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.     

The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging.

Controversy persists regarding the relationship of the superficial facial fascia (SMAS) to the mimetic muscles, deep facial fascia, and underlying facial nerve branches. Using fresh cadaver dissection, and supplemented by several hundred intraoperative dissections, we studied facial soft-tissue anatomy. The facial soft-tissue architecture can be described as being arranged in a series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad. The anatomic relationships existing within the facial soft-tissue layers are (1) the superficial facial fascia invests the superficially situated mimetic muscles (platysma, orbicularis oculi, and zygomaticus major and minor); (2) the deep facial fascia represents a continuation of the deep cervical fascia cephalad into the face, the importance of which lies in the fact that the facial nerve branches within the cheek lie deep to this deep fascial layer; and (3) two types of relationships exist between the superficial and deep facial fascias: In some regions of the face, these fascial planes are separated by an areolar plane, and in other regions of the face, the superficial and deep fascia are intimately adherent to one another through a series of dense fibrous attachments. The layers of the facial soft tissue are supported in normal anatomic position by a series of retaining ligaments that run from deep, fixed facial structures to the overlying dermis. Two types of retaining ligaments are noted as defined by their origin, either from bone or from other fixed structures within the face.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arctic roars – laryngeal anatomy and vocalization of the muskox (Ovibos moschatus Zimmermann, 1780, Bovidae)

The impressive roaring of adult male muskoxen most often occurs during rutting contests. Roaring in adult females is primarily relevant to mother–infant communication. Loud roars are produced by taking up a specific roaring posture. Acoustic recordings were made in a small herd of zoo muskoxen during three successive rutting seasons. Earlier recordings of a different herd were used for comparison. Head-and-neck specimens were subjected to vascular injection, macroscopic anatomical dissection, computer tomographic analysis and skeletonization. Isolated preserved larynges of young animals were dissected for ontogenetic comparison. Despite a pronounced sexual dimorphism of head mass, larynx size is almost identical in adult male and female muskoxen, as is the fundamental frequency of their roars. Remarkably, the larynges of both sexes of muskoxen are provided with an unpaired ventrorostral ventricle. Probably, this ventricle is inflated during the initial phase of a roar. The ventricle may have two functions: to increase the amplitude of roaring and to darken the timbre of the roars by acting as an additional resonance space. The vocal fold of adult female and young individuals has a sharp rostral edge and a vocal ligament is still present. During male ontogeny the vocal ligament becomes transformed into a large fat pad extending into the wall of the laryngeal vestibulum. Accordingly, the glottic region in the adult male lacks any sharp edges of the mucosa. In both sexes the thyroarytenoid muscle is divided into three portions. A single roar may comprise phases of different sound volume. The roars of both muskox sexes are characterized by a pulsed structure. We suggest that two oscillating systems are involved in the production of roars: one comprising only the medial portion of the vocal fold and one including its lateral portion.     

The nasolabial fold: an attempt at synthesis

There is now enough information on the nasolabial fold to try to synthesize it with other well-known structures, such as the dermal terminations of the facial muscles, the superficial musculoaponeurotic system, and the fat pad. Rest dynamic equilibrium is a good concept to use to understand the nasolabial fold, because the nasolabial fold is not a passive, definitive structure, but an evolutive border whose limits depend on the absence or presence of fibromuscular terminations crossing the superficial musculoaponeurotic system of the cheek. A simple photograph of two men will help illustrate the difference between the convex and the concave nasolabial fold.     

Genetic variation and correlation of dietary response in an advanced intercross mouse line produced from two divergent growth lines

Levels of human obesity have increased over the past 20 years worldwide, primarily due to changes in diet and activity levels. Although environmental changes are clearly responsible for the increasing prevalence of obesity, individuals may show genetic variation in their response to an obesogenic environment. Here, we measure genetic variation in response to a high-fat diet in a mouse model, an F16 Advanced Intercross Line derived from the cross of SM/J and LG/J inbred mouse strains. The experimental population was separated by sex and fed either a high-fat (42% of energy from fat) or low-fat (15% of energy from fat) diet. A number of phenotypic traits related to obesity and diabetes such as growth rate, glucose tolerance traits, organ weights and fat pad weights were collected and analysed in addition to serum levels of insulin, free fatty acids, cholesterol and triglycerides. Most traits are different between the sexes and between dietary treatments and for a few traits, including adult growth, fat pad weights, insulin and glucose tolerance, the dietary effect is stronger in one sex than the other. We find that fat pad weights, liver weight, serum insulin levels and adult growth rates are all phenotypically and genetically correlated with one another in both dietary treatments. Critically, these traits have relatively low genetic correlations across environments (average r =0.38). Dietary responses are also genetically correlated across these traits. We found substantial genetic variation in dietary response and low cross environment genetic correlations for traits aligned with adiposity. Therefore, genetic effects for these traits are different depending on the environment an animal is exposed to.     

Facial morphology and vibrissal movement in the golden hamster

The major cranial vibrissae in the golden hamster can be moved in complex ways that suggest they are served by a finely controlled motor system. Movements are hypothesized to be the products of differential blood flow and pressure regulation in the sinus surrounding each vibrissal follicle, contractions of the striated facial muscles, and elastic rebound in the connective tissues. The vasculature contributes hydrostatic forces that erect the vibrissae slightly and distort their connective tissue bedding, rigidify the vibrissal capsules, thus forming firm bases of attachment for certain facial muscles, and theoretically provide a pressure plate around the follicle, important in lowering the firing thresholds of receptor endings. The facial muscles supply the major forces in erection and protraction of the vibrissae by acting on both the capsules and the connective tissue bedding. The connective tissues are organized into capsular and extracapsular systems that serve to stabilize the vibrissae and return them to initial rest positions. The slight movements of the genal vibrissa are the effects of vascular and connective tissue dynamics, the musculature being uninvolved. Wide angle movements of the supraorbital vibrissae are products of the vasculature and connective tissues, plus contractions of the Mm. orbicularis oculi and frontalis. Mystacial vibrissal movement is quite complex. The vasculature supplies a small degree of capsular erection and mystacial pad distortion, but primarily rigidifies the capsules. The bulk of erection and protraction is produced by the M. nasolabialis profundus (NLP) and the vibrissal capsular muscles (VCM). The NLP distorts the mystacial pad; the VCM tilt the capsules relative to the pad. Retraction is mainly accomplished by elastic rebound in the pad, this being aided in its extreme degrees by the Mm. nasolabialis and maxillolabialis. The Mm. nasolabialis superficialis and buccinator pars orbicularis oris help to spread the vibrissae into a dorsoventral fan and stabilize the mystacial pad during whisking.     

Facial attractiveness signals different aspects of “quality” in women and men

We explored the relationships between facial attractiveness and several variables thought to be related to genotypic and phenotypic quality in humans (namely fluctuating asymmetry (FA), body mass index (BMI), health, age). To help resolve some controversy around previous studies, we used consistent measurement and statistical methods and relatively large samples of both female (n=94) and male (n=95) subjects (to be evaluated and measured), and female (n=226) and male (n=153) viewers (to rate attractiveness). We measured the asymmetry of 22 traits from three trait families (eight facial, nine body and five fingerprint traits) and constructed composite asymmetry indices of traits showing significant repeatability. Facial attractiveness was negatively related to an overall asymmetry index in both females and males, with almost identical slopes. Female facial attractiveness was best predicted by BMI and past health problems, whereas male facial attractiveness was best predicted by the socioeconomic status (SES) of their rearing environment. Composite FA indices accounted for a small (<4%) but usually significant percentage of the variation in facial attractiveness in both sexes, when factors related to asymmetry were controlled statistically. We conclude that, although facial attractiveness is negatively related to developmental instability (as measured by asymmetry), attractiveness also signals different aspects of “quality” in the two sexes, independent of FA.     

The trochanteric fat pad

Technological developments based on the use of autologous white adipose tissue (WAT) attracted attention to minor fat depots as possible sources of adipose tissue. In plastic surgery, the trochanteric fatty pad is one of the most used WAT depots for its location and organoleptic characteristics that make it particularly suitable for reconstructive procedures. Despite its wide use in clinic, the structure of this depot has never been studied in detail and it is not known if structural differences exist among trochanteric fat and other subcutaneous WAT depots. The present study was performed on trochanteric fat pad with the aim to clarify the morphology of its adipocytes, stroma and microcirculation, with particular reference to the stem niches. Histological and ultrastructural studies showed that the main peculiar feature of the trochanteric fat concerns its stromal component, which appears less dense than in the other subcutaneous WATs studied. The intra-parenchymal collagen stroma is poor and the extracellular compartment shows large spaces, filled with electron-light material, in which isolated collagen bundles are present. The adipocytes are wrapped in weak and easily detachable collagen baskets. These connective sheaths are very thin compared to the sheaths in other subcutaneous WAT depots. The capillaries are covered by large, long and thin elements surrounded by an external lamina; these perivascular cells are poor in organelles and mainly contain poly-ribosomes. In conclusion, when compared to other WAT deposits, the trochanteric fatty pad shows structural peculiarities in its stroma and microcirculation suggesting a high regenerative potential. Resistance, dissociability, microvascular weft and high regenerative potential make the trochanteric fatty pad a privileged source for harvesting in autologous WAT-based regenerative procedures.     

Aplasia of the maxillary sinus in a Tibetan macaque (Macaca thibetana) with implications for its evolutionary loss and reacquisition

The skull of an adult female Tibetan macaque, Macaca thibetana, was found to completely lack the maxillary sinus (MS). This absence was accompanied by a slight lateral concavity where the ostium should have formed in the MS, a slight drop of the orbital floor, posterior and medial displacement of the zygomaxillary suture, an unusual position of the lacrimal canal, malocclusion with severely worn cheek teeth, and abnormalities in the temporomandibular joints. The facial component was disproportionally large compared with the neurocranium and mandible. This hypertrophic face probably caused the malocclusion and associated anatomical disorders and simultaneously displaced the lacrimal canal posterior to other nasal structures to preclude the possibility of maxillary pneumatization. These modifications in the spatial relationships to nasal structures might help explain the evolutionary loss and reacquisition of the MS in some primate lineages displaying great variations in facial anatomy.     

Juvenile hormone-dependent vitellogenin synthesis in Locusta migratoria fat body: Inducibility related to sex and stage

Juvenile hormone (JH)-dependent vitellogenin (Vg) synthesis in the fat body of Locusta migratoria is normally limited to sexually mature adult females. As a step toward examining the basis of this limitation, we have tested female and male locusts in a series of stages after the third larval molt for inducibility of Vg synthesis by the synthetic JH analog, methoprene. We find that in the fourth and fifth larval instars fat body of both sexes can be induced to produce Vg, but in the adult stage females respond strongly while no more than trace amounts can be induced in males. Quantitative assays show relative responsiveness in the order: adult female > fifth instar female > fifth instar male ? adult male. During the fifth instar of both sexes, maximal vitellogenic response was obtained in midinstar. After the larval-adult ecdysis, female fat body was unresponsive during the first 4 days, then responsiveness increased and by Day 8 after ecdysis fat bodies were fully as competent to produce Vg as at Day 14, the usual maximum of the first vitellogenic cycle due to endogenous JH. Larval and adult female fat bodies implanted into male larvae are competent for Vg synthesis after metamorphosis, so that the differences between adult male and female cannot be imposed by the male milieu intérieur during the larval-adult molt. In male and female precocious adults, produced by treatment of fourth instars with precocene, fat body responded to methoprene as in normal adults. We conclude that factors intrinsic to the fat body cells, determined early in development, are responsible for differential gene programing in males and females, which is partially expressed by the fifth instar but fully manifest only after a molt in the absence of JH.     

Rejuvenation of the midface by elevating the malar fat pad: review of technique,cases, and complications

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.     

Body size and composition of Crabeater seals (Lobodon carcinophagus), with observations on tissue and organ size in Ross seals (Ommatophoca rossi)

Linear body measurements and body weights of 17 Crabeater seals and four Ross seals were recorded, and the relationships of weight to linear dimensions were calculated. There were no significant differences between sexes of these relationships in Crabeater seals. All Ross seals were males.
The major body components (blood, fat, skin, muscle, bone, connective tissue and viscera) of seven Crabeater seals were weighed after dissection.
Blood, fat and skin of two Ross seals were weighed. Weights of 22 visceral organs of the same animals, and linear bone dimensions of eight Crabeater seals and skull measurements of five Ross seals were recorded.
There was no significant difference between sexes or ages in body composition of Crabeater seals. Relatively, Crabeater and Ross seals had less blood (9–10% body weight) than Elephant seals, and less fat (21–22% body weight) than most other marine mammals. The low body fat content may have been attributable to season and physiological status of the animals when dissected. The percentages of body weight represented by the other major components of Crabeater seals were: skin 8%, muscle 44%, bone 10%, connective tissue 0.7% and total viscera 8%. These figures, and the relative sizes of individual organs, were discussed in relation to their possible function in Crabeater and Ross seals.     

Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad

The anatomy of the temporal region, with reference to the frontal branch of the facial nerve, was examined in 12 fresh cadaver dissections. In all dissections, the frontal branch traveled in a constant plane along the undersurface of the temporoparietal fascia and was quite superficial as it crossed the zygomatic arch. The deep temporal fascia and superficial temporal fat pad are anatomically important structures which adjoin the periosteum of the zygomatic arch and lie deep to the frontal nerve. Based on these relationships, a safe method of dissection within the temporal region is formulated.     

What is normal? A characterization of the values and variability in reproductive endpoints of the fathead minnow, Pimephales promelas

Jensen et al. [Jensen, K.M., Korte, J.J., Kahl, M.D., Pasha, M.S., Ankley, G.T., 2001. Aspects of basic reproductive biology and endocrinology in the fathead minnow (Pimephales promelas). Comp. Biochem. Physiol. C 128, 127-141.] investigated aspects of the normal reproductive biology of the fathead minnow (FHM, P. promelas), and subsequent studies have generated a large amount of additional reproductive data for endpoints such as plasma steroid hormone and vitellogenin concentrations, spawn interval, and secondary sex characteristics (i.e., nuptial tubercle score and fat pad weight). These data were analyzed and fitted with statistical distributions to improve understanding of the variability in normal, unexposed, adult male (n=154) and female (n=186) FHM. Summary statistics for most endpoints were consistent with results from other more limited studies of FHMs. Male fat pad weight, and in both sexes gonad and liver weights were found to be proportional to body weight. Multiple statistical distributions were found to characterize each endpoint with the exception of spawn interval. Based on one of the largest datasets ever compiled for controlled studies, results presented herein provide a robust point of reference for the quantitative assessment of reproductive processes in the fathead minnow.     

5 alpha-reductase activity in rat adipose tissue

We measured the 5 alpha-reductase activity in isolated cell preparations of rat adipose tissue using the formation of [3H]dihydrotestosterone from [3H]testosterone as an endpoint. Stromal cells were prepared from the epididymal fat pad, perinephric fat, and subcutaneous fat of male rats and from perinephric fat of female rats. Adipocytes were prepared from the epididymal fat pad and perinephric fat of male rats. Stromal cells from the epididymal fat pad and perinephric fat contained greater 5 alpha-reductase activity than did the adipocytes from these depots. Stromal cells from the epididymal fat pad contained greater activity than those from perinephric and subcutaneous depots. Perinephric stromal cells from female rats were slightly more active than those from male rats. Estradiol (10(-8) M), when added to the medium, caused a 90% decrease in 5 alpha-reductase activity. Aromatase activity was minimal, several orders of magnitude less than 5 alpha-reductase activity in each tissue studied.     

Bidirectional signaling of mammary epithelium and stroma: implications for breast cancer--preventive actions of dietary factors

The mammary gland is composed of two major cellular compartments: a highly dynamic epithelium that undergoes cycles of proliferation, differentiation and apoptosis in response to local and endocrine signals and the underlying stroma comprised of fibroblasts, endothelial cells and adipocytes, which collectively form the mammary fat pad. Breast cancer originates from subversions of normal growth regulatory pathways in mammary epithelial cells due to genetic mutations and epigenetic modifications in tumor suppressors, oncogenes and DNA repair genes. Diet is considered a highly modifiable determinant of breast cancer risk; thus, considerable efforts are focused on understanding how certain dietary factors may promote resistance of mammary epithelial cells to growth dysregulation. The recent indications that stromal cells contribute to the maintenance of the mammary epithelial ‘niche’ and the increasing appreciation for adipose tissue as an endocrine organ with a complex secretome have led to the novel paradigm that the mammary stromal compartment is itself a relevant target of bioactive dietary factors. In this review, we address the potential influence of dietary factors on mammary epithelial-stromal bidirectional signaling to provide mechanistic insights into how dietary factors may promote early mammary epithelial differentiation to decrease adult breast cancer risk.     

Regional shape change in adult facial bone curvature with age

Life expectancies have increased dramatically over the last 100 years, affording greater opportunities to study the impact of age on adult craniofacial morphology. This article employs a novel application of established geometric morphometric methods to examine shape differences in adult regional facial bone curvature with age. Three-dimensional semilandmarks representing the curvature of the orbits, zygomatic arches, nasal aperture, and maxillary alveolar process were collected from a cross-sectional cranial sample of mixed sex and ancestry (male and female; African- and European-American), partitioned into three age groups (young adult = 18-39; middle-aged = 40-59 years; and elderly = 60+ years). Each facial region's semilandmarks were aligned into a common coordinate system via generalized Procrustes superimposition. Regional variation in shape was then explored via a battery of multivariate statistical techniques. Age-related shape differences were detected in the orbits, zygomatic arches, and maxillary alveolar process. Interactions between age, sex, and ancestry were also identified. Vector plots revealed patterns of superoinferior compression, lateral expansion, and posterior recession depending on the population/subpopulation, location, and age groups examined. These findings indicate that adult craniofacial curvature shape is not static throughout human life. Instead, age-related spatial modifications occur in various regions of the craniofacial skeleton. Moreover, these regional alterations vary not only through time, but across human populations and the sexes.     

Developmental changes in the facial morphology of the Borneo orangutan (Pongo pygmaeus): possible signals in visual communication

Orangutans display remarkable developmental changes and sexual differences in facial morphology, such as the flanges or cheek-pads that develop only on the face of dominant adult males. These changes suggest that facial morphology is an important factor in visual communication. However, developmental changes in facial morphology have not been examined in detail. We studied developmental changes in the facial morphology of the Borneo orangutan (Pongo pygmaeus) by observing 79 individuals of various ages living in the Sepilok Orangutan Rehabilitation Centre (SORC) in Malaysia and in Japanese zoos. We also analyzed photographs of one captive male that were taken over a period of more than 16 years. There were clear morphological changes that occurred with growth, and we identified previously unreported sexual and developmental differences in facial morphology. Light-colored skin around the eyes and mouth is most prominent in animals younger than 3 years, and rapidly decreases in area through the age of approximately 7 years. At the same time, the scattered, erect hairs on the head (infant hair) become thick, dense hairs lying on the head (adult hair) in both sexes. The results suggest that these features are infant signals, and that adult signals may include darkened face color, adult hair, whiskers, and a beard, which begin to develop after the age of approximately 7 years in both sexes. In females, the eyelids remain white even after 10 years, and turn black at around the age of 20; in males, the eyelids turn black before the age of 10. The whiskers and beards of adults are thicker in males than in females, and are fully developed before the age of 10 in males, while they begin to develop in females only after approximately 20 years. White eyelids and undeveloped whiskers and beards may be visual signals that are indicative of young adult females. Our results also show that the facial morphology of the unflanged male is similar to that of the adult female, although it has also been pointed out that unflanged males resemble younger individuals.     

Maturation and aging of adult fat body and oenocytes in Drosophila as revealed by light microscopic morphometry

A morphological and cytometric analysis of the adult fat body cells and oenocytes was made on sections of abdomens from immature, mature and senescent Drosophila melanogaster of both sexes. There are about 18,000 fat body cells in abdomens of female and mature male flies. Immature and senescent males have about 12,000 and 15,000 cells, respectively. The size of the cells is almost the same for immature flies of both sexes and increases about six-fold to approximately 2600 micron2, so that mature flies of both sexes have equivalent amounts of fat body tissue. The proportions of lipid, glycogen, and background cytoplasm of fat body cells also remain relatively constant throughout adult life, but dense, proteinaceous granules are observed in cells of senescent flies. The amounts of cellular components change dramatically due to change of cell size with age; the amount of lipid shows the greatest sexual difference with about 2x more in the females at all stages studied. The oenocytes number about 6,000 in the abdomens of all but immature male flies, which have approximately 4,000. Although the cells of both sexes triple in size to about 700 micron 2, the oenocytes of males reach maximum size earlier than those of females. The major features of oenocytes appear to be dense background cytoplasm, putative lipid droplets found only in mature flies, and pigmented granules first seen in the cells of mature flies which accumulate with age to 33% of the cytoplasm. The number of cells and their anticipated capacity for protein synthesis is discussed in relation to the production of yolk protein precursors.     

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.