| INJECTABLES | PEER-REVIEW
Deep fat compartments Medial sub-orbicularis oculi fat (medial SOOF) It lies adherent to the periosteum along the orbital rim18
,
inferiorly to the orbicularis retaining ligament and under the orbicularis oculi muscle (Figure 3–4). It extends from the medial limbus to the outer cantum. The zygomatic cutaneous ligament separates the medial SOOF from the deep medial cheek fat.
Lateral sub-orbicularis oculi fat (lateral SOOF) Located at the lateral orbital rim in the sagittal plane (Figure 4). The lateral orbital thickening represents the upper-limit of the lateral SOOF and does not extend superiorly to the lateral canthus. Its medial half is covered by the orbicularis oculi muscle. It lies above the prominence of the zygoma but does not reach above the superior margin of the zygomatic arch. The lateral SOOF lies above another more deeply situated fat compartment, therefore it is not directly in contact with the periosteum18
.
Deep medial cheek fat (DMCF) Located under the SMAS plane, its superior part lies under the orbicularis oculi muscle (Figure 3–4). Its superior boundary is the zygomatic-cutaneous ligament that divides it from the medial SOOF and it laterally borders with the buccal fat and with the zygomaticus major muscle. The medial boundary is the pyriform ligament surrounding the nasal base, and the inferior boundary is the sub–orbicularis oris fat. This fat compartment lies on the periosteum of the maxilla. Between the periosteum and the fat compartment a potential space is present, defined as Rislow’s space8 Other authors19
. describe this compartment divided into
two parts: the medial part, located beneath the nasolabial fat, does not lie immediately on the periosteum of the maxilla but is bordered posteriorly by another small, triangular compartment; the lateral part is located under the superficial medial cheek fat and is positioned directly on the maxilla.
The ability to
Buccal fat Located inferiorly to the zygoma and anteriorly to the ramus of the mandible surrounding the medial pterygoid and masseter muscle. This fat compartment has a buccal extension adjacent to the medial cheek fat, the deep medial cheek fat, the middle cheek fat, the sub–orbicularis oculi fat, the jowl fat, and the fat of the pre-masseter space. Gierloff et al., in their computed tomography study have observed a hypothetical anatomical boundary between the buccal extension and the buccal fat pad. They have hypothesized that the buccal extension can be regarded as a distinct fat compartment19 theory20
. Other authors share this . Often, injectors can have some difficulty understanding
the specific localization of the fat compartments and, consequently, treating them accurately. This can be a difficulty especially for doctors that have no experience
understand the changes occuring related to the aging process is essential in order to correctly plan a treatment with fillers.
Figure 4 Deep cheek fat compartments: A) medial sub-orbicularis oculi fat, B) lateral sub-orbicularis oculi fat. The sub-orbicularis oculi fat are located below the orbicularis oculi muscle. In this anatomic dissection the SOOFs are visible thanks to the divarication of muscular fibers of orbicularis oculi muscle. C) Deep medial cheek fat. The upper part of DMCF is below the orbicularis oculi muscle. It borders laterally with the zygomaticus major muscle
with cadaver dissections and anatomic studies. Improving knowledge of these aspects is essential to increase the effectiveness of treatments.
Anatomy of aging fat compartments The fat compartments undergo specific modifications due to the aging process. Sometimes the changes are hypotrophic, other times they are hypertrophic or ptotic. The ability to understand the changes occurring related to the aging process is essential in order to correctly plan a treatment with fillers.
Superficial fat compartments Medial cheek fat The aging process causes a global volume increase in the medial cheek fat with an inferior volume shift within the fat compartment. The volume increases in the lower two thirds and remains stable in the upper one.
Figure 5 (A,B) before and (C,D) after treatment for a type 1 patient with 4 ml of volumizer filler injected using the bolus technique in the DMCF, lateral SOOF, and medial SOOF as well as with a microcannula in lateral cheek fat
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