Anterior Septal Fat (ASF) – Novel Anatomical Finding in Patients with Malar Bags

Goals/Purpose: Malar bags can be classified as malar edema, congenital (malar mounds) and acquired festoons. Malar bags are anatomically described to be due to laxity in periorbital skin/muscle that allows for descent of postseptal fat and Suborbicularis oculi fat (SOOF) into the prezygomatic space in theory however the true pathophysiology remains unclear. Lack of understanding and appropriate diagnosis leads to patients being treated with malar fillers, fat grafting, and injection of Botox which worsens their malar bags. Other treatment modalities such as tetracycline, radiofrequency, direct excision and traditional lower blepharoplasty often lead to sclerosis, scar formation, and persistent malar bags. Our purpose is to describe a new anatomical finding observed intraoperatively in our patient population with congenital malar mounds and acquired festoons observed which is imperative to address for successful treatment of these patients.

Methods/Technique: In our practice we use detailed patient history and preoperative physical examination with lateral pull test and forceful closure of the eye to differentiate between the type of malar bags. Intraoperatively we use the subciliary approach to the lower eyelid blepharoplasty. When lifting the skin and muscle flap, in many patients with malar bags we have observed a layer of anterior septal fat under the orbital orbicularis oculi muscle that is differentiated from Suborbicularis oculi fat (SOOF) and is not found in other patients undergoing lower eyelid blepharoplasty. Removal of this fat and/or muscle suspension is crucial to obtaining satisfactory results and resolution of malar bags in this patient population.

Results/Complications: We retrospectively studied 56 patients who underwent lower eyelid blepharoplasties by a single surgeon in the past two years. For some patients this was a primary lower eyelid blepharoplasty and for many a revision lower eyelid blepharoplasty. Of these, 34 patients (61%) had malar bags. All patients underwent a midface lift to address the malar bags. The ASF was observed in every 1 out of 3 patients with malar bags. After removal of this ASF patients had resolution of malar bags and increased satisfaction in appearance in comparison to previous treatments.

Conclusion: We hope to bring to light this novel anatomical finding in patients with malar bags so surgeons can be better equipped to treat these patients and achieve satisfactory results.