COSMETIC

The Fat Compartments of the Face: Anatomy

and Clinical Implications for Cosmetic Surgery
Rod J. Rohrich, M.D.
Background: Observation suggests that the subcutaneous fat of the face is
Joel E. Pessa, M.D. partitioned as distinct anatomical compartments.
Dallas, Texas Methods: Thirty hemifacial cadaver dissections were performed after methyl-
ene blue had been injected into specified regions. Initial work focused on the
nasolabial fat. Dye was allowed to set for a minimum of 24 hours to achieve
consistent diffusion. Dissection was performed in the cadaver laboratory using
microscopic and loupe magnification.
Results: The subcutaneous fat of the face is partitioned into multiple, inde-
pendent anatomical compartments. The nasolabial fold is a discrete unit with
distinct anatomical boundaries. What has been referred to as malar fat is com-
posed of three separate compartments: medial, middle, and lateral temporal-
cheek fat. The forehead is similarly composed of three anatomical units in-
cluding central, middle, and lateral temporal-cheek fat. Orbital fat is noted in
three compartments determined by septal borders. Jowl fat is the most inferior
of the subcutaneous fat compartments. Some of the structures referred to as
“retaining ligaments” are formed simply by fusion points of abutting septal
barriers of these compartments.
Conclusions: The subcutaneous fat of the face is partitioned into discrete an-
atomic compartments. Facial aging is, in part, characterized by how these com-
partments change with age. The concept of separate compartments of fat
suggests that the face does not age as a confluent or composite mass. Shearing
between adjacent compartments may be an additional factor in the etiology of
soft-tissue malposition. Knowledge of this anatomy will lead to better under-
standing and greater precision in the preoperative analysis and surgical treat-
ment of the aging face. (Plast. Reconstr. Surg. 119: 2219, 2007.)

C
linical observation and laboratory investi- In the cadaver laboratory, dye injected into
gation suggest that the subcutaneous fat of the upper forehead flows down the cheek and
the face exists in distinct anatomical com- into the neck in a distinct and reproducible man-
partments (Fig. 1). When the operating surgeon ner. This test has been repeated at least a dozen
performs a face lift, zones of adherence are times. Moreover, dye injected into the nasolabial
encountered that alternate with zones where fold partitions in a discrete fashion (Figs. 3).
dissection proceeds with relative ease. This sug- Taken as a whole, these clinical and laboratory
gests that barriers exist between different zones observations suggest that the subcutaneous fat of
of facial fat. the face is highly partitioned, that it is not a
Patients with facial atrophy and midface hol- confluent mass, and that further study is war-
lowing consistently show preservation of the na- ranted to investigate this concept as it pertains to
solabial fold and jowl fat (Fig. 2). This common facial aging and cosmetic surgical techniques.
clinical observation suggests that regions of fat
behave differently during the aging process. MATERIALS AND METHODS
Thirty hemifacial fresh cadaver dissections
From the Department of Plastic Surgery, University of Texas were performed on 18 male and 12 female spec-
Southwestern Medical Center. imens ranging in age from 47 to 92 years. Pre-
Received for publication July 27, 2006; accepted October 13, liminary work was performed on multiple spec-
2006. imens to determine the best dye staining
Copyright ©2007 by the American Society of Plastic Surgeons technique. Letraset, Bombay India Ink, indocya-
DOI: 10.1097/01.prs.0000265403.66886.54 nine green, and methylene blue were all evalu-

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 Plastic and Reconstructive Surgery • June 2007

Fig. 1. An artist’s rendition of the subcutaneous compartments Fig. 2. Lipoatrophy and midface hollowing (red arrow) are noted
of the face. with preservation of the nasolabial and jowl fat (black arrows).

ated. Methylene blue consistently displayed the partment. Nasolabial fat can be noted medial to
best tissue diffusion.1 In other studies, rehydrating the deeper fat of the suborbicularis fat compart-
some of the specimens was found to improve dye ment. The lower border of the zygomaticus major
diffusion. muscle is adherent to this compartment.
Dye was allowed to set for a minimum of 24 As an incidental observation, the volume of
hours to allow for adequate tissue diffusion. Al- this compartment did not vary much between ca-
lowing the dye to set for 48 to 72 hours actually davers, regardless of age or sex. The only variable
improved distribution and facilitated dissection. noted was that medial cheek fat overlapped naso-
Each compartment was verified by injecting a min- labial fat to a greater degree in certain cadavers.
imum of three and a maximum of 10 cadaver
hemifaces. All work was performed in the cadaver
laboratory. Cheek Fat Compartments
Microscopic and 4.5- and 6.0-power loupe There are three distinct cheek fat compart-
magnification facilitated dissection. Photographic ments: the medial, middle, and lateral temporal-
documentation was obtained with a Canon 20D cheek fat.
system and F2.8 macro lens. Images were scanned Medial cheek fat is lateral to the nasolabial fold
into Adobe Photoshop (CS2; Adobe Systems, Inc., (Fig. 5). This compartment is bordered superiorly
San Jose, Calif.). All results are shown from the by the orbicularis retaining ligament and the lat-
cadaver’s left side for the sake of consistency. eral orbital compartment. Jowl fat lies inferior to
this fat compartment.
RESULTS Middle cheek fat lies superficial in its midpor-
tion (Fig. 6). This fat compartment is found an-
Nasolabial Fat Compartment terior and superficial to the parotid gland. At its
The nasolabial fat was injected in 10 hemifaces superior portion, the zygomaticus major muscle is
from three male and two female cadavers. The adherent. A confluence of septa occurs at this
cadaver face was allowed to set at least 24 hours, location where three compartments meet, and
although immediate staining of a distinct area forms a dense adherent zone where the zygomatic
could be seen through the skin. A distinct com- ligament has been described.2
partment was noted in all specimens (Fig. 4). The The fusion of septal boundaries is an anatom-
nasolabial fat lies anterior to medial cheek fat, and ical principle and can be simply illustrated by
overlaps jowl fat. The orbicularis retaining liga- cross-sectional anatomy (Fig. 6, right). Middle
ment represents the superior border of this com- cheek fat abuts medial cheek fat, and their septal

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Fig. 3. (Left) Methylene blue dye injected into the forehead flows down the cheek in a spe-
cific and reproducible manner. The nasolabial fat also stains as a specific region. (Right) An
artist’s rendition of how dye flows from the forehead to the neck with a distinct medial bound-
ary (arrow). Dye partitioning would not occur if the face were a confluent mass.

Fig. 4. The nasolabial fat compartment is the most medial of the Fig. 5. Malar fat is composed of three compartments: the medial,
major cheek compartments. Blue dye has stained this region. The middle, and lateral temporal-cheek. The medial fat, shown here,
orbicularis retaining ligament is the superior boundary (ORL), and lies adjacent to the nasolabial fat. The superior boundary is again
the suborbicularis fat is a lateral and deep boundary (SOOF). Me- the orbicularis retaining ligament (ORL). The lateral boundary
dial cheek fat has been reflected off the nasolabial compartment. is the middle cheek septum. The red arrow represents a point
The zygomaticus major is tethered at its inferior border (ZM). of fixation.

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Fig. 6. (Left) The middle cheek fat compartment lies between medial and lateral temporal-cheek fat. The
superior border is defined by the superior cheek septum (SCS). A zone of fixation (red arrow) is noted where this
compartment adjoins the middle compartment and inferior orbital compartment. (Right) The cross-sectional
anatomy illustrates the anatomic principle that fusion planes exist between adjacent fat compartments. A
dense fascial system (red arrow) exists where the medial and middle fat compartments meet. The zygomaticus
major muscle is noted deep to this fusion plane.

boundaries fuse into a dense fascial network (Fig. barrier and could be referred to as the central
6, right, arrow). Again, this corresponds to what has temporal septum.
been described as the zygomatic ligament. The The middle temporal fat compartments lie on
zone where the medial fat abuts the middle cheek either side of the central forehead fat (Fig. 9). The
fat corresponds to the location of the parotido- inferior border is the orbicularis retaining liga-
masseteric ligaments.3 ment, and the lateral border corresponds to the
The lateral temporal-cheek compartment is superior temporal septum.4
the most lateral compartment of cheek fat (Fig. 7). The lateral temporal-cheek compartment has
This fat lies immediately superficial to the parotid previously been described. It connects the lateral
gland and connects the temporal fat to the cervical forehead fat to the lateral cheek and cervical fat
subcutaneous fat. (Fig. 7).
A true septum can be located anterior to this
compartment. This septum, the lateral cheek sep- Orbital Fat Compartment
tum, can be dissected and clearly identified as a Three subcutaneous fat compartments exist
vertical septal barrier with loupe magnification. around the eye. The most superior compartment
This is the first transition zone encountered dur- is bounded by the orbicularis retaining ligament
ing a face lift when proceeding medially from the as it courses around the superior orbit (Fig. 10).
preauricular incision. The orbicularis retaining ligament is a truly cir-
cumferential structure that spans the superior
and inferior orbits and blends into the medial and
Forehead and Temporal Fat Compartments lateral canthi. Dye injected into the superior com-
The subcutaneous fat of the forehead is com- partment does not stain the inferior orbital com-
posed of three compartments. The central com- partment.
partment is located in the midline region of the The inferior orbital fat is a thin, subcutaneous
forehead (Fig. 8). It has a consistent location that layer that lies immediately below the inferior lid
abuts the middle temporal compartments on ei- tarsus (Fig. 11). Its inferior boundary is the orbic-
ther side and has an inferior border at the nasal ularis retaining ligament or malar septum. The
dorsum. The lateral boundary probably is a septal medial and lateral extents are, again, the canthi.

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Fig. 7. The lateral temporal-cheek fat spans the forehead to the Fig. 9. The middle forehead fat compartments are situated on
cervical region. It is the most lateral of the cheek fat compart- either side of the central fat and are located medially to the su-
ments and has an identifiable septal barrier medially called the perior temporal septum (STS). The inferior border is the orbicu-
lateral cheek septum (LCS). The superior and inferior temporal laris retaining ligament of the superior orbit. The lateral tempo-
septa (STS and ITS, respectively) represent the superior bound- ral-cheek fat has already been described and is the third of the
aries. This cadaver dissection is noteworthy because several fat forehead fat compartments.
compartments are seen without dye staining, including the in-
ferior orbital fat (IOF) and medial cheek fat (M). Nasolabial fat has
been stained with methylene blue dye.

Fig. 10. There are three periorbital fat compartments. The superior
Fig. 8. Three forehead fat compartments have been identified to orbital fat is shown here. The boundary is the orbicularis retaining
date. The central fat is a midline region. It has an inferior boundary at ligament (ORL), a truly circumferential membrane that inserts at the
the nasal dorsum. The lateral border is a dense fascial plane that medial and lateral canthi. The superior and inferior orbital compart-
appears to be a septum, termed the central temporal septum. ments are, however, distinct from one another.

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The lateral orbital fat compartment is the

third of the subcutaneous orbital fat compart-
ments (Fig. 12). Its superior border is the inferior
temporal septum4; the inferior border is desig-
nated the superior cheek septum. The zygomati-
cus major muscle is again noted to be adherent to
this compartment. Transitioning the zygomaticus
major muscle plays a major role in adequately
releasing soft tissues if one attempts to elevate
medial fat or jowl fat.

Jowl Fat Compartment

Jowl fat is separate from nasolabial fat (Fig. 13,
left). Jowl fat adheres to the depressor anguli oris
muscle. The medial boundary of this compart-
ment is the lip depressor muscle, and the inferior
boundary is determined by a membranous fusion
of the platysma muscle. The fusion point between
these two muscles occurs at the region of the man-
Fig. 11. The inferior orbital fat compartment is analogous to the
dibular retaining ligament.2 The difference be-
superior orbital fat and, again, is bordered by the orbicularis re-
tween nasolabial fat and jowl fat can be shown by
taining ligament (ORL). This compartment is noted clinically with
cross-sectional anatomy (Fig. 13, right).
periorbital ecchymosis.
DISCUSSION
This study suggests that facial subcutaneous
fat is highly compartmentalized. Because the
face is composed of multiple discrete anatomi-
cal regions, it is unlikely that it ages as a con-
fluent mass.
A youthful face is characterized by a smooth
transition between subcutaneous compartments:
aging leads to abrupt contour changes between
these regions. This may occur due to volume loss
as described by Lambros5 or to malposition of
specific compartments from a number of causes.
Attenuation of ligaments alone would be insuffi-
cient to explain compartment changes, especially
in light of the septated architecture of the fat
compartments noted herein.
This anatomical arrangement is in agree-
ment with that noted clinically. The operating
surgeon encounters areas of fixation or adher-
ence in dissecting from lateral to medial. These
areas are vascular and occur in the transition
region between compartments. The zygomatic
major muscle provides an important area of fix-
ation to three compartments, and dissection be-
Fig. 12. The lateral orbital fat lies below the inferior temporal comes much easier once the zygomaticus muscle
septum (ITS) and above the superior cheek septum (SCS). The is transitioned. The plane between the lateral
zygomaticus major muscle is adherent superiorly (ZM). Inter- and middle cheek compartments can easily lead
estingly, the zygomaticus muscle is adherent to several fat into the buccal fat; again, the zygomaticus major
compartments. This is clinically important, because dissection muscle is a major landmark in avoiding this
past the zygomaticus major is necessary to move or alter me- pitfall. As a clinical point, if one chooses to
dial cheek fat. dissect medially to elevate jowl fat, dissection has

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Volume 119, Number 7 • The Fat Compartments of the Face

Fig. 13 (Left) Jowl fat is the most inferior fat on the face. It is bounded medially by the de-
pressor anguli oris muscle (DAO). The relationship of this muscle to the compartment may be
analogous to that of the zygomaticus major and its adjacent fat compartments. Nasolabial fat
(NLF) and medial fat (M) are located superiorly. This is the least understood of the fat com-
partments described and may be the most important in terms of midfacial aging. How this
compartment behaves during the aging process is not known. (Right) Vertical cross-sectional
anatomy illustrates that jowl fat is separate from nasolabial fat. The nasolabial fold (NL) has
been injected with red latex, and the jowl has been injected with blue latex (J). Intervening
upper lip fat is noted, as well as the labial artery.

to proceed medially to the zygomaticus major Other examples exist of fusion planes between
muscle to free the fat compartments from their compartments. The mandibular ligament occurs
adherence to this muscle. where the submental crease (platysma skin inser-
Ligaments may be formed where septal barri- tion) fuses with the origin of the depressor anguli
ers and fat compartments meet. This is apparent muscle, and then across the lower border of the
in the zygomatic area, where the inferior orbital, mandible. The parotido-masseteric ligaments cor-
lateral orbital, and middle cheek compartments respond to the plane between the middle and
meet. This is a highly vascular area that corre- medial cheek fat compartments (medial cheek
sponds to the zygomatic ligament. This fusion area septum). Fusion planes occur in many regions of
represents an area of risk to the facial nerve, due the face, in both the transverse and vertical di-
to the tethering function where several compart- rections.
ments merge. This anatomy is not entirely without prece-
The area beneath the ear is another point of dent. Whetzel and Mathes described the ar-
fusion. The lateral temporal-cheek compart- terial anatomy of the face using several dye
ment ends right in front of the ear. There is a techniques6 and expanded Taylor and Palmer’s
postauricular fat compartment that abuts this. concept of angiosomes to the face, forehead,
Between these two compartments, a septal fu- and neck.7 It is of interest that in their article,
sion occurs that represents a barrier. What is the authors show perforating vessels in cross-
thought of as the platysma ligament2 may simply sectional anatomy that occur exactly in the same
be a fusion point between two compartments. If location as the transition zone between fat com-
the operating surgeon is not aware of this fusion partments seen in Figure 6, right. This is in ac-
region, it places the greater auricular nerve at cord with the clinical observation that transition
risk by improper transition of the subcutaneous zones between subcutaneous fat compartments
plane at this point. are highly vascular. These fat compartments are

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 Plastic and Reconstructive Surgery • June 2007

not angiosomes; rather, they occur between vas-

cular perforating vessels that supply the skin.
More evidence is the important role played by
the zygomaticus major and depressor anguli oris
muscles, which may have myocutaneous perfo-
rators traveling in septa.
Deep layers of facial fat, including the sub-
orbicularis, retro-orbicularis, and buccal fat,
have been studied in detail.8 –11 This study sug-
gests that additional deep fat compartments ex-
ist (Fig. 6, right). For example, a fat compart-
ment surrounds the levator anguli muscle, and
there exists a fat compartment beneath the lip
elevator muscles. A tenet of facial anatomy is
that fat is noted both above and below most
facial muscles, probably to facilitate the neces-
sary gliding mechanism.
With this knowledge in mind, the aging face
can be analyzed as a change in volume and posi-
tion of these separate compartments, both super-
ficial and deep (Fig. 2). The cadaver shown in
Figure 2 has a loss of midfacial projection, prom-
inence of the nasojugal crease, malar mound
show, jowl prominence, and a deep nasolabial
fold. These findings are not unrelated.
Jowl prominence may occur from malposi-
tion of the labiomandibular compartment. In
addition, loss of volume of the deep midfacial fat
(Fig. 14) may be a primary determinant of mid-
facial aging. This decreases support for the me- Fig. 14. The nasolabial fat compartment can be repositioned be-
dial cheek compartment and results in dimin- neath the medial cheek fat compartment experimentally to di-
ished midface projection. The nasolabial fold is minish the contour deformity. Understanding the anatomic
unmasked, just as is the malar mound. A cascade compartments explains why simple lateral traction of skin or skin
occurs from malposition of this compartment. and fat has little overall effect on the nasolabial fold prominence.
The negative vector, caused by loss of support This technique may be applicable to jowl fat and midface pro-
for the medial cheek compartment and volume jection. (Above) The nasomaxillary fat is seen medially (black ar-
loss of the deep compartment fat, allows excess row). The deep compartment fat—the deep midfacial fat—is
traction to be placed on the lower eyelid.12 This noted by the red arrow. This has not been previously described.
leads to scleral show. Confirmatory evidence for There is likewise a lateral deep compartment fat (red arrow later-
this last statement is noted clinically by the snap ally) beneath the lateral temporal-cheek compartment (ZM, zy-
test13: if a prolonged amount of time is noted for gomaticus major muscle). (Below) The deep midfacial fat has
an individual’s lower lid to return to the normal been injected with methylene blue dye (red arrow), which stains
position, this can be improved by simple medial around the levator anguli oris muscle. This deep compartment
cheek elevation. Lid laxity, orbicularis laxity, may be a primary determinant of a youthful, anteriorly projecting
and loss or attenuation of the canthi may play a midface. Loss of volume in this deep compartment, similar to
small or no role in what is actually encountered what may occur in the temporal fat, may lead to the cascade ef-
clinically. Rather, subcutaneous fat malposition fect described.
and atrophy simply place downward traction on
the lower lid and distorts its position.
We suggest that jowl fat may be an important key this technique will find application in repositioning
to rejuvenating the midface. In the cadaver labora- attempts of the jowl fat.
tory, dissection of the nasolabial fat and reposition- The eye sees what the mind knows. The con-
ing of this compartment beneath the medial cheek cept of subcutaneous fat compartments shifts
fat can efface the nasolabial fold (Fig. 14). Perhaps one’s perspective from visualizing the face as a

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discrete mass to viewing the face as a set of archi- blue and India ink in root-filled teeth. Int. Endod. J. 28: 30,
tectural compartments. These compartments may 1995.
2. Furnas, D. W. The retaining ligaments of the cheek. Plast.
age independently, and mass shifts of facial soft Reconstr. Surg. 83: 11, 1989.
tissue may not sufficiently address the complexity 3. Stuzin, J. M., Baker, T. J., and Gordon, H. L. The relationship
of the aging process. The answers to this and many of the superficial and deep facial fascias: Relevance to rhyt-
other questions suggested by this study await fur- idectomy and aging. Plast. Reconstr. Surg. 89: 441, 1992.
ther research. 4. Moss, C. H., Mendelson, B. C., and Taylor, G. I. Surgical
anatomy of the ligamentous attachments in the temple and
Joel E. Pessa, M.D. periorbital regions. Plast. Reconstr. Surg. 105: 1475, 2000.
Department of Plastic Surgery 5. Lambros, V. Personal communication. July 2006.
5323 Harry Hines Boulevard 6. Whetzel, T. P., and Mathes, S. J. Arterial anatomy of the face:
Dallas, Texas 75390-9132 An analysis of vascular territories and perforating cutaneous
[email protected] vessels. Plast. Reconstr. Surg. 89: 591, 1992.
7. Taylor, G. I., and Palmer, J. H. The vascular territories (an-
ACKNOWLEDGMENTS giosomes) of the body: Experimental study and clinical ap-
The authors thank Melinda Mora of the University plications. Br. J. Plast. Surg. 40: 113, 1987.
of Texas Southwestern Willed Body Program. This study 8. Aiache, A. E., and Ramirez, O. H. The suborbicularis oculi
fat pads: An anatomic and clinical study. Plast. Reconstr. Surg.
would not have been possible without her help. Kind 95: 37, 1995.
thanks are also extended to Holly Smith, from the medical 9. May, J. W., Jr., Fearon, J., and Zingarelli, P. Retro-orbicularis
illustration department, for her help in preparing the oculi fat (ROOF) resection in aesthetic blepharoplasty: A
article. 6-year study in 63 patients. Plast. Reconstr. Surg. 86: 682, 1990.
10. Stuzin, J. M., Wagstrom, L., Kawamoto, H. K., Baker, T. J., and
DISCLOSURE Wolfe, S. A. The anatomy and clinical applications of the
The authors have no financial interests in this re- buccal fat pad. Plast. Reconstr. Surg. 85: 29, 1990.
11. Jackson, I. T. Anatomy of the buccal fat pad and its clinical
search project or in any of the techniques or equipment significance. Plast. Reconstr. Surg. 103: 2059, 1999.
used in this study. 12. Jelks, G. W., and Jelks, E. B. Preoperative evaluation of the
blepharoplasty patient: Bypassing the pitfalls. Clin. Plast.
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1. Ahlberg, K. M., Assavanop, P., and Tay, W. M. A comparison 13. Furnas, D. W. Festoons, mounds, and bags of the eyelids and
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