Fat pad overlooked in facial rejuvenation

Aspen, Colo. - Physicians offering rejuvenation treatments to patients in their 50s frequently overlook the lateral temporal-cheek fat pad, says Timothy M. Greco, M.D., an expert in the aging face.

Dr. Greco says that common problems for patients in their 50s include midface asymmetry, brow ptosis, and temporal, lateral cheek and lateral mandibular hollowing. In addressing these issues, his approach centers largely around the lateral temporal-cheek fat pad.

“It starts in the temple, then proceeds in front of the ear over the parotid gland, and extends to the neck,” he says. Dr. Greco believes it’s one of the most neglected areas when inject thing the face. He is a facial cosmetic plastic surgeon based in Bala Cynwyd, Pa., who is double board-certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology-Head and Neck Surgery.

When addressing this pad with Juvéderm Ultra Plus (hyaluronic acid/HA, Allergan) injected through a 27-gauge cannula, he starts by making a minute injection site in the midface with a 25-gauge needle - which he leaves in place so he can find the opening when later injecting the nasolabial folds. He typically uses approximately 1.0 cc per lateral temporal-cheek fat pad.

To elevate the corner of the lip with Juvéderm Ultra Plus, Dr. Greco says he uses a deep lateral injection to lay linear threads in a crosshatching fashion in this area with a cannula.

“Lips are great to inject with a cannula. I just make a small injection site at the lateral commissure; my first pass is below the vermilion-cutaneous border. I make sure I inject the medial tubercle and the two lateral tubercles. These tubercles are derived from the three embryological units from which the upper lip develops. Then I’ll actually flip the patient’s lip up. From the same injection site at the lateral commissure, I can inject anterior to the frenulum. That creates eversion of the lip,” he says. He typically injects 0.1 cc in this area.

If patients can feel the material with their tongue, Dr. Greco says, “I massage the region.” He uses a similar technique for the lower lip, injecting perhaps 0.1 cc on each side of the frenulum through a single injection point.

Dr. Greco injects the lower lip in a similar fashion, but only two tubercles are injected (the lower lip develops from two embryological units). In this regard, “It is important to maintain a subtle central cleft when injecting the lower lip.”

For the temporal hollows, he typically injects Radiesse (calcium hydroxylapatite, BioForm/Merz) using a needle. To help locate veins in this area, “Just take the skin and stretch it using your thumb and forefinger while illuminating the area with a bright light. You can see the temporal veins more easily with this technique. Then I can safely inject into the temporal fossa with minimal bruising,” Dr. Greco says.

To add volume in the cheek and midface region, Dr. Greco might inject a point at the height of the cheekbone, which allows him to inject deeply, right onto bone. Also in this area, he will direct the cannula medially to augment the sub-orbicularis oculi fat pad, which sits just below the orbital rim.

“There’s always an indentation right where the infraorbital nerve emerges. I put a small amount of Radiesse in this region to provide volume that also improves the anterior projection of the cheek. Then I’ll inject inferiorly, going after the deep cheek fat pad that sits below the nasolabial fold. I find that placing product in this region gives effective volume restoration - which may result in less product being injected into the nasolabial folds.”

Disclosures: Dr. Greco is a speaker and consultant with Merz and Valeant/Medicis and a speaker, consultant and researcher with Allergan.