PEER-REVIEW | INJECTABLES | of the scientific literature and of eighteen hemifacial


cadavers dissections undertaken at the University of Malta’s Department of Anatomy. As suggested by Rorich and Pessa1


, clinical observation


and laboratory investigations show that the subcutaneous fat of the face is highly partitioned, that it is not a confluent mass, and it exists in distinct anatomical compartments. The fat compartments are determined by fascial membranes that arise from the superficial fascia and attach to the dermis of the skin2


.


The midface fat compartments are classified as either superficial or deep. It’s very important to distinguish between these two different categories. The superficial fat compartments are located between the skin and the plane of the Superficial Muscular Aponeurotic System (SMAS). The SMAS is a continuous and organized fibrous network connecting the periosteum, the facial muscles, or other fascial types (such as parotid fascia), with the dermis. It consists of a three-dimensional architecture of collagen fibers, elastic fibers, fat cells, and muscle fibers3–5


. The fat


tissue of superficial compartments is located within this fibrotic network. Under the SMAS plane, posteriorly to the mimetic muscles, we find the deep fat compartments that reach and adhere to the periosteal plane. The fat compartments of the cheek are described below


and can be found in Figure 2.  Superfical fat compartments: » Infraorbital fat » Medial cheek fat » Nasolabial fat » Middle cheek fat » Lateral temporal-cheek fat » Superior jowl fat » Inferior jowl fat.


 Deep fat compartments » Medial sub-orbicularis oculi fat (Medial SOOF) » Lateral sub-orbicularis oculi fat (Lateral SOOF) » Deep medial cheek fat (DMCF) » Buccal fat.


Clinical observation and


laboratory investigations show that the subcutaneous fat of the


face is highly partitioned, that it is not a confluent mass, and it exists in distinct anatomical compartments.


Figure 1 The structure of the Anatomologic™ approach has four phases: anatomy knowledge, aging assessment, treatment planning, and injection technique


Superficial fat compartments Infraorbital fat Its superior margin corresponds on the skin surface to the tear trough and to the palpebro malar groove (Figure 3). In fact, the superior boundary of this compartment is the orbicularis retaining ligament that originates 1–2 mm inferiorly to the margin of the orbital cavity and, passing through the orbicularis oculi muscle, reaches the dermis9,10


. According to Muzzafar et al, this ligament spans


from the periosteum, just outside the orbital rim, to the fascia on the undersurface of the orbicularis oculi muscle11


. The orbicularis retaining ligament contributes


to the formation of the tear trough and palpebro malar groove. Positioned cranially to these two grooves, the palpebral part of the orbicularis oculi muscle is found immediately under the skin of the eyelid; caudally to them, the orbital part is covered by infraorbital fat. Inferiorly, the infraorbital fat is defined by the zygomatic cutaneous ligament12


. Mendelson


described zygomatic ligaments medial to the junction of the arch and body of zygoma, located along the origins of the facial expression muscles as the the zygomaticus major, zygomaticus minor, and levator labii superioris13


. At the level of the junction stronger and is described as the McGregor patch14


of the arch and body of the zygoma, just lateral to the origin of the zygomaticus major muscle, this ligament becomes thicker and .


The fat of this compartment has a high tendency for


water retention. Frequently being the site of persistent oedema it often forms the so called malar mound6,15


.


Medial cheek fat It is located caudally to the infraorbital fat from which it is separated by the zygomatic cutaneous ligament (Figure 3). It has a triangular shape and is wedged


Figure 2 Superficial and deep cheek fat compartments


Superficial cheek fat compartments


a) infraorbital fat b) medial cheek fat c) nasolabial fat d) middle cheek fat e) lateral cheek fat f) superior jowl fat g) inferior jowl fat


a c


b d f


g 32  e


Deep cheek fat compartments


h) medial sub-orbicularis oculi fat


i) lateral sub-orbicularis oculi fat


j) deep medial cheek fat k) buccal fat


h j


i k


October 2015 | prime-journal.com


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