What are the different techniques to elevate malar fat pads? And which is the strongest one?

Question

I have low and heavy malar fat pads and tear through lines. And the junction/line where the lower eyelid and cheek meet is very low. How can you lift the malars fat pads so that this junction between the lower eyelid and the cheek comes higher up? How do you fixate the malar fat pad higher up? Would a facelift where skin and SMAS is trimmed, malar/rim implants and a malar fat pad elevation be able to lift and tighten the midface area sufficiently? Thank you!

Alejandro J. Quiroz, MD · Answer

Thank you for your question. The droopy fat pads in the malar area can be elevated with the SMAS that procedure can be done with a face-lift. Also a middle face lift can elevated the fat pads but which procedure is best you need to discuss with your surgeon and also needs to evaluated your face in general.

Thomas A. Mustoe, MD, FACS · Answer

The malar or cheek fat lads are positioned above the SMAS, which is a thin but tough musculofascial layer that is anchored to the deeper tissues overlying the bone by multiple collagen bundles that are called retaining ligaments.   More superficial procedures that rely on sutures without release of the retaining ligaments give limited benefit.  Subperiosteal that release the deeper layers immediately over bone often give a prolonged unnatural swelling of the cheeks and eyelid area with severe swelling.   The best procedure is a deep plane subSMAS facelift that thoroughly releases the retaining ligaments of the midface extending up to the lower part of the lower eyelid and medically over the smile muscle.   Then the superficial muscle surrounding the eyelid (orbicularis oculi) can be mobilizes and rightened.   When consulting surgeons you should ask to see before and after pictures that address your issues.   The procedure requires more technical precision but is worth it.

Lucian Ion, FRCS · Answer

Thank you for your inquiry.

Your description suggests that there is a moderate amount of fullness in the lower eyelids that makes them more prominent. This usually is associated with the perception that the orbital rim, the junction between the lower eyelid and the cheeks, sits relatively low.

The treatment is not necessarily to lift the malar fat pad, but rather to create the impression that it is lifted by restoring the continuity between the volume of the cheek and the volume of the lower eyelid. This can be done through a combination of a mid-face lift and lower eyelid blepharoplasty. In some instances, lower eyelid blepharoplasty can achieve this through redistribution of the lower eyelid fatty tissue over the rim of the bone, producing the impression that the separation between the cheek and the lower lid has moved up.

Deep-plane facelift surgery also produces a significant amount of volume redistribution for the face and could be a solution for you. To better understand what a deep-plane facelift can offer, I suggest examining your facial features when you lie down completely flat with no pillow. The redistribution of the volume of the lower and mid-face in this position is relatively well aligned with the changes that you would experience with a deep-plane facelift intervention.

Zoran Potparic, MD · Answer

Since introduction of concept of volume replacement in the past 20 years or so, indications for cheek lift has changed significantly. We found that it is primarily deflation (loss of volume) in cheek/malar/eyelid junction area that created malar flatness and long, tired looking eyelids, rather than sagging. For that reason, volume replacement by means of fillers and fat grafts was introduced as a primary treatment of this area. True cheek/malar lift is used only in selected patients either with pull and fixation of SMAS, suture to temporal fascia or fixation to the lower orbital rim. Malar implants, fat grafts, fillers can be used in addition to lift based on individual needs. Good luck.

Ronald Schuster, MD · Answer

Malar fat pads frequently need to be addressed for a complete natural appearance from facelift surgery. Sometimes the can be elevated and/or trimmed from the facelift approach. Other times they are best elevated with a midface lift. Midface lifts are done several different ways. I like to approach them vertically through the lower eyelid and attach them directly to the bone.

Sean Alemi, MD · Answer

The best option for malar fat pad rejuvenation is often debated among surgeons, so this is a great question! The most natural and long lasting way to rejuvenate the midface is with a deep plane facelift which releases the zygomatic retaining ligaments that tether the malar fat pad. Once these tension points have been released, the midface is mobilized and can be lifted nicely back into position to create a more youthful midface contour. SMAS type facelift operations are not able to adequately address the midface because these ligaments are not released. Depending on the anatomy of your lower eyelids and the degree of tear trough hollowing you may be a good candidate for lower blepharoplasty which could also improve your lower eyelid-cheek junction as well, but you would need an in person consultation with a plastic surgeon to determine candidacy. Hope this helps you!