December 15, 2022

fillers tear trough eye anatomy

In a previous blog, Dr Tim Pearce explored why superficial fat pads are important in facial aesthetics, how to discuss them with your patients, and develop your treatment design.

In this blog, Dr Tim continues looking at the importance of fat pad anatomy, moving onto the deep fat pads in the upper, middle, and lower third of the face, including how to decide when to inject the deep fat pads versus the superficial fat pads. You can use this anatomy knowledge during your consultation to predict the amount of dermal filler required to achieve patient goals. Remember, discussing anatomy during the consultation can build trust and help your patients to understand their ageing so you can both get better results from the treatment plan.

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What are deep fat pads?

The fat pads of the face are broadly divided into superficial and deep, with the division between the two being the SMAS or Superficial Musculoaponeurotic System. This layer of connective tissue and muscle divides these two fat compartments – the superficial fat pads are above the SMAS, underneath the skin, and the deep fat pads are underneath the SMAS – although, it is a little more complex than that in the mid face, so keep reading.

The purpose of the deep fat pads is quite complex; thus, Dr Tim breaks it down into three primary roles.

  1. Deep Fat Pads and LigamentsDeep fat pads have a biochemical, biophysiological role to produce energy when needed, which is perhaps something we are less interested in when it comes to facial aesthetics.
  2. Deep fat pads have a functional role to provide a degree of support for the muscles to prevent them from sagging or getting stretched too easily. They also provide a point of leverage, so a smaller contraction might pull more tissue, in some cases more easily, and they dampen the movement of the muscle, so a contraction is not overly overt – creating a harmonising effect.
  3. Deep fat pads have an aesthetic role to project and convey a sense of health; if they are in the ‘right’ place, have the correct levels of volume, it creates what we perceive, as a social survival mechanism, as a beautiful and healthy individual. The fat pads play an important role in projecting an individual’s health to others through the way that they look.

Why not get your hands on a great deep fat pads and ligaments 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.

Where are the deep fat pads?

Dr Tim urges caution when researching the topic of deep fat pads, noting that you may find differing and conflicting information and illustrations returned when using search engines. In the main, this reflects on the detail of the anatomical content you will find, with some only referencing primary fat pads and missing more in-depth observations.

Some clinical documentation refers to four or five fat compartments in the forehead alone. These include the subprocerus or galeal fat pad and the subfrontal deep fat pad compartment, essentially meaning underneath the frontalis muscle, which is divided into two frontal septums. There are two subfrontal fat pads between the inferior frontal septum and the middle frontal septum and three deep fat pads superior to the medial frontal septum. Therefore, adding all of them together, you get five deep fat pads underneath the frontalis muscle, which is very important for some injections where we are restoring a more youthful shape to the forehead.

Around the eyes, the deep fat pads focus on the SOOF or suborbicularis oculi fat pad. The SOOF is divided into two different fat pads, the lateral and the medial SOOF. This is an important consideration when treating the tear trough effectively, as you are restoring this fat pad.

Things are more complex when we look at deep fat pads in the mid face, and here Dr Tim again cautions that you will encounter different illustrations when searching for reference materials on the Internet. Most illustrations will define the two main fat pads – the buccal fat pad which extends all the way underneath the zygoma into the temple, and the deep medial cheek fat pad.

More detailed descriptions will include the deep lateral cheek fat pad and the deep nasolabial fat compartment which is in the pre-maxillary space. The latter is a deep fat pad which lies on top of the levator labii superioris alaeque nasi muscle. Dr Tim affirms that it is important to understand this because this is where the mid face is different to the lateral part of the face because our deep fat pads can lie on top of muscles, like a roof tile effect, which is quite unusual. Thus, even though a fat pad is deep, there may sometimes be muscles underneath because of the way that they are placed.

It can be difficult to locate anatomical information on deep fat pads in the lower face, highlights Dr Tim, but with a little digging, there is evidence of their existence – particularly the retro orbicularis oris fat pad. He notes the relevance of this fat pad when viewing faces in older patients (70+), particularly if they have lost volume or are very slim, as it affects the whole structure of the mouth. With more holistic restorations, when you are trying to take years off someone and you are treating some of these deep fat pads, the retro orbicularis oris fat pad may be a consideration.

Within the lower face and medially, we also find the deep chin fat, in the middle of the chin underneath the mentalis muscle and laterally, lies the deep labiomandibular fat pad. These fat pads are important for stabilising the position of the chin. Dr Tim notes that he performs a lot of treatments, relatively deep using a cannula, to help restore the chin and a heart-shaped face.

How do you decide whether to inject the superficial or deep fat pads?

When approaching treatment, you often start with the deep fat pads, as you seek to restore the underlying structure and work on the foundations. However, Dr Tim maintains that you are often injecting all the fat pads with most treatments. If there is a crease, or you want to create a little more projection, he often layers his injections, some deep and some superficial, using his aesthetic judgement. Once you understand the anatomy of the fat pads, it becomes quite clear where you need to inject and how much dermal filler you need to deposit.

 

Taking temples as an example, the focus is on the deep temple fat pad and the buccal fat pad. The latter is quite a large structure, with an approximate volume of 15mls in youth, however with ageing, it shrinks. If you choose to recommend a treatment, and are focusing on volume, then it is useful to know the normal volume of the buccal fat pad, because by adding 2mls of dermal filler, you are not performing a very large treatment, although it might seem that way. It therefore helps to know where you are injecting, why you are injecting, and how much you are injecting by understanding some of the properties of the fat pads. Dr Tim concludes that the most common treatment for the temple would be approximately 0.5ml-2ml on each side, but there are always patients at the extreme who may benefit from 4mls or more on each side.

 

In summary, Dr Tim spells out that changes in the fat pads are one of the primary changes when we consider ageing, however, it gets even more interesting when we start to relate them to the ligaments which run through the fat pads and attach the skin to the surface. The fat pads create potential spaces, which change as you get older, losing volume or acquiring excess volume when combined with the ligaments. As an aesthetic practitioner, you start to see dips in the skin with ageing denoting the relationship between the superficial fat pads, the deep fat pads, and the ligaments, with 70-80% of visible ageing due to these structures and their relationships – more on that in another blog.

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

Deep fat pads

In this episode, Dr Tim gives a detailed anatomy lesson on the upper, middle and lower third deep fat pads, including how to decide when to inject deep vs superficial fat pads. He also discusses how to use the deep fat pads to build trust in the consultation and treatment design stages, including how to predict the number of mls of dermal filler you will need in certain areas.. Watch the full Aesthetics Mastery Show here.

Read more and join in the debate on our YouTube channel.

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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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