New research claims that a deep fat compartment located within the cheek is imperative to maintaining a youthful-looking face.

As we age, the fat compartments found in all areas of the face—including the mouth, cheeks, eyes, and forehead—age at different rates and change in shape, causing hollows and sagging.

Researchers now report that returning volume to these fat compartments improves volume loss under the eyes, eliminates lines around the nose and mouth, and gives more curve to the upper lip, restoring a youthful overall appearance.

“Midface volume is one of the most frequently neglected things in cosmetic facial surgery,” says Joseph A. Niamtu III, DMD, a cosmetic facial surgeon who practices in Midlothian, Va. “People perform eyelid and brow surgery for the upper face, lip enhancement, liposuction, and facelift for the lower face, and forget about the midface. This is why so many patients have an ‘operated’ look. They were made to look tighter, but not younger.”

Joel Pessa, MD, a Dallas-based plastic surgeon, and colleagues conducted a study that included 14 cadavers injected with dye to identify the deep cheek fat compartments located beneath the skin. After latex was injected into the compartments, which set overnight, the researchers located the boundaries of the fat compartments as well as their relationship with adjacent muscles.

One of the key fat compartments that the researchers found was deep in the cheeks. They reported that the size of this compartment decreases as we age, leading to excess skin and the formation of folds that form around the nasolabial folds.

According to the study, volume loss in the deep cheek fat compartment leads to “hollowing” of the face. Volume loss of the deep cheek fat compartment can be the determining factor of aging in the midface.

If volume is restored to this deep fat compartment in the cheeks, using either fat, tissue fillers, or implants, the result is an immediate improvement in the hollowing of the face and an improvement in the nasolabial folds, more volume in the eyes, which improves the “v-deformity” of the lower lid, and changes in the shape of the lips, according to the researchers.

They also report that when the injection was done correctly, a smaller volume of fat or filler was needed.

“Almost all men and women over the age of 40 are candidates for some level of midface volume restoration,” Niamtu says. “The exponential growth of fillers has provided a convenient (albeit temporary) means of midfacial volume enhancement.”

According to Niamtu, huge advances have been made with midfacial and cheek implants over the past 30 years. Anatomic implants provide the surgeon and patient with a variety of shapes with which to customize the augmentation.

The good thing about anatomic facial implants, Niamtu says, is that they can be used to increase volume exactly where the patient needs it or wants it.

“They are also reversible,” he continues. “They take about 15 minutes to put in and about 2 minutes to remove, if the patient does not like the result. They can also be switched to a larger or smaller size.”


There are several ways to resculpt the face and increase volume in the cheeks. Some options include fat injections, also called liposculpture; collagen injections; and soft filler materials, such as AlloDerm, Fascian, Gortex, and Softform.

Liposculpture uses the patient’s own fat to fill in areas of the face, reducing the chance of infection. The fat can be harvested from multiple sites, providing a natural look.

See also “Surgical Rejuvenation of the Midface” by Malcom D. Paul, MD, FACS, in the June 2005 issue of PSP.

Collagen injections can be used to fill in lines and give the skin a plumper and smoother appearance. When injected beneath the skin, collagen plumps up lines and wrinkles and adds fullness to sunken areas of the face.

Alloderm, Fascian, Softform, and Gortex are nonsynthetic filler materials. Alloderm and Fascian are made from collagen and other protein-like substances taken from the human body.

As with fat, they can be used to fill in or plump up facial features and other areas of the body. Gortex and Softform are synthetic fillers.