Licensed to Kelli marcari - kellimarcari@gmail.

com

COSMETIC

Deep Pyriform Space: Anatomical Clarifications

and Clinical Implications
Christopher K. Surek, D.O.
Background: The purpose of this study was to define the anatomical bound-
James Vargo, M.D.
aries, transformation in the aging face, and clinical implications of the Ris-
Jerome Lamb, M.D.
tow space. The authors propose a title of deep pyriform space for anatomical
Kansas City, Kan.; continuity.
and Independence, Mo. Methods: The deep pyriform space was dissected in 12 hemifacial fresh cadaver
dissections. Specimens were divided into three separate groups. For group 1,
dimensions were measured and plaster molds were fashioned to evaluate shape
and contour. For group 2, the space was injected percutaneously with dyed
hyaluronic acid to examine proximity relationships to adjacent structures. For
group 3, the space was pneumatized to evaluate its cephalic extension.
Results: The average dimensions of the deep pyriform space are 1.1 × 0.9 cm.
It is bounded medially by the depressor septi nasi and cradled laterally and
superficially in a “half-moon” shape by the deep medial cheek fat and lip el-
evators. The angular artery courses on the roof of the space within a septum
between the space and deep medial cheek fat. Pneumatization of the space
traverses cephalic to the level of the tear trough ligament in a plane deep to
the premaxillary space.
Conclusions: The deep pyriform space is a midface cavity cradled by the pyri-
form aperture and deep medial cheek compartment. Bony recession of the
maxilla with age predisposes this space for use as a potential area of deep
volumization to support overlying cheek fat and draping lip elevators. The po-
sition of the angular artery in the roof of the space allows safe injection on the
bone without concern for vascular injury. (Plast. Reconstr. Surg. 138: 59, 2016.)

I
n the landmark 2007 article describing the With our current understanding of bony
deep medial cheek fat compartment, Rohrich resorption that occurs with aging in the midface,
et al. alluded to a space medial and deep to the coupled with selective atrophy of the deep facial
deep medial cheek fat compartment abutting the fat compartments, we believe this space enlarges
pyriform aperture. The authors titled this space with age and becomes a relevant target area for
“Ristow’s space,” referencing a personal com- volumization.3–12 It is well documented that the
munication with Bruno Ristow.1 Gierloff et al. pyriform aperture recesses and the maxilla rotates
described the Ristow space to be a triangular para- with age, thereby diminishing anterior cheek pro-
nasal structure and postulated that volumization jection and widening the orbital aperture. There-
of this area in conjunction with the deep medial fore, as the pyriform recedes and the maxilla
cheek fat compartment elevates and effaces the
nasolabial fold.2 With the exception of these two
citations, very little information has been pub- Disclosure: The authors have no financial interest
lished on the anatomical construct of the space to declare in relation to the content of this article.
and potential clinical implications for volumizing
procedures.
Supplemental digital content is available for
this article. Direct URL citations appear in the
From the Department of Plastic Surgery, University of Kan- text; simply type the URL address into any Web
sas Medical Center; and private practice. browser to access this content. Clickable links
Received for publication September 3, 2015; accepted Febru- to the material are provided in the HTML text
ary 17, 2016. of this article on the Journal’s Web site (www.
Copyright © 2016 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000002262

www.PRSJournal.com 59
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Licensed to Kelli marcari - [email protected]

Plastic and Reconstructive Surgery • July 2016

Fig. 1. Medical illustration of the deep pyriform space and important adjacent
structures. OO, orbicularis oculi muscle. (Reproduced with permission from
James Vargo, M.D. © James Vargo, M.D.)

rotates, it causes the deep medial cheek fat to fall In the second four specimens, the deep pyri-
laterally, resulting in increased dimension of the form space was injected percutaneously with
described Ristow space. The purpose of this study dyed hyaluronic acid. A separate color of dye was
was to further define the anatomical boundar- homogenized with hyaluronic acid and injected
ies, transformation in the aging face, and clini- into the premaxillary space. Layered dissection
cal implications of the Ristow space. In addition, was performed to isolate both the deep pyriform
we propose a title change to the deep pyriform space and the premaxillary space. In addition, the
space for anatomical continuity with other named
potential spaces in the face, including the prezy-
gomatic and premaxillary spaces.9,13

MATERIALS AND METHODS

The deep pyriform space was dissected in 12
hemifacial fresh cadaver dissections. All dissec-
tions were performed under loupe magnification.
Before injection, certain facial fat compartments
were dyed with methylene blue for reference.
Specimens were divided into three separate
groups. In the first four specimens, no material
was injected into the deep pyriform space before
dissection. Layered dissection proceeded to the
level of the space, and dimension measurements
were performed. After measurements, a plaster
mold of the deep pyriform space was made in Fig. 2. Demonstration of post–orbicularis oris fat (POOF).
each specimen to evaluate the shape and contour Cephalic to this fat compartment lies the entrance into the deep
of the space. pyriform space.

60
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Licensed to Kelli marcari - [email protected]

Volume 138, Number 1 • Deep Pyriform Space

extension of the space relative to the orbitomalar

and tear trough ligaments. Video footage of the
pneumatization was obtained.

RESULTS
The average dimensions of the deep pyriform
space are 1.1 × 0.9 cm, with a range of 0.5 to 1.6 cm
× 0.8 to 1.8 cm. In situ, the deep pyriform space
possesses an inverted triangular shape bounded
inferomedially by the depressor septi nasi, the soft-
tissue insertions on the pyriform aperture, and
post–orbicularis oris fat (Figs. 1 through 3). It is
cradled laterally and superficially in a half-moon
shape by the deep medial cheek fat (Fig. 4). The
angular artery courses in the roof of the Ristow
space within a septum between the space and deep
Fig. 3. Red-dyed hyaluronic acid injected percutaneously into medial cheek fat (Figs. 3 through 5). The pre-
the deep pyriform space. The depressor septi nasi muscle is maxillary space and levator labii superioris reside
demonstrated as the inferomedial border of the space. The superficial to this space. Based on pneumatization,
angular artery and adjacent deep medial cheek fat are noted the deep pyriform space traverses cephalic to the
laterally. level of the tear trough ligament and exists in a dis-
tinctly deeper plane than the premaxillary space
angular artery and deep medial cheek fat were (Fig. 6). (See Video, Supplemental Digital Content
1, which demonstrates pneumatization of the deep
identified and examined for positional relation-
pyriform space, http://links.lww.com/PRS/B766.)
ship relative to the deep pyriform space. In the
last four specimens, the deep pyriform space was
accessed percutaneously with a blunt cannula DISCUSSION
attached to a 10-cc syringe filled with air. The space Recent studies suggest that selective atrophy of
was then pneumatized to evaluate the cephalic deep fat compartments and relative hypertrophy

Fig. 4. The deep pyriform space is cradled medially by the pyriform aperture
and depressor septi nasi. The angular artery courses between the space and
the deep medial cheek fat compartment. Note that the artery is not directly
on the periosteum, but superficial and lateral within the roof of the space.
Post–orbicularis oris fat (POOF) is stained green.

61
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Licensed to Kelli marcari - [email protected]

Plastic and Reconstructive Surgery • July 2016

space reside in distinctly different planes (Figs. 1

and 6). Intuitively, the combination of pyriform
aperture recession and deep medial fat deflation
with aging leads to diminished structural support
of the anterior cheek. The rotation of the maxilla
with age leads to lateral movement of the deep
medial cheek fat. These factors likely translate
into expansion of the deep pyriform space with
age; however, the small sample size and limited
age distribution of this study cannot statistically
support this postulation. Given the described
anatomy, volumization in the deep pyriform space
may provide a fulcrum lifting of the deep medial
cheek compartment and draping lip elevators that
reside superficial to this space (Fig. 7).
Pneumatization of this space demonstrates its
Fig. 5. Side-by-side comparison of a 27-gauge cannula and the cephalic extension to the level of the tear trough
angular artery on the boundary of the deep pyriform space. Post– ligament and lateral extension along the maxilla
orbicularis oris fat is stained green. DPS, deep pryiform space. deep to the medial cheek soft-tissue layers (See
Video, Supplemental Digital Content 1, http://
of superficial fat compartments occurs in the links.lww.com/PRS/B766). Although not proven,
aging face. This corresponds to larger adipocyte we believe this space may play a role in lymphatic
size in superficial fat compared to deep fat. The drainage of the periorbita. Further cadaveric
proposed concept of pseudoptosis, or selective study will be needed to explore this concept.
deflation of deep fat compartments leading to loss In this study, the angular artery coursed superfi-
of support and sagging of the superficial cheek cial and lateral to the deep pyriform space within a
fat, leads authors to advocate for deep volumiza- septum separating the space from the deep medial
tion techniques.3–12 We and others have attempted cheek compartment (Figs. 3 and 4). Given the
volumization of the deep medial cheek fat and position of the artery, it is conceivable that filler or
premaxillary spaces to obtain improved anterior autologous fat placed deep in the space on perios-
cheek projection. This study demonstrates that teum is a safe approach and void of unwanted vas-
these two structures along with the deep pyriform cular injury. For clinical purposes, we performed a

Fig. 6. Instruments are placed in the premaxillary space and the deep pyri-
form. The instruments were advanced through the tear trough ligament, dem-
onstrating that these structures reside in distinctly different planes.

62
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Licensed to Kelli marcari - [email protected]

Volume 138, Number 1 • Deep Pyriform Space

Video. Supplemental Digital Content 1 demonstrates pneumatiza-

tion of the deep pyriform space, http://links.lww.com/PRS/B766.

Fig. 7. Demonstration of the mimetic muscle insertions into the nasolabial

fold. Note that the pre–orbicularis oris fat is fibrofatty, in contrast to superficial
nasolabial compartment fat, which is more lobular in appearance.

side-by-side comparison of a 27-gauge cannula and cannula is in. Effectively, once the cannula is deep
angular artery diameters (Fig. 5). to the nasolabial fold, the injector has arrived in
Unlike the well-defined prezygomatic space a sub–superficial musculoaponeurotic system
and premaxillary spaces, there is no discernible plane. A steeper, 60- to 90-degree vector down to
encapsulation of the deep pyriform space,9,12 bone will safely place the cannula within the deep
which raises the question of material confine- pyriform space. In contrast, a shallower 30-degree
ment and possible migration outside of the space vector will place the cannula in the premaxillary
following volumization. The borders of the space space. The clinical confirmation that the cannula
are well defined. The fanning insertion of the has arrived in either of the targeted spaces is a
depressor septi nasi and septation of the post– perceptible free passage and movement of the
orbicularis oris fat provides a robust inferior ham- cannula. If the injector feels resistance, the can-
mock for the space (Figs. 1 through 3). Clinically, nula is likely in the deep medial cheek fat. Anec-
we access both the premaxillary space and the dotally, we recommend highly cohesive filler,
deep pyriform space with blunt cannulas. Once hydroxyapatite, or autologous fat for the deep
the cannula is subcutaneous, the angle of vec- pyriform space volumization. We do not recom-
tor helps the injector determine which space the mend aqueous-based filler.

63
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Licensed to Kelli marcari - [email protected]

Plastic and Reconstructive Surgery • July 2016

CONCLUSIONS A computed tomographic study. Plast Reconstr Surg.

2012;129:263–273.
The deep pyriform space is a midface cavity 3. Wan D, Amirlak B, Giessler P, et al. The differing adipo-
cradled by the pyriform aperture and deep medial cyte morphologies of deep versus superficial midfacial
cheek compartment. Bony recession of the maxilla fat compartments: A cadaveric study. Plast Reconstr Surg.
with age predisposes this space to use as a poten- 2014;133:615e–622e.
tial area of deep volumization to support overlying 4. Gierloff M, Stöhring C, Buder T, Wiltfang J. The subcuta-
neous fat compartments in relation to aesthetically impor-
cheek fat and draping lip elevators. The position of
tant facial folds and rhytides. J Plast Reconstr Aesthet Surg.
the angular artery in the roof of the space allows safe 2012;65:1292–1297.
injection on the bone without concern for vascular 5. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumet-
injury. With time, this may prove to be a vital target ric analysis of soft-tissue changes in the aging midface using
area for restructuring the aging anterior midface. high-resolution MRI: Implications for facial rejuvenation.
Plast Reconstr Surg. 2005;115:1143–1452; discussion 1153.
Christopher Surek, D.O. 6. Guyuron B, Rowe DJ, Weinfeld AB, Eshraghi Y, Fathi A,
Department of Plastic Surgery Iamphongsai S. Factors contributing to the facial aging of
University of Kansas Medical Center identical twins. Plast Reconstr Surg. 2009;123:1321–1331.
3901 Rainbow Boulevard 7. Donofrio LM. Fat distribution: A morphologic study of the
Kansas City, Kan. 66160 aging face. Dermatol Surg. 2000;26:1107–1112.
[email protected] 8. Wan D, Amirlak B, Rohrich R. The clinical importance of the
fat compartments in midfacial aging. Plast Reconstr Surg Glob
Open 2104;1:e92.
ACKNOWLEDGMENTS 9. Mendelson B, Wong C. Anatomy of the aging face. In:
The authors thank the Department of Anatomy, Neligan PC, ed. Plastic Surgery. Vol. 2. 3rd ed. New York:
Kansas City University; and James Vargo, M.D., for Elsevier Saunders; 2013:78–92.
10. Farkas JP, Pessa JE, Hubbard B, Rohrich RJ. The science
medical illustration. and theory behind facial aging. Plast Reconstr Surg Glob Open
2013;1:e8–e15.
11. Lambros V. Observations on periorbital and midface aging.
REFERENCES Plast Reconstr Surg. 2007;120:1367–1376; discussion 1377.
1. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and 12. Pessa J, Rohrich R. Facial Topography: Clinical Anatomy of the
the deep medial fat compartment. Plast Reconstr Surg. Face. St. Louis: Quality Medical; 2012.
2008;121:2107–2112. 13. Wong CH, Mendelson B. Facial soft-tissue spaces and retain-
2. Gierloff M, Stöhring C, Buder T, Gassling V, Açil Y, Wiltfang ing ligaments of the midcheek: Defining the premaxillary
J. Aging changes of the midfacial fat compartments: space. Plast Reconstr Surg. 2013;132:49–56.

64
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.