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Pertinent Anatomy and Analysis for Midface Volumizing Procedures

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

Plastic and Reconstructive Surgery: May 2015 - Volume 135 - Issue 5 - p 818e–829e
doi: 10.1097/PRS.0000000000001226
Cosmetic: Original Articles
Cover Article

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.

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 reproducible method can be used both procedurally and in record-keeping for midface volumizing procedures.

Kansas City, Kan.; New York, N.Y.; Independence, Mo.; and Palma de Mallorca, Spain

From the Department of Plastic Surgery, University of Kansas Medical Center; the Department of Anatomy, Kansas City University of Medicine and Biosciences; the Department of Plastic and Reconstructive Surgery, New York University; private practice; and Instituto Dr. Beut.

Received for publication April 20, 2014; accepted August 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 ASAPS Las Vegas 2014 Aesthetic Symposium, in Las Vegas, Nevada, January 23 through 25, 2014; and Plastic Surgery The Meeting 2014, the 83rd Annual Meeting of the American Society of Plastic Surgeons, in Chicago, Illinois, October 10 through 14, 2014.

Disclosure: The authors have no conflicts of interest to disclose.

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Christopher C. Surek, D.O., Department of Plastic Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 3015, Kansas City, Kan. 66160,, (Requests for Reprints)

Jerome Lamb, M.D., Private Practice, 4820 South Arrowhead Drive, Independence, Mo. 64055,

©2015American Society of Plastic Surgeons