Purpose

Restoration of cheek volume is recognized as an important part of facial rejuvenation.  However, there have been no previous studies that have determined whether any soft tissue technique is effective in achieving lasting malar augmentation.  Magnetic resonance imaging offers a noninvasive means to assess change in malar volume in patients and has been used previously to assess the nasolabial crease.¹

Methods

This study prospectively evaluated a subset of 5 patients who were also included in a prospective clinical study of facial rejuvenation.  All 5 patients had deep plane facelifts with fat injection, and other facial cosmetic procedures.  In all cases, the fat was harvested from the abdomen.  The mean volumes of fat injected were 9.1 cc (range 4-12 cc) into the right cheek and 8.5 cc (range 4-11.5 cc) into the left cheek. 

MRIs were done before surgery and at intervals after surgery up to 6 months (and 1 year in one patient) for a total of 22 studies.  Axial, coronal and sagittal images, weighted T1 and T2, were obtained through the head and neck.  Vertical projection of the malar fat pad on both sides was measured on axial images (fig. 1). 

Results

Malar thicknesses showed significant increases at the time of the 1-month follow-up appointments (p < 0.01). This increase was maintained at the next follow-up appointment (p < 0.01). There was no significant difference in thickness between the first postoperative appointment and the second postoperative appointment (fig. 2).  The T1 and T2-weighted images showed that the increase was due to tissue with fat density, not fluid.  The average amount of increased malar augmentation was 0.66 cm for the right cheek and 0.60 cm for the left cheek. 

Conclusions

Fat injection at the time of facelift surgery produces an increase in malar volume that is still present up to 6 months after surgery. This study confirms the rationale for injecting fat at the time of facelift surgery to treat the soft tissue deflation that is an important component of facial aging. 

References

1. Gosain AK, Amarante MTJ, Hyde JS, Yousif NJ.  A dynamic analysis of changes in the nasolabial fold using Magnetic Resonance Imaging: Implications for facial rejuvenation and facial animation surgery.  Plast. Reconstr. Surg. 1996;98:622-636.

Fig. 1.  (Above, left) Patient CC before and (above, right) 2 months after a facelift, submental lipectomy, upper and lower blepharoplasties, facial fat injection (36 cc), CO₂ laser skin resurfacing, and an endoscopic forehead lift.  (Below, left) MRI scans taken before surgery and (below, right) on the same date 2 months after surgery.  This 42-year-old woman with a history of extensive photodamage had an apparent age of 60.6 years before surgery and an apparent age of 46.9 years 6 months after surgery (photos in separate paper), as determined by a companion study.  Her apparent age reduction was 14.2 years (60.6-46.9+ 0.5).¹⁷  In these T2 images, the cerebrospinal fluid appears white and the fat is relatively dark.

Fig. 2.  MRI Study.  Right Cheek Thickness after Fat Injection in 5 Patients.  There is a significant increase in cheek thickness one month after surgery (p < 0.05), with no significant change at subsequent follow-up times.