Fat pad anatomy: why are superficial fat pads key to aesthetics?
When it comes to discussions on anatomy, these do not always have to be in the context of aesthetic medical training or highbrow conversations between medical clinicians, what about referring to anatomy and talking about it during the consultation? This can help your patients to understand their ageing and how you can both get better results from the treatment plan.
In this blog, Dr Tim Pearce kicks off with the superficial fat pads in the face, the lateral fat depletion that comes with ageing, and how this changes the shape of the face; alongside how you can effectively explain this to your patients during a consultation.
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What are superficial fat pads?
Fat is used as an energy storage, but it also has a functional role to help muscles slide more easily across each other. Similarly, fat, and more specifically fat in the face has an aesthetic role in relation to appearance. Dr Tim believes appearance is a function of health. How you look affects how you feel, behave, and function as an organism.
Fat pads are involved in creating an aesthetic outcome; the way that a person makes you feel when you look at them, the way you feel when you are in your skin is partly about the position and the state of your fat pads.
What is the aesthetic impact of superficial fat pads?
Once you learn and understand more about fat pads, you will start to notice them in people’s faces, particularly in older individuals. As we age, fat pads shift and are usually defined by ligaments which hold on to the surface of the skin. The cutaneous ligaments that attach the skin to the bone will reveal some of the fat compartments so you can see where fat has become depleted and revealed the anatomy underneath.
Aesthetic functions of the fat pads include creating a sense of harmony, contributing to volume which in turn means that they are contributing to the proportions of the face. If a patient loses their lateral fat pads, for example, which often happens more noticeably in women, they become squarer in appearance due to the loss of lateral projection and an increase in the volume of the fat pads lower down the face. As aesthetic practitioners, we are aiming to restore the fat pads higher up and trying to reduce the size of the fat pads that are lower down the face to create a more feminine, heart-shape.
If a patient has maintained their weight during their lifetime and is slim in nature, you will note that they lose fat laterally first and medially later, thus they will appear squarer and heavier in the middle. A good aesthetic treatment approaches from lateral to medial. If your patient is very slim, you can see fat depletion more easily – with bony areas or hollowness more apparent – than in someone with a higher BMI where you will note relative fat depletion with some fat pads bigger than others, but a less obvious missing fat pad in need of replacement.
What are the key superficial fat pads?
Within the face, the superficial fat pads compose the layer of fat between the SMAS (Superficial Musculoaponeurotic System) and the skin. The SMAS is a layer of connective tissue and muscle, with fat compartments on top. The superficial fat pads refer to the fat in this layer straight after the skin, which is why they are aesthetically important.
Dr Tim explains that most anatomical textbooks reference a total of twelve named superficial fat fads.
These break down as three fat pads in the forehead –
- The central forehead fat pad in the middle of the forehead
- Confusingly there are ones to the side of the central forehead referred to as middle or medial forehead fat pads that sit on the lateral aspect of the forehead
- Moving even more laterally is the lateral temporal-cheek (forehead) fat pad on each side of the temples that extends down the side of the face.
There are three fat pads around the eyes –
- Lateral orbital fat pads
As you move further down the face, there are three fat pads in the anterior part of the cheek
- Medial fat pad
- Middle fat pad
- Nasolabial fat pad.
Finally, there are three in the lower face –
- Jowl (superior jowl fat pad and inferior jowl fat pad)
- Pre-mental fat pad
- Pre-platysmal fat pad
How can you explain superficial fat pads to your patients, and why is it important during the consultation?
He goes on to explain that if you tell your patient that they need to have some volume added into their cheeks, they may accept it, but they will not feel certain about the procedure. Yet, when you explain the presence of a fat pad which has shrunk with ageing, they can visually see and understand the impact. Then, as you go on to explain that if you replace it with dermal filler, they will look younger, they understand that you are putting back something that is missing and feel more certain about the process.
You can describe the whole process of ageing and the facial disharmony caused by the loss of the fat pads. Remember, as they lose fat, lateral to medial, it causes the descent of tissue in the mid face resulting in jowls, melo-labial folds (marionette lines), and nasolabial folds, partly because of the lost support higher up the face. This allows the fat pads that do not shrink as much to slip forward. This can be a powerful layer of understanding for your patient and will bring trust to your relationship.
Why not get your hands on a great superficial fat pads poster as part of Dr Tim Pearce’s collection of individual artistic anatomy posters for your clinic. These are great to use during a consultation with your patients.
Can you inject patients in an area with a scar?
A viewer noticed in one of Dr Tim’s educational videos that he was injecting a patient who had a scar on her lip. The practitioner had been taught not to inject patients if they have a scar in an injection site area because there is an increase in risk and wondered what Dr Tim’s justification process is for treating a patient with a scar.
Dr Tim approaches risk differently, unlike those who think that everything is black or white. He believes that risk is relative and there are always exceptions to any ‘oh that never happens’ arguments. A patient may appear to be a higher risk, but that does not mean that you should choose never to treat them without doing a full assessment first. You may find as you make your decision that the risk is slightly higher than a standard patient, but not so high as to not justify the difference you can make for them by treating.
When considering injecting a scar around a lip, if it is a simple scar, there is little increased risk than in other areas if you assess the individual anatomy. You can test the depth of your needle in the lip, by elevation, to ensure you are not within the labial arteries. Similarly perform small volume additions at a time so you can assess in between injections, you may choose to aspirate more often for reassurance, and if you have access to a device, you could use ultrasound before the treatment to determine if the scar has influenced the anatomy or would impede your technique in any way. This level of evaluation might enable you to step into an area that might be seen as a high risk, but to do it in such a way that makes it a justifiable risk, says Dr Tim.
How do superficial fat pads impact treatment design?
Once you understand the fat pads and you know where they are, Dr Tim notes that you will start to analyse faces more easily and quite often you will see a specific fat pad that has shifted or lost volume. Once you have discussed this and explained your planned approach with your patient, and all is agreed, you will find that you get much better results because you have treated the missing fat pad as opposed to executing a template or one-size-fits-all injection pattern that you learned in your training.
You can find Dr Tim Pearce on Instagram if you have any questions or comments about facial anatomy, including superficial and deep fat pads (coming in another blog).
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Aesthetics Mastery Show
Why fat pads are a key piece of aesthetics
In this episode, Dr Tim talks how this anatomical feature is central to successful aesthetic treatments because of the impact on the shape of the face; the harmony between structures; and its proportions. He discusses fat pad depletion with age; the vital impact that fat pads have on the consultation process and educating our patients; and how we should use them to design injectable treatments. Watch the full Aesthetics Mastery Show here.
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