Review
Submitted: 10.4.2018
Accepted: 3.7.2018
Conflict of interest and Funding
N. L. received financial support from
the Obaid Vascularized Composite
Tissue Award. S. C. has no commercial
associations or financial disclosures
that might pose or create a conflict of
interest.
Sebastian Cotofana1,
Nirusha Lachman2
(1) Department of Medical Education,
Albany Medical College, Albany, New
York, USA
(2) Department of Anatomy and
Department of Surgery, Division of
Plastic Surgery, Mayo Clinic College
of Medicine and Science, Mayo Clinic,
Rochester, Minnesota, USA
Introduction
Facial aging is a multifactorial process. Physiological and
morphological changes occur in both skeletal and soft tissue
composites – the bones, ligaments, muscles, fascia, fat, and
skin. The onset and rate of these structural changes varies
between individuals of different genders and ethnicities [1].
Due to the heterogeneity of the effects of each of the struc-
tures, it is difficult to ascertain which is the key player in
the clinical changes that occur as the face ages. Thus, it is
challenging to modify a specific structure with rejuvenation
procedures, especially as limited treatment options are avai-
lable to target bone, muscle, or ligaments.
© 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
DOI: 10.1111/ddg.13737
Anatomy of the Facial Fat
Compartments and their Relevance
in Aesthetic Surgery
Summary
Objective: There has been a significant shift in the understanding of facial anatomy
during the last decade. Newer minimally invasive therapeutic options for facial reju-
venation procedures are increasing the need for a better knowledge of anatomy.
Material and Methods: The current literature is summarized, analyzed and presen-
ted along with the experience of the author for this narrative review, which summa-
rizes the current understanding of the superficial and deep facial fat compartments
and their relevance for minimally invasive facial procedures. A schematic facial model
was created in order to facilitate a better understanding of the complexity of facial
anatomy.
Results: The face is arranged in five layers as follows: layer 1: skin; layer 2: subcuta-
neous fat including the retinacula cutis (composed of fibrous connective tissue); lay-
er 3: superficial musculo-aponeurotic system (SMAS); layer 4: deep fat; and layer 5:
periosteum or deep fascia. This arrangement varies between facial regions, especially
when the line of ligaments is incorporated into the model. The facial fat compart-
ments are located in layers 2 and 4; each layer has unique characteristics and spatial
relationships with the surrounding tissues.
Conclusions: The concept of the layered arrangement is a new way to understand
the spatial relationship and functional interplay of the soft tissues of the face. Under-
standing the layers, the precise location of the superficial and deep facial fat compart-
ments and their boundaries is crucial for the conduct of safe and effective minimally
invasive facial procedures.
Most available therapeutic options are aimed at resto-
ring the redistributed volume of superficial and deep facial
fat [2–4] with soft-tissue volumizers based on substances
such as hyaluronic acid, calcium hydroxyapatite and po-
ly-L-lactic-acid [5–8]. Other therapeutic options target the
skin and the superficial fascial system [9] (which includes the
superficial fascia) with energy-based devices to tighten the
skin and overlying soft tissues [10–13]. The efficacy of the-
se modalities is established, and the number of non-surgical
minimally invasive procedures increased by 312 % between
2000 and 2017 according to survey data from the American
Society of Plastic Surgeons [14]. In order to design an effec-
tive pan-facial treatment, a comprehensive understanding of
399
 Review The Fat Compartments of the Face

facial anatomy and the effects of aging is of paramount im-

portance.

The Layers of the Face

With increasing interest in the anatomy of the face, surgeons
and clinical anatomists have turned their attention towards
the gross anatomy of the face. This welcome trend demons-
trates that anatomical knowledge continues to develop in
parallel with clinical approaches [15]. In the last decade, a
multitude of new fi ndings and concepts regarding facial ana-
tomy have been introduced, of which the most influential
is probably the layered arrangement of the face [16 ]. These
layers are arranged as follows: layer 1: skin; layer 2: subcuta-
neous fat including the retinacula cutis, composed of fibrous
connective tissue; layer 3: superficial musculo-aponeurotic
system (SMAS); layer 4: deep fat and layer 5: periosteum or
deep fascia.
However, this general concept has to be adapted for each
facial region, since there are regions where more layers (e.g.
the temple with 10 layers) or fewer layers (e.g. the tear trough
with three layers) can be identified. Moreover, the under- Figure 1 Virtual model of the face showing the major facial
standing of a parallel arrangement of layers has to be altered ligaments. Note how the ligaments are arranged as a single
when considering the line of ligaments. The line of ligaments line located immediately lateral to the lateral orbital rim
separates the medial from the lateral midface. In the medi- and extending from the temporal crest to the mandible.
al midface there is no distinct parallel arrangement of the Abbr.: SFS, superior frontal septum; MFS, middle frontal
layers; here the muscles of facial expression course obliquely septum; IFS, inferior frontal septum; STS, superior temporal
from bone to skin, whereas in the lateral midface the layers septum; TLA, temporal ligamentous adhesion; ITS, inferior
are in parallel and continuous with each other while exten- temporal septum; LOT, lateral orbital thickening; ZL, zygo-
ding from the neck to the scalp. matic ligament; ML, mandibular ligament.

The Line of Ligaments

Facial ligaments are well known to plastic surgeons as they
are released during face-lifting procedures to achieve the
desired effects [17–24]. Of the described ligaments, the zy-
gomatic ligament (also called McGregor’s patch [25]) is the
strongest, resisting the greatest force before ultimate failure
during biomechanical testing [26 ]. Interestingly, all major fa-
cial ligaments (irrespective of whether they are true or false)
can be arranged into a single line located immediately lateral
to the lateral orbital rim and extending from the temporal
crest to the mandible. From superior to inferior, the liga-
ments are the temporal ligamentous adhesions, lateral orbital
thickening, zygomatic ligament and mandibular ligament
(Figure 1).
In the medial midface (i.e. medial to the line of ligaments)
are the midfacial deep fat compartments; surgically relevant
spaces are found in the lateral midface, e.g. premasseteric
spaces [7, 27 ]. It is of some clinical importance that injections
medial to the line of ligaments will result in projection of the
overlying soft tissues, whereas injections lateral to this line
lead to a lifting effect in more inferiorly located regions. This
is a result of the oblique arrangement of the medial midface
vs. the parallel arrangement of the lateral midface.
Deep and Superficial Fat Compartments
of the Forehead
Therapeutic options for the forehead mostly include neuro-
modulator applications in order to temporarily reduce the
contractile activity of the frontalis, corrugator supercilii,
depressor supercilii and orbicularis oculi muscles. The treat-
ment approach has changed from rigid injection schemes to
more individualized treatments based on each person’s indi-
vidual anatomy [28]. A recent trend includes restoration of
the volume loss of the frontal soft tissue [8, 29].
This is due to fact that the frontal bone undergoes
age-related changes, similar to those of the midfacial bones
[30–36 ]. As the covering soft tissues are thinner than tho-
se of the midface and fat is redistributed from superficial to

400 © 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
Review The Fat Compartments of the Face
abdominal or ectopic locations (liver, bone marrow) [2–4],
frontal hollowing can result. This contributes significantly to
a more skeletal appearance of the face. Volume can be resto-
red in the superficial and deep compartments of the forehead
using soft tissue fi ller.
The superficial fat compartments of the forehead were
fi rst delineated in 2007 (Table 1) [37 ], confi rmed in 2012 [38]
and updated in 2017 [29]. Three superficial fat compartments
are present and located in layer 2 between the skin (layer 1)
and the frontalis muscle (Figure 2). Recent research suggests
that the frontalis muscle is covered on deep and superficial
aspects by a thin sheet of fascia, the deep fascia being more
prominent [29], but valid results are still lacking to confi rm
this description. As the frontalis muscle is a continuation of
the galea aponeurotica, it can be regarded as layer 4 (if the
thin sheet covering the muscle is regarded as layer 3). Bet-
ween the frontalis muscle (layer 4) and its underlying fascia
(layer 6), a thin layer of fat can be identified: the subfrontal
fat (layer 5) (Figure 3). Inside this fat, the supraorbital and su-
pratrochlear vessels travel superiorly after they emerge from
their respective foramina. The subfrontal fat lies between the
inferior and middle frontal septa, which are formed by the
transition of the vasculature from deeper to superficial layers
and extend from the periosteum to the fascia covering the
underside of the frontalis muscle (Figure 4).
Deep to the frontalis muscle and its fascia (layer 6) the
three deep forehead compartments can be found. These
compartments are located in layer 7 and are bounded infe-
riorly by the middle frontal septum and superiorly by the
superior frontal septum (Figure 5) and are located between
the frontalis muscle complex and the periosteum (layer 8)
(Table 3) [29].
Located between the inferior frontal septum (superior
boundary) and the orbicularis retaining ligament (inferi-
or boundary) (Figures 1, 6) and lateral to the emergence of
the supraorbital neurovascular bundle from the supraorbital
foramen, the retro-orbicularis fat (ROOF) is located [39, 40].
This fat is located deep to the orbicularis oculi muscles (lay-
er 3) and superficial to the periosteum of the frontal bone; it
is connected with the lower temporal compartment via the
superior interval.
Temporal Fat Pads
Volumizing procedures of the temple are used to restore vo-
lume loss, which may be due to changes of the bony skeleton
[41–43] and/or to reduced volume of the temporalis muscle
or temporal fat pads. As the fat pads are related to the res-
pective layers, the layered anatomy of the temple should be
kept in mind [44].
The layers of the temple are directly contiguous with the
five layers of the SCALP: Skin; Connective tissue (here sub-
© 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
cutaneous fat); Aponeurosis (here galea aponeurotica); Loose
connective tissue and Periosteum. These five layers are conti-
nuous into the temple, although they change their names after
passing the superior temporal septum (Figure 1). The galea
aponeurotica becomes superficial temporal fascia, while the
periosteum is now the deep temporal fascia [44]. The anterior
and posterior branches of the superficial temporal artery can
be found within the superficial temporal fascia (Figure 7). Ap-
plication of soft tissue fillers using the superficial technique
places the product into the subcutaneous fat, i.e. into layer 2,
which is thus superficial to the superficial temporal artery.
Two compartments are located between the superficial and
deep temporal fascia in layer 4: the upper and lower temporal
compartments. The upper temporal compartment is located
between the superior and inferior temporal septa and contains
no relevant neurovascular structures (Figure 8), whereas the
lower temporal compartment is located between the inferior
temporal septum and the adhesions of the zygomatic arch,
and contains the frontal branches of the facial nerve (motor),
the zygomaticotemporal branches (sensory) and the temporal
part of the sentinel vein (Figure 8) (Table 2) [44].
Between 2–5 cm cranial to the zygomatic arch, the deep
temporal fascia divides into a superficial lamina (layer 5) and
a deep lamina (layer 7) of the deep temporal fascia, and en-
closes the superficial temporal fat pad and the proximal part
of the sentinel vein (layer 6), which is here termed the medi-
al zygomaticotemporal vein [45]. The superficial lamina is
continuous in the midface with the parotideomasseteric fas-
cia (layer 5) and extends into the neck as the investing layer
of the deep cervical fascia [7 ]. The deep lamina of the deep
temporal fascia travels deep to the zygomatic arch into the
masticatory space and is connected there to the buccotem-
poral fascia [46, 47 ]. Deep to the deep temporal fascia, the
temporal extension of the buccal fat pad (of Bichat) is loca-
ted; here it is referred to as the deep temporal fat pad and is
located in layer 8 (Figure 9) [24, 48, 49]. The temporalis mu-
scle is located in layer 9 and receives its arterial blood supply
from branches of the internal maxillary artery, the anterior
and posterior deep temporal arteries, which travel superficial
to the periosteum (layer 10).
Soft tissue fi ller applied with the deep technique are in
contact with the bone and should be placed in proximity to
the temporal crest in order to avoid contact with the deep
temporal arteries [8].
Infraorbital Region: Tear Trough and
Sub-Orbicularis Oculi Fat (SOOF)
The infraorbital region is one of the most difficult areas to
treat, although the layering is less complex than that of the
temple or the forehead. Clinically, dark circles in the medial
401
402
Table 1 Names and boundaries of the superficial facial fat compartments.

Superior Border Inferior Border Medial/Anterior Lateral/Posterior Floor Roof

Border Border
Superficial Superior frontal Cutaneous insertion of Superficial Superior temporal Frontalis muscle Skin
Lateral Forehead septum orbicularis oculi muscle central forehead septum
Compartment complex compartment
Superficial Superior frontal Cutaneous insertion of – Superficial Frontalis muscle Skin
Central Forehead septum orbicularis oculi muscle lateral forehead
Compartment complex and procerus compartment
muscle
Superficial Superior Inferior temporal septum Superior temporal Superior temporal Superficial temporal fascia Skin
Upper Temporal temporal Septum Septum Septum
Compartment
Review The Fat Compartments of the Face

Superficial Inferior temporal Adhesions to the Cutaneous insertion Inferior temporal Superficial temporal fascia Skin
Lower Temporal septum zygomatic bone of Lateral Orbital septum
Compartment Thickening (LOT)
Superficial Tear trough Nasolabial sulcus Lateral side and ala Superficial medial Orbital part of the orbicularis oculi Skin
Nasolabial Fat of nose cheek and jowl fat muscle (in its superior part) and by the
Compartment compartment midcheek superficial musculo-aponeu-
rotic system (in its lower part)
Superficial Cutaneous Jowl fat compartment Tear trough and su- Superficial Orbital part of the orbicularis oculi Skin

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Medial Cheek Fat insertion of orbi- perficial nasolabial middle cheek fat muscle (in its superior part) and by the
Compartment cularis retaining fat compartment compartment midcheek superficial musculo-aponeu-
ligament rotic system (in its lower part)
Superficial Adhesions of zy- Cutaneous adhesions to Superficial medial Superficial Orbital part of the orbicularis oculi Skin
Middle Cheek Fat gomatic bone the platysma cheek and jowl fat lateral cheek fat muscle (in its superior part) and by the
Compartment compartment compartment midcheek superficial musculo-aponeu-
rotic system (in its lower part)
Superficial Adhesions to the Cutaneous adhesions to Superficial midd- Auricle Superficial musculo-aponeurotic system Skin
Lateral Cheek Fat zygomatic bone the platysma le cheek fat
Compartment compartment
Jowl Fat Superficial Cutaneous adhesions to Labiomandibular Superficial Midfacial superficial musculo-apon- Skin
Compartment medial cheek fat the platysma sulcus medial cheek fat eurotic system (in its upper part) and
compartment compartment platysma (in its lower part)
Review The Fat Compartments of the Face
Figure 2 Virtual model of the face showing the superficial
fat compartments of the central face. In the forehead, the su-
perficial lateral forehead compartments (SLFCs) can be found
bilaterally, lateral to the superficial central forehead com-
partment (SCFC). In the central medial midface, the medially
located superficial nasolabial compartment (SN) is adjacent to
the superficial medial cheek fat compartment (SMC), which is
also called the malar fat pad. The jowl fat compartment (JC)
can be identified in the buccal region of the lateral midface.
infraorbital area (i.e. tear troughs) as well as palpebromal-
ar grooves (i.e. lateral depressions between the lower eye lid
and the cheek eminence) are of concern [50]. The depression
immediately inferior to the tear trough is called the naso-
jugal groove and is continuous with the mid-cheek groove
(also referred to as a mediojugal fold). Together, the nasoju-
gal groove and the palpebromalar groove form the so called
“V-frame” deformity, which is a sign of facial aging and can
be related to the loss of subcutaneous fat from the super-
ficial nasolabial and superficial medial cheek fat compart-
ments. The infraorbital area can be separated into medial
and lateral parts by a vertical line through the medial mar-
© 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
Figure 3 Virtual model of the face showing layer 5 of the fore-
head, with the subfrontal fat (SubF) between the inferior and
middle frontal septum. Inside the subfrontal fat, the supraor-
bital (SO) and supratrochlear (STr) vessels travel superiorly
after they emerge from their respective foramina.
gin of the pupil. In the medial part (area of the tear trough)
only three layers can be identified: skin (layer 1), orbicularis
oculi muscle (orbital part) (layer 2) and periosteum (layer 3)
[7, 50, 51]. The angular artery is located in the groove bet-
ween the cheek and the lateral aspect of the nose, running
vertically deep to the orbicularis oculi muscle, whereas the
angular vein is located in the depth of the nasojugal groove,
4.2 ± 0.7 mm inferior to the inferior orbital rim and running
obliquely from inferolateral to superomedial deep to the or-
bital part of the orbicularis oculi muscle [51]. Several layers
are present in the lateral infraorbital part. Deep to the orbital
part of the orbicularis oculi muscle (layer 3) the sub-orbi-
cularis oculi fat (SOOF) is located; this usually has separa-
te medial and lateral parts [7 ]. This fat is separated by the
403
 Review The Fat Compartments of the Face

Figure 4 Virtual model of the face showing how the supra-

trochlear (STr) and supraorbital (SO) vasculature emerges
from deeper to superficial layers while crossing the inferior
frontal septum (IFS) and the middle frontal septum (MFS).
Abbr.: SFS, superior frontal septum.

Figure 5 Virtual model of the face showing the deep fat

superficial lamina of the deep temporal fascia (layer 5) from
the fat within the prezygomatic space (layer 6) overlying
the periosteum (layer 7) [52–54]. The inferior boundary of
both the SOOF and of the prezygomatic space is the zygo-
matico-cutaneous ligament and the superior boundary is
the bilaminar orbicularis retaining ligament (Table 3) [55].
The SOOF is connected via the temporal tunnel to the lower
temporal compartment, since both are located in layer 4 and
reside on top of the superficial lamina of the deep temporal
fascia [44]. Along the medial wall of the zygomatico-cuta-
neous ligament, the angular vein can be identified after it
emerges deep to the zygomaticus major muscle; it has a va-
riable course superficial or deep to the zygomaticus minor
muscle. The zygomatico-cutaneous ligament fuses with the
orbicularis retaining ligament where it crosses the vertical
medial pupillary line just before reaching the tear trough – in
other words, the tear trough is the superficial landmark for
the medial end of the SOOF. Treatment of malar mounds can
be challenging due to the multi-layered arrangement in the
lateral infraorbital area.
compartments of the forehead in layer 7. The deep lateral
forehead compartments (DLFCs) can be found bilaterally,
adjacent to the deep central forehead compartment (DCFC).
The deep fat compartments of the forehead are bounded
inferiorly by the middle frontal septum and superiorly by the
superior frontal septum. Abbr.: CSM, Corrugator supercilii
muscle.
Midface: Parotideo-masseteric (lateral
midface), Buccal (lateral midface) and
Central midface (medial midface) Regions
The midface has three cranio-caudal subdivisions: upper,
middle and lower with reference to the horizontal. Howe-
ver, an additional subdivision of the midface should be made
when incorporating functional anatomy and its relation to
the line of ligaments (see above).

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Review The Fat Compartments of the Face
Figure 6 Virtual model of the face showing the retro-orbicu-
laris fat (ROOF), located lateral to the emergence of the su-
pratrochlear (STr) and supraorbital (SO) neurovascular bundle
and superior to the orbicularis retaining ligament (ORL) and
to the lateral orbital thickening (LOT).
Parotideo-masseteric region located in the lateral
midface
The parotideo-masseteric (PM) region contains the masseter
muscle and the parotid gland. It extends from the auricle to a
vertical line at the lateral margin of the bony orbit (when vie-
wed from lateral). Its layers are parallel and include the follo-
wing structures: Skin (layer 1), Subcutaneous fat, i.e. middle
and lateral superficial fat compartments (Figure 10) (layer 2),
SMAS (layer 3), Deep (sub-SMAS) spaces (layer 4) and Pa-
rotideo-masseteric fascia (layer 5). Deep to layer 5 are the
branches of the facial nerve, the parotid gland, the parotid
duct and the variable accessory parotid gland. The marginal
mandibular, buccal and zygomatic branches of the facial ner-
ve travel within fibrous connective tissue sheets that connect
the PM fascia to the SMAS, which encloses surgical access
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Figure 7 Virtual model of the face showing the course of the
anterior (aSTA) and posterior (pSTA) branch of the superfi-
cial temporal artery below the superficial temporal fascia
(STF). Note that the superficial temporal fascia (STF) is a
continuation of the superficial musculo-aponeurotic system
(SMAS), which is itself a continuation of the inferiorly located
platysma. Abbr.: OOM, orbicularis oculi muscle.
spaces that are used in face-lifting procedures. These spaces
are the lower, middle and upper premasseter spaces (Table 2)
[7, 27, 56, 57 ]. The transverse facial artery runs in the superi-
or premasseter space and gives off a branch that runs within
the zygomatic ligament (McGregor’s patch) to provide axial
blood supply to the overlying SMAS. Deep to the masseter
muscle is the buccal fat pad with its four extensions, of which
the temporal extension is called the deep temporal fat pad.
The buccal fat pad is located in a separate spaces called the
masticatory space, and is separated from the premasseter
spaces by the masseter muscle and from the buccal spaces by
the facial vein within the facial vein canal [46, 47 ].
Buccal region of the lateral midface
The buccal region is less well defi ned as it can be assigned to
both the medial and lateral midface. However, with respect
405
 Review The Fat Compartments of the Face
Figure 8 Virtual model of the temporal region of the face
showing the temporalis muscle (TM) in layer 9 and the deep
lamina of the deep temporal fascia (dl DTF) in layer 7. This and
the superficial lamina of the deep temporal fascia (layer 5)
enclose the superficial temporal fat pad (STFP) located in
layer 6. The fat inside the lower temporal compartment (LTC)
is located in layer 4.
to the underlying anatomy, this area covers the most mobi-
le area of the face, specifically the cheek and its contents,
which are dominated by the buccinator muscle in layer 6. The
layers in this region are parallel, and it contains the follo-
wing structures: Skin (layer 1); Subcutaneous fat (i.e. jowls
fat compartment) (Figure 10) (layer 2); SMAS in its superi-
or part and the horizontal, modiolar part of the platysma
(Figure 11) (layer 3); Buccal space (layer 4); Buccopharyngeal
fascia (layer 5) and Buccinator muscle (layer 6). The facial
artery travels inside the buccal space, whereas the facial vein
runs inside the facial vein canal, which forms the posterior
boundary of the buccal space and is not considered as a con-
tent of the buccal space [47 ]. The buccal fat pad is located in
the masticatory space, which is posterior to the buccal space
within the masticatory space [47 ].
The jowls deformity is caused by the gliding of the pla-
tysma against the mandible, since between the mandibular
ligament and the masseter muscle the facial artery and faci-
al vein cross the mandible and are covered in deep fat here.
This fat is not connected to the fat within the buccal space or
406 © 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
Figure 9 Virtual model of the face showing the temporal
extension of the buccal fat pad (t BF) in layer 8 deep to the
deep lamina of the deep temporal fascia (dl DTF) in layer 7,
which covers the temporalis muscle (TM) located in layer 9.
The deep lamina of the deep temporal fascia (dl DTF) travels
deep to the zygomatic arch into the masticator space and
is connected there to the buccotemporal fascia. Abbr.: SV,
sentinel vein.
to the buccal fat pad in the masticatory space. With age-re-
lated facial changes, the platysma glides and the overlying
(subcutaneous) jowl fat compartment glides inferiorly and
causes the appearance of jowls.
Central midface located in the medial midface
The central midface is the facial region where the majority
of minimally invasive aesthetic injections are performed.
The deep and superficial midfacial fat compartments are
located here and this area is prone to age-related changes
as the underlying bone undergoes remodeling, with a cor-
responding change in the maxillary angle [30, 32, 33, 35,
58, 59]. If this angle changes, the position of the fat com-
partments changes too and the clinical signs of facial aging
become visible.
 Table 2 Names and boundaries of the deep facial fat compartments when viewed from the lateral side of the face.

Superior Border Inferior Border Anterior Border Posterior Border Floor Roof
(Deep) Upper Superior temporal Septum Inferior Temporal Septum Temporal – Superficial lamina of Superficial
Temporal Ligamentous the deep temporal temporal fascia
Compartment Adhesion fascia
(Deep) Lower Inferior temporal septum Adhesions of the SMAS to Lateral Orbital Inferior temporal Superficial lamina of Superficial
Temporal the zygomatic bone Thickening septum the deep temporal temporal fascia
Compartment fascia
Superficial Fusion of superficial and Zygomatic arch Posterior surface Fusion of superficial Deep lamina of Superficial
Review The Fat Compartments of the Face

Temporal Fat Pad deep lamina of deep of the frontal and deep lamina of deep temporal lamina of deep
temporal fascia process of the deep temporal fascia fascia temporal fascia
zygomatic bone
Deep Temporal Temporalis muscle Masticatory space Posterior surface Temporomandibular Temporalis muscle Deep lamina of
Fat Pad of the frontal joint deep temporal
process of the fascia
zygomatic bone
Superior Fascial connection between Fascial connection between Zygomaticus Adhesion of Parotideomasseteric SMAS
Premasseter zygomatic branch of facial buccal branch of facial major muscle parotideomasseteric fascia

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Compartment nerve, parotideomasseteric
fascia and SMAS
Middle Fascial connection between
Premasseter buccal branch of facial
Compartment nerve, parotideomasseteric
fascia and SMAS
Lower Premasseter Fascial connection between
Compartment buccal branch of facial
nerve, parotideomasseteric
fascia and SMAS
nerve, parotideomasseteric fascia, SMAS und
fascia and SMAS parotid fascia
Fascial connection between Facial vein canal Adhesion of Parotideomasseteric SMAS
buccal branch of facial parotideomasseteric fascia
nerve, parotideomasseteric fascia, SMAS und
fascia and SMAS parotid fascia
Fascial connection bet- Facial vein canal Adhesion of Parotideomasseteric SMAS
ween marginal mandibular parotideomasseteric fascia
branch of facial nerve, paro- fascia, SMAS und
tideomasseteric fascia and parotid fascia
SMAS

407
408
Table 3 Names and boundaries of the deep facial fat compartments when viewed from the anterior aspect of the face.

Superior Border Inferior Border Medial Border Lateral Border Floor Roof
Deep Lateral Superior frontal Middle frontal septum Fibrous envelope of Temporal ligamentous Periosteum Fibrous sheet covering
Forehead septum the supraorbital neu- adhesion the underside of the
Compartments rovascular structures frontalis muscle
Deep Cent- Superior frontal Middle frontal septum – Supraorbital neurovascular Periosteum Fibrous sheet covering
ral Forehead septum structures traveling in a the underside of the
Compartment longitudinal orientation frontalis muscle
Retro-orbicu- Middle frontal Orbicularis retaining liga- Supraorbital neu- Open and connected via the Periosteum of the Underlying fascia of
laris Oculi Fat septum ment ro-vascular bundle superior interval to the infe- frontal bone frontalis muscle
Compartment rior temporal compartment
Medial Sub- Orbicularis re- Zygomatico-cutaneous Angular vein Lateral SOOF Midfacial extension Orbicularis oculi muscle
orbicularis taining ligament ligament of the superficial
Oculi Fat Com- lamina of the deep
partment temporal fascia
Review The Fat Compartments of the Face

Lateral Sub-or- Orbicularis re- Zygomatico-cutaneous Medial SOOF Open and connected via the Midfacial extension Orbicularis oculi muscle
bicularis Oculi taining ligament ligament temporal tunnel to the infe- of the superficial
Fat Compart- rior temporal compartment lamina of the deep
ment temporal fascia
Premaxillary Angular Vein Fascial fusion of the mid- Lateral nasal wall and Angular vein Levator labii supe- Orbital part of the orbi-
Space cheek SMAS and the leva- lateral nasal vein rioris alaeque nasi cularis oculi muscle (in
tor labii superioris alaeque muscle its superior part) and by
nasi muscle the midcheek superficial
musculo-aponeurotic

© 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
system (in its lower part)
Deep Pyriform Bony attachment Levator anguli oris muscle Lateral nasal wall Infraorbital neurovascular Levator anguli oris Levator labii superioris
Space of the levator labii and depressor septi bundle muscle and peri- alaeque nasi muscle
superioris alaeque nasi muscle ostium of maxilla
nasi muscle
Deep Medial Bony attachment Fusion of the levator anguli Infraorbital neurova- Angular vein and deep Periosteum of the Levator labii superioris
Cheek Fat of the levator labii oris and the levator labii scular bundle lateral cheek fat maxilla alaeque nasi muscle
Compartment superioris alaeque superioris alaeque nasi mu-
nasi muscle scle in its medial part and
by the zygomaticus major
and the transverse facial
septum in its lateral part
Deep Lateral Zygomatico-cuta- Zygomaticus major mu- Angular vein and Zygomaticus major muscle Periosteum of the Orbicularis oculi musc-
Cheek Fat neous ligament scle and transverse facial deep medial cheek and transverse facial septum maxilla le and the mid-cheek
Compartment and/or zygomati- septum fat SMAS
cus minor muscle
Review The Fat Compartments of the Face
Figure 10 Virtual model of the face showing the superfi-
cial fat compartments of the lateral face. SLFC, superficial
lateral forehead compartment; SUTC, superficial upper
temporal compartment; SLTC, superficial lower temporal
compartment; SMIC, superficial middle cheek compartment;
SLC, superficial lateral cheek compartment. The superficial
nasolabial compartment (SN), superficial medial compart-
ment (SMC) and jowl fat compartment (JC) are superficial fat
compartments of the central face.
The layers are arranged differently because the deep
fat compartments are bound by the muscles of facial ex-
pression; these originate from the bone and insert into the
nasolabial sulcus, the orbicularis oris muscle complex or the
modiolus [60]. Thus, it is most important for a practitioner
to understand the two- and three-dimensional anatomy of
this region for safe and effective results following surgical
and non-surgical procedures: Skin (layer 1); Subcutaneous
fat i.e. the superficial nasolabial and the superficial medial
cheek fat compartment (layer 2); SMAS and orbital part of
orbicularis oculi muscle (layer 3) [61]; Deep nasolabial fat
compartment (located within the premaxillary space) [62]
(Figures 12, 13) (layer 4); Levator labii superioris alaeque
nasi muscle (layer 5); Deep pyriform space (medial to the
infraorbital foramen) (Figure 14) [63] (layer 6); and Deep
medial cheek fat compartment (between the infraorbital
© 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
Figure 11 Virtual model of the face showing layer 3 of the
face: the continuation of the platysma (lower face and neck),
the superficial musculo-aponeurotic system (SMAS), the su-
perficial temporal fascia (STF) and the galea aponeurotica.
The orbicularis oculi muscle (OOM) can be found in the same
layer as the SMAS and the above-mentioned structures.
foramen and the angular vein) (Figure 14) [38, 51, 64]
(layer 6) and Deep lateral cheek fat compartment (between
the angular vein and the zygomaticus major muscle (Figure
14) [7, 38, 51, 64] (layer 4) (Table 3); and Periosteum (lay-
er 7 medial to the angular vein; layer 5 lateral to the angular
vein). Next to the origin of the zygomaticus major muscle,
the zygomatic ligament (McGregor’s patch) is located; this
is included in the line of ligaments and forms the boundary
between the medial and lateral midface. The presence of the
zygomaticus minor muscle is variable; it follows the cour-
se of the zygomatico-cutaneous ligament, which forms the
superior boundary of the deep medial and lateral cheek fat
compartments [65, 66 ], whereas the constant zygomaticus
major muscle is connected via a broad fascial membrane (the
transverse facial septum) to the underlying maxilla [47, 66 ].
The transverse facial septum forms the inferior boundary of
the deep lateral cheek fat and thus the superior boundary of
the buccal space. It is the leading cause of “apple-cheeks”
when smiling (Table 3) [7, 47 ].
409
 Review The Fat Compartments of the Face

Figure 13 Virtual model of the face showing the deep

nasolabial fat compartment (DNL) located within the
premaxillary space, lying on top of the levator labii superioris
alaeque nasi muscle (LLS). The image shows layer 4 after the
Figure 12 Virtual model of the face showing the buccal orbicularis oculi muscle has been removed.
space through which the facial artery travels. The facial vein
runs inside the facial vein canal, which forms the posterior
boundary of the buccal space and is thus not considered as
a content of the buccal space. The green circle shows the
close relationship of the facial artery, facial vein and margi-
nal mandibular nerve at the mandible. Abbr.: OOM, orbicu-
laris oris muscle.

Fat Distribution around the Perioral

region and the Chin
The boundaries of the perioral region are the nasolabial sul-
ci, the nose, the modiolus, the labiomandibular sulci and in-
feriorly the submental septum. The major difference between
this region and all other facial regions is that there is no clear
layered arrangement and there are no subcutaneous fat com-
partments (Figure 15) [67 ]. The subcutaneous fat is disper-
sed, since the underlying muscles of facial expression and the
collagenous fibers form a strong network that connects the Figure 14 Virtual model of the face showing the deep midfa-
skin fi rmly to the underlying muscular layer [61]. This ma- cial fat compartments after the levator labii superioris alaeque
kes precise movements of the overlying skin possible; these nasi muscle has been removed: deep pyriform space (DP)
are needed for various facial expressions and for food intake. located medial to the infraorbital foramen (IOF). The deep
The layers can be best summarized as follows: Skin (layer 1), medial cheek fat (DMC) is located between the infraorbital fo-
Subcutaneous fat (layer 2), Musculature (e.g. orbicularis ramen (IOF) and the angular vein (AV). The deep lateral cheek
oris muscle) (layer 3), Deep fat (deep chin fat in the midline fat (DLC) is located between the angular vein (AV) and the
[68] and the (deep) labiomandibular fat located around the zygomaticus major muscle (ZMM).

410 © 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
Review The Fat Compartments of the Face
Figure 15 Three-dimensional reconstruction of a cranial CT
scan showing the perioral region including the chin. The
nasolabial sulcus (NLS), the labiomental sulcus (LMS) and the
submental sulcus (SMS) are indicated. There are no distinct
layered arrangements with subcutaneous fat compartments
in this region.
mental foramen) [38] and Periosteum (layer 5) (Figure 16).
The fat located between the periosteum and the musculature
is an important gliding space that protects the neurovascular
bundle as it emerges from the mental foramen.
The change in subcutaneous arrangement between the
fi rm perioral attachment and the loose and layered arran-
gement of the remainder of the facial regions where a clear
subcutaneous layer is present underlies the formation of the
nasolabial as well as the labiomandibular sulcus [1].
Concluding Remarks
The concept of the layered arrangement of the face is an effec-
tive way to understand the spatial relationship and the func-
tional interplay of the soft tissues of the face. Understanding
the layers, the compartments and their contents is crucial for
safe and effective minimally invasive rejuvenation procedu-
© 2019 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2019/1704
Figure 16 Virtual model of the face showing the layered
arrangement of the perioral region including the chin. The
deep chin fat (DCF) is located in the midline, whereas the
(deep) labiomandibular fat (DLF) is located around the mental
foramen, deep to the orbicularis oris muscle (not shown) and
above the periosteum. Abbr.: SN, superficial nasolabial fat; JC,
jowl fat compartment.
res. Since each structure (bone, ligaments, fascia, muscles,
fat compartments, skin) exhibits specific contributions to the
process of facial aging, it is important to determine which
structure is the key player in the presenting clinical scena-
rio. Injection of soft tissue fi llers should thus be performed
with caution and with a precise anatomical understanding of
the facial fat compartments, as one must target a specific fat
compartment in order to achieve the desired effect. Applying
the product in the wrong fat compartment might yield an
aesthetically undesirable result.
Acknowledgement
We would like to thank: Konstantin Frank, Michael P. Smith,
Konstantin C. Koban and Thilo L. Schenck for their sup-
port during the data acquisition; the team of the Sectra
411
 Review The Fat Compartments of the Face
Visualization Table from Linköping, Sweden, during the
data visualization; and the team at Nestlé Skin Health
SHIELD, the Chamberlain Group, and BioDigital for the
ideation and development of the facial model.
Correspondence to
Sebastian Cotofana MD, PhD, PhD
Albany Medical College
47 New Scotland Avenue MC-135
Albany, NY 12208, USA
E-mail: cotofas@amc.edu
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