Fil ler Placement and the FatCompartmentsRebecca Fitzgerald, MD*, Ashley G. Rubin, MD

on our perception of a face, making it appearolder or younger in an almost imperceptible way.Erasing lines and folds, tightening sagging skin,or restoring young full lips may rejuvenate somefaces, but as we are all unfortunately aware, canalso look odd and a bit out of perspective onothers. Patients new to fillers often bring up fearof this kind of unnatural result, causing some toavoid treatments altogether. The restoration of anatural volume distribution is a major goal in facialrejuvenation. Using the evolving knowledge offacial fat anatomy to recognize whats been lostwhere on a case-by-case basis so as to individu-alize treatment plans may help us to offer the sortof subtle and natural-looking results desired by

not addressed here. Additionally, as this article ismeant to serve as an introduction to a concept,and not an exhaustive review, more detailed de-scriptions of this anatomy can be found elsewhereand are referenced in this work.

FACIAL FAT COMPARTMENTS

The discovery that facial fat does not exist as onehomogeneous object on the face as traditionallythought, but rather as many dynamic com-partments that can be evaluated, augmented,and modified, represents a major breakthrough inour understanding of facial aging.The central role of volume loss and deflation,

rather than ptosis alone, in the aging face has

Division of Dermatology, University of California, Los Angeles (UCLA), 200Medical Plaza, Suite 450, Los Angeles,

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.comDermatol Clin 32 (2014) 3750CA 90095-6957, USA* Corresponding author.E-mail address: fitzmd@earthlink.netand how it changes over time. Seemingly subtlechanges over time can have an enormous impact

sults). Specific techniques and particular fillers aretalization of facial fat, and the role of bony support

placing filler in specific fat compartments to obtainspecific, predictable, and natural-appearing re-INTRODUCTION

Our understanding of how the face ages and howto best mitigate these changes, is in a perpetualstate of evolution and refinement. Evolving insightsinto the anatomy of aging are clarifying our under-standing of the pathophysiology of aging, thechanges in elasticity of the skin, the compartmen-

KEYWORDS

Facial fat compartmentalization Filler placeme

KEY POINTS

Understanding the anatomy and distribution ofaging process is essential to effectively and pre

Over the past several years, through cadavericmuch has been discovered concerning the adipnamic process of aging.

Site-specific augmentation with fillers can nowmore predictable and precise fashionhttp://dx.doi.org/10.1016/j.det.2013.09.0070733-8635/14/$ see front matter Published by Elsevier Inmany patients (I dont want to look done, I justdont want to look tired).The purpose of this article was simply to provide

an introduction to some of the recent literatureconcerning facial fat compartmentalization, alongwith a few clinical examples that were chosen toillustrate the utility of site-specific placement (ie,

Fat compartments Facial adipose tissue

ial fat and the alterations that occur during theely achieve facial rejuvenation.

ssections and computed tomographic studies,tissue of the face and how it influences the dy-

used to refine facial shape and topography in ac. der

beeneloquently illustratedbyLambros1 in a longitu-dinal photographic analysis of more than 100patients spanning an average period of 25 years.This invaluable work contributed inspiration to agroundbreaking study done at the University ofTexas, Southwestern (UTSW) in 2007, elucidatingthe compartmentalization of facial fat.2 Since thattime,manysubsequent studies fromseveral groupshave contributed to this body of knowledge.315

Pessa and Rohrich16 recently published a text-book presenting findings from more than 1000dissections encompassing more than 20 years ofwork that is an excellent resource on this subject.The landmark studies by Rohrich and Pessa at

UTSW utilized fresh cadaveric anatomic dissec-tions with dye staining for visualization of indi-vidual compartments. Fig. 1 shows an image ofthe superficial fat compartments of the midfacefrom the original study, which revealed thecompartmentalization of facial fat in this area.The nasolabial fat compartment is the most medialof the major cheek compartments, followed by themedial and the middle cheek compartments. Sub-sequent studies revealed that subcutaneous fat,both superficial and deep to the superficial mus-culoaponeurotic system, is compartmentalized,

suggestion that the face ages three-dimensionally,with separate compartments changing relative toone another by both position and volume.The superficial adipose tissue has as its

boundaries vascularized membranes arising fromsuperficial fascia, whereas deep fat is compart-mentalized by nonvascularized fascial boundariesthat most likely represent fusion zones of variousfascias.17

A working hypothesis of facial fat aging is theconcept that folds occur at transition pointsbetween thicker and thinner superficial fat com-partments; in contrast, loss and/or ptosis of thedeep fat compartments leads to changes incontour.11

Both may play a role in facial shape, as illus-trated by the remaining figures.

UPPER FACE

Fig. 2 shows an image of the lateral temporalcheek fat. The superior and inferior temporal septa(STS and ITS) represent the superior and inferiorboundaries, respectively. The temporal fat ex-tends beyond the hairline. This compartmentspans the forehead to the cervical region. It is

mRL)e zeriowitl toral-ee

cal

Fitzgerald & Rubin38specifically by fascial extensions that form aframework that provides a retaining system forthe human face. Implicit in this concept is the

Fig. 1. (A) The nasolabial fat compartment is the moststained this region. Theorbicularis retaining ligament (Oarrowspoint to the sub-orbicularis oculi fat (SOOF) and thcompartment lies adjacent to the nasolabial fat. The supzone of fixation where this fat compartment intersectscheek fat compartment is found anterior and superficiamedial fat compartment, medial to the lateral tempo(SCS).The red arrow designates a zone of fixation betwThe fat compartments of the face: anatomy and clini

2007;119:221927 [discussion: 222831]; with permission.)edial of the major cheek compartments. Blue dye hasis the superior boundary (black arrow). Additional blackygomaticusmajormuscle (ZM). (B) Themedial cheek fatr boundary is again the ORL. The red area designates ah the inferior orbital fat compartment. (C) The middlethe parotid gland. This compartment is lateral to the

cheek fat, and inferior to the superior cheek septumn adjacent compartments. (From Rohrich RJ, Pessa JE.implications for cosmetic surgery. Plast Reconstr Surgthe most lateral of the cheek fat compartmentsand has an identifiable septal boundary mediallycalled the lateral cheek septum. (The nasolabial

This method allows for a reproducible three-

Filler Placement and the Fat Compartments 39cheek compartment is stained in this imageas well. Note the difference in the size of thiscompartment in this cadaver as opposed to thesize of the same compartment in the cadaverpictured in Fig. 1.) The clinical photographs inFigs. 3 and 4 show women who have lost fat indifferent areas of this compartment with aging.The woman in Fig. 3A has lost temporal fat beyondher hairline, changing the shape of her face to apeanut shape, which is restored to an oval withvolume augmentation in this area. The woman inFig. 3B has lost temporal fat at the superiorborder, resulting in a somewhat harsh skeleton-ized appearance that softens with volumeaugmentation in that area.The patient in Fig. 4 has ample temporal

volume, but an absence of lateral cheek fat, givingher lateral face a concave (almost horselike)appearance that is softened as her face is ovalizedby treatment in this area. Note that the tragus is

Fig. 2. The lateral temporal-cheek compartment is themost lateral compartment of cheek fat and connectsthe temporal fat to the cervical subcutaneous fat. Thesuperior and inferior temporal septa (STS and ITS,respectively) represent the superior boundaries, andit has an identifiable septal barrier medially called thelateral cheek septum (LCS). (From Rohrich RJ, Pessa JE.The fat compartments of the face: anatomy andclinical implications for cosmetic surgery. Plast ReconstrSurg 2007;119:221927 [discussion: 222831]; withpermission.)dimensional (3D) depiction of the compartmentsthat can be used for detailed investigationsregarding the shape, size, and volume of thedistinct fat compartments.19,20

An additional advantage of the use of radi-opaque dye with CT is that it allows compartmentsto be visualized from any plane. Gierloff and col-leagues,19 authors of the first study using this noveltechnique, studied 12 cadavers divided evenly intoyounger (5975) and older (76104) age groups.They presented evidence that is in concordancewith what has been observed in the cadavericdissection and dye sequestration studies; a sche-matic from their article depicting the superficialfat compartments of themidface is shown in Fig. 5.In 2007, Rohrich and Pessa2 determined, via

dye injection into cadaveric heads, that there are3 fat compartments of the forehead. The centralcompartment is located in the midline and extendsinferiorly to the nasal dorsum and laterally to aborder that they refer to as the central temporalseptum.Fig. 6A shows an image of the central forehead

compartment in 3D from the Gierloff and col-leagues19 CT study. The forehead is a key areaof facial expression. Note in Fig. 6B and C thatsite-specific augmentation of this particular fatpad reduces the perceived look of anger in thispatient.

MIDFACE

In 2008, Rohrich and colleagues8 discovered thedeep medial cheek fat compartment that islocated just medial to the buccal fat pad and zygo-maticus major muscle. This compartment isbounded medially by the pyriform ligament of thenasal base, superiorly by the orbicularis retainingligament, and lies just deep to the superficial fatcompartments. The compartment is distinct fromthe suborbicularis oculi fat. A potential space ex-ists between the periosteum of the maxilla andthe deep medial cheek fat and has been termedvisible in an anterior view in a patient withoutmuch lateral cheek fat and is less visible whenthis area is full (this is often seen in thin patientsafter facelifting).Augmenting specific areas has a specific effect

and enables the clinician to tailor his or hertreatment based on the individuals particularmorphology.18

The most recent advance in the visualization ofthese compartments is the use of a novel tech-nique using a thin-slice computed tomographic(CT) scan with an iodinated contrast medium.Ristow space.

Fitzgerald & Rubin40In 2009 an additional study by Rohrich and col-leagues11 showed that the suborbicularis oculi fat(SOOF) is composed of two distinct anatomiccompartments. The deep cheek fat is the medialboundary of lower eyelid periorbital submuscularfat. Medial suborbicularis fat is located betweendeep cheek fat and lateral suborbicularis oculifat. This lateral compartment extends from thelateral canthus to the lateral orbital thickening.The CT study by Gierloff and colleagues19 also

provided additional new information concerningdeep midfacial fat. Specifically, they noted thatthe deep medial cheek fat consists of both amedial and lateral compartment, as is seen in theSOOF. These deep midfacial fat compartmentsare depicted in a schematic from their article inFig. 7. Note the medial extension of the deepmedial cheek fat compartment seen around the

Fig. 3. (A) The patient pictured here has lost temporal faaffects the shape of her face, changing it to a sort of peaaugmentation in this area. (B) The patient here has lostresulting in a somewhat harsh skeletonized appearancearea. (Courtesy of Rebecca Fitzgerald, MD, Los Angeles, Cpyriform ligament that is not present in the sche-matic of superficial fat. The investigators of thisstudy also observed radiopaque dye sequestra-tion in a buccal extension of the buccal fat padindicating that this is an independent compart-ment. This buccal extension of the buccal fat padis felt by these investigators to play a pivotal rolein the support of the compartments above it. Addi-tional new observations made in this study will bediscussed later in this section.Now turn your attention to the patient in Fig. 8.

Deep midfacial fat is visible clinically. There is noundereye hollowing or nasolabial fold and thereis a convex contour to her midface. However,because of a congenital lipodystrophy, there is astriking lack of superficial fat. This is most obviousin her temple and lateral cheek (as well as her peri-orbital area), but on closer observation the lack of

t in the area posterior to her hairline. Note that thisnut shape, which is restored to an oval with volumetemporal fat at the superior temporal septum (STS), which softens with volume augmentation in thatA.)

Filler Placement and the Fat Compartments 41superficial fat in her midface is causing a gooddeal of shadowing. This shadowing corrects withtreatment in the areas of the superficial medialand middle cheek fat compartments.Fig. 9 is a three-dimensional image of the medial

part of the deep medial cheek compartment

Fig. 4. This patient has ample temporal volume, but an aconcave (almost horselike) appearance that is softeneNote that the tragus is visible in an anterior view in a patwhen this area is full (this is often seen in thin patients aLos Angeles, CA.)showing fat extending under the nasolabial fold,as well as up to the inferior border of the orbitalrim. It easy to appreciate what the clinical effectsof a treatment in this specific area might accom-plish. The dotted red line represents the nasolabialfold. The lateral part of the deep medial cheek

bsence of lateral cheek fat, giving her lateral face ad as her face is ovalized by treatment in this area.ient without much lateral cheek fat and is less visiblefter facelifting). (Courtesy of Rebecca Fitzgerald, MD,

Fig. 5. Stylistic drawing of theanatomic relationships of the facialfat compartments. The midfacial fatis arranged in 2 and paranasally in 3independent anatomic layers. Thesuperficial layer (yellow) is composedof the nasolabial fat, the medialcheek fat, the middle cheek fat, thelateral temporal cheek compartment,and 3 orbital compartments. (FromGierloff M, Stohring C, Buder T,et al. Aging changes of the midfacialfat compartments: a computed tomo-graphic study. Plast Reconstr Surg2012;129(1):26373; with permission.)

Fig. 6. (A) CT image of the subcutaneous central forehead compartment. The yellow line indicates the position ofthe glabellar fold that is located superficially to the inferior portion of the compartment. (B, C) Note that site-specific augmentation of this particular fat pad reduces the perceived look of anger in this patient. ([A] FromGierloff M, Stohring C, Buder T, et al. The subcutaneous fat compartments in relation to aesthetically important

012

Fitzgerald & Rubin42compartment is not shown. An elevation andeffacement of the nasolabial fold can be achievedby augmentation of the deep medial cheek fat(medial part) and augmentation of the deepest fatcompartment in the paranasal region (Ristowspace), which both extend further medially thanthe overlying nasolabial fold. In contrast, because

facial folds and rhytides. J Plast Reconstr Aesthet Surg 2Rebecca Fitzgerald, MD, Los Angeles, CA.)of the topography, the lateral part of the deepmedial cheek fat is responsible for the anteriorcheek projection. This is well illustrated by the

Fig. 7. Stylistic drawing of the anatomic relationships of dsuborbicularis oculi fat (medial and lateral parts) and the dlayers of distinct fat compartments are found laterally to(blue) is located posterior to the medial part of the dbuccal fat pad extends from the paramaxillary space to tBuder T, et al. Aging changes of the midfacial fat compartSurg 2012;129(1):26373; with permission.)image in Fig. 10, where the deep medial cheekcompartment has been filled with saline in acadaver. Note the effacement of the nasolabialfold and undereye hollowing as well as the projec-tion and shape of the cheek. Note that the blackarrow shows how the skin stretches as this areais filled.

;65(10):12927, with permission; and [B, C] Courtesy ofLook now at Fig. 11 for clinical examples oftreatment in the same area. Again, treatment ofthis one area leads to effacement of the nasolabial

eep midfacial fat compartments. It is composed of theeep medial cheek fat (medial and lateral parts). Threethe pyriform aperture, where a deep compartment

eep medial cheek fat. The buccal extension of thehe subcutaneous plane. (From Gierloff M, Stohring C,ments: a computed tomographic study. Plast Reconstr

Fig. 8. (A) Deep midfacial fat is visible clinically. There is nconvex contour to her midface. However, due to a congenfat. This is most obvious in her temple and lateral cheek (asthe lack of superficial fat in hermidface is causing a good dement in theareasof the superficialmedial andmiddle cheekLos Angeles, CA.)

Fig. 9. CTof the medial part of the deep medial cheekfat (DMC). The yellow line indicates the position of theoverlying nasolabial fat compartment. The red dashedline indicates the course of the nasolabial crease. (FromGierloffM, Stohring C, Buder T, et al. The subcutaneousfat compartments in relation to aesthetically impor-tant facial folds and rhytides. J Plast Reconstr AesthetSurg 2012;65(10):12927; with permission.)

Filler Placement and the Fat Compartments 43fold and improvement in undereye hollowing.Obviously, the older patient (see Fig. 11A) withmore volume loss required more product for thisresult than the younger patient (see Fig. 11B)with less volume loss. Note that the area of thelateral SOOF in both of these patients had volumebefore this treatment and therefore blends in wellwith the newly treated area. In the cadaver in theprevious image, volume restoration of the deepmedial cheek fat makes the lack of volume in hislateral SOOF even more obvious. This area clearlydid not fill with the treatment shown, because it is aseparate fat compartment not accessed by thetreatment. This anatomy has enormous clinicalrelevance in facial filling, as it allows specific areasto be targeted for specific effects. Lack of volumein the lateral SOOF truncates the cheek. Treatmentin the area of the lateral SOOF augments theprominence of the cheek.16

This effect is well illustrated by the clinical imageseen in Fig. 12. At first glance, the issue seems tobe a prominent nasolabial fold, but knowledge ofthe specific fat compartments facilitates recog-nition of the relatively empty medial and lateralSOOF compartments. Treatment in these fat pads

o undereye hollowing or nasolabial fold and there is aital lipodystrophy, there is a striking lack of superficialwell as her periorbital area), but on closer observational of shadowing. (B) This shadowing correctswith treat-fat compartments. (CourtesyofRebecca Fitzgerald,MD,

Fig. 11. Clinical examples of treatment in the same area as the cadaver pictured in the previous figure. Again,treatment of this one area leads to effacement of the nasolabial fold and improvement in undereye hollowing.Obviously, the older patient (A) with more volume loss required more product for this result than the youngerpatient (B) with less volume loss. Note that the area of the lateral SOOF in both of these patients had volumebefore this treatment and therefore blends in well with the newly treated area. In the cadaver in the previousimage, volume restoration of the deep medial cheek fat makes the lack of volume in his lateral SOOF evenmore obvious. (Courtesy of Rebecca Fitzgerald, MD, Los Angeles, CA.)

Fig. 10. Photograph of a deflated midface (A). (B) Saline injected specifically into the deep medial cheek fatrestores anterior projection, diminishes the nasolabial fold, and effaces the nasojugal trough. Note that thecheek has a natural appearance. Recognize that this is because the fascial boundaries of the deep medial cheekcompartment determine and define its shape. This means that filler placed specifically into this fat compartmentwill reflect this shape and have a natural appearance. (From Rohrich RJ, Pessa JE, Ristow BR. The youthful cheekand the deep medial fat compartment. Plast Reconstr Surg 2008;121:210712; with permission.)

Fitzgerald & Rubin44

Fig. 12. (A) At first glance, the patients issue seems to be a prominent nasolabial fold, but knowledge of the spe-cific fat compartments facilitates recognition of the relatively empty medial and lateral SOOF compartments. (B)Treatment in these fat pads achieves a natural-appearing correction. This patient was also treated with neuromo-dulators and filler in the brow. (Courtesy of Rebecca Fitzgerald, MD, Los Angeles, CA.)

Filler Placement and the Fat Compartments 45achieve a natural-appearing correction. This pa-tient was also treated with neuromodulators andfiller in the brow.The patient in Fig. 13 was treated in the deep

medial cheek fat as well as in the medial and lateralSOOF. The volumization of the lateral SOOF canbe most appreciated on the right side of her facein this three-quarter view. This patient was treatedwith neuromodulators and filler in the brow fatas well.These specific areas of treatment are well illus-

trated in the 3-D CT image in Fig. 14, which showsboth themedial aspect of thedeepmedial cheek faton the right as well as the medial and lateral SOOFon the left. This image also illustrates 2 importantnew observations made possible by the use ofthe 3D technique by Gierloff and colleagues.19

They studied 12 cadavers divided evenly into ayounger (5975) and an older (76104) age group.They observed (1) an inferiormigration or saggingof themidfacial fat compartments and (2) an inferiorvolume shift within the compartments in the olderversus younger group.For evaluation of the sagging of the compart-

ments, the distance between the cephalad borderand the infraorbital rim was determined. ForFig. 13. (A) Prior to treatment. (B) Thispatient was treated in the deep medialcheek fat as well as in the medial andlateral SOOF. The volumization of thelateral SOOF can be most appreciatedon the right side of her face in thisthree-quarter view. This patient wastreatedwith neuromodulators and fillerin the brow fat as well. (Courtesy ofRebecca Fitzgerald, MD, Los Angeles,CA.)

evaluation of the volume distribution within a spe-cific compartment, the sagittal diameter of the up-per, middle, and lower thirds of each compartmentwas determined. Representation of both of thesechanges can be appreciated in this image.The investigators noted that these observations

are consistent with some of the changes wesee with aging. For instance, volume loss of the

of the inferior part of the nasolabial fat would leadto a pronounced nasolabial fold and a pronouncedsuperior jowl. Also, inferior migration of the fatcompartments could contribute to the crescent-shaped hollow below the lower edge of theorbicularis oculi muscle and the deepening of thenasojugal fold seen with aging.19

Fig. 14. The deep midfacial fat com-partments. The deep medial cheekfat is composed of a medial part(DMC) and a lateral part (not shown).The medial part extends mediallyalmost to the lateral incisor tooth.Augmentation of the deep medialcheek fat will consequently elevateand efface the nasolabial fold. Thesuborbicularis oculi fat is composedof a medial part (MS) and a lateralpart (LS). With aging, an inferiormigration of these compartmentsoccurs, as well as an inferior volumeshift within the compartments. (From

Gierloff M, Stohring C, Buder T, et al. Aging changes of the midfacial fat compartments: a computed tomographicstudy. Plast Reconstr Surg 2012;129(1):26373; with permission.)

Fitzgerald & Rubin46cephalad part of the nasolabial and medial cheekfat would consequently worsen the appearanceof the tear trough deformity, the nasojugal fold,and the palpebromalar groove. A volume increaseFig. 15. (A) Just as there is suborbicularis fat around theHistologic examination confirms the macroscopic finding thof the lip. Vertical sectioning of the upper lip reveals fat deto the buccal mucosa. (B) Vertical sectioning of the lower liular note, this specimens lower lip showed anterior proyounger individual. The clinical impression from this researicantly to the appearance of the youthful lip. ([B] From Rothe deep medial fat compartment. Plast Reconstr Surg 20and clinical implications of perioral submuscular fat. PlastLOWER FACE

Finally, lets take a look at the perioral area of thelower face. Fig. 15 shows a cadaveric dissectioneye, there is suborbicularis fat of the perioral region.at the orbicularis insertion defines the wet-dry borderep to the orbicularis oris muscle (arrow) and superficialp again shows deep submuscular fat (arrow). Of partic-jection and eversion similar to that seen in a muchch is that the volume of deep lip fat contributes signif-hrich RJ, Pessa JE, Ristow BR. The youthful cheek and08;121:210712; and Rohrich R, Pessa J. The anatomyReconstr Surg 2009:124(1):26671; with permission.)

Fig. 16. (A) Images of a volume-rendered 3D spiral CT of the lower face demonstrating the surface of the skin(above) and the anterior part of themandiblewith the labiomandibular fat compartments (LM) and the left inferiorjowl fat (below). The yellowarrows indicate the position of the labiomandibular fold. Thewhite arrow indicates theposition of the mandibular retaining ligament. (B) Images of a volume-rendered 3D spiral CT of the chin demon-strating the submentalis fat. Note that this compartment deso not lie immediately adjacent to the mentolabialsulcus. (From Gierloff M, Stohring C, Buder T, et al. The subcutaneous fat compartments in relation to aestheticallyimportant facial folds and rhytides. J Plast Reconstr Aesthet Surg 2012;65(10):12927; with permission.)

Fig. 17. (A) Following previous injection the patients lips appeared unnatural. (B) Removing suboptimally placedfiller in the vermillion border (with hyaluronidase) followed by placement of filler in a submuscular location in themucosal and cutaneous portion of the patients upper and lower lip as well as in her lateral and anterior chinprovide more support for her lips and a more natural appearing result. (Courtesy of Rebecca Fitzgerald, MD,Los Angeles, CA.)

Filler Placement and the Fat Compartments 47

that illustrates the fat deep to the orbicularis orismuscle in both the mucosal and cutaneous portionof the upper and lower lips. It is thought that thisfat may help facilitate eversion in a young lip,whereas the lack of this support may contribute tothe inversion seen in an older lip.10 Fig. 16 showsimages of a volume-rendered 3-D spiral CT of thelower face demonstrating the surface of the skin(above) and the anterior part of the mandible, withthe labiomandibular fat compartments and the leftinferior jowl fat (below). The yellow arrows indicatethe position of the labiomandibular fold. The whitearrow indicates the position of the mandibular re-taining ligament.One layer of fat was identified in the region of the

labiomandibular fold (marionette line). The labio-mandibular crease lies between the labioman-dibular fat compartment (LM) and the jowl fat, asindicated by the yellow line. The lateral edge ofthe LM appeared to be thinner in cadavers with a

prominent labiomandibular fold than in cadaverswith no obvious fold. The medial edge of thedepressor anguli oris muscle follows the courseof the crease.Knowledge of this anatomy enables correction

of the suboptimal placement of lip filler seen inthe patient shown in Fig. 17. Fear of this unnaturalduck lip is probably one of the most common pa-tient concerns we hear regarding lip augmenta-tion. Removing the filler in the vermillion border(with hyaluronidase), followed by placement offiller in a submuscular location in the mucosaland cutaneous portion of her upper and lower lipas well as in her lateral and anterior chin providemore support for her lips and a more natural-appearing result.In the final clinical example shown in Fig. 18, we

see a patient who has been treated suboptimally inthe tear trough area with hyaluronic acid. This re-sulted in an unnatural convexity to her infraorbital

boareasl chk faalst thep

Fitzgerald & Rubin48Fig. 18. A 51-year-old patient who has been treated suwhich gives an unnatural convexity to her infraorbitalTyndall effect and Raleigh scattering). Hyaluronidase warea and product was instead placed in the deep mediashe also received treatment in the lateral temporal-cheeand inferior temporal septa, as shown in Fig. 3. She waswell as in the medial and lateral SOOF. Finally, to correcmedial and middle cheek fats were also treated, as d

Los Angeles, CA.)ptimally in the tear trough area with hyaluronic acid,a as well as a bluish reflection (referred to as both theused to remove the hyaluronic acid in the infraorbitaleek fat. To give her a softer, more natural appearance,t pad, both behind the hairline and along the superioro treated in the lateral cheek fat, as shown in Fig. 4, ase mild shadowing noted in her midface, the superficialicted in Fig. 8. (Courtesy of Rebecca Fitzgerald, MD,

size, and volume of the distinct fat compartments.

Filler Placement and the Fat Compartments 49This technique also allows compartments to bevisualized from any plane.The first study using this method found that a

buccal extension of the buccal fat exists as anindependent fat compartment and may play apivotal role in the aging face. Two other significantobservations made in this study were (1) an inferiormigration of the midfacial fat compartments and(2) an inferior volume shift within the compart-ments occurs during aging.The information garnered from both cadaveric

dissections and CT studies have important aes-thetic clinical implications. Site-specific augmen-tation with fillers (or fat) can now be used torefine facial shape and topography in a more pre-dictable and precise fashion. The purpose of thisarticle has been simply to provide a few clinicalarea as well as a bluish reflection referred to asboth the Tyndall effect and Raleigh scattering.Hyaluronidase was used to remove the hyaluronicacid in the infraorbital area and product wasinstead placed in the deep medial cheek fat.To give her a softer, more natural appear-

ance, she also received treatment in the lateraltemporal-cheek fat pad, both behind the hairlineand along the superior and inferior temporal septa,as previously shown in Fig. 3. She was also treatedin the lateral cheek fat as previously shown inFig. 4, as well as in the medial and lateral SOOF.Finally, to correct the mild shadowing notedin her midface, the superficial medial and middlecheek fats were also treated, as previouslydepicted in Fig. 8.

SUMMARY

To summarize, the superficial fat is composed ofthe nasolabial, medial cheek, middle cheek, andlateral temporal cheek compartments, the threesuperficial periorbital compartments (as seen inthe schematic in Fig. 5), as well as the three fore-head compartments. The deep adipose layer iscomposed of the suborbicularis fat and the deepmedial cheek fat, each with a medial and lateralcompartment (as seen in the schematic inFig. 7). Three layers of distinct fat compartmentsare found just lateral to the pyriform aperture,where a compartment termed Ristow space islocated posterior to the medial part of the deepmedial cheek fat. These findings are in concor-dance in all studies to date.The most recent advance is a newmethod using

contrast CT, which allows a reproducible 3-Ddepiction of the compartments that can be usedfor detailed investigations regarding the shape,examples to illustrate this concept. There is stillREFERENCES

1. Lambros V. Observations on periorbital and mid-

facial aging. Plast Reconstr Surg 2007;120:136776.

2. Rohrich RJ, Pessa JE. The fat compartments of

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cosmetic surgery. Plast Reconstr Surg 2007;119:

221927 [discussion: 222831].

3. Hwang SH, Hwang K, Jin S, et al. Location and

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laris oculi fat. J Craniofac Surg 2007;18:38790.

4. Ghavami A, Pessa J, Janis J, et al. The orbicularis

retaining ligament of the medial orbit: closing the

circle. Plast Reconstr Surg 2008;121(3):9941001.

5. Reece EM, Pessa JE, Rohrich RJ. The mandibular

septum: anatomical observations of the jowls in

aging. Implications for facial rejuvenation. Plast

Reconstr Surg 2008;121:141420.

6. Garcia de Mitchell CA, Pessa JE, Schaverien MV,

et al. The philtrum: anatomical observations from a

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175660.

7. Rohrich RJ, Pessa JE. The retaining system of the

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Reconstr Surg 2008;121:18049.

8. Rohrich RJ, Pessa JE, Ristow BR. The youthful

cheek and the deep medial fat compartment. Plastmuch to be learned about the underlying anatomyof facial adipose tissue and the changes that occurthrough the aging process, as well as how to bestapply this knowledge clinically. The ability to deter-mine the physiologic size and shape of each facialfat compartment, including its age-dependentchanges, would allow us to redistribute the fat ofeach compartment in a physiologic way andmimicthe facial fat distribution in youth. This would notonly lead to a more natural volume distribution,but also enable a smaller consumption of fat orfiller.Of course, a major limitation that is present in all

of the studies presented is the lack of longitudinal-ity. Eventually, as longitudinal studies are under-taken, we will know more regarding the dynamicchanges that occur within and between each fatcompartment with aging.We all recognize that optimal, predictable, and

reproducible patient outcomes are best facilitatedby carefully predicting (patient selection), planning(facial analysis and mapping), and performing(proper preparation and injection of product) treat-ments in an informed manner. It is our hope thatthe information provided here will help to facilitatethis goal. We look forward to further developmentsin this interesting and fascinating field.Reconstr Surg 2008;121:210712.

9. Rohrich RJ, Ahmad J, Hamawy AH, et al. Is the intra-

orbital fat extraorbital? Results of cross-sectional

anatomy of the lower eyelid fat pads. Aesthet Surg

J 2009;29:18993.

10. Rohrich R, Pessa J. The anatomy and clinical impli-

cations of perioral submuscular fat. Plast Reconstr

Surg 2009;124(1):26671.

11. Rohrich RJ, Arbique GM, Wong C, et al. The anat-

omy of suborbicularis oculi fat: implications for

periorbital rejuvenation. Plast Reconstr Surg 2009;

124:94651.

12. Schaverien MV, Pessa JE, Rohrich RJ. Vascularized

membranes determine the anatomical boundaries of

the subcutaneous fat compartments. Plast Reconstr

Surg 2009;123:695700.

13. Pilsl U, Anderhuber F. The chin and adjacent fat

compartments. Dermatol Surg 2010;36:2148.

14. Pilsl U, Anderhuber F. The septum subcutaneum

parotideomassetericum. Dermatol Surg 2010;36:

20058.

15. Rohrich R, Taylor N, Ahmad J, et al. Great auricular

nerve injury, the subauricular band phenomenon,

and the periauricular adipose compartments. Plast

Reconstr Surg 2011;127(2):83543.

16. Pessa JE, Rohrich RJ. Facial topography. Clinical

anatomy of the face. St Louis (MO): Quality Medical

Publishing, Inc; 2012.

17. Rohrich R, Pessa J. Discussion: aging changes of the

midfacial fat compartments: a computed tomographic

study. Plast Reconstr Surg 2012;129(1):2745.

18. Sandoval SE, Cox JA, Koshy JC, et al. Facial fat

compartments: a guide to filler placement. Semin

Plast Surg 2009;23(4):2837.

19. Gierloff M, StohringC, Buder T, et al. Aging changes of

the midfacial fat compartments: a computed tomogra-

phic study. Plast Reconstr Surg 2012;129(1):26373.

20. Gierloff M, Stohring C, Buder T, et al. The subcu-

taneous fat compartments in relation to aesthetically

important facial folds and rhytides. J Plast Reconstr

Aesthet Surg 2012;65(10):12927.

Fitzgerald & Rubin50

Filler Placement and the Fat CompartmentsKey pointsIntroductionFacial fat compartmentsUpper faceMidfaceLower faceSummaryReferences