaver dissections were studied. With the standard preauricular, subcutaneous approach, the malar fat pad was identified, and a suspension suture was placed at the inferior and lateral aspect of the fat pad. The vector of pull was directed vertically, and the tension that was applied to the suture was measured. The dermis was then elevated from the malar fat pad to examine suture placement and ensure that the dermis was not caught in the suture. Results: An average tension of 11 lb was applied before rupture of the suture. In none of the cases did the suture pull through the malar fat pad. Conclusions: Suture suspension is an effective technique for elevation of the malar fat pad. The results are easy to reproduce and are very effective in addressing the changes that accompany aging and the descent of the malar fat pad. (Aesthetic Surg J 2002;22:446-450.)

Peter McKinney, MD Sam T. Hamra, MD Andre Camirand, MD Allen M. Putterman, MD Dr. McKinney: Blepharoplasty, much like rhinoplasty, has evolved from a procedure of simply removing skin and fat to one of shaping and repositioning these structures, especially the fat. Our current thinking about blepharoplasty has been shaped by the work done by Drs. Leob and De LaPlaza in the 1970s and 1980s. The first patient (Figure 1) is a 55-year-old woman who is in good health and would like improvement in the appearance of her eyes. Dr. Camirand, what potential problems do you see for this patient, and how would you correct them? Figure 1 A 55-year-old woman seeks improvement of the tired look in her eyes. Dr. Camirand: Assuming that this patient is in good health, I would not discuss thyroid ophthalmopathy. First, her brow is too low, which reduces the distance between the brow and the lashes. She also has dynamic and static crow's feet, enophthalmia, and a sunken upper eyelid—more on the right side than on the left. The lateral canthus is low, causing scleral show. She also has actinic skin damage and a prominent infraorbital sulcus because the premalar fat pad has descended. For this patient I would consider doing a brow lift and a canthopexy to raise the lateral canthus. I think she would need a release of the lid retractors and a spacer in the posterior lamella as well to support the lower eyelid. I would relocate the orbital fat rather than excise it. In addition, I would consider lifting the premalar fat pad and eventually resurfacing her skin. Dr. Hamra: Because this patient is 55 years old, I would consider doing surgery on the eyes, brows, and complete face. The lower eyelids are the secret to achieving a good result. I would …

Background: Prominent fat pads of the lower eyelids are a frequent complaint prompting patients to seek cosmetic surgery. Previous studies have stated that these fat pads exist as three compartments in the lower eyelids. An accepted anatomic concept is that these lower eyelid fat pads are intraorbital. Objective: This study evaluates the possibility of distinct compartments of lower eyelid fat pads not being different from each other, but rather being separate from posterior intraorbital fat. Methods: This study used eight hemifacial cadaver dissections. Methylene blue injections were used to stain the middle and medial fat pads on each side. Sagittal cross-sections were obtained to visualize the area of fat staining. An axial cross-section of one additional specimen was obtained as confirmatory evidence. Results: Each specimen showed that lower eyelid fat pads stain as discrete fat compartments that are not in continuity with the posterior intraorbital fat. Their anterior boundary is the orbital retaining ligament at the anterior aspect of the inferior orbital rim. Their posterior boundary is an insertion point on the floor of the orbit in line with the midpoint of the globe, called the circumferential intraorbital retaining ligament. Conclusions: Lower eyelid fat pads are not in continuity with posterior intraorbital fat. They can accurately be described as partially intraorbital and partially extraorbital in location. This information augments our previous understanding of the anatomy of the lower eyelid fat pads and is important for studies that attempt to determine their etiology.

Background Subcutaneous injection of Lipostabil Endovena (Nattermann & Cie, Koln, Germany) has been used to treat periorbital fat pads, as well as localized fat deposits in the abdomen, neck, arms, and thighs. Objecive The goal of this article was to identify complications resulting from the use of Lipostabil Endovena for treating fat deposits. Methods A prospective study was conducted to identify complications associated with injection lipolysis with Lipostabil Endovena. Patients were surveyed at 48 hours, 2 weeks, and 2 months after the last injection session. Results The 739 patients surveyed received a total of 2852 vials injected. No general symptoms, such as fever, dizziness, gastrointestinal disturbances, or visual disturbances occurred, although local symptoms, including edema, hematoma, pain, and nodules, were reported. Conclusions The lack of any reported general complications after injection lipolysis with Lipostabil Endovena is encouraging. However, larger studies are needed to confirm that the use of Lipostabil Endovena is safe.

Background: Rejuvenation of the periorbital area requires an understanding of the morphologic changes that occur with aging. Blending the lid/cheek junction is a goal of periorbital rejuvenation. Objective: Transblepharoplasty techniques are proposed to achieve aesthetic periorbital rejuvenation with predictable improvement and minimal morbidity. Methods: Techniques of blending the lid/cheek junction are presented that include septal advancement with both septal tightening and subseptal fat pad contouring when indicated, or complete release of the orbital orbicularis oculi muscle, along with vascularized and/or free fat transfer over the inferior orbital rim, to produce a youthful contour. Lid support was enhanced with a medially based orbicularis oculi muscle sling, which further improves the contour of the lid/cheek junction through muscle release to the medial inferior orbital rim. Results: Fifty-eight consecutive cases were reviewed that included lower lid blepharoplasties with or without a concomitant midface lift. Four cases of midface lift did not require any lower eyelid procedures. Septal reset or aggressive orbicularis oculi release with fat transfer were performed in 30 patients. A medially based orbicularis oculi flap was developed to support the lid, and canthopexy or canthoplasty was performed as indicated. Complete release of the medial fibers of the orbital orbicularis oculi muscle allowed for tension-free placement of vascularized fat or free fat grafts and a more profound blending of the lid/cheek junction, since the flap advancement acted as a handle to carry the upper midface soft tissues. Conclusions: Transblepharoplasty options for repositioning periorbital soft tissues are reliable means for blending the lid/cheek junction.

Transconjunctival blepharoplasty is a commonly performed procedure. Corneal protection, avoidance of damage to the inferior oblique muscle of the eye, avoidance of hemorrhage from the fat pads, and adequate fat removal are important considerations when transconjunctival blepharoplasty is performed. The described surgical technique provides consistently satisfactory results and avoids the use of cumbersome corneal protectors.