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Surgery and Cosmetics

Doris M. Hexsel, MD

Face Fats: A Discussion on the Maldistribution of Facial Fat

Doris M. Hexsel, MD

Thursday, February 11, 2010

This article discusses a new minimally invasive technique to treat facial adiposities, which increases with age and contributes to the appearance of an aged face together with other changes.

The many processes involved in the senescence of facial features are the result of the association between a number of intrinsic and extrinsic factors, causing anatomical, histological and physiological changes.

Chronological aging or intrinsic factors include thinning of the epidermis and dermis, alteration to the dermal structures, decreased sebum production, and a decreased growth of body hair.1

Extrinsic or external influences, including ultraviolet (UV) light, are responsible for the development of photoaging signs, such as actinic tanning, solar elastosis, telangiectasias and wrinkling. Moreover, circulating hormones (e.g. estrogen, progestins and androgens), genetic characteristics, sleep and smoke habits, and muscular activity, as well as a loss of soft and hard tissues, which are also involved in cutaneous alterations of the senescent face.2

According to Shuster et al., the overall collagen content per unit area of skin surface decreases approximately 1% per year.3 Furthermore, an aged dermis is characterized by a progressive reduction in electron-dense granules of hyaluronic acid until they completely disappear around the age of 60.4 In relation to elastin, aged skin loses the network that ascends perpendicularly from the uppermost portion of the papillary dermis to just below the basement membrane.5

These changes happen as an intrinsic part of aging, occurring deeper in the subcutaneous tissues and most often manifesting as atrophic in nature.6

Facial fat

A redistribution of facial fat occurs during aging; some fatty areas of the face become reduced in size, whereas an increased amount and deposition of fat occurs in unwanted facial areas, such as the submental and infraorbital areas, and around the jowl (Figure 1).7

There is also a reduction in the function, size and number of adipocytes, a process known as lipoatrophy. Additionally, there is a reduction of pre-adipocyte differentiation, probably caused by alterations in important transcription factors, such as the CCAAT/enhancer-binding protein (C/EBP) and peroxisome proliferator-activated receptor.8 

Figure 1. The perimandibular area is commonly affected with age-related fat pads

A youthful face is characterized by its fullness and by a smooth transition between subcutaneous compartments. A recent study has shown that the subcutaneous fat of the face is partitioned into discrete anatomical compartments: nasolabial fat, cheek fat, forehead and temporal fat, orbital fat and jowl fat.9 Facial aging is, in part, characterized by how these compartments alter with age. Aging can lead to abrupt contour changes, in volume loss and, in a number of cases, in malposition of these compartments.10 Loss of the temporal and buccal fat pads can also lead to concavities in these areas.11

Lipoatrophy and other diseases

Remodeling of bone, in addition to fat loss, is also associated with changes of the face. Skeletal remodeling in adulthood decreases the ratio of the maxillary height to the orbital height and might be responsible for the resultant jaw that can be seen in both infants and aged adults.12

Moreover, in human immunodeficiency virus (HIV)-infected patients, antiretroviral therapy promotes lipoatrophy, and it could affect up to 35% of patients who have received antiretroviral regimens for more than one year.13 Age-related facial lipoatrophy and facial lipoatrophy caused by other diseases have some differences , including the dramatic fat loss of the lipoatrophy associated with HIV treatment.14 Both lipoatrophy and lipohypertrophy could progress toward nearly complete subdermal facial fat loss in the secondary diseases, such as HIV.

Aging is accompanied by changes in the soft tissues of the face, leaving atrophic regions and generalized tissue ptosis, as well as other skin-intrinsic and -extrinsic changes. An aged face can display minimal fat loss in some areas and increased fat pads in other areas. Such increased fat pads are also observed in a great number of aged patients, and are more prominent in obese patients and those with a familial history of facial fat pads. This contributes to the appearance of a senescent face, and also increases the sagging of the skin and worsening of the facial contour.

The regional anatomical assessment of the face produces a more thorough understanding of the progression that characterizes volume changes associated with aging.

Diagnosis and treatment

In addition to the cosmetic problem, facial lipodystrophy can result in depression, social isolation, and career barriers. Face lipodystrophy can be identified easily through clinical assessments, and minimal changes or clinical follow-up can be carried out by MRI.15 Importantly, MRI can detect substantial ongoing changes in facial fat, and a characteristic pattern of compartmental change distinguishes lipodystrophy from wasting and weight gain and/or recovery. MRI should be considered for use in clinical trials for interventions to prevent or treat both lipoatrophy and lipohypertrophy. Further to MRI scans, three-dimensional laser scans can be used for the evaluation of face fat16.

Minimally invasive procedures are being performed to improve the appearance of aged faces worldwide. Treatments for lipoatrophy include dermal fillers, such as poly-L-lactic acid, calcium hydroxylapatite, polyalkylimide gel, hyaluronic acid products, and autologous fat transplants. These materials can restore facial volume caused by facial fat loss and are being widely used for treating lipoatrophy of the face.

Nowadays, patients presenting with or who are prone to present with age-related fat pads are also seeking treatment. Liposuction is considered as being quite aggressive for this indication, especially in mild cases. However, given that there are currently no treatments to reduce or prevent the increased volume of aged-related fat pads, alternative treatments are needed.

A recent study17 evaluated the efficacy of a minimally invasive, simple and safe treatment to treat small areas of localized facial fat. The investigators used local injections of triamcinolone with the aim of treating and preventing the early appearance of this condition. Applications of this treatment include the following:

  • to reduce facial fat pads;
  • for cosmetic reasons or asymmetries;
  • to prevent the evolution of mild cases in patients with a family history;
  • to treat residual fat after blefaroplasty;
  • as an adjunctive treatment in facial rejuvenation; and
  • to improve facial contouring.

This study included 56 female patients presenting with areas of localized fat pads on the face. The treated areas were the jowl, the submental area and the infraorbital area. Biopsy results showed atrophy of the adipocytes in the treated areas, caused by local injections of triamcinolone in the subcutaneous fat, and an MRI scan showed a reduction of a few millimeters per injection session (see Figure 2).

Before                           1 month after 1 session     2 months after 1 session

Figure 2: Same patient at baseline and 1 and 2 months after single session of triamcinolone injections in the mandibular fat pads

After one to three sessions, there was a reduction of facial fatty areas apparent by both physicians and patients, resulting in an improvement of the beauty and facial contour. All patients were satisfied with the results and stated that they would like to repeat the treatment, some opting for more sessions than are established for the current protocol. For safety reasons and to avoid systemic effects, a limited series of three subcutaneous injections of 4 to 8 mg of triamcinolone, diluted in 2% lidocaine solution, were applied monthly into the selected fatty areas of the face.

Conclusion

Both lipoatrophy and an increase of fat pads can be observed in the aged face, which is sometimes associated with co-morbidities.

A few small doses of triamcinolone (total of 4 to 8 mg) injected monthly into the localized age-related fat pads is considered safe and useful as a new method to promote cosmetic lipoatrophy of selected areas of the face. It was shown to improve the appearance of an aging face, delaying the need for more-aggressive procedures.

References

  1. Roenigk Jr HH. Treatment of the aging face. Dermatol Clin 1995;13:245-261.
  2. Lavker RM. Structural aspects of intrinsic vs. photo-aging. In: Burgdorf WHC, Katz SI (eds) Dermatology: progress and perspective, proceedings of the 18th World Congress of Dermatology. Parthenon Publishing, New York, pp 825-827, 1993.
  3. Shuster S, Black MM, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol 1975;93:639-643.
  4. Ghersetich I, Lotti T, Campanile G, Grappone C, Dini G. Hyaluronic acid in cutaneous intrinsic aging. Int J Dermatol 1994;33:119-122.
  5. Baumann L, Saghari S. Basic Science of the Dermis. In: Baumann L (ed) Cosmetic Dermatology: Principles & Practice, 1st edition. Mc Graw Hill, New York, 2002.
  6. Donofrio LM. Structural autologous lipoaugmentation: a pan-facial technique. Dermatol Surg 2000;26:1129-1134.
  7. Darcy SJ, Miller TA, Goldberg RA, et al. Magnetic resonance imaging characterization of orbital changes with age and associated contributions to lower eyelid prominence. Plast Reconstr Surg 2008;122:921-929.
  8. Kirkland JL, Tchkonia T, Pirtskhalava T, Han J, Karagiannides I. Adipogenesis and aging: does aging make fat go MAD? Exp Gerontol 2002;37:757-767.
  9. Reece EM, Pessa JE,Rorich RJ. The mandibular septum: anatomical observations of the jowls in aging-implications for facial rejuvenation. Plast Reconstr Surg 2008;121:1414-1420.
  10. Ghersetich I, Lotti T, Campanile G, Grappone C, Dini G.. Hyaluronic acid in cutaneous intrinsic aging. Int J Dermatol 1994;33:119-122.
  11. Donofrio LM. Panfacial volume restoration with fat. Dermatol Surg 2005;31:1496-1505.
  12. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg 1999;103:635-644.
  13. Hornberger J, Rajagopalan R, Shewade A, Loutfy MR. Cost consequences of HIV-associated lipoatrophy. AIDS Care 2009;21:664-671.
  14. Coleman S, Saboeiro A, Sengelmann R. A comparison of lipoatrophy and aging: volume deficits in the face. Aesthetic Plast Surg 2009;33:14-21.
  15. Paton NI, Yang Y, Tha NO, Sitoh YY. Changes in facial fat in HIV-related lipoatrophy, wasting, and weight gain measured by magnetic resonance imaging. HIV Clin Trials. 2007;8:227-234.
  16. Yang Y, Yap M, Oo Tha N, Paton NI. Objective assessment of facial lipoatrophy changes in a cohort of HIV-infected patients taking combination antiretroviral therapy. HIV Clin Trials 2008;9:399-406.
  17. Hexsel D, Rulan P, Soirefmann M, Dal Forno T. Cosmetic lipoatrophy of the face, JAAD 2009. Poster presented at the AAD Annual Meeting 2009 in San Francisco, CA.
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