The malar fat pad is a discrete, triangular shaped area of thickened subcutaneous fat, based at the nasolabial fold with its apex at the malar eminence in the youthful face. It is attached to the overlying skin and is supported by multiple fibrous septae that extend from the superficial musculoaponeurotic system (SMAS) and into the dermis. Loss of skin elasticity and weakening of these septae, as well as volume loss within the deep medial cheek fat, lead to a downward and forward descent of the skin and malar fat pad until it bulges against the fixed nasolabial fold.
These sequelae of ageing result in deepening of the nasolabial folds, progressive hollowing of the cheeks, and loss of prominence of the malar eminences. The lower eyelid lengthens, increasing visibility of the orbicularis oculi muscle, coupled with the formation of tear trough and a crescent or “V”-shaped deformity along the maxilla and zygoma. There is recession of the nasal alar cheek junction. Individual fat pockets become discernible as separate entities rather than the smooth transitions from convexities to concavities seen in youth. It is the author’s view that no other facial injection site provides greater rejuvenation than the midface.