Plastic and Reconstructive Surgery • April 2020
it powered, to make a definitive conclusion regarding
the intermediate or long-term effect of fat grafting on
locoregional breast cancer recurrence. Through our
data analysis, we did investigate the effect of pathologi-
cal diagnosis in our study population on subsequent
imaging. Although limited by power, it was not statis-
tically significant. However, this again highlights the
fact that the finding of a palpable mass is one of the
strongest predictors of patients obtaining subsequent
unanticipated postmastectomy imaging despite histo-
pathologic findings. While we did not encounter any
cases of local recurrence during the follow-up period,
we wholeheartedly agree that oncologic safety is para-
mount. Given the ubiquity of fat grafting in breast can-
cer reconstruction, this issue demands well-designed
studies with long-term follow-up, perhaps with matched
cohorts, as well as comprehensive analyses of data such
as that contained in the GRAFT registry.
We thank Dr. Munhoz for affirming the utility of
our proposed algorithm as a multidisciplinary para-
digm for managing the palpable breast mass after
implant reconstruction. We join him in reinforcing the
need for ongoing study of oncologic safety of fat graft-
ing in breast cancer patients.
DOI: 10.1097/PRS.0000000000006705
Graham S. Schwarz, M.D.
Department of Plastic Surgery
Cleveland Clinic
Cleveland, Ohio
James Gatherwright, M.D.
Department of Plastic Surgery
MetroHealth
Cleveland, Ohio
Eliana F. R. Duraes, M.D., Ph.D.
Department of Plastic Surgery
Cleveland Clinic
Cleveland, Ohio
Dana Ataya, M.D.
Department of Radiology
Moffitt Cancer Center
Tampa, Fla.
Rebecca Knackstedt, M.D., Ph.D.
Department of Plastic Surgery
Cleveland Clinic
Cleveland, Ohio
Correspondence to Dr. Schwarz
Department of Plastic Surgery
Cleveland Clinic
9500 Euclid Avenue, A60
Cleveland, Ohio 44195
schwarg@ccf.org
DISCLOSURE
The authors have no financial interest to declare in rela-
tion to the content of this communication.
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Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
REFERENCE
1. Knackstedt RW, Gatherwright J, Ataya D, Duraes EFR,
Schwarz GS. Fat grafting and the palpable breast mass in
implant-based breast reconstruction: Incidence and implica-
tions. Plast Reconstr Surg. 2019;144:265–275.
The Functional Anatomy of the Deep Facial
Fat Compartments: A Detailed Imaging-Based
Investigation
Sir:
W
e read with interest the article by Cotofana et al.1
on functional anatomy of the deep facial fat com-
partments. In their elegantly detailed dissections, the
authors proposed anatomic boundaries to the deep
fat compartments and contrasted them with the ones
previously described in the literature.1 The superior
boundary of the medial and lateral sub–orbicularis
oculi fat compartments was described to be the bilami-
nar orbicularis retaining ligament. In fact, their Figure
7 showed both the medial and lateral sub–orbicularis
oculi fat compartments to have a hard stop superi-
orly at a white line that was referred to as the orbicu-
laris retaining ligament.1 Wong and Mendelson have
detailed the anatomy of the tear trough and orbicularis
retaining ligament in their anatomic articles, stating
the same relationship of the orbicularis retaining liga-
ment and prezygomatic space that contains the sub–
orbicularis oculi fat compartment.2,3 We believe that
rather than forming the superior boundary, the orbi-
cularis retaining ligament is encased within the sub–
orbicularis oculi fat compartment.
Our group has performed dissections in injected
fresh cadaver heads in the periorbital area to study the
lateral orbital fat distribution. We consistently observed
that the sub–orbicularis oculi fat compartment
extended superiorly to the level of the infraorbital rim
and that it is traversed by the orbicularis retaining liga-
ment, specifically, the inferior lamella. In other words,
the orbicularis retaining ligament is sandwiched by fat
superiorly and inferiorly (Fig. 1). This finding is consis-
tent with the senior authors’ (M.S.A. and J.E.Z.) intra-
operative observations during lower blepharoplasty.
Using a skin-muscle flap preseptal approach, a liga-
ment is encountered just caudal to the rim, and upon
release, the sub–orbicularis oculi fat compartment is
seen immediately. This ligament is the superior lamella
of the orbicularis retaining ligament (Fig. 2). Another
ligament is encountered a few millimeters inferiorly,
which is the inferior lamella of the ligament. This latter
structure is responsible externally for the palpebroma-
lar groove, which is palpated a few millimeters inferior
to the infraorbital rim. One of the earliest signs of facial
aging is the appearance of the palpebromalar groove
laterally. We believe this is explained by volumetric
deflation of the sub–orbicularis oculi fat compartment
superior to the inferior lamella of the orbicularis retain-
ing ligament. This is clinically important in that this
area responds extremely well to volume enhancement.
 Volume 145, Number 4 • Letters
Fig. 1. Lateral oblique view of the lower periorbita with the orbi-
cularis oculi muscle reflected anteriorly. The inferior lamella of
the orbicularis retaining ligament is shown with the sub–orbi-
cularis oculi fat pad (SOOF) spanning both cranial and caudal
to the orbicularis retaining ligament. The inferior orbital rim is
indicated by the dotted line.
Fig. 2. Surgeon’s view of the lower eyelid preseptal space, with
the orbicularis oculi muscle held back at the top of the image
with hooks. The medial and lateral sub–orbicularis oculi fat pads
(SOOF) are shown abutting the lateral inferior orbital rim. The
superior lamella of the orbicularis retaining ligament (arrow-
head) is seen just caudal to the inferior orbital rim (RIM).
Injection of fat or fillers over the rim in the lateral half
of the infraorbital rim causes almost immediate correc-
tion of the palpebromalar line and seamless blending
of the eyelid-cheek junction. This is mainly due to the
fact that the orbicularis retaining ligament is naturally
surrounded by fat, contrary to the tear trough liga-
ment, which is an area of adhesion devoid of fat. This
clear distinction of the medial infraorbital area, where
the orbicularis oculi is adhered to bone, and the lateral
infraorbital area, where the orbicularis is lying over
a plush layer of fat, should be kept in mind, as it has
implications in periorbital rejuvenation.
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Finally, although not clearly mentioned or dis-
cussed in the text, Cotofana et al.1 showed the lateral
and medial sub–orbicularis oculi fat compartments
to extend to the infraorbital rim in computed tomo-
graphic scans shown in their Figures 1 and 2, while
Wong et al. showed fat sandwiched between the two
orbicularis retaining ligament lamellae in their Fig-
ure 9.2,3 This further supports our aforementioned
conclusions.
DOI: 10.1097/PRS.0000000000006706
Mohammed S. Alghoul, M.D.
Elbert E. Vaca, M.D.
Lauren M. Mioton, M.D.
Division of Plastic and Reconstructive Surgery
Northwestern University Feinberg School of Medicine
Chicago, Ill.
James E. Zins, M.D.
Department of Plastic and Reconstructive Surgery
Cleveland Clinic
Cleveland, Ohio
Correspondence to Dr. Alghoul
Division of Plastic Surgery
Northwestern University Feinberg School of Medicine
675 North St. Clair Street, Suite 19-250
Chicago, Ill. 60611
mo.alghoul@gmail.com
Instagram: @Alghoulplasticsurgery
Facebook: Alghoulplasticsurgery
‍ ISCLOSURE
D
None of the authors has conflicts of interest to disclose.
REFERENCES
1. Cotofana S, Gotkin RH, Frank K, et al. The func-
tional anatomy of the deep facial fat compartments: A
detailed imaging-based investigation. Plast Reconstr Surg.
2019;143:53–63.
2. Wong CH, Mendelson B. Facial soft-tissue spaces and retain-
ing ligaments of the midcheek: Defining the premaxillary
space. Plast Reconstr Surg. 2013;132:49–56.
3. Wong CH, Hsieh MK, Mendelson B. The tear trough liga-
ment: Anatomical basis for the tear trough deformity. Plast
Reconstr Surg. 2012;129:1392–1402.
Reply: The Functional Anatomy of the Deep
Facial Fat Compartments: A Detailed Imaging-
Based Investigation
Sir:
We read with interest the observations of Alghoul et
al. in their correspondence regarding our recent publi-
cation on the functional anatomy of the deep facial fat
compartments.1 The authors shared their belief in an,
up to this point, undescribed relationship of the orbi-
cularis retaining ligament and the sub–orbicularis oculi
fat, where “the orbicularis retaining ligament is encased
within the sub–orbicularis oculi fat compartment.” They
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