Treatment of the midface with fillers

Injectables, Aesthetic Features

Salvatore Fundarò describes the benefits of planning filler treatments based on a deeper
understanding of the facial anatomy and the changes that occur through aging.
The rejuvenation of the midface with volumizing fillers has marked a turning point in the
treatment of the region. The anatomic complexity of the area, the significant difficulties in
evaluating the patient’s aging, and the introduction of alternative injection techniques (either
with needle or with cannula) has made the therapeutic strategic choice increasingly more
complicated. The variables to consider are numerous and a logical approach is required in order
to manage them effectively.

During the evaluation of patients who require midface treatments, the physician has to answer
four questions:

 What are the anatomical causes for the aging in the patient?

 In what type of patient should we perform specific treatments and are there any
alternatives?

 Where should the filler be injected to obtain the best possible result?

 Which injection technique should be used?

Once these questions have been answered the therapeutic project can begin. In this way, the
most suitable treatment for each patient can be defined through a logical evaluation process. A
therapeutic program defined on specific characteristics guarantees a high level of aesthetic
correction. If practitioners avoid standardised treatments the success rate increases, because
injections will first correct the specific causes of aging and then the minor defects.
 Anatomologic™ is the name of the author’s approach for facial
treatments described in this article. The pillars of architecture for the Anatomologic™ approach
are the knowledge of facial anatomy and the analysis of the anatomical modifications that occur
during facial aging. These two aspects give an answer to the earlier question referring to the
anatomical causes for the aging in the patient. On these pillars leans the architrave made of the
treatment planning for each patient. This gives an answer to the second and third questions.
Finally, the choice of the most effective injection technique is the top of this imaginary building
(Figure 1).
You do not have to be an expert anatomist to use the Anatomologic™ approach. The anatomic
knowledge required is very basic and focusses on the final aim: good aesthetic correction. The
aging analysis and the treatment planning are purposefully synthetic, and the injection
techniques are as minimally traumatic as possible. The philosophy of the
Anatomologic™ approach is: Think logical. Think simple.

The anatomy of midface fat compartments

The anatomical description of fat compartments presented in this article are the result of a wide
review of the scientific literature and of eighteen hemifacial cadavers dissections undertaken at
the University of Malta’s Department of Anatomy.

As suggested by Rorich and Pessa1, clinical observation and laboratory investigations show that
the subcutaneous fat of the face is highly partitioned, that it is not a confluent mass, and it
exists in distinct anatomical compartments. The fat compartments are determined by fascial
membranes that arise from the superficial fascia and attach to the dermis of the skin2.
The midface fat compartments are classified as either superficial or deep. It’s very important to
distinguish between these two different categories. The superficial fat compartments are located
between the skin and the plane of the Superficial Muscular Aponeurotic System (SMAS). The
SMAS is a continuous and organized fibrous network connecting the periosteum, the facial
muscles, or other fascial types (such as parotid fascia), with the dermis. It consists of a three-
dimensional architecture of collagen fibers, elastic fibers, fat cells, and muscle fibers3–5. The fat
tissue of superficial compartments is located within this fibrotic network. Under the SMAS
plane, posteriorly to the mimetic muscles, we find the deep fat compartments that reach and
adhere to the periosteal plane.

The fat compartments of the cheek are described below and can be found in Figure 2.
Superfical fat compartments:

 Infraorbital fat

 Medial cheek fat

 Nasolabial fat

 Middle cheek fat

 Lateral temporal-cheek fat

 Superior jowl fat

 Inferior jowl fat.

Deep fat compartments

 Medial sub-orbicularis oculi fat (Medial SOOF)

 Lateral sub-orbicularis oculi fat (Lateral SOOF)

 Deep medial cheek fat (DMCF)

 Buccal fat.

 Superficial fat compartments

Infraorbital fat
Its superior margin corresponds on the skin surface to the tear trough and to the palpebro malar
groove (Figure 3). In fact, the superior boundary of this compartment is the orbicularis
retaining ligament that originates 1–2 mm inferiorly to the margin of the orbital cavity and,
passing through the orbicularis oculi muscle, reaches the dermis9,10. According to Muzzafar et
al, this ligament spans from the periosteum, just outside the orbital rim, to the fascia on the
undersurface of the orbicularis oculi muscle11. The orbicularis retaining ligament contributes to
the formation of the tear trough and palpebro malar groove. Positioned cranially to these two
grooves, the palpebral part of the orbicularis oculi muscle is found immediately under the skin
of the eyelid; caudally to them, the orbital part is covered by infraorbital fat.
Inferiorly, the infraorbital fat is defined by the zygomatic cutaneous ligament12. Mendelson
described zygomatic ligaments medial to the junction of the arch and body of zygoma, located
along the origins of the facial expression muscles as the the zygomaticus major, zygomaticus
minor, and levator labii superioris13. At the level of the junction of the arch and body of the
zygoma, just lateral to the origin of the zygomaticus major muscle, this ligament becomes
thicker and stronger and is described as the McGregor patch14.
The fat of this compartment has a high tendency for water retention. Frequently being the site
of persistent oedema it often forms the so called malar mound6,15.

Medial cheek fat

It is located caudally to the infraorbital fat from which it is separated by the zygomatic
cutaneous ligament (Figure 3). It has a triangular shape and is wedged between the
infraorbitary and nasolabial fat. Laterally, this compartment is bordered by the zygomaticus
major muscle and the middle cheek fat. Infero-medially to the medial cheek fat is the nasolabial
fat, which is positioned parallel to the nasolabial fold.
Nasolabial fat
With an oblong form, it lies laterally to the nasal pyramid and parallel and cranially to the
nasolabial fold. The orbicularis retaining ligament represents the superior border of this
compartment. It borders supero-laterally with the medial cheek fat, infero-medially with the
nasolabial fold. Its inferior part borders and overlaps the superior jowl fat.

Middle cheek fat

Located laterally to the medial cheek fat, it is bordered superiorly by the zygomatic ligament.
Above this compartment the ligament is thick and constitutes the McGregor patch. The middle
cheek fat does not extend above the inferior margin of the zygomatic arch. Anteriorly it is
bordered by the masseter ligament that begins inferiorly to the McGregor patch and descends
vertically along the anterior border of the masseter muscle. The ligament arises from the fascia
of the masseter muscle and inserts into the SMAS and the overlying dermis of the cheek. The
middle cheek fat laterally borders with the lateral temporal-cheek fat. The parotid-masseter
septum divides these two compartments. Caudally to the middle cheek fat we find the inferior
jowl fat.

Lateral temporal-cheek fat

Is the most lateral compartment of the cheek. This fat lies in direct contact with the parotid
gland and connects the temporal fat to the cervical subcutaneous fat. The cheek section is
firmly attached to the parotid fascia.

Superior jowl fat

It is inferior to the nasolabial fat and it is lateral to the modiolus. Its lateral boundary is the
middle-cheek fat.

Inferior jowl fat

Located inferiorly to the middle-cheek fat and the superior jowl fat. Its medial boundary is the
mandibular ligament and its posterior boundary is the lateral temporal-cheek fat. The inferior
boundary is determined by the mandibular septum.

The first three superficial fat compartments (infraorbital, medial cheek, and nasolabial fat) are
described as a unique anatomical structure: the malar fat pad. It has a triangular shape with the
base parallel to the nasolabial fold and with the apex near the malar projection. The malar fat
pad is loosely attached to the deep plane (SMAS), but it is firmly attached to the skin16. The
malar fat pad is supported in its location in youthful individuals by multiple fibroelastic fascial
septa that extend through the fatty cheek mass originating from the underlying superficial
fascia, which allows the mimetic muscles to attach to the overlying cutaneous dermis17.
Deep fat compartments
Medial sub-orbicularis oculi fat (medial SOOF)
It lies adherent to the periosteum along the orbital rim18, inferiorly to the orbicularis retaining
ligament and under the orbicularis oculi muscle (Figure 3–4). It extends from the medial
limbus to the outer cantum. The zygomatic cutaneous ligament separates the medial SOOF
from the deep medial cheek fat.
Lateral sub-orbicularis oculi fat (lateral SOOF)
Located at the lateral orbital rim in the sagittal plane (Figure 4). The lateral orbital thickening
represents the upper-limit of the lateral SOOF and does not extend superiorly to the lateral
canthus. Its medial half is covered by the orbicularis oculi muscle. It lies above the prominence
of the zygoma but does not reach above the superior margin of the zygomatic arch. The lateral
SOOF lies above another more deeply situated fat compartment, therefore it is not directly in
contact with the periosteum18.
Deep medial cheek fat (DMCF)

Located
under the SMAS plane, its superior part lies under the orbicularis oculi muscle (Figure 3–4). Its
superior boundary is the zygomatic-cutaneous ligament that divides it from the medial SOOF
and it laterally borders with the buccal fat and with the zygomaticus major muscle. The medial
boundary is the pyriform ligament surrounding the nasal base, and the inferior boundary is the
sub–orbicularis oris fat. This fat compartment lies on the periosteum of the maxilla. Between
the periosteum and the fat compartment a potential space is present, defined as Rislow’s space8.
Other authors19 describe this compartment divided into two parts: the medial part, located
beneath the nasolabial fat, does not lie immediately on the periosteum of the maxilla but is
bordered posteriorly by another small, triangular compartment; the lateral part is located under
the superficial medial cheek fat and is positioned directly on the maxilla.
Buccal fat
Located inferiorly to the zygoma and anteriorly to the ramus of the mandible surrounding the
medial pterygoid and masseter muscle. This fat compartment has a buccal extension adjacent to
the medial cheek fat, the deep medial cheek fat, the middle cheek fat, the sub–orbicularis oculi
fat, the jowl fat, and the fat of the pre-masseter space. Gierloff et al., in their computed
tomography study have observed a hypothetical anatomical boundary between the buccal
extension and the buccal fat pad. They have hypothesized that the buccal extension can be
regarded as a distinct fat compartment19. Other authors share this theory20.
Often, injectors can have some difficulty understanding the specific localization of the fat
compartments and, consequently, treating them accurately. This can be a difficulty especially
for doctors that have no experience with cadaver dissections and anatomic studies. Improving
knowledge of these aspects is essential to increase the effectiveness of treatments.
Anatomy of aging fat compartments
The fat compartments undergo specific modifications due to the aging process. Sometimes the
changes are hypotrophic, other times they are hypertrophic or ptotic. The ability to understand
the changes occurring related to the aging process is essential in order to correctly plan a
treatment with fillers.

Superficial fat compartments

Medial cheek fat
The aging process causes a global volume increase in the medial cheek fat with an inferior
volume shift within the fat compartment. The volume increases in the lower two thirds and
remains stable in the upper one.

Nasolabial fat
Undergoes an inferior volume shift of fat tissue. In elderly patients, the sagittal diameter of the
upper third is smaller and the sagittal diameter of the lower third is higher19.
This modification creates an overall hypertrophy of the lower part of the malar fat pad due to
the ptosis and caudal migration of fat tissue. Aging of the malar fat pads can be described as
ptotic/hypertrophic. The ptosis and the hypertrophy of these fat compartments contributes to the
increase in the depth of the nasolabial fold17.
Middle cheek fat
As the malar fat pad is loosely adherent to the SMAS plane, its aging is characterized by ptosis,
caudal migration of fat, and hypertrophy. These modifications produce an increase of convexity
to the central portion of the cheeks.
Lateral temporal-cheek fat
Located adherent to the parotid fascia without any deep fat compartment between it and the
fascial plane. The aging determines a hypotrophic involution and it usually does not have any
tendency for caudal migration.

Deep fat compartments

Medial and lateral SOOF

Both lie on the

periosteum and have an aging characterized by hypotrophy with a low tendency for ptosis. The
hypotrophic involution of medial SOOF produces the formation of the hollow in the infraorbital
region. Reduction of the medial SOOF has been noted to increase the orbital cheek crease and
the ‘V’ deformity of the lower-lid described by Mendelson et al13. The medial SOOF acts to
support the palpebral tissues of the inferior eyelid, so its volume reduction increases the
relaxation of the tissue of the inferior eyelid and of the intraorbital fat. The hypotrophy of
lateral SOOF decreases the projection of the malar area and cheekbone, facilitating the ptosis of
superficial fat compartments of the cheek.
Deep medial cheek fat
This compartment undergoes a gradual and global decrease of volume and a caudal migration.
The hypotrophy is greater in the upper two thirds and minor in the lower third where the caudal
migration of fat compensates the hypotrophy.

Buccal fat
The area of this fat compartment that influences the aesthetic of cheeks is the buccal extension.
It seems to be mainly affected by hypotrophic aging. Several authors have observed a lower
volume of buccal extension in older patients19,21. The deflation of this fat compartment leads
consequently to a lack of support for the medial cheek and middle cheek fat, aggravating the
descent of these compartments. Other authors22,23 have observed an antero-inferior protrusion of
buccal fat that increases the convexity of the cheeks and jowl ptosis.
Treatment planning
Now the two pillars of the Anatomologic™ approach (anatomy and anatomy of aging) have
been introduced, the physician should use this knowledge to plan the best filler treatments for
different patient types. The knowledge of anatomical changes related to the aging process can
guide the physican’s choice and suggest which fat compartments should be treated and
volumized. This phase is crucial because if the physican chooses an inappropriate treatment the
patient will probably have a partial or lacking result. If, however, the planning is correct, the
results will be satisfactory.
To facilitate the treatment choice the author uses a personal classification of the aging types
that simplifies the patient’s placement and the treatment planning: the Aging Type
Classification of Midface (ATC Midface)(Table 1).
Treatment of deep fat compartments
First of all, physicians have to consider that deep fat compartments predominately need an
augmentation of volume. For this reason, plan patient treatments with volumizer fillers with a
high elastic and viscous moduli (G’ and G’’) that, by definition, can give the volume
augmentation required. These fillers can have a lifting action only if injected in specific
anatomical regions within specific deep fat compartments that, regaining their lost volume,
have a lifting action on the superficial fat compartments.

In type 1 and 2 patients, physicians have to first treat the main defects, which are volume
reduction of the deep medial cheek fat and lateral SOOF. Therefore, to reduce the adipose
hypotrophy, physicians first need to enhance the volume of DMCF. With this first correction, a
volume augmentation and an initial lifting action of the soft cheek tissue will be achieved.
Next, the physician should treat the lateral SOOF, enhancing the cheekbone projection, and
further increasing the lifting action of the soft cheek tissue. In type 2 patients
(hypotrophic/ptotic), it will be beneficial to augment the quantity of filler injected in lateral
SOOF because they need a greater lifting action than type 1 patients. Lastly, the author would
treat the medial SOOF to correct the hollow in the infraorbital region (Figure 5–6).
In type 3 patients (ptotic/hypertrophic) the main defects are ptosis and the downward migration
of adipose tissue of the superficial fat compartments. In this case, physicians have to lift the
ptotic fat compartments but to do this they have to increase the volume of lateral SOOF. The
volume restoration of this compartment will augment the projection of the cheekbone and will
give a lifting action to the superficial fat. Only after the assessment of the obtained lifting
action, the physician will be able to increase the volume of the DMCF. Attention must be paid
not to inject too much filler in the DMCF because the inferior part of the maxillary region is
already characterized by hypertrophy and volume excess in this patient type. In type 3 patients
it will be necessary to treat the medial SOOF to eliminate the infraorbital hollow (Figure 7).
A similar approach was used with type 4 patients in which it was necessary to augment the
volume of lateral SOOF to lift the soft cheek tissue and to balance the excessive volume in the
inferior part of the maxillary region. The DMCF is usually not treated if not in its higher
location at the border with the lateral SOOF. The main strategies of the treatments are
summarized in Table 2.
Treatment of superficial fat compartments
Most superficial fat compartments have an aging process characterized by ptosis and
hypertrophy. Only lateral temporal-cheek fat is characterized by a hypotrophic aging process.
The treatment of superficial fat must be accurate to avoid adding too much volume and increase
the ptosis. For these reasons the author recommends use of fillers with intermediate G’ and G’’
in these compartments. Only in lateral temporal-cheek fat does the author suggest using a
volumizer fillers with high G’ and G’’. The infraorbital fat has a high tendency for water
retention and for this reason the author does not suggest treating with fillers of hyaluronic acid
that, due to their hydrophylicity, can increase the oedema.

In type 1 patients it will be useful to inject the medial cheek fat and the nasolabial fat to
complete the volume enhancement that begun from injecting the DMCF. In type 2 patients only
treat the medial cheek fat to avoid increasing the initial ptosis of the nasolabial fat. In those
patients with hypotrophic middle cheek fat, treat this compartment to reduce the concavity of
the cheek.

In type 3
and 4 patients, the author does not treat the superficial cheek fat compartments because in these
patients they are already hypertrophic and any treatments could increase their ptosis.
Special reference needs to be made to the lateral temporal-cheek fat. It is characterized by a
hypotrophic aging process and for this reason it can often be treated with fillers. The volume
restoration of this compartment causes the reduction of the pre-auricular hollow and gives a
lifting effect to the middle cheek fat and the soft tissue of the jawline.
Injection technique
The author regularly treats the deep fat compartments of the midface with a volumizer filler of
hyaluronic acid (HA) or of calcium hydroxyapatite (CaHA) with a high elastic and viscous
moduli (G’ and G’’). The use of filler with lidocaine reduces the pain and makes the treatment
more comfortable for patients24–26.
The injection technique used for the treatment of deep fat compartments is the preperiostal
bolus technique. In the author’s experience, it is the most effective and least traumatic because
it allows for a precise injection and the path of the needle through soft tissues is as short as
possible. With good experience, physicians are able to treat every single fat compartment with
a single injection. In this way, physicians no longer need to perform other injections, which
increases the possibility of bleeding and bruising.
Volumetric restoration occurs at the level of the deep fat compartments that are most subject to
hypotrophy and, therefore, the bolus technique guarantees an anatomically correct volumetric
correction. The volume is increased in the deep fat compartments subject to hypotrophy and not
in the superficial fat compartments that prevalently undergo ptotic/hypertrophic aging.

The bolus technique is

suitable in the treatment of single compartments because it allows an anatomical precision of
injection superior to other techniques. The bolus is injected inside the specific fat compartment
and all the filler contributes to the volumetric correction of the compartment without useless
dispersion in other anatomical localizations. This causes a better performance of the injected
product.
The injection given using this technique allows the filler to be placed in the deep fatty tissues
which, as we have seen, are the ones that are most attached to the underlying periosteal level.
Insertion of filler in these particularly stable compartments, which are not too subject to ptosis,
prevents it from migrating due to the effects of gravity.
All deep fat compartments are treated with the same bolus technique. The injection is done by
inserting the needle vertically to the underlying bone plane until the tip is touching the
periosteum (Figure 8). After withdrawing the needle by a few millimeters and ascertaining, by
withdrawing the plunger, that vessels have not been penetrated, the author proceeds with the
supraperiosteal release of a bolus of the product.
The amount of product injected for each release varies according to the deficit to be corrected.
It is recommended not to exceed 0.5 ml for each main release and for each single point in order
not to risk overcorrection. It is possible to integrate it with another injection immediately after
the first one following the evaluation of the effect obtained. It’s important to massage the
product after injection to equally distribute it inside the fat compartment.
The superficial fat compartment is treated using a microcannula (25G). The microcannula is
flexible with rounded ends that can go through the fat compartment in multiple directions
without damaging the vessels and nerves. The filler is released through a small hole placed
laterally, thereby allowing a uniform and regular outflow. The microcannula is inserted through
an entry point made with a needle that has the same or a slightly larger diameter than the one of
the microcannula, so as to allow the cannula to penetrate easily. When the cannula is inserted, it
is slowly slid above the SMAS plane, releasing the filler by means of an antero-retrograde fan-
wise technique (Figure 8). This technique allows for an homogeneous spread of filler within
the compartment with a low rate of side-effect thanks to the atraumatic design of the
microcannula27.
The amount of product injected for each superficial compartment varies according to the deficit
to be corrected. It is important to avoid the overtreatment of these compartments because their
superficiality exposes the risk of unnatural and excessive corrections.

Conclusion
In the author’s experience, the Anatomologic approach has proven to be safe and extremely
effective. It has increased the correction capability of the age related defects of the midface.
There is a low rate of side-effects and complications. When treating the deep fat compartments
with the bolus technique it’s important to remember to make sure not to inject inside vessels,
withdrawing the plunger before injecting. The intravascular injection is in fact the main cause
of serious complications that can occur in this area (expecially in the infraorbital zone)
including skin necrosis and/or ischemic injuries of the retina.