The subcutaneous fat spaces of the face are subdivided into (1) submental, (2) submandibular, (3) pre-parotid, (4) lower nasolabial, (5) upper nasolabial, and (6) malar fat pads.1-3 These spaces are highly compartmentalized and change at different rates with time.4 In a youthful face, transitions between these different subcutaneous compartments are smooth, whereas in the aging face, disruptions between these spaces break up cosmetic units and draw attention to these discrepancies. The malar fat pad is an area composed of subcutaneous fat between the obicularis oris muscle and the deep dermis. Due to its superficial location, any bulge or pouching in this region is particularly noticeable. Throughout the literature many have attempted to correct this deformity through various techniques including direct suspension of fat pads, muscular rotation and splitting, and surgical excision.5 We, however, subscribe to facial liposuction of the area. The discussion that follows presents a brief overview of this technique. OPERATIVE TECHNIQUE Liposuction is an office-based outpatient procedure. Local tumescent anesthesia, alone, is perfectly adequate to accomplish correction of the malar fat pad. However, we have found the combination of tumescent infiltration with monitored sedation by a nurse anesthetist or anesthesiologist optimizes the patient’s overall procedural experience. Prep Method First, the areas to be treated are outlined and marked with a surgical pen. These areas are then scrubbed and prepped in a surgical fashion. Anesthesia Approach Second, conscious sedation utilizing intravenous midazolam and profol is initiated. The patient’s EKG, blood pressure, pulse and oxygen saturation are then continuously monitored.6 Next, with the patient in the supine position, one small stab incision (2 mm) is made in the orbital rim near the lateral canthus of the lower eyelid, bilaterally. Over the years, our choice of local anesthesia has evolved. In earlier cases, a small blunt-tip Zaki infusor was next introduced and 0.25% lidocaine/1:400,000 epinephrine solution slowly delivered to the malar pouch. Volumes infused average 10 cc to 15 cc per each side. However, our more updated protocol enlists the use of 1% lidocaine/1:100,000 epinepherine (1cc to 2 cc per side) — rather than Klein’s solution — which is delivered through a 1-inch, 30g needle. Liposuction Steps and Caveats • After waiting 15 minutes for the entire treatment zone to completely blanche, a small Tulip cannula (2.1 mm spatula tip) attached to a 10 ml syringe is introduced. (See Figure 1.) • Suctioning is then performed in a back-and-forth motion in a radial fashion with feathering of the edges. • When the fat is no longer palpable, suctioning is stopped, as this is the procedure’s endpoint. • Typically, about 1.0 cc of fat is extracted from each side. • To prevent puckering and depressions, over-suctioning should be avoided. Site Closure Finally, the incision sites are closed with one 6.0 Prolene suture if liposuction is combined with laser resurfacing of the area. However, if liposuction alone is employed, only steri-strips are required to create slight compression over the treatment area. After Surgery After surgery, the patient is moved to the recovery room with the intravenous line in place and is monitored until alert, hemodynamically stable and ambulatory. It is imperative that post-operatively, a firm pressure dressing is applied to the area for a minimum of 24 hours, after which time, it is ideal to apply ice packs to the treated area for several hours per day for 1 week. Sutures are removed 5 days post-operatively. POST-OPERATIVE COMPLICATIONS Post-operative complications have been minimal and we have not experienced hematomas, infections, neuralgia or skin slough. Perforations are possible, especially with thin skin or over-aggressive suctioning. Over-aggressive suctioning can also lead to skin depressions, which form if too much fat is extracted from the pouch. Therefore, there exists a fine balance between over-suctioning and under-suctioning, which contrastingly can produce marginal results. RESULTS Since 1986, we have performed more than 2,000 cases of facial liposuction, using the described technique. Post-operative pain and discomfort are minimal; however, ecchymosis and edema are not uncommon and can be significant. Patients should be informed of this temporary result prior to the procedure, but reassured that any bruising or swelling should resolve with time. For this reason, it is also important that the patient be cautioned about pre-operative use of blood thinners. Additionally, ultimate improvement in the treated area may not be completely realized for 3 to 6 months, as is generally true whenever liposuction is performed. The outlined procedure can also be safely combined with lower eyelid blepharoplasty and carbon dioxide laser resurfacing. But overall, our correction technique alone has consistently produced good to excellent results. (See Figures 2 and 3.) Conclusion The malar bulge is a superficial, localized collection of subcutaneous fat positioned inferiorly to the lateral lower eyelid. As the face ages, supporting structures that secure this fat pad lose their integrity and overlying skin becomes more redundant, making this “pouch” more obvious. Attempts to correct this change in facial contouring with lower lid blepharoplasty, alone, are often unsuccessful. Though such a procedure can improve lower eyelid festooning, it does not correct the small portion of fat that often extends into the malar region from the underlying orbicularis oculi muscle. Thus, despite the fact that we have found malar fat pad correction alone to be easily achieved with local liposuction, in selected patients it can also nicely complement lower lid blepharoplasty, giving the periorbital region a more rejuvenated look. If in addition to malar puffs, there exists a significant redundancy of skin, the carbon dioxide laser, or even direct excision, can further optimize cosmesis. In summary, correction of malar fat pads with localized liposuction yields satisfying results, and is simple to perform. Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University College of Physicians and Surgeons in New York City. Dr. Eickhorst is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, Ohio. Disclosures: Drs. Bisaccia, Eickhorst, Rogachefsky and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
Liposuction of the Malar Fat Pads
The subcutaneous fat spaces of the face are subdivided into (1) submental, (2) submandibular, (3) pre-parotid, (4) lower nasolabial, (5) upper nasolabial, and (6) malar fat pads.1-3 These spaces are highly compartmentalized and change at different rates with time.4 In a youthful face, transitions between these different subcutaneous compartments are smooth, whereas in the aging face, disruptions between these spaces break up cosmetic units and draw attention to these discrepancies. The malar fat pad is an area composed of subcutaneous fat between the obicularis oris muscle and the deep dermis. Due to its superficial location, any bulge or pouching in this region is particularly noticeable. Throughout the literature many have attempted to correct this deformity through various techniques including direct suspension of fat pads, muscular rotation and splitting, and surgical excision.5 We, however, subscribe to facial liposuction of the area. The discussion that follows presents a brief overview of this technique. OPERATIVE TECHNIQUE Liposuction is an office-based outpatient procedure. Local tumescent anesthesia, alone, is perfectly adequate to accomplish correction of the malar fat pad. However, we have found the combination of tumescent infiltration with monitored sedation by a nurse anesthetist or anesthesiologist optimizes the patient’s overall procedural experience. Prep Method First, the areas to be treated are outlined and marked with a surgical pen. These areas are then scrubbed and prepped in a surgical fashion. Anesthesia Approach Second, conscious sedation utilizing intravenous midazolam and profol is initiated. The patient’s EKG, blood pressure, pulse and oxygen saturation are then continuously monitored.6 Next, with the patient in the supine position, one small stab incision (2 mm) is made in the orbital rim near the lateral canthus of the lower eyelid, bilaterally. Over the years, our choice of local anesthesia has evolved. In earlier cases, a small blunt-tip Zaki infusor was next introduced and 0.25% lidocaine/1:400,000 epinephrine solution slowly delivered to the malar pouch. Volumes infused average 10 cc to 15 cc per each side. However, our more updated protocol enlists the use of 1% lidocaine/1:100,000 epinepherine (1cc to 2 cc per side) — rather than Klein’s solution — which is delivered through a 1-inch, 30g needle. Liposuction Steps and Caveats • After waiting 15 minutes for the entire treatment zone to completely blanche, a small Tulip cannula (2.1 mm spatula tip) attached to a 10 ml syringe is introduced. (See Figure 1.) • Suctioning is then performed in a back-and-forth motion in a radial fashion with feathering of the edges. • When the fat is no longer palpable, suctioning is stopped, as this is the procedure’s endpoint. • Typically, about 1.0 cc of fat is extracted from each side. • To prevent puckering and depressions, over-suctioning should be avoided. Site Closure Finally, the incision sites are closed with one 6.0 Prolene suture if liposuction is combined with laser resurfacing of the area. However, if liposuction alone is employed, only steri-strips are required to create slight compression over the treatment area. After Surgery After surgery, the patient is moved to the recovery room with the intravenous line in place and is monitored until alert, hemodynamically stable and ambulatory. It is imperative that post-operatively, a firm pressure dressing is applied to the area for a minimum of 24 hours, after which time, it is ideal to apply ice packs to the treated area for several hours per day for 1 week. Sutures are removed 5 days post-operatively. POST-OPERATIVE COMPLICATIONS Post-operative complications have been minimal and we have not experienced hematomas, infections, neuralgia or skin slough. Perforations are possible, especially with thin skin or over-aggressive suctioning. Over-aggressive suctioning can also lead to skin depressions, which form if too much fat is extracted from the pouch. Therefore, there exists a fine balance between over-suctioning and under-suctioning, which contrastingly can produce marginal results. RESULTS Since 1986, we have performed more than 2,000 cases of facial liposuction, using the described technique. Post-operative pain and discomfort are minimal; however, ecchymosis and edema are not uncommon and can be significant. Patients should be informed of this temporary result prior to the procedure, but reassured that any bruising or swelling should resolve with time. For this reason, it is also important that the patient be cautioned about pre-operative use of blood thinners. Additionally, ultimate improvement in the treated area may not be completely realized for 3 to 6 months, as is generally true whenever liposuction is performed. The outlined procedure can also be safely combined with lower eyelid blepharoplasty and carbon dioxide laser resurfacing. But overall, our correction technique alone has consistently produced good to excellent results. (See Figures 2 and 3.) Conclusion The malar bulge is a superficial, localized collection of subcutaneous fat positioned inferiorly to the lateral lower eyelid. As the face ages, supporting structures that secure this fat pad lose their integrity and overlying skin becomes more redundant, making this “pouch” more obvious. Attempts to correct this change in facial contouring with lower lid blepharoplasty, alone, are often unsuccessful. Though such a procedure can improve lower eyelid festooning, it does not correct the small portion of fat that often extends into the malar region from the underlying orbicularis oculi muscle. Thus, despite the fact that we have found malar fat pad correction alone to be easily achieved with local liposuction, in selected patients it can also nicely complement lower lid blepharoplasty, giving the periorbital region a more rejuvenated look. If in addition to malar puffs, there exists a significant redundancy of skin, the carbon dioxide laser, or even direct excision, can further optimize cosmesis. In summary, correction of malar fat pads with localized liposuction yields satisfying results, and is simple to perform. Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University College of Physicians and Surgeons in New York City. Dr. Eickhorst is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, Ohio. Disclosures: Drs. Bisaccia, Eickhorst, Rogachefsky and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
The subcutaneous fat spaces of the face are subdivided into (1) submental, (2) submandibular, (3) pre-parotid, (4) lower nasolabial, (5) upper nasolabial, and (6) malar fat pads.1-3 These spaces are highly compartmentalized and change at different rates with time.4 In a youthful face, transitions between these different subcutaneous compartments are smooth, whereas in the aging face, disruptions between these spaces break up cosmetic units and draw attention to these discrepancies. The malar fat pad is an area composed of subcutaneous fat between the obicularis oris muscle and the deep dermis. Due to its superficial location, any bulge or pouching in this region is particularly noticeable. Throughout the literature many have attempted to correct this deformity through various techniques including direct suspension of fat pads, muscular rotation and splitting, and surgical excision.5 We, however, subscribe to facial liposuction of the area. The discussion that follows presents a brief overview of this technique. OPERATIVE TECHNIQUE Liposuction is an office-based outpatient procedure. Local tumescent anesthesia, alone, is perfectly adequate to accomplish correction of the malar fat pad. However, we have found the combination of tumescent infiltration with monitored sedation by a nurse anesthetist or anesthesiologist optimizes the patient’s overall procedural experience. Prep Method First, the areas to be treated are outlined and marked with a surgical pen. These areas are then scrubbed and prepped in a surgical fashion. Anesthesia Approach Second, conscious sedation utilizing intravenous midazolam and profol is initiated. The patient’s EKG, blood pressure, pulse and oxygen saturation are then continuously monitored.6 Next, with the patient in the supine position, one small stab incision (2 mm) is made in the orbital rim near the lateral canthus of the lower eyelid, bilaterally. Over the years, our choice of local anesthesia has evolved. In earlier cases, a small blunt-tip Zaki infusor was next introduced and 0.25% lidocaine/1:400,000 epinephrine solution slowly delivered to the malar pouch. Volumes infused average 10 cc to 15 cc per each side. However, our more updated protocol enlists the use of 1% lidocaine/1:100,000 epinepherine (1cc to 2 cc per side) — rather than Klein’s solution — which is delivered through a 1-inch, 30g needle. Liposuction Steps and Caveats • After waiting 15 minutes for the entire treatment zone to completely blanche, a small Tulip cannula (2.1 mm spatula tip) attached to a 10 ml syringe is introduced. (See Figure 1.) • Suctioning is then performed in a back-and-forth motion in a radial fashion with feathering of the edges. • When the fat is no longer palpable, suctioning is stopped, as this is the procedure’s endpoint. • Typically, about 1.0 cc of fat is extracted from each side. • To prevent puckering and depressions, over-suctioning should be avoided. Site Closure Finally, the incision sites are closed with one 6.0 Prolene suture if liposuction is combined with laser resurfacing of the area. However, if liposuction alone is employed, only steri-strips are required to create slight compression over the treatment area. After Surgery After surgery, the patient is moved to the recovery room with the intravenous line in place and is monitored until alert, hemodynamically stable and ambulatory. It is imperative that post-operatively, a firm pressure dressing is applied to the area for a minimum of 24 hours, after which time, it is ideal to apply ice packs to the treated area for several hours per day for 1 week. Sutures are removed 5 days post-operatively. POST-OPERATIVE COMPLICATIONS Post-operative complications have been minimal and we have not experienced hematomas, infections, neuralgia or skin slough. Perforations are possible, especially with thin skin or over-aggressive suctioning. Over-aggressive suctioning can also lead to skin depressions, which form if too much fat is extracted from the pouch. Therefore, there exists a fine balance between over-suctioning and under-suctioning, which contrastingly can produce marginal results. RESULTS Since 1986, we have performed more than 2,000 cases of facial liposuction, using the described technique. Post-operative pain and discomfort are minimal; however, ecchymosis and edema are not uncommon and can be significant. Patients should be informed of this temporary result prior to the procedure, but reassured that any bruising or swelling should resolve with time. For this reason, it is also important that the patient be cautioned about pre-operative use of blood thinners. Additionally, ultimate improvement in the treated area may not be completely realized for 3 to 6 months, as is generally true whenever liposuction is performed. The outlined procedure can also be safely combined with lower eyelid blepharoplasty and carbon dioxide laser resurfacing. But overall, our correction technique alone has consistently produced good to excellent results. (See Figures 2 and 3.) Conclusion The malar bulge is a superficial, localized collection of subcutaneous fat positioned inferiorly to the lateral lower eyelid. As the face ages, supporting structures that secure this fat pad lose their integrity and overlying skin becomes more redundant, making this “pouch” more obvious. Attempts to correct this change in facial contouring with lower lid blepharoplasty, alone, are often unsuccessful. Though such a procedure can improve lower eyelid festooning, it does not correct the small portion of fat that often extends into the malar region from the underlying orbicularis oculi muscle. Thus, despite the fact that we have found malar fat pad correction alone to be easily achieved with local liposuction, in selected patients it can also nicely complement lower lid blepharoplasty, giving the periorbital region a more rejuvenated look. If in addition to malar puffs, there exists a significant redundancy of skin, the carbon dioxide laser, or even direct excision, can further optimize cosmesis. In summary, correction of malar fat pads with localized liposuction yields satisfying results, and is simple to perform. Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University College of Physicians and Surgeons in New York City. Dr. Eickhorst is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, Ohio. Disclosures: Drs. Bisaccia, Eickhorst, Rogachefsky and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
