| FACIAL AESTHETICS | PEER-REVIEW
orbital and malar fat gives both protection and shape by means of forming a fatty pad. A structure less dense than the deep malar fat, the superficial malar fat adheres to the skin. The face is not static, but is dynamic. The orbicularis
muscle is the principal motor in the mid-face for its movement in facial expression, and the superficial orbital malar fat is also involved in the mobility of this zone. The face is not static, but ages. The resulting sagging
together with the skin defines the palpebromalar groove, which with the mid-cheek groove and nasolabial fold forms the three principal grooves, and mark the changes of the ageing face. In addition, the orbital rim becomes more exposed owing to the fat loss and the descent of the superficial malar fat. The internal part of the palpebromalar groove and the
Figure 1 Appearance of the periorbital in younger patients
superiorÐ internal part of the mid-cheek groove join together as a Y-shape to create the tear trough. Poets often refer to the hollow formed between the tear trough and the mid-cheek groove as the Ôvalley of tearsÕ . The skin covers all these elements. There is a transition
between the very fine palpebral skin and the thicker jugal skin. To summarise, there is the deep fixed and static fat,
and a superficial mobile fat, the latter being dynamic in the creation of expression and age-induced sagging. The skin, superficial malar fat, and orbicularis muscle are all mobile and dynamic. All move as though through a sliding space situated between the deep malar fat and the orbicularis muscle, and between the orbicularis muscle and the superficial malar fat.
Is the palpebromalar junction stable? In his observations of the periorbital area and the mid-face, Lambros5
wrote, Ô the lidÐ cheek junction is very
Figure 2 With ageing, the periorbital area undergoes changes protection for the inferior orbital rim just as the
CharpyÕs fat pad protects the superior orbital rim. As a result of its deep bony adherence, this fat is fixed. Immobile in the facial dynamic of facial expressions, this deep fat does not sag with the tissue relaxation caused during ageing. However, similar to the superficial malar fat, it is subject to partial atrophy during the ageing process. The orbicularis oculi muscle is a
sphincter muscle responsible for voluntary movements; the constriction of the eyelids and elevation of the cheek, and of the superficial malar fat, which overlies it. The muscle contracts with laughter, elevating the lower eyelid and cheek. With age, it becomes less homogenous and less compact, losing its tonicity and spreading downward (Figures 4 and 5). Its fibres can become dissociated, resulting in gaps between them1, 4, 5 The superficial orbital malar fat lies under the skin and covering the orbicularis muscle; the superficial
.
stable because it sits on tissues which are fixedÕ. A number of authors concur with Lambros in this regard; however, the authors of the present article are not of the same opinion. As already described, the bony rim of the orbital rim, which tends to recede with age, is fixed, as is the deep malar fat, which is fixed to the bony rim for protection. The skin, superficial malar fat and orbicularis muscle are not fixed: they are mobile. It is obvious that the inferior eyelid lengthens during
Using a needle is certainly easier;
however, a fine blunt cannula easily penetrates due to the fineness of the skin at the level of the lidÐc heek junction.
the age-related sagging and the palpebromalar junction becomes lower. This is evidenced by rejuvenation and embellishment with volumising products (such as hyaluronic acid or autologous fat, in the authorsÕ experience), which raise the level of the palpebromalar junction and shortens the lower eyelid.
Where and how to inject There are two major considerations: the hydrophilic nature of hyaluronic acid and the thinness of the palpebral skin. A placement of hyaluronic acid that is too superficial and injected just under this fine skin can give an unaesthetic blue appearance (Tyndall effect),
prime-journal.com | January/February 2013 ❚ 21
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92