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Background Autologous abdominal fat grafts are occasionally used in the repair of skull base exposures. This surgical procedure typically requires an additional surgical site and may have unexpected postoperative complications. Objective To describe an operative technique for harvesting subfascial fat from the temporal extension of the buccal fat pad for the repair of skull base defects. Methods We review the pertinent anatomy of the temporalis subfascial fat pad and discuss the technique used to harvest the subfascial fat component in a clinical presentation. Results A pretemporal approach was performed for clip ligation of an anterior circulation aneurysm. A standard frontotemporal incision was made with an interfascial flap to preserve the frontalis branches of the facial nerve. The subfascial fat was inspected and determined to be adequate for harvesting. Monopolar cauterization was carefully utilized to remove the fat. During closure, the graft was used to repair a pneumatized clinoid sinus and for the dural repair of the pretemporal exposure. The patient did not have any postoperative complications. Conclusion Autologous temporalis subfascial fat graft is a viable and safe technique for skull base dural and sinus repair during frontotemporal approaches in select patients. This technique avoids an additional surgical procedure and potential complications that may be associated with it.

Purpose To determine whether thyroid eye disease (TED) is associated with a change in temporal fossa soft tissue volume. Methods CT imaging studies were selected from patients with TED considering orbital decompression surgery and from an age-matched group of controls presenting to the Emergency Department for nontraumatic conditions requiring CT imaging. Measurements of the temporal fossa fat pad and soft tissue thickness were used as a proxy for volume and were performed using the zygomaticotemporal suture as a reference point. Categorical variables were described using frequencies and percentages, while continuous variables were described using medians and standard deviations. Chi-square tests were used to assess the relationship between gender and age group, while t-tests were used to examine the relationship between continuous variables and age group. Results A total of 56 CT scans were evaluated, including scans from 28 patients with TED and 28 controls. The following measurements were found to be significantly larger in the TED population: left fat pad measured 5 mm above the zygomaticotemporal suture (p = 0.012), right fat pad measured 15 mm above the suture (p = 0.005), right soft tissue measured 15 mm above the suture (p = 0.026), left fat pad measured 15 mm above the suture (p = 0.006), and the left soft tissue measure 15 mm above the suture (p = 0.032). Conclusions Thyroid eye disease is associated with an increase in temporal fossa fat pad and soft tissue volume. These findings suggest that TED disease may produce pan-facial changes rather than changes confined to the peri-orbital region.

Purpose To quantify the complete dimensions of the retro-orbicularis oculi fat (ROOF) pad and to determine its relationship to other fat compartments of the forehead. Methods The entire forehead of 14 hemifaces of seven fresh frozen human cadavers (four female, three male) was dissected in the subcutaneous and submuscular planes. For each plane, a ruler was placed at the facial midline, and images of the dissection plane were taken at 90° and 45°. Images were analyzed for vertical height, horizontal length, the distance to midline from the point of maximal height, and area for each hemiface of the ROOF and for the entire fat compartment contiguous with the ROOF. A two-tailed t test was conducted between ROOF and ROOF plus the extended fat plane across all measurements. A Wilcoxon nonparametric signed rank test was performed to determine equivalent fat distribution of the extended fat plane over each cadaver's respective eye. Results The deep fat originating from the ROOF consistently extended laterally and superiorly in each specimen, distinctly separated via septae from the deep central, deep lateral, and the deep temporal fat compartments. The color, composition, and distribution of this contiguous deep fat did not differ phenotypically from the traditional ROOF. The extended deep fat plane possessed an average vertical height of 3.09 ± 0.68 cm, average distance to midline from point of maximal height of 3.56 ± 0.53 cm, an average horizontal length of 5.37 ± 0.82 cm, and an average area of 13.40 ± 2.69 cm. The extended deep fat demonstrated a statistically significant increase in maximal height, length, and total area compared with the ROOF. A Wilcoxon nonparametric signed rank test was nonsignificant (α = 0.01) across all measurements, demonstrating that the extended fat plane was similarly distributed over each eye. Conclusions A layer of deep fat originating from the traditionally defined ROOF extends superiorly and laterally beneath the frontalis muscle, separate from the deep lateral, deep central, and deep temporal fat pads. This is the first study to clearly demonstrate a contiguous superficial musculoaponeurotic system layer of fat extending under both the orbicularis oculi and frontalis muscles. This plane of fat is more appropriately described as the retro-orbicularis oculi and frontalis fat.

BACKGROUND Soft-tissue filler injections for the treatment of facial aging can result in different skin surface effects depending on the targeted facial fat compartment and fascial plane. This work investigates the tissue response of defined amounts of soft-tissue filler material injected into superficial and deep facial fat compartments by means of the calculation of the surface-volume coefficient. METHODS Four fresh frozen cephalic specimens obtained from human donors (three female and one male; mean age, 74.96 ± 22.6 years; mean body mass index, 21.82 ± 6.3 kg/m) were studied. The superficial and deep lateral forehead compartments, deep temporal fat pad, sub-orbicularis oculi fat compartment, and deep medial cheek fat compartment were injected with aliquots of 0.1 cc of contrast-enhanced material and scanned using three-dimensional surface imaging, resulting in a total of 226 injection and scanning procedures. RESULTS The sub-orbicularis oculi fat compartment revealed the highest correlation coefficient (rp = 0.992; p < 0.001) and the highest surface-volume coefficient (0.94). The compartment with the lowest tissue response was the deep medial cheek fat compartment (rp = 0.745; p < 0.001; surface-volume coefficient = 0.29), followed by the deep lateral forehead compartment (rp = 0.814; p < 0.001; surface-volume coefficient = 0.68), superficial lateral forehead compartment (rp = 0.824; p < 0.001; surface-volume coefficient = 0.74), and deep temporal fat pad (rp = 0.947; p < 0.001; overall surface-volume coefficient = 0.64). CONCLUSIONS These results, confirmatory in their nature to current injection strategies, provide evidence for the validity and reliability of the surface-volume coefficient. Injection procedures should be targeted in terms of facial fat compartments and fascial planes for a desired aesthetic outcome, as each fat compartment and fascial plane has unique tissue responses to injected soft-tissue fillers.

Purpose Loss of volume in the sub-brow fat pad with associated descent of the eyebrow is a common anatomical finding resulting in both functional and aesthetic consequences. A variety of techniques have been described to address brow position at the time of blepharoplasty. To our knowledge, none of these techniques treat the sub-brow fat pad as an isolated unit. Doing so enables the surgeon to stabilize and volumize the brow without resultant tension on the blepharoplasty wound. The authors describe a technique for addressing volume loss in the eyebrow with associated brow descent that treats the sub-brow fat pad as an isolated unit. Methods A retrospective review of all patients undergoing brow ptosis repair by a single surgeon (J.W.S.) over an 11-month period was performed. Results Eighteen patients and 33 brows underwent the technique described. Patients were followed for an average of 11 weeks (range: 4 weeks to 20 weeks). All patients preoperatively displayed both visually significant dermatochalasis and brow descent below the orbital rim. Evaluation of pre- and postoperative photos demonstrates successful volumization of the brow with skin redraping without focal dimpling or undue tension on the eyelid wound. Conclusions Performing a dissection that allows the sub-brow fat pad to be elevated in isolation from the overlying orbicularis and underlying periosteum allows for volumization and of the brow without compromising closure. This technique is a safe and effective means of volumizing the brow and treating secondary brow descent.

Purpose To evaluate the safety, subjectively assess outcome, and emphasize surgical pearls and critical clinical observations of upper blepharoplasty performed in conjunction with the brow fat pad suspension suture procedure, previously referred to as a "browpexy variant" or "brassiere suture procedure." Methods A retrospective 4-year analysis of patients who underwent the brow fat pad suspension suture with upper blepharoplasty was performed. Adjunctive procedures (brow lift and ptosis repair) were categorized. The surgical technique is detailed with emphasis placed on nuances to aid in optimal outcome. Results Two hundred and sixteen patients (149 women and 47 men) underwent upper blepharoplasty with the brow fat pad suspension suture. The average patient age is 54 years and follow up is 11 months. One hundred patients had adjudicative brow lift or ptosis repair, and in 20 patients the blepharoplasty was a revision procedure. Subjective assessment of outcome showed excellent aesthetic results with improved brow projection, and enhanced lateral tarsal platform show and eyebrow/eyelid contour. Surgical complications were infrequent and patient satisfaction was high. Conclusions This initial large series description of the brow fat pad suspension suture demonstrates that it is a safe adjunct to upper blepharoplasty, which the authors believe subjectively improves overall outcome. Evidence-based quantitative assessments of objective measures of surgical results are currently underway.

The aim of this study was to obtain information by assessing the relationship between temporal region fascial structures, fat pads, and temporal branches of facial nerve in human fetuses to use the knowledge on treatment of early childhood period surgeries. This anatomic dissection study was conducted on 40 hemifaces with no visible external abnormalities on their faces. Fascial layers and related fat pads of temporal region were dissected layer by layer beginning from superficial to deep. The relations of temporal branches of facial nerve and temporoparietal fascia and the structures of these fascial layers were evaluated. Temporoparietal fascia showed continuity below zygomatic arc with superficial musculoaponeurotic system. Temporal branches of facial nerve showed a multiple branching. Parotid-masseteric fascia became very thin on the superficial of zygomatic arch and ran with superficial layer of temporal fascia above without attaching to periosteum. Temporal branches of facial nerve entered between multilayered layers of temporoparietal fascia. Temporoparietal fascia became thicker on anterior and middle parts because of the localization of superficial temporal fat pad. Temporal fascia was a 2-layered thick and fibrous tissue enveloping intermediate fat pad. Deep layer connected to periosteum of zygomatic arch and superficial layer continued passing superficial of zygomatic arch and connected to the parotid-masseteric fascia. Deep temporal fat pad was found on the deep to deep layer of temporal fascia and surface of temporal muscle. The findings of this study may contribute to the knowledge of the topographical localization of temporal branches of facial nerve with temporal region fascial structures and fat pads in fetuses.

The buccal space, with its fat pad, is a valuable, overlooked target in facial rejuvenation procedures. The authors identified a specific group of patients who have normal or prominent malar projection in the presence of atrophy of the buccal fat pad, with or without prominent gonial angles. Eight of 24 prospectively studied patients (Biomedical Research Institute of America) who had fat grafts and face lifts received an average of 2.7 ml of fat transferred into the buccal space. Immediate visual correction of the buccal depression was noted. No overcorrection was carried out. None of the eight patients suffered an adverse event from transoral buccal space fat grafting. Persistent facial volume in this area has been noted up to 24 months after treatment. In patients with buccal fat pad atrophy, fat grafting into the buccal space can be safely performed through an intraoral approach.

INTRODUCTION AND OBJECTIVES:Lymph node (LN) dissection has a significant impact on the oncologic outcomes of patients with prostate cancer. Previously, we have reported that the Prostatic Anterior ...

Epipericardial fat necrosis is a rare cause of acute pleuritic chest pain reported in approximately 40 cases. This diagnosis mimics a myocardial infarction, pulmonary embolism, or pericarditis; however, the cardiac enzymes and electrocardiogram are usually normal. We present the first reported case of epipericardial fat necrosis in an adolescent.

An isolated fat pad sign (i.e. joint effusion without a visible fracture), commonly seen in acute elbow injury, is associated with occult fracture and treated as such. However, the clinical relevance of an isolated fat pad is unclear, thereby questioning the need for specialized follow-up. In this study, 111 patients (median age 15 years, interquartile range 9-27 years) with an isolated fat pad sign after acute elbow injury were included. The clinical relevance of an isolated fat pad sign was derived from descriptives on pain, elbow function, treatment change, number of revisits and recovery time after 1 week follow-up and long-term follow-up. Treatment alterations were rarely made and none of the patients needed an operative intervention; also, none of the patients had persistent symptoms. The median recovery time was 3 weeks (interquartile range 2-12 weeks). This study shows that, unless symptoms persist or worsen, regular follow-up at a specialized outpatient clinic is not needed.

Background Although fat is transplanted into several layers, including subcutaneous, fat, and muscle layers, there is little (clinical) scientific basis for these procedures. Objective To determine the optimal recipient layer for fat transplantation. Materials and methods Fat harvested from inguinal fat pads of green fluorescent protein (GFP) mice was grafted into the subcutaneous and intramuscular planes and the fat pads of C57 mice. Specimens collected after 1, 4, 8, 12, and 16 weeks were stained with hematoxylin and eosin to determine angiogenesis and fibrosis in the grafts. The survival rate of donor adipose tissue was determined by measuring GFP expression. Results Fat was retained longer in fat pads than in subcutaneous layers of recipient mice and longer in subcutaneous than in intramuscular layers. Angiogenesis and vascularized connective tissue were greater in intramuscular than in subcutaneous or fat grafts. Neovascularization, however, was similar in fat pads and subcutaneous grafts. Survival rate was higher for intramuscularly injected fat than subcutaneously and fat pad injected fat. Conclusion Fat pad injection showed the highest graft retention rate, indicating that fat pads maybe the optimal area for fat transplantation. The increased blood supply to muscle suggests that intramuscular injection maybe optimal when there is little movement.

Background— Animal models suggest that the neurotransmitter inhibitor, botulinum toxin, when injected into the epicardial fat pads can suppress atrial fibrillation inducibility. The aim of this prospective randomized double-blind study was to compare the efficacy and safety of botulinum toxin injection into epicardial fat pads for preventing atrial tachyarrhythmias. Methods and Results— Patients with history of paroxysmal atrial fibrillation and indication for coronary artery bypass graft surgery were randomized to botulinum toxin (Xeomin, Merz, Germany; 50 U/1 mL at each fat pad; n=30) or placebo (0.9% normal saline, 1 mL at each fat pad; n=30) injection into epicardial fat pads during surgery. Patients were followed for 1 year to assess maintenance of sinus rhythm using an implantable loop recorder. All patients in both groups had successful epicardial fat pad injections without complications. The incidence of early postoperative atrial fibrillation within 30 days after coronary artery bypass graft was 2 of 30 patients (7%) in the botulinum toxin group and 9 of 30 patients (30%) in the placebo group ( P =0.024). Between 30 days and up to the 12-month follow-up examination, 7 of the 30 patients in the placebo group (27%) and none of the 30 patients in the botulinum toxin group (0%) had recurrent atrial fibrillation ( P =0.002). There were no complications observed during the 1-year follow-up. Conclusions— Botulinum toxin injection into epicardial fat pads during coronary artery bypass graft provided substantial atrial tachyarrhythmia suppression both early as well as during 1-year follow-up, without any serious adverse events. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01842529.

PURPOSE To examine the post-aponeurotic space and to confirm and define the presence of a post-aponeurosis fat-pad. METHODS Experimental anatomic study. Nineteen-orbits from 10 freeze-preserved, unembalmed cadavers of caucasian subjects. In 12 orbits of 7 cadavers, a transconjunctival dissection of the everted upper eyelid was undertaken. Muller's muscle (MM) and conjunctiva were dissected as a composite flap exposing the posterior surface of the aponeurosis (LA) and the commencement of the levator palpebrae superioris (LPS) muscle. Anatomical localisation was agreed by 2 senior surgeons and an anatomist (VM). In the remaining 7 orbits a 1cm central upper eyelid wedge-excision was paraffin-embedded and studied histologically. RESULTS Nineteen upper-eyelids from 10 freeze-preserved, unembalmed caucasian cadavers (5-male, 5-female, mean age 80.9; range 67-91 years) were studied. Of 12 eyelids of 7 cadavers, dissected and macroscopically evaluated, a fat-pad was identified in the post-aponeurotic space of all eyelids. Of these, 8 (66%) were predominantly diffuse. The remainder, mixed diffuse-discrete. All 4 of the latter category appeared multi-lobular. The fat-pad was seen to lie predominantly centro-medially, overlying MM, extending superiorly beyond the LA to lie posterior to LPS. Of the 7 upper eyelid wedge-excisions examined microscopically, a fat-pad was identified in all post-aponeurotic spaces, lying between 2 distinct tracts of smooth muscle. The anterior smooth muscle tract was intimately related to the posterior aspect of the LA, in keeping with the posterior smooth muscle layer of the aponeurosis. The posterior smooth muscle tract was in keeping with MM, thicker than the anterior layer, multi-layered and in 6 of 7 eyelids, interspersed with fat. CONCLUSIONS We confirm and describe a distinct layer of fat in the post-aponeurotic space, consistently found between MM and the posterior smooth muscle layer of the aponeurosis. We refer to this as the post-aponeurosis fat-pad. These findings provide further anatomical detail for the surgeon undertaking blepharoptosis surgery, who may, in some cases, mistake the presence of fat in this space either for the pre-aponeurotic fat-pad, or for degenerative changes within MM that lies deep to it.

INTRODUCTION Preoperative computed tomography (CT) evaluation of patients with nonsyndromic craniosynostosis (NSC) has focused on the bony cranial vault while ignoring the surrounding soft tissues. In this study, we posit that novel CT-derived temporal muscle and temporal fat pad morphomics (tissue thickness, area, and volume) can be used to calculate temporal morphomic indices (TMIs), which are unique to each NSC subtype (metopic, coronal, and sagittal) and divergent from normal individuals. METHODS High-throughput image analysis was used to reconstruct the 3-dimensional anatomy and quantify a TMI. These steps were completed in a semiautomated method using algorithms programmed in MATLAB v13.0. Differences in TMI across various craniosynostosis subtypes were assessed using Wilcoxon nonparametric tests for both patients with NSC and a control cohort of patients with trauma. RESULTS Using preoperative CT images, we evaluated 117 children with NSC from the University of Michigan Health System and 50 age-matched control patients between 1999 and 2011. Results indicate significant differences in TMI among the normal and NSC groups, with normal patients having significantly higher TMI values than patients with metopic, sagittal, and coronal synostosis. In addition, significant differences were found to exist between each craniosynostosis category. CONCLUSIONS Patients with craniosynostosis demonstrate diminished temporalis muscle and overlying fat pad volume and thickness compared with control patients. The unique changes in temporal morphomics presented in this article demonstrate not only that the bony calvaria is affected by craniosynostosis but also that there exist quantifiable aberrations in the temporalis muscle and temporal fat pad. The methodologies described offer a novel methodology to use pre-existing CT scans to glean additional preoperative information on the soft tissue characteristics of patients with craniosynostosis.

Anatomical studies show that facial fat is partitioned into distinct compartments, with the nasolabial fat pad in a superficial compartment and the deep medial cheek fat in a deep compartment. Gross morphologic differences may exist between these fat depots, but this has never been established at the cellular level.Adipose tissue specimens from nasolabial fat and deep medial cheek fat pads were obtained from 63 cadaveric specimens (38 female and 25 male cadavers) aged 47 to 101 years (mean, 71 years). Thirty-seven cadavers had a normal body mass index (≤25 kg/m) and 26 cadavers had a high body mass index (25 kg/m). Cross-sectional areas of individual adipocytes were calculated digitally and averaged from histologic sections of the adipose tissue samples.The average adipocyte size of nasolabial fat is significantly (p0.0001) larger than that of deep medial cheek fat. The average adipocyte size in both nasolabial and deep medial cheek fat is significantly (p0.0001) larger in subjects with high compared with low body mass index. Although the overall average adipocyte size is significantly (p0.0001) larger in female than in male subjects, this sexual dimorphism is lost in the nasolabial fat depots of overweight subjects and in the deep medial cheek depots of normal-weight subjects.The significantly smaller adipocyte size in deep medial cheek fat relative to nasolabial fat in elderly subjects supports the theory that deep and superficial facial fat pads are morphologically different. Future investigation of the metabolic and structural properties of these fat compartments will help us understand the different patterns of volumetric facial aging.

Background Fat grafting is promising, but clinical outcomes are not always predictable. The mechanisms of tissue revascularization/regeneration, and tissue necrosis and subsequent absorption/fibrosis of the graft, are poorly understood. Methods An autologous inguinal fat pad was transplanted under the scalp of mice, and detailed cellular events during the first 3 months were investigated with immunohistochemistry. Results Except for the most superficial surviving zone, death of all adipocytes was confirmed at 1 week. Perilipin-positive small new adipocytes appeared at 1 week and peaked in number at 4 weeks in the regenerating zone (the second zone). In the most central necrotizing zone, adipogenesis did not occur and many inflammatory cells were observed after 2 weeks. CD34+/Ki67+ proliferating adipose stem/progenitor cells were seen at 1 to 4 weeks, but the majority of proliferating cells were MAC2+ monocytes/macrophages. Although CD206+ M1 macrophages surrounded oil droplets for phagocytosis, CD206+ M2 macrophages appeared in areas where adipocyte replacement failed and formed multiple layers for cicatrization of oil drop spaces. Adipogenesis was complete by 12 weeks, but stabilization of nonregenerated areas was still ongoing at that time. Lipid droplets derived from dead adipocytes were absorbed slowly and thus aided adipose remodeling by maintaining the space until adipocyte regeneration. Conclusions Dynamic remodeling after fat grafting was confirmed. Adipocyte fate differed, depending on the microenvironment: intact survival, replacement with a new adipocyte, or replacement with cicatrization/oil cyst. This detailed understanding will help refine surgical grafting procedures and postoperative evaluation.

Exposure to maternal obesity or a maternal diet rich in fat during development may have adverse outcomes in offspring, such as the development of obesity and hypertension. The present study examined the effect of a maternal high-fat diet (m-HFD) on offspring blood pressure and renal sympathetic nerve activity, responses to stress, and sensitivity to central administration of leptin and ghrelin. Offspring of New Zealand white rabbits fed a 13% HFD were slightly heavier than offspring from mothers fed a 4% maternal normal fat diet ( P P =0.015). Mean arterial pressure, heart rate, and renal sympathetic nerve activity at 4 months of age were 7%, 7%, and 24% greater, respectively ( P P P

The aim of this study was to introduce a technique of dividing forehead depressor muscles with a subbrow excision for improvement of brow ptosis or redundant upper eyelid skin and glabella wrinkles. Upper incisions were designed at the lower limit of the eyebrow with a lateral extension along the eyebrow curvature. After measuring the redundant upper eyelid skin, the excess skin was excised. The orbital part of the orbicularis oculi muscle was identified and split longitudinally. The forehead depressor muscles (depressor supercilii, oblique and transverse head of corrugator, and medial part of orbicularis oculi) in the brow fat pad were identified and avulsed. In the patients who have a lowered brow, the brow was elevated and fixed to the underlying periosteum about 1 cm above the superior orbital rim after subgaleal dissection. During the dissection, the supraorbital nerve was preserved. Preaponeurotic fat was transferred and sutured between the cut stumps of the corrugator and procerus. The 78 patients (19 men, 60 women; age range, 41-72 years [mean, 52.0 ± 7.1 years]) were operated on. The follow-up periods ranged from 3 to 48 months. Preoperative and postoperative photographs were taken, and the following evaluations were conducted by 1 surgeon via a Likert scale (1 = not improved, 2 = slightly improved, 3 = somewhat improved, 4 = much improved, 5 = markedly improved). The mean score for improvement of the glabella frowns in contraction was 3.7 ± 1.6. The mean score for the improvement of the glabella frowns in relaxation was 4.1 ± 1.3. The mean score for improvement of drooping eyelids was 4.7 ± 0.5. The mean score for the improvement of forehead wrinkles was 4.8 ± 0.7. We improved brow ptosis, redundant upper eyelid skin, and glabella wrinkles simultaneously using a subbrow excision and depressor muscle division while preserving the superficial branch of the supraorbital nerve.

The infrapatellar fat pad is one of the structures that obscures exposure in minimally invasive total knee arthroplasty (MIS TKA). Most MIS TKA surgeons (and many surgeons who use other approaches as well) excise the fat pad for better exposure of the knee. There is still controversy about the result of fat pad excision on patella baja, pain, and function.In the setting of a randomized controlled trial, we sought to determine whether infrapatellar fat pad excision during MIS TKA causes (1) patellar tendon shortening (as measured by patella baja); (2) increased anterior knee pain; (3) decreases in the Knee Society Score or functional subscore; or (4) more patella-related complications.We randomized 90 patients undergoing MIS TKA at one institution into two groups. In one group, 45 patients underwent MIS TKA with complete infrapatellar fat pad excision and in the other group, 45 patients received MIS TKA without infrapatellar fat pad excision. The patella was selectively resurfaced in these patients; there was no difference between the groups in terms of the percentage of patients whose patellae were resurfaced. We measured patellar tendon shortening, knee flexion, anterior knee pain, Knee Society Score (KSS), functional subscore, and patellar complications at preoperative and postoperative periods of 6 weeks, 3 months, 6 months, and 1 year; complete followup data were available on 86% of patients (77 of 90) who were enrolled.At the final followup, no significant differences were observed in patellar tendon shortening, KSS, functional subscore, or knee flexion in either group. However, patients with their infrapatellar fat pad excised experienced more anterior knee pain (8.3% versus 0%; p = 0.03; 95% confidence interval, -0.007 to 0.174) at the end of the study. No patellar complications were found in either group.Infrapatellar fat pad excision in MIS TKA resulted in an increasing small percentage of patients with anterior knee pain after surgery. Surgeons should keep the fat pad if excellent exposure can be achieved but resect it if needed to improve exposure during TKA.

Background— Supraventricular arrhythmias (junctional ectopic tachycardia [JET] and atrial tachyarrhythmias) frequently complicate recovery from open heart surgery in children and can be difficult to manage. Medical treatment of JET can result in significant morbidity. Our goal was to develop a nonpharmacological approach using autonomic stimulation of selective fat pad (FP) regions of the heart in a young canine model of open heart surgery to control 2 common postoperative supraventricular arrhythmias. Methods and Results— Eight mongrel dogs, varying in age from 5 to 8 months and weighting 22±4 kg, underwent open heart surgery replicating a nontransannular approach to tetralogy of Fallot repair. Neural stimulation of the right inferior FP was used to control the ventricular response to supraventricular arrhythmias. Right inferior FP stimulation decreased baseline AV nodal conduction without altering sinus cycle length. AV node Wenckebach cycle length prolonged from 270±33 to 352±89 ms, P =0.02. Atrial fibrillation occurred in 7 animals, simulating a rapid atrial tachyarrhythmias. FP stimulation slowed the ventricular response rate from 166±58 to 63±29 beats per minute, P P Conclusions— Right inferior FP stimulation had a selective effect on the AV node, and slowed the ventricular rate during postoperative JET and atrial tachyarrhythmias in our young canine open heart surgery model. FP stimulation may be a useful new technique for managing children with JET and atrial tachyarrhythmias.

Introduction Analytical morphomics is the term we created to describe an innovative, highly automated, anatomically indexed processing of 3D medical imaging data captured during the course of a patients' preoperative CT scan. Our specific aim is to determine the efficacy of craniofacial morphomic indices (CMI) such as temporalis muscle and temporal fat pad morphometric values to predict blood transfusion requirement and hospital stay in a cohort of children with nonsyndromic craniosynostosis (NSC). Methods High-throughput, semi-automated image analysis was used to reconstruct the 3-dimensional anatomy of the temporalis muscle and temporal fat pad and to quantify CMIs. The prognostic effect of CMI on clinical outcomes were evaluated among all NSC patients and compared across various craniosynostosis subtypes using Wilcoxon nonparametric tests and Kendall's τ to determine significance. Results Using preoperative CT images, we evaluated 117 children with NSC from the University of Michigan Health System. Results demonstrate that increased temporal fat pad volume and local temporalis muscle volume are associated with better clinical outcomes in craniosynostosis patients. More specifically, temporal fat pad volume was shown to be a significant predictor of perioperative blood transfusion requirements (P = 0.0033) and increased temporal muscle volume correlated with decreased hospital stay (P = 0.016) when controlling for other covariates including age, sex, weight, and preoperative hematocrit. In addition, the same significant predictors were found when examining individual subtypes of craniosynostosis. Conclusion Our findings demonstrate that maxillofacial CT scans provide a useful quantitative index reflecting general patient health, risk stratification, and probabilities of intervention in addition to their previously established ability to determine the specific pathology of the patient. We demonstrate that temporal morphomics predict the incidence of blood transfusion, hospital stay, and serve as a proxy for fitness in patients undergoing craniosynostosis surgery.

Introduction Traditional upper blepharoplasty is a subtractive form of surgery that involves the excision of variable amounts of skin, muscle, and fat from the eyelid. The goal of surgery is to improve field of vision and/or appearance. While surgical debulking of the eyelid may improve appearance early on, the volume loss inherent to this process (especially fat excision) can contribute to a hollowed appearance with an associated deep and sunken superior sulcus. This skeletonized look may be mitigated by repositioning a prominent nasal fat pad, if present, to the central upper eyelid. Methods The charts of patients who underwent upper blepharoplasty with repositioning of the nasal fat pad (as described in this manuscript) to the central arcus marginalis of the superior orbital rim during surgery were reviewed. Patients with a history of previous eyelid surgery or trauma or who had concurrent ptosis or other eyelid malpositions were excluded from the study. Also excluded were patients who did not manifest prominent nasal fat pads at surgery. Postoperative interval follow up was consistent until 6 months after surgery and more sporadic thereafter, as patients more frequently missed appointments. Postoperative healing issues, patient complaints, complications, and subjective physician and patient satisfaction assessments were noted. Final results were gauged on each patient's final visit after surgery. Results Seventy-six patients were included in the study. Forty-eight patients (63%) were women, and 28 patients (37%) were men. The surgical procedure was uneventful in all patients. The average patient age was 66 years and the mean follow up was 11 months (range 6-22 months). There was one case of postoperative pseudo-Brown syndrome, which resolved with steroid injections. There were 2 cases of postoperative presumed mechanical ptosis, early in the series, lasting for 2 weeks, which in both cases responded to oral steroids. Subjectively, there was no new or worsening superior sulcus hollowness observed by patient or surgeon at last follow up in all cases. Conclusions Volume loss and the value of fat preservation in lower blepharoplasty are well-documented and accepted among eyelid surgeons. The affect of iatrogenic volume depletion in upper eyelid blepharoplasty, while understood, has gained less attention. Repositioning the prominent nasal fat pad of the upper eyelid to the central sulcus adds little time to surgery, allows preservation of upper eyelid fat during surgery, and may be a useful adjunct to the upper blepharoplasty surgeon. While further studies are needed to more critically assess eyelid volumetric changes, this technique holds promise as a preventative measure for superior sulcus hollowing after surgery.

The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture.A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow-up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture).Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P0.01).Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP.

Background Temporal hollowing occurs frequently following surgical correction of unicoronal synostosis. This is characterized by a depression in the posterolateral orbitotemporal region. Both soft-tissue and bony causes have been postulated to underpin this problem. The authors investigated the soft-tissue and bony morphology of the temporal region in surgically treated unicoronal synostosis patients. Methods A retrospective analysis of adolescent patients with temporal hollowing who underwent unicoronal synostosis repair as infants was carried out. Demographic data and computed tomographic craniometric parameters were obtained and analyzed using the t test. Photographs were graded subjectively and compared with quantitative data. Results Fifteen children (seven boys and eight girls; mean age, 13 years) were identified. Seventeen patients (10 boys and seven girls; mean age, 14 years) were used as controls. The affected side showed temporal constriction, compared with controls, along the supraorbit and anterior temple. The sella-to-pterion distance was also less, but not statistically so. Soft-tissue analysis revealed decreased thickness of the affected temporalis muscle compared with unaffected and control sides (range, 1 to 3 mm less). The affected fat pad width was not statistically different from unaffected and controls. Subjective clinical grading did not demonstrate statistical correlations with quantitative data. Conclusions Temporal hollowing occurs following surgical correction of unicoronal synostosis, despite original overcorrection, because of bony constriction along the anterior bandeau. Decreased thickness of the temporalis muscle may also contribute to this depression, whereas the superficial fat pad does not play a role. Subjective clinical scoring does not strictly correlate with severity of craniometric measurements. Clinical question/level of evidence Therapeutic, III.(Figure is included in full-text article.).

To demonstrate the anatomical features of Kager fat pad (KFP) and its fasciae using magnetic resonance imaging, gross anatomy, and histology in cadavers; and to correlate the data with image findings in patients.The KFP was analyzed in 10 fresh human cadavers and 152 clinical cases. The retrospective clinical study was institutional review board approved. The specimens were studied by magnetic resonance imaging and sectioned for anatomical/histological correlation. Clinical cases were selected to evaluate the frequency, distribution, and patterns of edema/inflammation in KFP. The square of the Pearson product moment correlation coefficient and Student t tests were performed.Fasciae about KFP are double layered and derived from the union of the fascia of the leg and flexor and peroneal retinacula. Edema in KFP could be divided into diffuse, confined anteriorly, confined posteriorly, and confined externally. Confined patterns of edema were associated with paratenonitis and fluid in the Achilles bursae (P0.05).Four patterns of edema occur in KFP. Paratenonitis and bursal fluid were associated with confined edematous patterns. The double layer about KFP may contain edema that affects this region.

Aesthetic surgery for correction of the lower lid bulge can be classified into 3 groups of subtractive surgery, redraping, and repositioning. The authors present a new repositioning technique with vertical plication of the orbital septum for correction of lower lid bulge. This procedure was performed on 30 individuals during a 3-year period between March 2003 and March 2006. The length of follow-up varied from 3 months to 1 year, with an average of 6 months. There was no lower lid retraction or ectropion. Contour was smooth without any visible deformation or palpable suture line along the vertical plication. In the follow-up visits of minimum of 3 months, no recurrence of bulge was present and the scar was inconspicuous. Vertical plication of the orbital septum is an effective way to reposition the orbital fat inside the orbit. It anatomically corrects lower lid bulge, preserves the orbital fat pad and the vertical dimension of the lower lid, and provides a smooth contour in the periorbital area without the need to penetrate the orbital septum or manipulate the fat pad. Morbidity is minimal and transient, and the results are satisfactory. We suggest this technique for correction of lower lid bulge when there is excess lower lid skin and a subciliary approach is selected.

BACKGROUND The effect of ageing on beta-cell regeneration under hyperglycemia has not been defined and may best be addressed using a unique islet-transplantation model. METHODS Streptozotocin-induced diabetic FVB/NJ mice were rendered normoglycemic with a therapeutic mass of syngeneic islets implanted in the epididymal fat pad, followed by a subrenal capsular implantation of a subtherapeutic mass of 25 islets from young (3 months) or old (24 months) mice. Three weeks after the second transplant, the islet containing fat pad was removed to reintroduce hyperglycemia. Bromodeoxyuridine (BrdU) was provided to mice continuously in drinking water. Islet grafts under the kidney capsule were harvested at different time points and examined for markers of beta-cell regeneration by immunohistochemistry. RESULTS After a 7-day labeling, BrdU was detected in 54.2% or 53.0% beta cells of the young or old islet grafts, respectively, under hyperglycemia when compared with 3.3% in grafts under normoglycemia. Ki67-positive beta cells were enhanced from a baseline level of 0.5% to 5.2% (young islets) or 4.0% (old islets) on day 7 of hyperglycemia, then decreased to 2.4% on day 21, at which time point an accumulative 75.3% or 66.8% BrdU-positive beta cells was detected in the young or old grafts, respectively. No statistic difference in the percent BrdU- or Ki67-positive beta cells was detected between the young and aged grafts at any time point studied. CONCLUSIONS These data reveal that islet beta cells from aged mice can replicate in response to hyperglycemia after transplantation at a capacity and frequencies not significantly different than that of the young adult ones.

Temporal hollowing after lateral facial skeletal exposure via a coronal approach is not uncommon. This is caused by injury to the superficial temporal fat pad. However, to prevent facial nerve injury at the zygomatic arch, incision of the superficial layer of the temporalis fascia (TF) and exposure of the temporal fat pad are accompanied with most coronal approaches. Here we introduce our method of dissection of the suprasuperficial layer of the TF without exposure of the temporal fat pad and report on its safety and efficacy. Temporal dissection just superficial to the superficial layer of the TF was performed to the superior border of the zygomatic arch. After identifying the zygomatic arch, an incision was made at the posterosuperior aspect of the arch, when exposure of the arch was necessary for access to the lateral skeleton. From 1989 to 2008, 522 patients undergoing craniofacial surgery via coronal approach were analyzed retrospectively. No patient developed temporal hollowing. However, 14 patients (2.7%) developed frontal weakness immediately postoperatively, and 2 of them had permanent paresis. The frequency of this motor morbidity was low compared with that of other reports. Preservation of the temporal fat pad in coronal approach is essential for the prevention of temporal hollowing, and for this, we recommend suprasuperficial layer of TF dissection.

Background: Interlocking nailing is a standard procedure in the surgical treatment of tibial fractures. Despite it has been described to be a safe technique with excellent functional results compared with conservative treatment, a common problem is the development of anterior knee pain. The anatomic relation of Hoffa’s fat pad with its nociceptors to the nail entry point has not been investigated, yet. Methods: Eighteen formalin-fixed lower cadaver extremities of 11 cadavers (five females, six males) were matched into three groups: three approaches (medial paratendinous, transligamentous, and lateral paratendinous) were performed and the anterosuperior tibial cortex was opened with a cheese cutter. To investigate the relationship of the nail entry point and Hoffa’s fat pad, the joint capsule was incised, and Hoffa’s fat pad was exposed and then dissected carefully. Damage to the fat pad was recorded as well as meniscal lesions, cartilage lesions, and ligamentous lesions. After full extension and flexion of the knee joint, the motion of Hoffa’s fat pad (millimeter) was recorded with a measuring gauge. The zone for safe nail insertion (millimeter square) without any lesion to intra-articular structures was recorded. Results: Violation of Hoffa’s fat pad was recorded if the lateral and transligamentous approach were used. With the medial approach, no damage of the fat pad was recorded. Total mean lateralization of the fat pad from extension to flexion over 90 degrees was 18.5 mm compared with its location in the fully extended knee. The safe zone for nail insertion without violation of menisci, cartilage, or ligaments was a triangle in the posteromedial aspect of the Hoffa with a mean dimension of 19.4 mm2. Conclusion: On the basis of our results, we can recommend the nail insertion via a medial paratendinous surgical approach to avoid injuries to the Hoffa fat pad and to menisci, cartilage, and ligaments.

Objective The release of the transverse carpal ligament (TCL) for relief of carpal tunnel syndrome has been a standard operative procedure since the early 1950s. Although complications are not common after the open surgical technique, a small but significant group of patients will have similar symptoms after surgery or will experience new symptoms in the postoperative period. Incomplete section of the TCL is the major cause of these complications. The authors have described two signs that confirm a complete release of the TCL, called the "fat pad" and "little finger pulp" signs. Methods Between 2000 and 2003, we treated 643 hands in 611 patients (45 men and 566 women; age range, 32-76 yr; mean age, 58.2 yr). All patients were examined 6 months after the procedure, with special attention given to the persistence or recurrence of symptoms. The presence of palmar scar pain, residual numbness, patient satisfaction, and time to return to work were also evaluated. A longitudinal incision (2 cm) at the base of the palm was used to release the TCL. A good indicator that the distal TCL has been released is the visualization of a fatty tissue ("fat pad" sign). This fatty tissue is always present underneath the most distal fibers of the TCL, covering the sensory digital branches of the median nerve. To confirm the complete release of the proximal fibers of the TCL, we should be able to introduce the little finger pulp in a proximal direction underneath the distal flexion crease of the wrist ("little finger pulp" sign). When both signs are confirmed, we can be certain that the TCL is completely released. Results Night pain disappeared immediately after surgery in all patients except three. There were seven complications (1%) not related to the palmar scar and 10 complications (1.5%) related to it. However, all of these complications disappeared an average of 3 months postoperatively. Patient satisfaction was 100%, and the mean time to return to work and full activity was 22 days (range, 14-36 d). Conclusion Two surgical observations that are reliable to confirm a complete release of the TCL were described. The first, called the "fat pad" sign, is useful to determine whether or not the distal end of the TCL has been adequately released, whereas the "little finger pulp" sign indicates whether or not the proximal end of the TCL has been fully divided.

Objective To test the feasibility of applying the magnetic resonance elastography (MRE) technique to map the elastic modulus of the plantar fat pads in diabetic and nondiabetic subjects. Methods A prototype MRE imaging apparatus was used to produce quantitative maps of the heel fat pad in a pilot study of 12 volunteers and 4 patients with diabetes with neuropathy. Anatomic images corresponding to MRE maps allowed precise selection of regions of interest in the fat. Results Magnetic resonance elastograms of the heel fat pads were successfully created; mean measurements in the volunteers and the diabetic patients were 4.85 and 5.26 kPa, respectively. Conclusion It is feasible to perform MRE on the plantar fat pads and to produce elasticity maps. The trend toward stiffer fat pads, as demonstrated in patients with diabetes, suggests that the fat pads were qualitatively different. Magnetic resonance elastography offers great potential to investigate the mechanical properties of soft tissues in vivo noninvasively.

Background The biomechanical integrity of the tendon sheath of the fingers has a significant effect on the success of flexor tendon surgery. As nonweightbearing elements, the membranous parts of the sheath have received little attention, and their contribution to sheath movement is still obscure. The authors presumed that Grayson's ligaments, which have been described as force-transmitting elements, might play a role in the biomechanics of the membranous flexor tendon sheath. Methods Twenty-two long fingers of cadaver hands were examined. The authors studied the movements of the inner aspect of the tendon sheath and the positions and patterns of the septa of the palmar soft tissues on picrosirius red-enhanced sagittal and transverse sections and hematoxylin and eosin-stained light microscopy specimens. Results The movements of the membranous flexor tendon sheath are controlled by subcutaneous structures. The septal patterns of the palmar fat pads indicate the existence of a highly flexible subcutaneous fibrous system in which the deformable fat pad keeps the force-transmitting elements tight. Collagen bundles in the microscopy specimens, which frequently form layers within the septa, are thought to correspond to Grayson's ligaments. The subcutaneous fibrous system adheres predominantly to the membranous parts of the flexor tendon sheath. Conclusions Folding of the membranous flexor tendon sheath is guided by the subcutaneous fibrous system, of which the macroscopically dissectible elements are Grayson's ligaments. The current surgical approaches might have a deteriorating effect on the biomechanics of the flexor tendon sheath.

UNLABELLED: After knee trauma, radiographs showing patella alta supercede other signs that suggest patellar tendon rupture. However, without patella alta the diagnosis may be missed. A standard lateral radiograph with the knee flexed showed the infrapatellar fat pad as a dark band with a smooth contour. Our pilot study identified a disruption of the fat pad contour as a radiographic sign of tendon rupture. Two blinded reviewers independently analyzed randomly selected lateral radiographs of the knees of 14 patients with knee injuries. Seven patients had confirmed ruptures diagnosed at surgery, and the other patients had different diagnoses. There were 12 men and two women with an average age of 49 years (range, 20-81 years). One observer detected five of the seven disrupted tendons and six of the seven intact tendons. The other observer detected six of the seven disrupted tendons and all seven intact tendons. Disruption in the contour of the infrapatellar fat pad on routine lateral view radiographs was a reasonably reliable sign of patellar tendon rupture. Diagnostic accuracy should increase when used with the patient's history, physical examination, and other radiographic signs. Absence of this sign should not supersede other suggestive signs of patella tendon rupture. LEVEL OF EVIDENCE: Diagnostic study, Level II (development of diagnostic criteria on consecutive patients--with universally applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

Background Amputation of the toe at the level of the distal metatarsal head (ray amputation) is a common surgical procedure in diabetic foot ulcers. The aim of this study was to introduce a new technique promoting primary healing by minimizing the dead space with the plantar dermo-fat pad flap after central ray amputation in diabetic foot ulcers. Methods Thirty-eight patients who had undergone central ray amputation and closure with the plantar dermo-fat pad flap between 1996 and 2003 were incorporated into the study. Results The mean follow-up period was 3.56 years. Single and multiple middle toe amputations were performed in 33 and five cases, respectively. In 14 cases with acute infection, split-thickness skin graft was used with the plantar dermo-fat pad flap to close the defect on the foot dorsum. Healing time was uneventful in all patients except three (8 percent), who were healed with local wound care. No patient showed signs of ulceration at the operative site during the follow-up. The mean time to total healing was 40.31 +/- 34.56 days. Conclusions The plantar dermo-fat pad flap promotes primary wound healing after central ray amputation in diabetic foot ulcers by filling the dead space. The osteotomy to the base of the remaining adjacent metatarsal base in an effort to close the defect can be avoided by using the plantar dermo-fat pad flap; thus, undesirable angulation of the remaining parts of the foot can be eliminated. The plantar dermo-fat pad flap also supports the weak articular capsule of the adjacent metatarsophalangeal joints while covering the amputated metatarsal end. The thick, healthy plantar soft tissue advanced up to the width of the deepithelialized area reestablishes a good, tough plantar surface which--in association with the pad effect of the flap--decreases the recurrence rates and provides comfortable ambulation.

We review the use of split-thickness skin grafting in children with concealed penis.Medical records were retrospectively reviewed for all patients younger than 20 years seen at our institution from 1995 to 2003 with a diagnosis of concealed penis. Patients were separated into "primary" and "secondary" groups based on the cause of concealment. Primary factors were prominent prepubic fat pad, dysgenetic dartos fascia or both. Secondary factors were post-circumcision phimosis and overzealous circumcision.A total of 26 patients 1 month to 19 years old were treated. In the primary group of 23 patients 11 underwent lysis of dartos fascia. Four of these 11 patients had insufficient skin, and split-thickness skin grafting was necessary to resurface the penile shaft. Five of the patients underwent excision of the fat pad only, and 2 underwent excision of the fat pad and lysis of fascia. Five patients are being observed. Of the 3 patients in the secondary group 1 underwent manual reduction of post-circumcision phimosis, 1 underwent scrotal flaps and 1 is being observed. Followup ranged from 2 weeks to 46 months (mean 13 months). Of 20 surgically repaired patients 19 (95%) had an excellent cosmetic result, were satisfied with penile length and reported no voiding complaints.The surgical approach for correcting concealed penis varies, depending on the cause. Of our 26 patients 4 (15%) had insufficient penile skin to resurface the penile shaft. In these select children split-thickness skin grafting provided a good cosmetic appearance and functional result.

Injectable phosphatidylcholine, a lecithin-derived phospholipid, has been previously demonstrated to improve the appearance of infraorbital fat pad herniation. Current use internationally has led to a significant interest in this novel substance.To evaluate the efficacy and safety of injectable phosphatidylcholine, we conducted an open-label study for the treatment of infraorbital fat pad herniation.Patients received 0.4-mL phosphatidylcholine (50 mg/mL) injections within infraorbital fat pads every 2 weeks. Patient and physician grading of fat herniation, side effects, digital photographs, and a follow-up questionnaire was recorded.Ten of the 13 enrolled patients had three to five treatments. Improvements in fat herniation were reported in 80% and 70% of patients as graded by the physician and patients, respectively. Sixty percent of patients assessed their improvement as equal or greater than 5 points (on a 10-point fat herniation scale); however, the physician judged 40% of patients improving to this degree. Little or no response was seen in three patients. Side effects included burning, erythema, and swelling at the injection site. At follow-up averaging 9 months, 50% of patients reported persistence of benefit, 20% experienced some fading, and 30% were the nonresponders.Injectable phosphatidylcholine is a novel treatment for infraorbital fat herniation that may benefit some patients who are considering blepharoplasty. Larger studies evaluating long-term safety and efficacy of phosphatidylcholine for cosmetic purposes are warranted.

Distinct anatomic structures provide attachments and support for the soft tissues of the central third of the face. Over time, laxity of these structures and descent of the malar fat pad contribute to the characteristic changes seen in the aging face. Mobilization of the midface soft tissues to allow reelevation of the malar fat pad is an effective method of rejuvenating the midface. A focused anatomic dissection of 8 fresh cadaver heads was performed to evaluate 4 soft-tissue structures that control mobilization of the malar fat pad. Specifically, the orbicularis retaining ligaments, the lateral orbital thickening, prezygomatic space, and zygomatic cutaneous ligaments were evaluated. The anatomic relationship of these structures explains the visible effect of aging in the central third of the face. In addition, it correlates with the outcomes of surgical rejuvenation as demonstrated in clinical cases. Effective repositioning of the malar fat pad was found to be reliably obtained by release of the lateral orbital thickening and the orbital retaining ligaments. Suspension of the malar soft tissue is in a cephalad direction after release of these structures recreates a youthful facial architecture. Motor nerve injury is less likely to occur with this technique than with traditional lateral facelift approaches. The conclusion reached is that ptosis of the malar fat pad can be corrected safely and effectively utilizing either the lower lid blepharoplasty approach or temporal prehairline incision. These findings were consistent with clinical data from facial rejuvenation procedures.

Tissue engineering approaches for promoting the repair of skeletal tissues have focused on cell-based therapies involving multipotent stromal cells. Recent studies have identified such cells in several tissues in the adult human, including skin, muscle, bone marrow, and subcutaneous fat. This study examined the hypothesis that the infrapatellar fat pad of the adult knee contains progenitor cells that have the ability to differentiate into chondrocytes, osteoblasts, or adipocytes under appropriate culture conditions. Cells isolated from the fat pad stroma had a profile of cell-surface molecules similar but not identical to that of bone marrow-derived mesenchymal stem cells. Using defined culture conditions, fat pad-derived stromal cells were induced to differentiate cells with phenotypic characteristics of: (1) chondrocytes, synthesizing cartilage matrix molecules; (2) adipocytes, producing lipid vacuoles and leptin; or (3) osteoblasts, forming mineralized tissue. The culture conditions also modulated the expression of characteristic gene markers for each lineage. This study supports the hypothesis that multipotent stromal cells are present in many connective tissues in the adult human. Given its location and accessibility, the fat pad may prove to be a potential source of progenitor cells for musculoskeletal tissue engineering.

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.

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.