147

SMAS Malar Fat Pad Lift with Short Scar Face Lift

Paul S. Nassif and Guy G. Massry

The malar fat pad lies superficial to the SMAS and the lip elevator muscles. It has a cheek and jowl portion. The buccal-maxillary retaining ligament courses through the fat pad. With age, there is anterio-inferior gravitational descent along with fat volume loss. Skeletal resorption of anterior facial skeleton also contributes to descent. Finally, loss of the retaining ligament occurs (zygomatic and buccal-maxillary support contribute to descent).

Aging of the malar fat pad and midface fat can cause a deep nasolabial groove, a heavy nasolabial fold, cheek folds, skeletonized appearance of the cheekbone, and a submalar hollow. Other effects of aging include a sad mouth, commissural lines, jowls (midfacial descent settles behind the mandibular retaining ligaments), marionette lines (labiomandibular groove), and lower cheek lines.

The principles of the SMAS malar fat pad lift (SMFPL) are that it elevates the malar fat pad to a more youthful position, elevates the anterior superficial SMAS, effaces the nasolabial folds, corrects the sad mouth, softens commissural marionette and lower cheek lines, and elevates the jowls. The anatomic basis of the SMFPL is the fact that the malar fat pad is adherent to the SMAS, which invests the lip elevators

(zygomatricus major and minor), the zygomatic retaining ligaments (McGregor’s patch is divided, and the buccal-maxillary ligaments are partially divided.)

Marking for the SMFPL is as follows: From the tragus to the inferior border of the zygomatic arch/zygoma (6 cm), from the tragus to the lateral commissure (7–8 cm), anterior to the mandible angle, from the tragus to the anterior border of the sternocleidomastoid (6 cm), and a postauricular short scar (Figures 147.01–3).

The anterior superficial SMAS and superior posterior malar fat pad is plicated in a vertical vector. With the SMAS elevation, the zygomaticus major and minor are elevated. With division of the retaining ligaments, the cheek skin flap and malar fat pad elevate easier. It is important to preserve the fat on the skin flap posterior to the malar fat pad. The fat on the skin flap at the malar fat pad should be minimal so that the malar fat pad is elevated with the SMAS.

457