Reply: Facial Contouring by Targeted Restoration of Facial Fat Compartment Volume

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We read with great interest the comments by Hartstein et al. concerning our article1 on compartment-based facial contouring, specifically with regard to the Ristow space. The Ristow space was first described by Drs. Rohrich, Pessa, and Ristow in 2008 in an anatomical study of deep face fat compartments.2 It is a relatively loose potential space between the periosteum of the maxilla and the medial part of the deep medial fat compartment, and was postulated to be of potential importance for facial rejuvenation. We confirmed this space in our study by cadaver dissection. Although we did not use it in our clinical practice, we concur with Dr. Ristow that this could be a potential space for fat grafting.1
In 2013, Dr. Hartstein’s group published a study of tear trough effacement in 114 sides of 57 cases by combined techniques of lower lid blepharoplasty, fat repositioning, and fat grafting in the Ristow space and deep medial fat compartment.3 Their study showed that the combined technique effaced the tear trough deformity and resulted in a fuller cheek contour. We agree with the idea that the lower lid and medial cheek be considered and addressed simultaneously whenever possible, as outcomes for these two subunits are complementary. Furthermore, restoring fullness to the deep medial fat compartment may help to support the superficial fat compartment and indirectly contribute to effacement of tear trough deformity.
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