#PRSJournalClub Wrap-Up: Three-Dimensional Topographic Surface Changes in Response to Compartmental Volumization of the Medial Cheek: Defining a Malar Augmentation Zone

by Ibrahim Khansa, MD (@IbrahimKhansaMD)

The May edition of the #PRSJournalClub was a rich discussion of a very timely PRS article, entitled “Three-Dimensional Topographic Surface Changes in Response to Compartmental Volumization of the Medial Cheek: Defining a Malar Augmentation Zone”, by Drs. Stern, Schreiber (@schreiber_md), Surek (@csurek11), Garfein, Jelks, Jelks (@thedoctorsjelks) and Tepper (@drorentepper). Dozens of participants were able to ask questions, and get answers from the authors of the article in real time on twitter over a two-day period (May 22-23). Vivid discussions took place, in which other experts in the field of facial rejuvenation and volumization, including Dr. Rohrich (@DrRodRohrich) and Dr. Nahai (@NahaiDr), shared their tips on rejuvenating the malar area.

In the article, Stern et al focus on the deep medial cheek compartment, which was first described in “The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery,”” by Rohrich and Pessa (Rohrich RJ, Pessa JE. . Plast Reconstr Surg. 2007;119:2219–2227). Using apple sauce as an analogue for fat, the authors augmented this compartment in eight cadavers, then obtained measurements of the malar area using a three-dimensional camera. In four of the cadavers, the medial portion of the arcus marginalis was released before augmenting the deep medial cheek compartment. They studied the effect of various injection volumes on the size and projection of the compartment.

The authors found that the arcus marginalis constituted the superior border of the deep medial cheek compartment. They found that the deep medial cheek compartment had a trapezoidal shape when the arcus marginalis was intact, and a shield-like shape when the arcus was released. The diameter, perimeter and projection of the compartment all increased with increasing injection volume. The dimensions of the augmentation zone did not differ when the arcus marginalis was released compared to when it was not. However, release of the arcus marginalis before malar augmentation resulted in a favorable effacement of the palpebro-malar interface.

YouTube Discussion

The article was first discussed by the current Resident Ambassadors to the PRS Editorial Board Sammy Sinno, MD (@sammysinnoMD), Amanda Silva, MD (@AmandaKSilvaMD), and Raj Sawh-Martinez, MD (@docrfsm) with special guest moderator Heather Furnas, MD (@drheatherfurnas). Listen to the discussion:

Tweets to get started:

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Top Q&A

@FrancescoEgro: How fresh were the cadavers? How differently would u expect live tissue to react. More elastic & less defined?

@drorentepper: very good point you raise – fresh cadavers but still key limitation…clinical paper is coming soon

 

@AmandaKSilvaMD: what are the limitations of 3D imaging?

@drorentepper: 3D imaging still requires someone to do analysis – but the software keeps getting easier

 

@shujashafqatmd: Could 3D imaging analysis be used to ID areas that are deflated and may benefit from filler/fat?

@drorentepper: creating left and right composite images are really helpful.

@shujashafqatmd: interesting. Mirroring the sides on each other to look for asymmetry?

@IbrahimKhansaMD: Or can you overlay old photos of patient from younger years?

@AmandaKSilvaMD: seems most helpful. @drorentepper @thedoctorsjelks is that possible w/ 3D imaging tech?

 

@drorentepper: seems like our patients all need a baseline office 3D image so we follow their aging

@shujashafqatmd: would be interesting to follow detailed changes over time

@IbrahimKhansaMD: Agreed. If software allows overlaying old pics, can use filler to literally “rejuvenate” face

 

@sammysinnoMD: Do you think the deep malar is most important compartment to inject?

@drorentepper: Deep medial not the most important – but data suggests gives reliable augmentation

 

@IbrahimKhansaMD: What is your preferred filler for deep medial compartment?

@csurek11: preferred filler would be a large particle size, high G-prime HA. Also…another option is small aliquots of autologous fat

@sammysinnoMD: how many ccs of fat?

@drorentepper: tailored for patient – but approx 1-2cc to each compart

@csurek11: I agree, sometimes 3 cc in severe deflation

 

@sammysinnoMD: do you recommend a depot or fanned injection?

@DrRodRohrich: use deep fat compartment fanned small volume injections

 

@AmandaKSilvaMD: Do you prefer filler over fat?

@drorentepper: I prefer fat for this deep inj (Foundation), but a great Q for a follow up study

 

@IbrahimKhansaMD: In terms of sequence, do you fill cheek first, then release arcus, or vice versa?

@drorentepper: release the Arcus first – the fill. This allows you to create space and then augment

 

@shujashafqatmd: How does medial release of the arcus allow for increased fill in lateral lower lid as in the diagram

@drorentepper: great Q- the clinical correlate is release with injection to both medial and lateral compartments…stay tuned

 

@pallabc: Many confounding factors. Amount of deflation, dermal thinning, injection technique

@drorentepper: valid limitations to the study…apple sauce as fat analogue not ideal either

@IbrahimKhansaMD: Could extend the study to fat and other fillers with different G prime values

 

@docrfsm: What is the future of 3D imaging in plastic surgery? Is a clinical correlate of malar fat aug coming?

@DamianMarucci: Office 3D imaging eg Vectra should be able to clinically correlate cadaver data soon

@pallabc: May not be easy to correlate in clinical situations. Live tissue swells up differently

@drorentepper: great point… but 3D photo will be important to understand how much swelling & how long.

 

@pallabc: How meticulous you had to be to measure subtle mm changes? Time consuming?

@schreiber_md: Software very sensitive to surface changes, we define sig change >1mm. Analysis fast with some experience

 

@shujashafqatmd: Could 3D imaging analysis be used to ID areas that are deflated and may benefit from filler/fat?

@pallabc: Seems ideal to do, doesn’t it? But may complicate a straightforward cosmetic procedure.

@shujashafqatmd: true. Would have to factor in surgeon judgment as with many technologies

@pallabc: That is where plastic surgeons with profound understanding of facial topography will score!

 

@IbrahimKhansaMD: Total or partial corrugator resection? Via upper bleph incision?

@FrancescoEgro: I have seen @NahaiDr performing tranpalpebral corrugator resection used during upper bleph

@IbrahimKhansaMD: Thanks @FrancescoEgro! Was resection total or partial? And was muscle replaced with fat graft?

@FrancescoEgro: I think it was partial and was not replaced by fat. Perhaps @NahaiDr can share his views with us : ) Of note there is less fat retention following fat grafting to muscle likely due to mobilization

@NahaiDr: I do routinely replace respected muscle with fat. Only selectively.

 

@FrancescoEgro: Would be interesting to correlate the injected volume and retention rate

@DrRodRohrich: it is about 50% fat retention

@FrancescoEgro: With that in mind do u aim to inject twice the amount?

@DrRodRohrich: you should only inject 2x more fat in superficial fat compartments not Deep!

 

@DrNikkiPhillips: Would u recommend routine arcus marginalis release for effects on tear trough/ NJ groove?

@drorentepper: not for all patients –just in those with really deep NJ groove. Still can see nice results with augmenting alone

 

@DrRodRohrich: The best Evidence is minimal fat manipulation and rapid reinjection

@pallabc: Coleman technique comes closest to that ideal, IMO. Centrifugation concentrates the vital stem cell portion

 

@pallabc: Would u consider injecting the compartment from intraoral route? Fat inj cannula may cause scarring

@DrRodRohrich: no don’t do intraoral !@DrRodRohrich no scarring noted -use 16 G needle only no incision ok!

 

@JordanFreyMD: What is cut off to fat graft? Concave submalar “B” point?

@DrRodRohrich: the stopping point for deep malar fat injection is correction of the malar V deformity

 

@RajaMohanMD: Question for all, but what is your take on fat repositioning vs autologous fat grafts for blephs and mid face lifts?

@DrRodRohrich: Fat transpositioning is too variable to in this area!! use DEEP malar fat aug always!

 

@pallabc: Clinically, is it practical to augment deep compartment? Motion of buccinator may reduce take of fat grafts

@DrRodRohrich: Key here is that Buccinator is in separate compartment that is unique as it goes deep to superficial -Don’t inject it

 

@SammySinnoMD: what studies are you planning next?

@drorentepper: the clinical correlate to this study – showing malar augmentation and Blending of lid-cheek jxn.

@drorentepper: soon to see follow up study on lateral cheek and clinical correlate. we should understand augmenting chin better

 

@ChadPurnellMD: Do you already obtain pre-and postop 3D images on all facial fat grafting pts?

@drorentepper: it’s routine at this point. My hope is that many others are also do -so we have a wealth of data soon!

 

Complete May Edition of #PRSJournalClub Podcast:

 

Complete June Edition of #PRSJournalClub Podcast:


REFERENCES
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  1. Rohrich RJ, Pessa JE. The fat compartments of the face: Anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227.
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