Meloplication of the malar fat pads by percutaneous cable-suture technique for midface rejuvenation: outcome study (392 cases, 6 years' experience)

The aging anterior midface is restored by reversing the contour undulations produced by sagging of the malar fat pad complex toward the nasolabial line. The convex irregularities include the exposed bulges of the post-septal fat, the unveiled malar bag, and the prominent nasolabial fold. The depressed irregularities are represented by the cresent-shaped hollow at the lid-cheek junction, the accentuated nasojugal groove, and the deepening nasolabial line. Repositioning of the ptotic malar fat pad, among other elements of meloplasty, represents a key procedure. In this study, the malar fat pad has been defined as a fan-shaped structure by external anatomic landmarks that correlate closely to the findings in cadaveric dissections and clinical cases, confirmed by the findings of spiral computed tomographic scanning. A simple but powerful adjustable and long-lasting percutaneous suture elevation technique was developed over the past 6 years by the senior author (G.H.S.) to reposition the fat pad in a superolateral direction. Through a dot incision within the nasolabial line, a permanent CV-3 Gore-Tex (or 4-0 clear Prolene) suspension suture, looped through a Gore-Tex anchor graft, suspends the malar fat pad in a direction perpendicular to the nasolabial line. A second suspension system is identically passed through another lower dot incision to broaden the repositioning vectors on the malar fat pad. Tension on each of the paired suture ends elevates the malar fat pad by 1 to 3 mm as measured from the nasolabial dot incisions. The sutures are fixed to the deep temporal fascia through a Gore-Tex tab, effectively stabilizing the soft-tissue repositioning. This maneuver may be performed in younger patients who present with an isolated malar fat pad ptosis without excess facial skin. The procedure may also be incorporated into open rhytidectomies to address this recalcitrant area along with superficial musculoaponeurotic system tightening. A total of 392 patients since 1995 underwent suture elevation of the malar fat pads. An outcome study indicated that the usage of two permanent sutures with Gore-Tex anchor grafts since 1998 resulted in improvement in midface rejuvenation of over 82 percent. Early and late complication rates were small and temporary. Patient acceptance was excellent, indicative of the benefits of anatomic repositioning of the malar fat pad complex.     

Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication

The rejuvenation technique of malar imbrication, which avoids dissection in the plane of the seventh cranial nerve, is presented to address the author's altered priorities in midfacial rejuvenation. These priorities target volumetric over tension-based goals in a manner that is simpler, safer, and more sculpturally effective than existing techniques. Volumetric manipulations in the subperiosteal and subcutaneous planes also bring substantial rejuvenation to the periorbital and perioral regions, without lip or lower lid incisions. Fourteen of the 172 patients (8 percent) who underwent consecutive procedures for primary facial rejuvenation suffered temporary upper lip paresis. Other complications were infrequent and limited. One patient underwent reoperation for asymmetry. Increased postoperative swelling and recovery are a necessary consequence of the subperiosteal component, just as increased operative time attends the wide undermining of the subcutaneous component. Despite these liabilities, the author recommends adding volumetric resculpture to the existing conventional tools of soft-tissue displacement under tension and topical resurfacing in pursuit of safer, more effective, and more natural rejuvenation of the aging face.     

Endoscopic forehead lift: review of technique,cases, and complications

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.     

The midface sling: a new technique to rejuvenate the midface

In the early 1990s, the midface became the focus of facial rejuvenation, and various techniques effected elevation by plicating, or on, the midface. Recent analyses of facial aging demonstrate that selective ptosis of the midfacial tissues lateral to the nasolabial fold results in an infraorbital hollow and deepening of the nasolabial fold. Therefore, the authors propose that the midface, from the lower portion of the cheek mass, will result in superior midface positioning. Since 1996, the authors have elevated the midface in select patients by placing a sling of prosthetic (Gore-Tex) or autogenous (tendon or fascia) material through the cheek mass. The sling is secured medially to the infraorbital rim using a nonabsorbable periosteal suture or a mechanical anchor. As variable tension is applied laterally toward the superficial temporal fascia, the sling functions as a fulcrum to return the cheek mass to a more youthful anatomical position. Elevating the cheek mass in this fashion fills the infraorbital hollow and results in amelioration of deep nasolabial folds and jowling. With a mean follow-up of 18 months, 50 patients treated with the midface sling report satisfaction with the procedure. There have been no instances of nerve damage, infection, or hematoma in the midface. None of the slings have required removal and ectropion has not occurred. Because of postoperative asymmetry in one patient, additional elevation of the ipsilateral cheek mass was performed by increasing the tension on the lateral cheek portion of the midface sling. Mathematical models demonstrate the biomechanical superiority of lift through the use of multiple vectors as compared with linear pull techniques. In this fashion, the midface sling supports the cheek mass, providing rapid, simple, and secure elevation. Because of the limited subcutaneous dissection, there is a reduced risk of facial nerve damage and cutaneous vascular compromise. Unlike with other techniques, the lateral portion of the sling may be easily identified through a small incision in the temporal scalp, facilitating subsequent postoperative adjustment of the midface suspension. Furthermore, because the entire cheek mass is permanently supported with an inelastic sling, the results may last longer than those with techniques that rely on sutures to plicate or lift portions of the superficial musculoaponeurotic system.     

Transblepharoplasty lower eyelid and midface rejuvenation: part I. Avoiding complications by utilizing lessons learned from the treatment of complications

Transblepharoplasty midface elevation has become a common aesthetic procedure in recent years. As new techniques have been utilized, complications have arisen. Management of these referred complications has resulted in the development of a technique that elevates the midface and restores the normal position and shape to the lower eyelid with minimal postoperative problems. Four principles must be followed to achieve satisfactory results. The orbicularis oculi/orbital septum bond must not be altered in midface surgery. The lateral canthus must be reattached to its normal anatomic location at the lateral orbital rim if there is lateral canthal tendon laxity. The orbital fat should be addressed via a transconjunctival approach, when necessary, to prevent middle lamella inflammation and orbital septum retraction. A suture at the inferior lateral orbital rim simulating the orbitomalar ligament, as well as orbicularis oculi muscle sutures, elevates the midface. Utilizing these steps, the midface and lower eyelid can be satisfactorily repositioned with minimal complications. This surgical approach can be utilized in all appropriate candidates but is especially useful in reoperative cosmetic surgery patients and the older patient population.     

The anatomy and clinical applications of the buccal fat pad

The buccal fat pad is an anatomically complex structure that has great importance in facial contour. In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in facial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated and its relationship to the masticatory space, facial nerve, and parotid duct is defined. An intraoral approach for buccal fat harvesting is described based on these anatomic findings. Clinical experience manipulating the buccal fat pad for aesthetic modification of facial contour is illustrated.     

Anatomy of the buccal fat pad and its clinical significance

Interest in the anatomy of the buccal fat pad was aroused by two clinical cases where the fat pad was involved by pathology. In one, there was an extensive lipoma of the buccal fat pad which had been unsuccessfully operated on on two previous occasions. The reason for the lack of success was incomplete removal of the fat pad. In the second case, there was an arteriovenous malformation involving the fat pad which necessitated complete removal. Fresh cadaver dissections were carried out to accurately determine the anatomy. Particular attention was paid to the temporal extension, since this area is frequently disregarded.     

An emerging player in knee osteoarthritis: the infrapatellar fat pad

The role of inflammation in the development, progression, and clinical features of osteoarthritis has become an area of intense research in recent years. This led to the recognition of synovitis as an important source of inflammation in the joint and indicated that synovitis is intimately associated with pain and osteoarthritis progression. In this review, we discuss another emerging source of inflammation that could play a role in disease development/progression: the infrapatellar fat pad (IFP). The aim of this review is to offer a comprehensive view of the pathology of IFP as obtained from magnetic resonance studies, along with its characterization at both the cellular and the molecular level. Furthermore, we discuss the possible function of this organ in the pathological processes in the knee by summarizing the knowledge regarding the interactions between IFP and other joint tissues and discussing the pro- versus anti-inflammatory functions this tissue could have. We hope that this review will offer an overview of all published data regarding the IFP and will indicate novel directions for future research.     

Material properties of the human calcaneal fat pad in compression: experiment and theory

The structural behaviour of the human heel pad has been studied extensively due to its ability to absorb shock, protect against excessive local stress, and reduce plantar pressures. However, the material properties of the tissue have not been adequately measured. These must be known in order to perform a finite element analysis of the effect of factors such as foot geometry and shoe/surface construction on heel pad function. Therefore, the purposes of this study were to (a) measure the viscoelastic behaviour of the fat pad in compression, and (b) to determine an appropriate constitutive equation to model the tissue. A series of unconfined compression tests were performed on 8 mm diameter cylinders of fat pad tissue, consisting of quasi-static, 175, 350 mm/s and stress-relaxation tests to 50% deformation. The tissue exhibited nonlinear, viscoelastic behaviour. No significant difference was found in the quasi-static behaviour between samples from different locations and orientations in the heel. The stress-relaxation tests were used to determine the time constant (τ₁=0.5 s), the 175 mm/s test to determine the relaxation coefficient (g₁=28), and the 350 mm/s compression test to determine the material constants (C₁₀₀=C₀₁₀=0.01, C₂₀₀=C₀₂₀=0.1 Pa) of a single-phase, hyperelastic, linear viscoelastic strain energy function (r²=0.98).     

Anatomical structure of the buccal fat pad and its clinical adaptations

Before performing plastic and aesthetic surgery around the buccal area, the authors reviewed the anatomical structures of the buccal fat pad in 11 head specimens (i.e., 22 sides of the face). The enveloping, fixed tissues and the source of the nutritional vessels to the buccal fat pad and its relationship with surrounding structures were observed in detail, with the dissection procedure described step by step. The dissection showed that the buccal fat pad can be divided into three lobes-anterior, intermediate, and posterior-according to the structure of the lobar envelopes, the formation of the ligaments, and the source of the nutritional vessels. The buccal, pterygoid, pterygopalatine, and temporal extensions (superficial and profound) are derived from the posterior lobe. The buccal fat pad is fixed by six ligaments to the maxilla, posterior zygoma, and inner and outer rim of the infraorbital fissure, temporalis tendon, or buccinator membrane. Several nutritional vessels exist in each lobe and in the subcapsular vascular plexus forms. The buccal fat pads function to fill the deep tissue spaces, to act as gliding pads when masticatory and mimetic muscles contract, and to cushion important structures from the extrusion of muscle contraction or outer force impulsion. The volume of the buccal fat pad may change throughout a person's life. Based on the findings of the dissections, the authors provide several clinical applications for the buccal fat pad, such as the mechanism of deepening the nasolabial fold and possible rhytidectomy to suspend the anterior lobe upward and backward. They suggest that relaxation, poor development of the ligaments, or rupture of the buccal fat pad capsules can make the buccal extension drop or prolapse to the mouth or subcutaneous layer. As such, the authors refined their methods and heightened their focus when using the buccal fat pad to perform a random or pedicled buccal fat pad fat flap or to correct a buccal skin protrusion or hollow.