Practitioners explore the impact of fat loss in the mid-face region and provide advice for treatment using injectables.
Fat. Everyone has it, and, in today’s society, almost one in two people want to lose it.1,2 In the UK, nearly half of adults who made a new year’s resolution in 2017 (48%) said they wanted to lose weight,1 while according to a US report released from the Centers for Disease Control and Prevention, almost half of adults (49.1%) made an effort to lose weight within the calendar years between 2013-2016.2
It’s safe to say that the word ‘fat’ generally has negative connotations and is not regarded as a desirable aesthetic.3 However, what many patients who present to clinic may not understand, is that fat is not all bad. In fact, fat plays a vital role in the youthful appearance of the face, especially the mid-face, where it’s degradation and movement can significantly alter an individual’s façade.4
In this article, Aesthetics talks to aesthetic surgeon Miss Jonquille Chantrey, aesthetic practitioner and cosmetic surgeon Mr Benji Dhillon, aesthetic practitioner and dentist Dr Heather Muir, aesthetic practitioner Dr Simon Ravichandran, and consultant plastic surgeon Mr Tunc Tiryaki about their treatment approaches to fat loss in the mid-face.
Prior to 2000, gravity was thought to be the major factor for mid-facial ageing, involving vertical descent of soft facial tissue, secondary to the attenuation or descent of ligaments.4 However, in 2000, Donofrio suggested that relative volume loss and gain in regions of the face create the deep creases of age.4,5 Seven years later, an analysis of 130 subjects by Lambros suggested that changing morphology of the mid-face was due to the relative deflation of certain fat pads, in addition to gravitational soft tissue descent.4,6 Studies following identified the importance of the different fat compartments in facial ageing. 4,7 Miss Chantrey, who owns her own clinic, explains, “We may lose a number of our fat cells through the ageing process and the fat cells themselves also become less plump. The fat changes in each fat compartment differently, which creates descent in the face and hollowness in certain areas.”
Mr Tiryaki, who practises at the Cadogan Clinic and has a clinic in Istanbul, adds, “The majority of the volume loss occurs at the bone and deep fat compartment level, which means that ligaments loosen and the superficial layers sag.”8
Dr Ravichandran, co-owner of Clinetix clinic, believes that the deep medial fat compartment in the cheek is the most significant area of the face for volume loss. “While we get volume loss both deep and superficially, fat loss and attenuation in the deep fat area is probably the greatest contributing factor to the ageing of the entire mid-face, and, by its connection, the lower face. That is because the superficial compartments are very dependent on the deep fat compartment, and if the deep fat compartment is gone, the tissues become lax,” he explains, adding, “Volume loss in the deep fat compartment is responsible for the development of nasolabial folds, lengthening of the lip-cheek junction, hollowing under the eyes, flattening of the mid-face, and loss of the contour as we go around the zygoma from the lateral cheek to the front. So, one cheek fat compartment right in the middle will affect the nasolabial, the cheek and the contour.”
There are many factors that can influence the loss of fat in the mid-face, which practitioners must consider.
Dr Ravichandran highlights that intrinsic ageing, which is hereditary, is a large factor. “The normal resorption of fat, weakening of collagen fibres and the laxity of ligaments with age will affect the positioning and the volume of the fat,” he says. Dr Muir, owner of Your Face Aesthetics, agrees that age is the primary factor. She says, “Younger individuals have a greater amount of fat in the face, both deep and subcutaneous. Body weight plays a factor as well, which can change with age as well as hormonally and is particularly evident in women.
Gender is another consideration – I find that females tend to have more prominent fat in the cheeks, so when they lose it, it is more noticeable.”
Extrinsic, lifestyle factors play a part too, says Dr Ravichandran, highlighting that smoking and alcohol can have a significant impact on the ageing process. “Increasing your free radicals will certainly speed up the rate of fat volume decline, and people who exercise a lot, such as high endurance long-distance runners, will burn fat off all parts of their body, including the face. Illness is also a factor; when you are unwell, you’re very highly metabolic; that can reduce facial fat as well,” he says.
It’s firstly important to note that fat is not the only factor that contributes to the ageing of the mid-face. Miss Chantrey emphasises, “We don’t just age from the fat compartments, we age from the bone, muscle and skin, so practitioners firstly need to think about their patient in the full 3D perspective.” Dr Muir also highlights that tooth loss can affect the mid-facial volume, so this needs to be considered when assessing the patient. To identify where the appropriate area for treatment is, Miss Chantrey will always observe patients in the frontal angle, oblique angle and the lateral profile, with and without different expressions. Mr Dhillon, founder of Define clinic, believes that practitioners should have a formula for assessing every patient. “I like to start with looking at the proportions of the face – so total face assessment. That involves looking at the face shape – in females this is usually an oval/heart shape and males have more of a square shape – and identifying where there is disproportion,” he explains, adding that the second consideration is to look at the thirds of the face, starting with the upper, then middle, then lower. “I’m assessing whether there is fat loss in the medial mid-face or fat loss in the lateral mid-face, or if there are changes to the tear trough, for example. I’ve got to identify differences in these on repose, which is when the patient’s rested, and on animation. From this assessment you can tell how fat moves and where fat loss is occurring, which is going to indicate where you need to treat and where you don’t need to treat,” he explains.
As mentioned, volume loss to the deep fat compartments is a significant area that will likely need replacement following ageing. To restore this, Dr Ravichandran says the goal is to inject underneath the muscle. He explains, “My preferred technique is to use a cannula, due to safety and to reduce the chance of bruising. I also find I get a more natural result. I tend to use a lateral entry point on the zygoma – this is a useful entry point as it doesn’t just allow me access to the mid-face, it allows me access to the eyebrow and up into the temples, should these also need restoration.” Dr Ravichandran aims to inject into the deep medial cheek fat compartment, which is underneath the superficial musculo-aponeurotic system (SMAS). To ensure you are below the SMAS, Dr Ravichandran recommends that practitioners palpate the cannula and then feel how much skin and fat is there. Dr Ravichandran will use the STERiGLIDE 22 gauge cannula, and his product of choice is Belotero Volume. He explains that he uses this filler because he believes it has a good lifting effect, as well as being soft and moldable, holding its shape. “It needs to behave the way fat should to replicate its normal movement, so instead of thinking of stiffness, we think in terms of plasticity, elasticity and cohesivity. Belotero Volume has the correct blend of those properties to give a natural lift without stiffness,” Dr Ravichandran explains. When considering technique, Dr Ravichandran doesn’t recommend bolus injections; instead, he says, “I move the cannula back and forth in a fanning pattern slowly, until I have the correct amount of lift or the correct amount of volume. Once I have done that, I can take the cannula out and reassess the patient. Because of the nature of the product, you can then quite easily mould it or sculpt it into the position you want it to be.”
Miss Chantrey prefers to use the Juvéderm portfolio. She explains that her first product of choice for the cheek area would be Voluma, because she believes it will give the most lift. “It has a nice ability to maintain facial movement and anchor the face in the important spots. However, in patients who are a bit younger and don’t need as much lift or projection, I really like Volift in the cheek because it creates a really beautiful soft contour and an attractive result,” she explains. When it comes to the mid-face, Miss Chantrey would always begin by placing her anchor point onto the bone with a needle. “I always start from the lateral aspect of the face and then go more medially as, in my experience, not all patients need large quantities of medial volume. Remember that not every patient needs all anatomical injections. For instance, not every patient would need every MD Code,” she says, adding, “I would personally never inject the nasolabial fat compartment because I think this can make the patient appear like they are sneering. Instead, we usually want to suspend the area upwards by injecting the laterial facial fat pads.” Miss Chantrey notes that when working in high-risk areas, such as the infraorbital foramen, she will opt to use a cannula to aim to avoid arterial penetration.
Mr Dhillon’s approach will always consider what products and techniques will target and improve the deep fat pads. He says, “It depends how much overlying fat there is in a superficial fat pad. If someone is very thin, I’m going to use a finer product, like Teosyal RHA 4, versus if someone has a bit more fat. In this case, I will use a slightly thicker, viscous and more volumising product like Teosyal Ultra Deep, which I would inject in the deep fat compartment, as you get a very good projection, lift and volumising effect with a very low amount of product usage.” When discussing injection areas, he says, “If you’re targeting the deep fat pads, you’re most often going to be injecting onto or just above the bone, because that’s where they lie. With the superficial fat pads, you’re not going to be on the bone, but you want to make sure you’re above muscle.” Mr Dhillon uses a mixture of needle and cannula to increase safety. “As an example, on the outer/lateral cheek I tend to use a needle, whereas in the medial cheek, which is a higher risk vascular area, I would tend to use a cannula,” he says. He also advises treating patients over a number of sessions. “Sometimes people try to do everything in one go but you don’t need to,” he says, explaining, “Treat or augment an area, wait and review the result and make sure that your patient understands that they may need another session. If you’re going to treat the whole face, 90% of the time you’ll start with the mid-face because that affects the rest of the face. If you’re just treating the mid-face and there’s ageing across the deep and superficial fat pads, I would recommend treating the identified deep fat pads and then review. You may get a really nice result from just treating that deep plane.” Mr Dhillon explains that the superficial plane can be treated with a less viscous product at a later date. He says, “I like to wait a minimum of three weeks – anecdotally that’s how long it takes for the HA to integrate into to the tissue, for any swelling or bruising to settle, if it were to occur, and to see the best results from your filler.”
Dr Muir starts her treatment approach with the upper part of the face, considering not just the mid-face but the temple volume loss too – treatment there may help lift the upper lateral section of the face. She says, “I personally think the mid-face trend is moving away from what magazines were terming ‘pillow face’, picturing celebrities who are full under their eyes and very full in the mid-cheek area. When treating the mid-face, I start with the very upper, lateral part of the face. I would normally start along the zygomatic arch to create a lift, then go laterally and upwards, and then place the product, which is usually Restylane Lyft. I use this because it has an extremely high G-prime, which supports the tissue and starts to pull the mid-face.” There are two techniques that Dr Muir tends to use, which is very much patient dependent. She explains. “The first is direct; I will insert the needle and pull the tissue upwards at the same time, then place the needle down onto the periosteum and aspirate, before placing the correct amount of product depending on the volume loss. If the patient, however, is very slim and looks quite skeletal, I will sometimes use Restylane Defyne.” This is because it has softer tissue integration and it won’t make the slim patient look too angular, she says. For this approach, Dr Muir will use a deep-to-bone technique, where she places linear threads of product deep to bone using a cannula. She will also use a cannula when treating the malar groove, she says, due to the vessels in the region. “I usually use a STERiGLIDE 25 gauge, 38mm cannula, I find longer cannulas are nice to use, often harder to control, but you can access hard-to-reach areas,” she explains.
As with all treatments, practitioners note the importance of understanding the relevant danger zones, complications and anatomy for safe and successful results. Mr Dhillon echoes, “The risk that everyone worries about in the mid-face area is vascular occlusion because there are several important vessels, including the facial artery, infraorbital artery and the angular artery in this area. The most common risk is bruising, so really understand the vascular network for prevention.” Those interviewed agree that fat compartments may not be causing the volume loss, and practitioners may be required to treat other areas of the face rather than treating the mid-face in isolation, so a comprehensive and full facial assessment is required. Tailoring treatments to individual patients is also essential, as is an appropriate consultation, which outlines all the treatment options for the patient to consider. Miss Chantrey reiterates, “Know your anatomy, treat every patient as an individual, select the tool you’re going to use rather than just being a needle/cannula person, and really choose your products carefully.” Dr Muir concludes with her final tip, “Less is always more. Patients don’t want to look too full in the face. I always recommend marking out any of the danger areas and working very carefully to avoid those structures.”
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