COSMETIC

Pertinent Anatomy and Analysis for Midface

Volumizing Procedures
Christopher C. Surek, D.O.
Background: The study was conducted to construct an anatomically inspired mid-
Javier Beut, M.D.
facial analysis facilitating safe, accurate, and dynamic nonsurgical rejuvenation.
Robert Stephens, Ph.D.
Emphasis is placed on determining injection target areas and adverse event zones.
Glenn Jelks, M.D. Methods: Twelve hemifacial fresh cadavers were dissected in a layered fashion.
Jerome Lamb, M.D. Dimensional measurements between the midfacial fat compartments, prezygo-
Kansas City, Kan.; New York, N.Y.; matic space, mimetic muscles, and neurovascular bundles were used to develop
Independence, Mo.; and Palma de a topographic analysis for clinical injections.
Mallorca, Spain Results: A longitudinal line from the base of the alar crease to the medial edge
of the levator anguli oris muscle (1.9 cm), lateral edge of the levator anguli oris
muscle (2.6 cm), and zygomaticus major muscle (4.6 cm) partitions the cheek
into two aesthetic regions. A six-step facial analysis outlines three target zones
and two adverse event zones and triangulates the point of maximum cheek
projection. The lower adverse event zone yields an anatomical explanation to
inadvertent jowling during anterior cheek injection. The upper adverse event
zone localizes the palpebral branch of the infraorbital artery. The medial malar
target area isolates quadrants for anterior cheek projection and tear trough
effacement. The middle malar target area addresses lid-cheek blending and
superficial compartment turgor. The lateral malar target area highlights lateral
cheek projection and locates the prezygomatic space.
Conclusions: This stepwise analysis illustrates target areas and adverse event
zones to achieve midfacial support, contour, and profile in the repose position
and simultaneous molding of a natural shape during animation. This reproduc-
ible method can be used both procedurally and in record-keeping for midface
volumizing procedures.  (Plast. Reconstr. Surg. 135: 818e, 2015.)

A
s the human face ages, soft-tissue descent Evidence has emerged discussing the anatomical
is seen and manifested in the form of deep changes that occur in compartmentalized facial fat
folds and wrinkles, prominent jowling, and facial retaining ligaments. As a result, a para-
and loss of malar projection. In recent decades, digm shift has occurred implicating descent and
clinical scientists in our field have redefined how deflation of fat compartments along with ligamen-
we perceive and understand midfacial anatomy. tous attenuation as components to facial aging.
These findings have provoked both cadaveric and
clinical studies exploring the cause, prevention,
From the Department of Plastic Surgery, University of Kan-
sas Medical Center; the Department of Anatomy, Kansas
and treatment of these aesthetic changes.1–28 To
City University of Medicine and Biosciences; the Department date, there is universal agreement that certain
of Plastic and Reconstructive Surgery, New York University;
private practice; and Instituto Dr. Beut. Disclosure: The authors have no conflicts of i­ nterest
Received for publication April 20, 2014; accepted August to disclose.
28, 2015.
Presented at Plastic Surgery The Meeting 2013, the 82nd
Annual Meeting of the American Society of Plastic Surgeons,
in San Diego, California, October 11 through 15, 2013; the Supplemental digital content is available for
ASAPS Las Vegas 2014 Aesthetic Symposium, in Las Vegas, this article. Direct URL citations appear in the
Nevada, January 23 through 25, 2014; and Plastic Surgery text; simply type the URL address into any Web
The Meeting 2014, the 83rd Annual Meeting of the Ameri- browser to access this content. Clickable links
can Society of Plastic Surgeons, in Chicago, Illinois, October to the material are provided in the HTML text
10 through 14, 2014. of this article on the J­ournal’s Web site (www.
Copyright © 2015 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000001226

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Volume 135, Number 5 • Midface Volumization Analysis

changes do exist; however, the spatial relationship understand the relationship between the orbito-
of these compartments with surrounding struc- malar ligament, orbicularis oculi muscle, and the
tures in dynamic facial movement has not been clinical malar mound. Based on our findings, we
fully established. A greater in-depth understand- intend to outline target areas and adverse event
ing of the fat compartment synergy with surround- zones to be used for dynamic nonsurgical and sur-
ing structures and topographic impact of facial gical (fat grafting) rejuvenation of the midface.
fat in the aging patient is essential. Understand- With knowledge of the membranous property
ing these relationships will facilitate more pre- of the posterior surface of the orbicularis oculi,
cise treatment modalities, providing an effective blunt cannulas should be able to penetrate the
and durable result for our patients, and facilitate prezygomatic space laterally and inferiorly, glid-
record-keeping in volumizing procedures. ing freely within the space.
Clinically, we have seen three particular
adverse events following midface injections. The
first is superficial volumizing of the infraorbital
MATERIALS AND METHODS
“malar” fat compartment following percutane- Twelve hemifacial fresh cadaver specimens
ous injection targeted at improving lateral cheek were injected with methylene blue using the tech-
projection. This results in an iatrogenic malar nique described previously by Rohrich et al.1,8 The
mound (Figs. 1 and 2). The second is intraarterial superficial and deep fat compartment layers were
needle injection following percutaneous injection injected in an alternating fashion to delineate sep-
targeted at tear-trough effacement. The last is tal partitions of each compartment. Each speci-
significant jowling following percutaneous injec- men was dissected under loupe magnification in a
tions targeted at the deep medial cheek fat com- layered fashion. The first layer consisted of a skin-
partment for increased anterior cheek projection only flap elevated medial to lateral from the alar
(Fig. 3). The objective of this study was to develop base along the lateral border of the nasolabial fat
a three-dimensional understanding of anatomi- compartment and superiorly along the cutaneous
cal relationships existing in the midface and to
translate this understanding into a functional
analysis for procedural planning and safety. We
hope to examine the anatomical sequence that
occurs between the fat compartment layers and
potential spaces during facial animation, to better

Fig. 2. Illustration of the anatomical depth relationships involved

in iatrogenic malar mounds. The prezygomatic space is dem-
onstrated in the deep suborbicularis plane (blue capsule). The
orbitomalar ligament is demonstrated arborizing through the
orbicularis oculi muscle inserting into the skin forming the tear-
trough crease. The zygomaticocutaneous ligaments arborize
Fig. 1. Photographic illustration of an iatrogenic malar mound through the orbicularis, forming a partition between the infra-
resulting from superficial injection in the infraorbital “malar” fat orbital “malar” fat compartment superiorly and superficial cheek
compartment. Note the cutaneous insertions of the orbitomalar compartment inferiorly. The cutaneous insertion of the liga-
ligament superiorly and the zygomaticocutaneous ligaments ments forms the characteristic skin crease demonstrated in clini-
inferiorly. (Printed with permission from Dr. Levent Efe.) cal malar mounds. (Printed with permission from Dr. Levent Efe.)

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Fig. 3. Preprocedure and postprocedure photographic series of deep medial cheek fat compartment injection.
(Above) Preprocedure photographs. (Below) Postprocedure photographs taken 2 weeks after attempted injection
of the deep medial cheek fat compartment demonstrating jowling.

insertion of the zygomaticocutaneous ligaments thickening. After removal of the second layer, the
(Fig. 1). The second layer consisted of the superfi- remaining in situ layer consisted of the mimetic
cial midface fat compartments (nasolabial, medial muscles and underlying deep midface fat compart-
superficial, middle superficial, and infraorbital ments (i.e., medial sub–orbicularis oculi fat, lateral
“malar” compartments). A separate dissection on sub–orbicularis oculi fat, and deep medial cheek).
the same specimen raised a classic skin and muscle On elevation of the orbicularis oculi and sub–orbi-
flap at the ciliary margin and exposed the arcus cularis oculi fat, the preperiosteal fat was identi-
marginalis. The arcus marginalis was released fied. The facial artery, zygomaticofacial vascular
and the space anterior to the preperiosteal fat bundle, and infraorbital neurovascular bundle
was entered. A vertical incision was made in the were identified (Figs. 4 and 5).
skin-muscle flap at the level of the pupil. This was The locations of the zygomaticus major, leva-
extended downward to the surface anatomy of tor anguli oris, and levator labii superioris muscles
the zygomaticocutaneous ligaments. Upward dis- were measured from the alar crease (Table 1).
traction of the two sides of the split lower eyelid Dimensions of the midface fat compartments
exposed an areolar space posteriorly bounded by were measured. Spatial relationships between
the dense capsule of the preperiosteal fat. Cau- the mimetic muscles and fat compartments were
dally, dense fibrous attachments are present com- documented. The collected measurements and
posed of the zygomaticocutaneous ligaments and dissection observations were used to create a step-
maxillary insertions of the orbicularis oculi. Lat- wise facial analysis (Figs. 4 and 6). (See Video,
erally, this space arborizes with the lateral orbital Supplemental Digital Content 1, which shows the

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Fig. 4. Topographic markings for midface analysis are demonstrated on the

left hemiface, including the malar equator (ME), medial vertical reference
(MVR), lateral vertical reference (LVR), lower malar partition (LMP), upper malar
partition (UMP), and infraorbital rim margin (SIRM). The right hemiface illus-
trates the deep fat compartment layers. The sub–orbicularis oculi fat is adher-
ent to the undersurface of the orbicularis oculi. The prezygomatic space (blue
capsule) overlies the preperiosteal fat. The orbitomalar ligament (OML) and
zygomaticocutaneous (Zyg) ligaments are represented as the superior and
inferior borders of the prezygomatic space. Injection caution areas including
the palpebral branch of the infraorbital artery and buccal recess are illustrated.
OO, orbicularis oculi; IOF, infraorbital fat; LAO, levator anguli oris; LLS, levator
labii superioris. (Printed with permission from Dr. Levent Efe.)

conceptual description of the midfacial anatomi- lower regions for anatomical analysis (Figs. 4
cal architecture, available in the “Related Videos” and 6).
section of the full-text article on PRSJournal.com In the lower malar region, the first structure
or, for Ovid users, available at http://links.lww.com/ of importance is the deep medial cheek fat com-
PRS/B272. See Video, Supplemental Digital Con- partment. The bulk of deep medial cheek fat lies
tent 2, which is a demonstration of a topographic between the alar crease and the medial edge of
analysis for midface volumization procedures, the levator anguli oris, a measured area of approx-
available in the “Related Videos” section of the imately 1.9 cm in width (Table 1). The compart-
full-text article on PRSJournal.com or, for Ovid ment lies deep on the maxilla posterior to the
users, available at http://links.lww.com/PRS/B273.) levator labii superioris. As the deep medial cheek
fat proceeds laterally (beneath the levator anguli
RESULTS oris) to the maxillary deflection, the fat becomes
thin, loose and weakly septated (Figs. 4, 5, and 7).
Part 1: Midfacial Anatomy The tail of the compartment approaches an areo-
A separate grouping of anatomical relation- lar cavern deep to the superficial fat compartment
ships and fat compartment composition was layer and lateral to the levator anguli oris. This
observed above a longitudinal line drawn from loose areolar plane descends posteroinferiorly
the base of the alar crease. Therefore, we begin into the buccal fat pad. This space is triangulated
by partitioning the midcheek into upper and by the zygomaticus major, levator anguli oris, and

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Fig. 5. Lateral view showing the superficial fat compartments retracted. The zygomati-
cus major (ZM) and levator labii superioris (LLS) are labeled. The orbicularis has been
resected along the prezygomatic space capsule. The preperiosteal fat is stained with
methylene blue, and remnants of lateral sub–orbicularis oculi fat (SOOF) are noted over-
lying on the capsule of the preperiosteal fat. Medial sub–orbicularis oculi fat and infra-
orbital (IO) neurovascular bundle are labeled. The loose areolar consistency of the deep
medial cheek fat is noted lateral to the levator anguli oris (LAO). A cavernous commu-
nication into the buccal recess is noted, denoting a deep injection adverse event zone.

zygomaticomaxillary prominence (Figs. 4, 5, and medial to the levator anguli oris (Figs. 4, 5, and 7).
7). The lateral border of the space is consistent Therefore, the area between the alar crease and
with the medial edge of the zygomaticus major levator anguli oris (1.9 cm) is a desired location to
(4.6 cm from the alar crease). The medial border inject within the deep medial cheek fat (Table 1
of the space is the lateral edge of the levator anguli and Figs. 4 and 6). We and others have clinically
oris (2.6 cm from the alar crease) (Table 1). observed inadvertent jowling by attempted volu-
The role of deep medial cheek fat in ante- mizing of the deep medial cheek fat29,32 (Fig. 1).
rior cheek projection has been anatomically dis- We believe this to be the result of laterally dis-
cussed in the literature.8,25 The delineation of the placed injections resulting in placement within
interplay between the levator anguli oris and the the described areolar space lateral to the levator
deep medial cheek fat is important for anatomi- anguli oris. Detailed examination of this areolar
cal isolation of the deep medial cheek fat (Fig. 4). zone reveals a direct cavern posterolaterally into
Previous studies have described the levator anguli the buccal fat. Gierloff et al. refer to a superficial
oris as the partition of medial and lateral portions extension of the buccal fat pad that likely traverses
of the deep medial cheek fat.18 The dissections within this region.18 In this cadaveric study, the
in this study find the compartment to be largest consistency of the buccal extension fat compart-
ment was found to be loose (nonfibrous) and
poorly confined.
Table 1.  Longitudinal Measurements from the Base There is a distinct plane between the superfi-
of the Alar Crease to Edges of Select Mimetic Muscles cial and deep layers of facial fat in the upper malar
Distance from region (Figs. 4 and 8 through 12). In this region
Anatomical Landmark Alar Crease (cm) lies the prezygomatic space. Previously described
Levator anguli oris (medial edge) 1.9 by Mendelson et al., this potential space is bor-
Levator anguli oris (lateral edge) 2.6 dered superolaterally by the lateral orbital thicken-
Zygomaticus major (medial edge) 4.6 ing within the temporomalar partition (Fig. 11).

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to form a uniform prezygomatic space capsule.

Adherent to the undersurface of the orbicularis
oculi and superficial to the capsule is the loose
and areolar sub–orbicularis oculi fat (Fig. 10). The
prezygomatic space is a trapezoidal space, which
becomes crescentoid during facial animation.
The medial and middle superficial fat compart-
ments were found to be fibrofatty in composition
(Fig. 10). Both superficial compartments become
thicker and denser laterally in the midface. Manual
superolateral traction on the superficial compart-
ment layer demonstrated ease of movement of the
medial superficial cheek compartment over the
suborbicularis contents. This gliding movement
simulates the sequence occurring during facial
animation. (See Video, Supplemental Digital Con-
tent 1, which shows the conceptual description of
the midfacial anatomical architecture, available in
the “Related Videos” section of the full-text article
on PRSJournal.com or, for Ovid users, available at
Fig. 6. Topographic facial analysis markings are displayed. Malar http://links.lww.com/PRS/B272.)
equator (blue lines); LVR, lateral vertical reference (pink lines); In an attempt to demonstrate the accessibility
MVR, medial vertical reference (green lines); UMP, upper malar of this pocket through percutaneous injection,
partition (orange lines); LMP, lower malar partition (yellow lines); red-dyed hyaluronic acid filler was injected into
black rectangle, upper malar adverse event zone; AEZ, lower this region before dissection in selected speci-
malar adverse event zone; MED, medial malar target area; MID, mens (Figs. 8 and 12). To target this space, the
middle malar target area; LAT, lateral malar target area. cutaneous insertion of the zygomaticocutaneous
ligaments was used as a guide for finding a point
The roof is the obliquely oriented orbitomalar liga- inferolateral to this surface anatomy (Fig. 1).
ment. The space is bordered inferiorly by a fibrous The zygomaticocutaneous ligaments arborize
network of zygomaticocutaneous ligaments and through the orbicularis inserting onto the skin.
maxillary insertions of the orbicularis oculi form- Cephalic to this skin insertion and superficial
ing a discernible capsule as previously reported to the orbicularis lies the infraorbital “malar”
by Mendelson30 (Figs. 4 and 10 through 12). This fat compartment (Fig. 2). Understanding this
fascial encasement coalesces with the thick and depth relationship is important because injec-
well-demarcated capsule of the preperiosteal fat tions placed in the infraorbital compartment are

Video 1. Supplemental Digital Content 1 shows the conceptual

description of the midfacial anatomical architecture, available in the
“Related Videos” section of the full-text article on PRSJournal.com or,
for Ovid users, available at http://links.lww.com/PRS/B272.

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Video 2. Supplemental Digital Content 2 is a demonstration of a

topographic analysis for midface volumization procedures, available
in the “Related Videos” section of the full-text article on PRSJournal.
com or, for Ovid users, available at http://links.lww.com/PRS/B273.

Fig. 7. Lateral view showing that the superficial fat compartment layer has been
reflected. Demonstration of the deep medial cheek fat and medial sub–orbicularis oculi
fat (SOOF) stained with methylene blue. Zygomaticus major (ZM), levator anguli oris
(LAO), levator labii superioris (LLS), and levator labii superioris alaeque nasi (LLSAN) are
labeled. Hyaluronic acid filler homogenized with red dye has been injected into the lat-
eral sub–orbicularis oculi fat overlying the preperiosteal fat compartment.

prone to poor aesthetic outcomes secondary to We postulate that the loss of volume pro-
diminished lymphatic drainage in this region.25 posed by Lambros occurs in the medial sub–orbi-
This can result in iatrogenic malar mounds cularis oculi fat and lateral sub–orbicularis oculi
(Fig. 1). In this study, blunt cannulas consis- fat, contributing to the formation of the malar
tently arrived at the deep prezygomatic space, mound. Given the position and loose consistency
positioned posterior to the orbicularis and ante- of the sub–orbicularis oculi fat, targeted augmen-
rior to the dense capsule of the preperiosteal fat tations can be challenging. The specimens in
(Figs. 11 and 12). this study had well-volumized fat within the tight

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prezygomatic space may achieve an optimal con-

gruency of projection through various phases of
facial animation, facilitating a consistent rejuve-
nation as the superficial compartments glide over
the deep compartments. (See Video, Supplemen-
tal Digital Content 1, which shows the conceptual
description of the midfacial anatomical architec-
ture, available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for
Ovid users, available at http://links.lww.com/PRS/
B272.) This avoids “double folds” seen with ani-
mation in patients who have received improper
filler placement.
The position of the zygomaticofacial vas-
cular bundle was noted and cross-referenced
with previous studies.4,15 This bundle was found
to run within the zygomatic retaining ligament
Fig. 8. Oblique view showing the nasolabial fat compartment (MacGregor patch).4 As described previously,
(NLF) stained with methylene blue for a reference point. Injected this ligament corresponds with a central point of
red dyed filler is demonstrated in the prezygomatic space. The fixation and coalescence of several fat compart-
zygomaticocutaneous (ZC) ligaments are demonstrated form- ments.25 The location of the infraorbital artery
ing the inferior border of the gliding prezygomatic space. was consistent with previous studies. Pessa and
Rohrich describe the junction of the lid-cheek
crease and nasojugal crease as a suitable topo-
graphic landmark to identify the emergence of
this bundle (Figs. 4 and 5).25 Injectors must be
cognizant of the descending infraorbital artery.
The artery assumes a more superficial course
during descent, facilitating safe entrance into the
deep medial cheek fat from a deep plane (Figs. 5
and 7). During our dissections, an ascending
branch of the infraorbital artery was noted tra-
versing over the preperiosteal fat. This has been
previously described as the palpebral branch of
the infraorbital artery.26 Hwang et al. reported
the location of the palpebral branch of the infra-
orbital artery to be approximately half the eye
width from the medial canthus26 (Figs. 4 and 11).
This artery is a potential bleeding risk following
Fig. 9. Frontal view showing the nasolabial fat (NLF) and preperi-
release of the arcus marginalis during a midface
osteal fat (PPF) compartments stained with methylene blue. The
lift, fat transposition, and blepharoplasty proce-
caudal margin of the prezygomatic space capsule is retracted by
dures. Injection into the vessel or tamponading
the forceps, and scissors are placed in the prezygomatic space. The
of the vessel can lead to undesirable postproce-
cavernous communication into the buccal fat recess is observed
dural complications. (See Video, Supplemental
inferior to the zygomaticocutaneous ligaments. This communi-
Digital Content 2, which is a demonstration of
cating space is a potential lower malar adverse event zone.
a topographic analysis for midface volumization
procedures, available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or,
capsule of the preperiosteal fat (Figs. 7, 9, 11, for Ovid users, available at http://links.lww.com/
and 12). Simple volumizing of the preperiosteal PRS/B273.)
fat does not yield a dynamic aesthetically pleas- In our study, we found the area between the
ing augmentation, a finding consistent with the pupil and medial corneal limbus to be a good visual
long-term results of subperiosteal cheek implant reference for the course of the artery (Figs. 4 and
placement. This region can be augmented in a 6). Medial to this reference point is the superior
static fashion; however, augmentation within the portion of the nasolabial fat compartment and

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Fig. 10. Oblique view showing the nasolabial fat compartment stained with methy-
lene blue for anatomical reference. The medial superficial fat compartment is seen as
a separate layer from the deeper compartments. The instrument is inserted into the
prezygomatic space. The inferior boundary of the space consists of a fibrous network of
zygomaticocutaneous ligaments. The sub–orbicularis oculi fat (SOOF) lies on the under-
surface of the orbicularis oculi, superficial to the prezygomatic space capsule. The pre-
periosteal fat is visualized on the bone.

Fig. 11. Frontal view showing retroseptal fat and orbicularis oculi muscle labeled for
anatomical reference. The lateral orbital thickening is shown as the adherent lateral
border of the prezygomatic space. The preperiosteal fat has been stained with methy-
lene blue and is noted in the floor of the prezygomatic space. The palpebral branch of
the infraorbital artery is noted coursing through the medial sub–orbicularis oculi fat
compartment.

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face (Figs. 4 and 6).28 This corresponds with the

lateral orbital thickening, a tight adherence of fas-
cia that serves as the lateral boundary of the prezy-
gomatic space (Fig. 11).
Step 3: Upper Malar Partition
The upper malar partition is an oblique line
drawn from the medial canthus to the junction
of the first two analysis lines (malar equator and
lateral vertical reference). This functions as a
dividing line for medial, middle, and lateral malar
target areas (Figs. 4 and 6). The medial malar
target area contains the superior segment of the
nasolabial fat compartment (Figs. 8 through 11).
The middle malar target zone isolates structures
in the superficial and deep fat layers. Superficially,
Fig. 12. Frontal view showing the prezygomatic space capsule the medial superficial cheek compartment can be
stained with methylene blue. The infraorbital “malar” fat com- targeted (Fig. 10). In the deep compartment layer,
partment is noted superficial to the prezygomatic space and the medial segment of the prezygomatic space can
orbicularis oculi. Blunt cannulas placed percutaneously before be isolated (Figs. 7 and 8). The lateral malar target
dissection are found inside the prezygomatic space. area isolates the infraorbital compartment super-
ficially (Fig. 12). In the deep compartment layer,
the lateral segment of the prezygomatic space can
the medial boundary of the prezygomatic space be targeted (Figs. 4, 10, and 11). Lastly, this parti-
(Figs. 4 and 8 through 10). tion will assist in preprocedural prediction for the
location of the palpebral branch of the infraor-
Part 2: Midfacial Analysis bital artery (Figs. 4, 6, and 11).
The described facial analysis uses easily iden-
tifiable topographic landmarks and simultane- Step 4: Lower Malar Partition
ously incorporates critical anatomical principles The lower malar partition is an oblique line
in the midface. We recognize that variation will drawn from the modiolus to the junction of
exist among patients and that this can lead to the first two analysis lines (malar equator and
“adverse event zones” and “target zones” exist- lateral vertical reference) (Figs. 4 and 6). This
ing outside the defined borders in this analysis. topographic line corresponds with the approxi-
However, we feel that this anatomical outline mate course of the zygomaticus major muscle,
encourages injectors to consider these areas the origin of which was 4.6 cm from the base of
during preprocedural planning and can assist the alar crease in this study (Table 1). The lower
in controlled, accurate record-keeping in volu- malar partition represents the lateral border of a
mizing procedures (Figs. 4 and 6). (See Video, cavernous space in the lower midface communi-
Supplemental Digital Content 2, which is a dem- cating with the buccal fat compartment (Figs. 8
onstration of a topographic analysis for mid- and 9). Given our clinical observations and oth-
face volumization procedures, available in the ers’ clinical observations of jowling in select
“Related Videos” section of the full-text article patients who underwent attempted deep medial
on PRSJournal.com or, for Ovid users, available cheek compartment augmentation, we believe
at http://links.lww.com/PRS/B273.) this space to be a potential adverse event zone
(Figs. 3 through 5, 7, and 8).29 We have therefore
Step 1: Malar Equator named this area the lower malar adverse event
The malar equator is a horizontal line drawn zone (Figs. 5 through 7). The medial border
from the base of the alar crease partitioning the of this space is defined in the next step of the
midcheek into upper and lower regions based on analysis.
key anatomical relationships (Figs. 4 and 6).
Step 5: Medial Vertical Reference
Step 2: Lateral Vertical Reference The medial vertical reference is a vertical
A vertical line drawn from the lateral orbital line drawn from the medial pupillary border
rim to the angle of the mandible delineates the to the upper lip (Figs. 4 and 6). Topographi-
anterior “mobile” face from the lateral “immobile” cally, this marking corresponds with the lateral

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border of the levator anguli oris muscle, which acknowledgment

lies approximately 2.6 cm from the base of the The supplemental digital content videos were funded
alar crease (Table 1). The medial vertical ref- by the University of Kansas Department of Plastic Sur-
erence is critical for multiple reasons. First, it gery. The medical illustrations were funded by Jerome
functions as the medial border of the lower Lamb, M.D.
malar adverse event zone (Figs. 4 through 6).
The region medial to this line is where we rec-
ommend injectors target the deep medial cheek patient consent
fat compartment, as this is where the compart- Patients provided written consent for the use of their
ment is most compact and may decrease the images.
chance of filler migration laterally into the
lower malar adverse event zone (Figs. 5 and 7).
As the line ascends into the upper malar region references
it will intersect with the upper malar partition 1. Rohrich RJ, Pessa JE. The fat compartments of the face:
Anatomy and clinical implications for cosmetic surgery. Plast
(Figs. 4 and 6). Topographically, this inter- Reconstr Surg. 2007;119:2219–2227; discussion 2228.
secting region represents the location of the 2. Aiache AE, Ramirez OH. The suborbicularis oculi fat pads: An
ascending palpebral branch of the infraorbital anatomic and clinical study. Plast Reconstr Surg. 1995;95:37–42.
artery. We have clinically observed intraarterial 3. Stuzin JM, Baker TJ, Gordon HL. The relationship of the
injections of this vessel following a volumizing superficial and deep facial fascias: Relevance to rhytidectomy
and aging. Plast Reconstr Surg. 1992;89:441–449; discussion 450.
procedure and therefore have delineated this 4. Furnas DW. The retaining ligaments of the cheek. Plast
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This cadaveric study yields a detailed visual rep-
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13. Rohrich RJ, Arbique GM, Wong C, Brown S, Pessa JE. The
absolute, as each patient is unique. This informa- anatomy of suborbicularis fat: Implications for periorbital
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inspired outline to assist in the delivery of safe, 14. Lambros V. Models of facial aging and implications for treat-
accurate, and reproducible dynamic rejuvenation ment. Clin Plast Surg. 2008;35:319–327; discussion 317.
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