# Pertinent anatomy and analysis for midface volumizing procedures / Midface volume rejuvenation with fillers.

Christopher C. Surek, D.O., Javier Beut, M.D., Robert Stephens, Ph.D., Glenn Jelks, M.D., Jerome Lamb, M.D.

This chapter examines the layered anatomic array of the midface and translates these anatomic principles into consistent midface injection analysis and technique. The cadaver dissections, video demonstrations, and three-dimensional patient photography provide injectors with a comprehensive armamentarium to deliver accurate and reproducible results in midface volume rejuvenation with fillers.

Background: The study was conducted to construct an anatomically inspired midfacial analysis facilitating safe, accurate, and dynamic nonsurgical rejuvenation. Emphasis is placed on determining injection target areas and adverse event zones.

Methods: Twelve hemifacial fresh cadavers were dissected in a layered fashion. Dimensional measurements between the midfacial fat compartments, prezygomatic space, mimetic muscles, and neurovascular bundles were used to develop a topographic analysis for clinical injections.

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As the human face ages, soft-tissue descent is seen and manifested in the form of deep folds and wrinkles, prominent jowling, and loss of malar projection. In recent decades, clinical scientists in our field have redefined how we perceive and understand midfacial anatomy.

Evidence has emerged discussing the anatomical changes that occur in compartmentalized facial fat and facial retaining ligaments. As a result, a paradigm shift has occurred implicating descent and deflation of fat compartments along with ligamentous attenuation as components to facial aging. These findings have provoked both  cadaveric and clinical studies exploring the cause, prevention, and treatment of these aesthetic changes.1–28 To date, there is universal agreement that  certain changes do exist; however, the spatial relationship of these compartments with surrounding structures in dynamic facial movement has not been fully  established. A greater in-depth understanding of the fat compartment synergy with surrounding structures and topographic impact of facial fat in the aging patient is essential. Understanding these relationships will facilitate more precise treatment modalities, providing an effective and durable result for our patients, and facilitate record-keeping in volumizing procedures. Clinically, we have seen three particular adverse events following midface injections. The first is superficial volumizing of the infraorbital “malar” fat compartment following percutaneous injection targeted at improving lateral cheek projection. This results in an iatrogenic malar mound (Figs. 1 and 2). The second is intraarterial needle injection following percutaneous injection targeted at tear-trough effacement. The last is significant jowling following percutaneous injections targeted at the deep medial cheek fat compartment for increased anterior cheek projection (Fig. 3). The objective of this study was to develop a three-dimensional understanding of anatomical 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 understand the relationship between the orbitomalar ligament, orbicularis oculi muscle, and the clinical malar mound. Based on our findings, we intend to outline target areas and adverse event zones to be used for dynamic nonsurgical and surgical (fat grafting) rejuvenation of the midface. With knowledge of the membranous property of the posterior surface of the orbicularis oculi, blunt cannulas should be able to penetrate the prezygomatic space laterally and inferiorly, gliding freely within the space.

MATERIALS AND METHODS

Twelve hemifacial fresh cadaver specimens were injected with methylene blue using the technique described previously by Rohrich et al.1,8 The superficial and deep fat compartment layers were injected in an alternating fashion to delineate septal partitions of each compartment. Each specimen was dissected under loupe magnification in a layered fashion. The first layer consisted of a skinonly flap elevated medial to lateral from the alar base along the lateral border of the nasolabial fat compartment and superiorly along the cutaneous

insertion of the zygomaticocutaneous ligaments (Fig. 1). The second layer consisted of the superficial midface fat compartments (nasolabial, medial superficial, middle superficial, and infraorbital “malar” compartments). A separate dissection on the same specimen raised a classic skin and muscle flap at the ciliary margin and exposed the arcus marginalis. The arcus marginalis was released and the space anterior to the preperiosteal fat was entered. A vertical incision was made in the skin-muscle flap at the level of the pupil. This was extended downward to the surface anatomy of the zygomaticocutaneous ligaments. Upward distraction of the two sides of the split lower eyelid exposed an areolar space posteriorly bounded by the dense capsule of the preperiosteal fat. Caudally, dense fibrous attachments are present composed of the zygomaticocutaneous ligaments and maxillary insertions of the orbicularis oculi. Laterally, this space arborizes with the lateral orbital thickening. After removal of the second layer, the remaining in situ layer consisted of the mimetic muscles and underlying deep midface fat compartments (i.e., medial sub–orbicularis oculi fat, lateral sub–orbicularis oculi fat, and deep medial cheek). On elevation of the orbicularis oculi and sub–orbicularis oculi fat, the preperiosteal fat was identified.

The facial artery, zygomaticofacial vascular bundle, and infraorbital neurovascular bundle were identified (Figs. 4 and 5). The locations of the zygomaticus major, levator anguli oris, and levator labii superioris muscles were measured from the alar crease (Table 1).....

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