Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 1292e1297

The subcutaneous fat compartments in relation to

aesthetically important facial folds and rhytides
M. Gierloff a,*, C. Stöhring b, T. Buder c, J. Wiltfang a

a
Department of Oral & Maxillofacial Surgery, Christian-Albrechts-University Kiel, Arnold-Heller-Strasse 16,
24105 Kiel, Germany
b
Department of Diagnostic Radiology, Christian-Albrechts-University, Kiel, Germany
c
Institute of Anatomy, University of Erlangen-Nuremberg, Erlangen, Germany

Received 29 August 2011; accepted 30 April 2012

KEYWORDS Summary The ideal treatment of the nasolabial fold, the tear trough, the labiomandibular
Facial fat fold and the mentolabial sulcus is still discussed controversially. The detailed topographical
compartments; anatomy of the fat compartments may clarify the anatomy of facial folds and may offer valu-
Filler; able information for choosing the adequate treatment modality.
Autologous fat grafts; Nine non-fixed cadaver heads in the age range between 72 and 89 years (five female and four
Volume male) were investigated. Computed tomographic scans were performed after injection of
augmentation; a radiographic contrast medium directly into the fat compartments surrounding prominent
Fat grafting; facial folds. The data were analysed after multiplanar image reconstruction.
Ageing face The fat compartments surrounding the facial folds could be defined in each subject.
Different arrangement patterns of the fat compartments around the facial rhytides were
found. The nasolabial fold, the tear trough and the labiomandibular fold represent an
anatomical border between adjacent fat compartments. By contrast, the glabellar fold
and the labiomental sulcus have no direct relation to the boundaries of facial fat. Deep
fat, underlying a facial rhytide, was identified underneath the nasolabial crease and the
labiomental sulcus.
In conclusion, an improvement by a compartment-specific volume augmentation of the na-
solabial fold, the tear trough and the labiomandibular fold is limited by existing boundaries
that extend into the skin. In the area of the nasolabial fold and the mentolabial sulcus, deep
fat exists which can be used for augmentation and subsequent elevation of the folds. The
treatment of the tear trough deformity appears anatomically the most challenging area since
the superficial and deep fat compartments are separated by an osseo-cutaneous barrier, the
orbicularis retaining ligament. In severe cases, a surgical treatment should be considered. By

* Corresponding author. Tel.: þ49 15142319383; fax: þ49 4315972107.

E-mail address: gierloff@mkg.uni-kiel.de (M. Gierloff).

1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2012.04.047
The subcutaneous fat compartments related to facial folds and rhytides 1293

contrast, the glabellar fold shows the most simple anatomical architecture. The fold lies
above one subcutaneous fat compartment that can be used for augmentation.
ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Even though recent advances regarding the facial soft-
tissue anatomy have been made,1e3 the complex process of
facial ageing is not fully understood. But how can a surgeon
restore a youthful facial anatomy without understanding its
age-dependent changes? The detailed knowledge of the
facial anatomy should be a prerequisite for every plastic
surgeon performing rejuvenating procedures. Rohrich et al.
contributed significantly to the current facial anatomical
understanding by describing the facial fat compartments
which seem to play a pivotal role in the development of the
aged face.3 But even though, since then, many authors
emphasised the importance of the facial fat compartments
to the process of facial ageing,4e6 the anatomical relation
of the facial fat compartments to aesthetically relevant
folds and rhytides have not yet been described. Yet, the
knowledge of the topography of the subcutaneous fat
compartments in relation to the nasolabial fold, the tear
trough deformity, the labiomandibular fold and the men-
tolabial sulcus could help a surgeon to address specifically
distinct fat compartments to achieve most natural, youth-
ful results. Regarding the hypothesis that the highly com-
partmentalised facial fat does not age as confluent mass.3
a volume restoration of each single fat compartment
would lead to a volume distribution that resembles the
facial appearance in youth. A youthful volume distribution
would also result in an improvement of prominent facial
folds. Volume augmentation or liposuction may be applied
specifically to distinct fat compartments with respect to
the physiological anatomy. This can be regarded as a main
step towards a compartment-specific volume restoration
which has not yet been performed.
The aim of the current study was to evaluate the
anatomy of the subcutaneous fat compartments in relation
to the nasolabial fold, the tear trough deformity, the
labiomandibular fold, the glabellar fold and the labio-
mental sulcus. Therefore, a recently described computer-
tomographic method6 was used.
on both sides of each fold/rhytide into three different
tissue layers e subcutaneously, supraperiosteally and in
between.
This technique assured the identification of existing fat
compartments in the regions of the studied facial folds. The
injection points are demonstrated in Figure 1. For a clear
identification of the compartmental borders, adjacent
compartments were not stained in identical specimens.
Cranial computertomographic scans were performed using
a 64-slice computed tomography (CT) with the following
scan parameters: Collimation 64  0.6 mm, Pitch 0.8,
380 mA s eff., 120 kV, reconstructed slice thickness 1.0 mm.
Multiplanar image reconstruction was performed by using
the Vitrea 2 Workstation (Toshiba Medical Systems GmbH,
Neuss, Germany). The images were analysed by the first,
second and last author.
Results
Nasolabial fold
In the region of the nasolabial fold, three layers of distinct
fat compartments were identified. The superficial layer
includes the nasolabial fat compartment (NL) which is
located laterally to the nasolabial crease and forms the
nasolabial fold. The nasolabial fat can prolapse over the
nasolabial crease. The superior jowl fat lies inferiorly in
continuation to the nasolabial fat (Figure 2).
The medium layer is formed by the medial part of the
deep medial cheek fat (DMC) (Figure 3) which is located
underneath the levator labii superioris muscle and the

Materials and methods

Investigated were nine non-fixed cadaver heads in the age

range between 72 and 88 years (five females and four
males). The cadavers were obtained from the Institute of
Anatomy, University of Erlangen-Nuremberg and had been
donated for anatomical studies.
The specimens were investigated using a radiographic
technique, which was previously described.6 Briefly,
computed tomographic scans were performed 40 min after
injection (1 ml/point) of a radiopaque dye (Lipidiol Ultra-
Fluid Iohexol: Omnipaque; Amersham, Princeton, NJ, USA)
directly into the compartments. As no established protocol
exists that allows a definite localisation of the fat Figure 1 Stylistic drawing of an aged face demonstrating the
compartments, injections were performed systematically points that were used for injection of the radiopaque medium.
1294
Figure 2 Computertomographic image demonstrating the
subcutaneous nasolabial fat, the superior jowl fat and the
superficial chin fat. The yellow line indicates the course of the
nasolabial crease.
levator labii superioris alaeque nasi muscle. The deepest
fat compartment in this region is located between the
periosteum and the medial part of the DMC. Both
compartments extend further medially than the overlying
nasolabial fat and are located underneath the nasolabial
crease.
Figure 3 Computertomographic image of the medial part of
the deep medial cheek fat. The yellow line indicates the
position of the overlying nasolabial fat compartment. The red
dashed line indicates the course of the nasolabial crease.
M. Gierloff et al.
Labiomandibular fold (Marionettes lines)
One layer of fat was identified in the region of the labio-
mandibular fold (Figure 4). The labiomandibular crease lies
between the labiomandibular fat compartment (LM) and
the jowl fat (J ). The lateral edge of the LM appeared to be
thinner in cadavers with a prominent labiomandibular fold
than in cadavers with no obvious fold. The medial edge of
the depressor anguli oris muscle follows the course of the
crease.
Mentolabial sulcus
Two distinct fat compartments were identified in the
mental region. First, a superficial fat compartment, the
superficial chin fat (SC), that reaches superiorly almost to
the mentolabial sulcus and is delineated laterally by the
labiomandibular fat and inferiorly by the superficial portion
of the submentalis fat (Figure 5). Second, the submentalis
fat, which consists of a superficial and a deep portion. The
deep portion is located above the periosteum and is
covered by the mentalis muscle (Figure 5). It is located
topographically underneath the mentolabial sulcus. The
superficial, inferior portion of this fat compartment is
located directly under the skin and accentuates the shape
of the mentum (Figure 5).
Glabellar fold (Anger fold)
Only one layer of facial fat was identified in this region. The
glabellar fold is located superficially to the subcutaneous
central forehead compartment and has no anatomical
relation to the borders of this compartment (Figure 6).
Figure 4 Images of a volume-rendered 3-D spiral CT of the
lower face demonstrating the surface of the skin (above) and
the anterior part of the mandible with the labiomandibular fat
compartments and the left inferior jowl fat (below). The
yellow arrows indicate the position of the labiomandibular
fold. The white arrow indicates the position of the mandibular
retaining ligament.
The subcutaneous fat compartments related to facial folds and rhytides 1295

Figure 5 Images of a volume-rendered 3-D spiral CT of the chin demonstrating the superficial chin fat (left) and the submentalis
fat (middle, right). Note that both compartments do not lie immediately adjacent to the mentolabial sulcus (yellow line).

Tear trough (Nasojugal fold, Anterior malar fold)
The tear trough deformity is located between the cephalad
portion of the nasolabial fat compartment and the inferior-
medial part of the infraorbital fat compartment (IO)
(Figure 7). It can continue laterally as the orbit cheek fold
and is then located between the medial cheek fat and the
infraorbital fat. In the depth, beneath the nasolabial and
medial cheek fat, inferiorly to the infraorbital rim, the
suborbicularis oculi fat (SOOF) is located. The SOOF abuts
superiorly the tear trough.
Discussion
The ideal treatment of aesthetically important rhytides
including the nasolabial fold, the tear trough deformity, the
labiomandibular fold and the mentolabial sulcus is still
discussed controversially. Current treatment modalities
include volumetric approaches,7e9 surgical techniques10e12
or Botulinumtoxin.13 It can be difficult for the practising
surgeon to choose the adequate technique for a specific
situation. Therefore, the detailed knowledge of the topo-
graphical anatomy of the subcutaneous fat compartments
may clarify the anatomy of the facial folds and rhytides and
may offer valuable information for choosing the adequate
treatment option. The aim of the current study was to
evaluate the anatomy of the subcutaneous fat compart-
ments in relation to facial folds and rhytides. Therefore,
a recently described computertomographic method6 was
used. This method, combined with volume rendering,
enables the examiner to melt away the skin and to visualise
superficial and deeper fat compartments, soft tissue and/or
the skeleton by simply changing the window settings. It

Figure 6 Computertomographic image of the subcutaneous Figure 7 Computertomographic image of the tear trough
central forehead compartment. The yellow line indicates the area. The yellow line indicates the course of the tear trough
position of the glabellar fold which is located superficially to deformity which is located between the infraorbital fat
the inferior portion of the compartment. compartment and the nasolabial fat compartment.
1296
allows the evaluation of the topographic relation between
the fat compartments, the skin, facial folds, muscles and
the skeleton without destroying the cadaver heads and
their anatomy by dissection.
As we have used elderly specimens, the ageing process
has clearly affected the facial soft tissues including the fat.
It is very likely that the position and the relationship
between the fat compartments and the overlying folds have
changed with increasing age. Despite inter-individual vari-
ations in shape and size of the compartments, we did not
observe clear associations to age or gender. We believe that
several parameters such as body weight, body height, body
mass index, gender, age and body fat percentage might
influence the anatomy of the facial fat compartments.
Taking into consideration all these factors, our sample size
is probably too small to draw valid conclusions on inter-
subject variations.
However, the fat compartments surrounding the facial
folds could be defined in each specimen and appeared to be
arranged in a reproducible anatomy in each subject. Clear
differences in the fat anatomy were observed between the
studied facial folds. It could be demonstrated that in the
nasolabial fold area, two deep fat compartments are
located topographically beneath the nasolabial crease. The
medial position of the two compartments, the medial part
of the DMC and the fat of the Ristow’s space,4 might benefit
an elevation and effacement of the nasolabial crease when
volume augmentation of these compartments is performed
(Figure 3). Whether the augmentation of the DMC or of the
fat of the Ristow’s space will lead to a better aesthetic
result has not yet been described. As the formation of
a prominent nasolabial fold is caused by multiple factors
including an inferior volume shift within the nasolabial fat,6
a sagging of the nasolabial fat and an atrophy of the medial
cheek fat,4 the volume augmentation of the deeper fat
alone will not lead to an optimal aesthetic outcome.
Additional treatments should address the inferior nasola-
bial volume excess, the midfacial ptosis and the tethering
effect of fascialedermal insertions at the nasolabial
crease. The volume excess within the inferior portion of the
nasolabial fat can be treated by a selective liposuction
laterally and cephalad of the nasolabial crease.14 The
tethering effect of cutaneous insertions of boundaries at
the nasolabial crease can be detached by sharp cannulae
(dissectors),9 and the age-dependent deflation of the DMC
and the superficial cheek fat can be improved by volume
augmentation.4,9 Sundine and Connell emphasise the
importance of superficial musculoaponeurotic system
(SMAS) elevation to improve the appearance of the naso-
labial fold.10
The computed tomographic images demonstrated that
the centre of the tear trough deformity is located between
the infraorbital fat compartment and the nasolabial fat
(Figure 7). This is where the orbicularis retaining ligament
is located which spans between periosteum and skin sepa-
rating the infraorbital fat compartment from the nasolabial
fat and SOOF. All structures are located within a very thin
soft-tissue layer which might be the reason for undesired
treatment results such as irregularities after volume
augmentation.15 As a patient ages, ‘sagging’ of the naso-
labial fat, medial cheek fat and the SOOF contributes to the
hollowness of the tear trough area. In addition, a pseudo-
M. Gierloff et al.
herniaton of the lower eyelid fat leads to a more anterior
projection of the infraorbital fat with a relative deepening
of the tear trough deformity. For this reason, volume
augmentation procedures should address the fat compart-
ments inferiorly to the orbicularis retaining ligament, that
is, the nasolabial fat, medial cheek fat and the SOOF. For
avoiding irregularities or xanthelasma-like deposits, the
deep, supraperiosteal SOOF should be preferred.16 The
aesthetic result may be compromised by the tethering
effect of the orbicularis retaining ligament. Therefore,
depending on the significance of the tear trough deformity,
a release of the orbicularis retaining ligament11 should be
considered.
It could be demonstrated that labiomandibular crease is
located between the labiomandibular fat and the jowl fat
(Figure 4). No deep fat was identified. The two subcuta-
neous fat compartments do not abut directly against each
other leaving a gap at the inferior mandibular border
(Figure 4). This is where a punctual retraction is visible at
the skin which is generated by dermal insertions of the
mandibular retaining ligament.17 Age-dependent changes
of the jowl fat such as a volume increase, sagging and an
inferior volume shift lead to a prolapse of the jowl fat over
the labiomandibular crease. The CT demonstrates a thin-
ning of the lateral edge of the labiomandibular fat
compartment. This observation suggests a volume loss of
the labiomandibular fat around the fibrous cutaneous
insertions which may be secondary to facial mimics.
Therefore, four aspects have to be considered for rejuve-
nation of the labiomandibular fold: (1) reduction of the
jowl fat, (2) volume augmentation of the lateral part of the
labiomandibular fat, (3) release of the tethering effect of
the cutaneous insertions of the depressor anguli oris muscle
and mandibular ligament and (4) treatment of the ptosis.
The decision as to which technique to use should be based
on the clinical significance of the fold.
According to Cardoso et al. the mentolabial sulcus is free
of fatty tissue and consists of fibres of the mentalis muscle,
of the depressor labii inferioris muscle and of the orbicularis
oris muscle.18 We also observed no fat directly related to the
mentolabial sulcus. Yet, in a deep supraperiosteal layer,
underneath the mentolabial crease, the cephalad extension
of the submentalis fat is located (Figure 5). A deep
augmentation of this compartment would lead to an eleva-
tion and effacement of the mentolabial sulcus. By contrast,
an augmentation of the subcutaneous chin fat compart-
ment, which lies inferiorly to the mentolabial sulcus
(Figure 5), would relatively deepen the mentolabial groove.
We found, in concordance to Rohrich et al. the subcu-
taneous central forehead compartment, which is located
immediately underneath the glabellar fold13 (Figure 6). In
contrast to the tear trough deformity, to the nasolabial fold
and to the labiomandibular fold, the glabellar fold does not
represent a boundary between independent fat compart-
ments which facilitates the treatment of this area. An
augmentation of the central forehead compartment will
lead to an elevation and effacement of the glabellar fold.
The additional application of Botulinumtoxin will reduce
the tonus of the corrugator supercillii and procerus muscle.
In conclusion, this study demonstrates the topographical
relation of facial fat compartments surrounding aestheti-
cally important facial folds. This anatomical knowledge
The subcutaneous fat compartments related to facial folds and rhytides
facilitates the choice of treatment modality for correction
of distinct facial folds. Furthermore, it reveals the limits of
non-surgical techniques as a result of anatomical specifics
such as cutaneous insertions of boundaries. In the area of
the nasolabial fold and the mentolabial sulcus, deep fat
exists which can be used for augmentation and subsequent
elevation of the overlying folds. The nasolabial fold, the
tear trough and the labiomandibular fold represent
boundary zones with septal barriers between two or more
independent fat compartments. In these cases, the
improvement by only volume augmentation is limited by
the tethering effect of the cutaneous insertions of the
boundaries. The treatment of the tear trough deformity
appears anatomically the most challenging area since the
superficial and deep fat compartments are separated by an
osseo-cutaneous barrier. Therefore, dependent on the
significance of the tear trough deformity, a release of the
orbicularis retaining ligament should be considered. By
contrast, the glabellar fold shows the most simple
anatomical architecture. The fold is located above one
central forehead fat compartment and shows no anatomical
relation to the boundaries of the underlying fat.
Conflict of interest
None.
Funding
None.
Acknowledgements
The authors thank the Willed Body Program at the Institute
of Anatomy, University Erlangen-Nuremberg, for their
collaboration and support in providing the necessary
cadaver specimens to perform this study. The authors
declare that they did not make a demand on any writing
assistance.
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