F a c i a l An a t o m y f o r Fi l l e r

Injection
The Superficial Musculoaponeurotic System
(SMAS) Is Not Just for Facelifting
Christopher C. Surek, DOa,b,c,d,*

KEYWORDS
 Facial fat compartments  Superificial musculoaponeurotic system (SMAS)  Facial artery
 Angular artery  Superficial temporal artery  Pre-zygomatic space
 Deep lateral chin fat compartment  Osseocutaneous ligaments

KEY POINTS
 The prezygomatic space is a desirable target for deep augmentation of the lateral cheek.
 The deep medial cheek fat compartment and deep pyriform space can be used to soften the na-
solabial fold and peripyriform shadow.
 Key landmarks and surface topography can be used to identify and potentially avoid the main trunk
and associated branches of the facial artery as it traverses through the face.
 Injection into the deep medial chin fat compartment is a desirable target for chin augmentation with
volume.
 The deep lateral chin fat compartment can be volumized to soften a prominent prejowl sulcus
shadow.

INTRODUCTION facial aesthetic rejuvenation. Whether the sur-

geons themselves are performing the injections
The Fear of Injections, is the Fear of Anatomy or extenders of the surgeon are performing the
—Adapted from Ian Taylor’s 1982 quote procedure, the tenants remain the same; strive
“The Fear of Surgery, is the Fear of Anatomy” for optimal results and avoid complications. The
American Society of Aesthetic Plastic Surgeons
In the spirit of this facelift edition of Clinics in Plas- statistics reported 722,394 injections in 2017 and
tic Surgery, this article journeys through facial this number continues to increase. There has
anatomy for the injector with a specific emphasis been a 40% increase in injectables over the past
on utilization of the superficial musculoaponeur- 5 years.1,2 Looking back even further, there has
otic system (SMAS) as a unique tool for the facial been a 312% increase in minimally invasive pro-
injector. The SMAS is a structure that is familiar cedures from 2000 to 2017.3
to the facelift surgeon and induces a mental image In contrast with facelift surgery where the sur-
that can be applied to injectable procedures geon can directly visualize the structures being
throughout the face. treated, facial injection is often a blind stick, leav-
The role of volume augmentation with filler ing the injector to estimate depth and location
plasticsurgery.theclinics.com

and/or fat has become increasingly important in based on surface topography and experience.

Disclosure: The author is a consultant for Allergan, Galderma and Cypris Medical.
a
Kansas City University, Kansas City, KS, USA; b University of Kansas Medical Center, Kansas City, KS, USA;
c
Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA; d Private Practice, Surek Plastic Surgery,
Overland Park, KS USA
* 7901 W. 135th Street, Overland Park, KS 66223, USA.
E-mail address: [email protected]

Clin Plastic Surg 46 (2019) 603–612

https://doi.org/10.1016/j.cps.2019.06.007
0094-1298/19/Ó 2019 Elsevier Inc. All rights reserved.
604 Surek

Therefore, this inability for injectors to directly visu-

alize anatomic targets is why anatomic accuracy is
critical to avoid suboptimal outcomes.
The objective of this article is to illustrate the
layered anatomy in each facial aesthetic subunit
and demonstrate high yield pearls that can be
used by the facelift surgeon when performing vol-
umizing procedures. The overarching concept is
depth. The face is a 3-dimensional structure with
lymphatic, neurovascular, and ligament networks,
all of which can come into play when performing
injections.
To navigate facial depth in the face the author
suggests thinking of the facial layers in each
aesthetic subunit as the supra-SMAS and the
sub-SMAS, thereby facilitating a comprehensive
categorization of the fat compartments, potential
spaces, ligaments, lymphatics, and neurovascular
networks in 2 distinct planes. Particular emphasis
will be given to the facial vasculature because
vascular compromise is one of the most dreaded Fig. 1. Concept diagram for the layered anatomic
complications of facial injection. In the worst of in- arrangement in the face. Demonstrating the SMAS
stances, this complication can lead to skin necro- as a central layer with categorized structures deep
sis and blindness.4–8 and superficial containing fat compartments and po-
tential spaces for target volumization. (Courtesy of
Levent Efe, CMI, Melbourne, Australia.)
THE TANGO BETWEEN THE SUPERFICIAL
MUSCULOAPONEUROTIC SYSTEM (SMAS) MIDFACE AND TEAR TROUGH
AND THE FACIAL VASCULATURE Sub-SMAS (Subsuperficial
Musculoaponeurotic System)
Described by Mitz and Peyronie9 in 1976, the
SMAS has been a cornerstone of facial rejuvena- The sub-SMAS midface has been a well described
tion for decades. In the modern day this structure target for cheek volumization.3,11,12 For the pur-
can now play an integral role in non-surgical volu- poses of anatomic classification, the deep midface
mization of the face. Joel Pessa10 teaches that the can be divided into upper and lower components
SMAS is a vestigial remnant of the pan-facial mus- partitioned by the zygomaticocutaneous liga-
cles of lower primates and explains that the SMAS ments. This imaginary division line has been
acts as a highway to traffic important structures termed the malar equator (Fig. 2).11,13
(mainly vessels and motor nerves) around the The lower sub-SMAS midface contains the deep
face. In many regions of the face, the facial vascu- medial cheek fat compartment and deep pyriform
lature demonstrates an intimate relationship with space. An additional potential space, the premax-
the SMAS, particularly in the jawline, perioral, illary space has been identified but has yet to
nasolabial fold, infrabrow, and temple re- be shown as a preferred target for cheek
gions.11–16 Therefore, using these principles as a augmentation.3,11–15
baseline the injector can navigate superficial and The deep medial cheek fat compartment lies on
deep to the SMAS while potentially avoiding inter- the anterior maxilla and is divided into medial and
actions with facial vasculature in the process. lateral segments by the levator anguli oris muscle.
A suggested analogy of this concept is the mid- Medial to this fat compartment lies the deep pyri-
dle layer of a 2-tiered cake. The platter that the form space. This space lies adjacent to the pyri-
cake sits on is analogous to the facial skeleton. form aperture. The angular artery has been
The middle layer of icing (ie, the SMAS) is the cen- described to traverse lateral and superficial to
ter point, with a layer of cake below it (ie, sub- this space; however, vascular anatomy in this re-
SMAS, preperiosteal, deep fat, and potential gion can be variable (Fig. 3).17
spaces) and a layer of cake above it (ie, supra- The deep pyriform space and deep medial
SMAS, subcutaneous) and then topped with icing cheek fat compartments lie underneath the lip ele-
(ie, the skin; Fig. 1). Consider this analogy as we vators, which are contained within the SMAS;
take a journey through key facial aesthetic therefore, clinical volumization of these targets
subunits. helps to soften the nasolabial fold prominence
 Facial Anatomy for Filler Injection 605

and peripyriform shadowing. Access to this space

has been demonstrated through a variety of inser-
tion points within a 1.5-cm area of the alar base
(Fig. 4).11,13–15
The upper sub-SMAS midface contains the sub-
orbiculairs oculi fat, preperiosteal fat, and the pre-
zygomatic space. The preperiosteal fat pad is
described as a thin fat pad residing on the surface
of the zygoma. The suborbicularis oculi fat (SOOF),
by definition, lies on the undersurface of the orbicu-
laris muscle. A potential gliding space exists be-
tween these two fat compartments, termed the
prezygomatic space. This space has been well-
described as a target for cheek volume restoration.
The prezygomatic space is bordered superiorly by
the orbital retaining ligament and inferiorly by the
zygomaticocutaneous ligaments. These ligaments
coalesce medially at the tear trough ligament.
Laterally, the space is bordered by the lateral
orbital thickening. The far lateral extent of the zygo-
maticocutaneous ligaments is the main zygomatic
ligament (Fig. 5). When using cannula, injectors
will often feel a palpable and even audible pop as
they traverse through the SMAS into the prezygo-
matic space. This is a confirmatory sign of safe
Fig. 2. Photograph of a model demonstrating the passage into the sub-SMAS upper midface.11
malar equator, a topographic landmark for the Of note, the deep chain of facial lymphatics
approximate location of the zygomaticocutaneous courses from the lower eyelid into the floor of the
ligaments.
prezygomatic space before descending in the

Lateral and
medial SOOF

Deep medial
cheek fat

Fig. 3. The sub-SMAS structures of the anterior mid-

face. The deep medial cheek fat compartment is
divided into medial and lateral components by the le-
vator anguli oris muscle. Adjacent to the pyriform
aperture is the deep pyriform space. SOOF, suborbicu- Fig. 4. Port insertion for access to the deep anterior
laris oculi fat. midface volumization targets.
606 Surek

Fig. 5. The sub-SMAS structures of the lateral midface.

The preperiosteal fat pad resides on the body of the
zygoma. The suborbicularis oculi fat (SOOF) lies on
the undersurface of the orbicularis oculi muscle. Be-
tween these 2 fat compartments is the prezygomatic
space. Note the ligamentous boundaries of the space,
the orbital retaining ligament and zygomaticocutane-
ous ligaments. The lymphatic and vascular networks
are also displayed. (Courtesy of Levent Efe, CMI,
Melbourne, Australia.)

lower midface.18 The angular vasculature predomi-

nantly lies medial to the prezygomatic space and Fig. 6. Topographic markings for the commonly
the tear trough ligament. A topographic marking described facial and angular artery trajectories in
1.7 cm from midline and 1.3 cm inferior to the the midface.
medial canthus has been described as an approxi-
mate location of the angular artery.11,19 However, the tear tough into the cheek is titled the nasojugal
aberrant angular vessels have been described in groove and has been noted to result from volume
up to 30% of cadaver samples. The course of this shifts in the nasolabial and medial cheek fat
aberrant system is more lateral within the nasojugal compartments.12
groove. Topographically, this difference corre-
sponds with a point 3.5 cm lateral from the midline,
level with the supratip break and converging with
the midpupillary line19 (Fig. 6). The angular vein
has been mapped 4.2 mm (0.7) inferior to the
infraorbital foramen coursing superomedially deep
to the orbital leaf of the orbicularis oculi muscle.3

Supra-SMAS (Suprasuperficial
Musculoaponeurotic System)
Infraorbital fat
The supra-SMAS midface consists of superficial compartment
fat that is divided by vascularized septae creating Medial
distinct compartments. These compartments superficial cheek
compartment
include the nasolabial, medial superficial, middle
superficial, and lateral temporal cheek compart- Nasolabial fat
compartment
ments12 (Fig. 7). During cannula injection in the
subcutaneous plane of the submalar hollow, resis-
tance is often readily felt as the cannula traverses
from one compartment to the next.11 In the aging Fig. 7. The nasolabial, medial superficial, middle super-
face, the depression that extends inferiorly from ficial, and lateral temporal cheek fat compartments.
 Facial Anatomy for Filler Injection 607

The most superior superficial fat compartment artery. The branching of the superior labial artery
in the midface is the infraorbital or malar fat off of the facial artery is generally in a 1.5 cm2
compartment.12 This compartment is straddled area from the oral commissure at a depth of
by the cutaneous insertions of the orbital retaining approximately 3.5 mm. The artery will commonly
ligament (superiorly) and the zygomaticocutane- traverse cephalic the white roll for the lateral
ous ligaments (inferiorly). The superficial lateral two-thirds of the lip and then dive caudal to the
chain of lymphatics course through this compart- white roll at the proximal third of the lip at a depth
ment. Iatrogenic malar mounds from filler injection of 3 mm as it terminates in the median tubercle of
have been documented in the literature and the upper lip. From there, the artery gives off an
disruption of this lymphatic chain may be a ipsilateral philtral branch22 (Fig. 8). The philtral
contributing factor to this phenomenon.11,13 branch is suborbicularis 75% of the time; however,
Based on the described anatomy, superficial data has shown that the artery can travel superfi-
volumization of the midface fat compartments cial to the muscle in 25% of studied specimens.27
in the submalar hollow can be a desirable tech- The facial artery then ascends from the perioral
nique to expand the cheek and overall facial pro- region medial to the nasolabial fold and most
portions, however superficial volumization of the commonly crosses the fold at an average depth of
upper midface between the cutaneous insertions 5 mm at the junction of the middle and proximal third
of the orbital retaining ligament and zygomatico- of the fold.11,28 It is at this point where there often
cutaneous ligament should be approached with seems to be an intimate relationship of the angular
caution because there is the potential for artery and the SMAS (see Fig. 8). This relationship
lymphatic disruption in this plane.11,13 seems logical since the artery’s path courses
through the insertions of SMAS into the nasolabial
fold.29–32 The SMAS and the angular artery are often
PERIORAL AND NASOLABIAL FOLD
interlaced until the artery approaches the region of
Sub-SMAS (Subsuperficial
the alar crease where it most commonly traverses
Musculoaponeurotic System)
subcutaneous as it gives of the lateral nasal artery.
The facial artery ascends over the mandibular It then courses in the alar facial groove to anasto-
border coursing just lateral and often deep to the mose with the dorsal nasal artery.
depressor anguli oris (ie, the sub-SMAS). It con- This vessel pattern is the reason several pub-
tinues into the perioral region intimate with the lished resources suggest deep preperiosteal
modiolus complex giving off the inferior and supe-
rior labial vessels. In the majority of instances,
these vessels remain deep to the orbicularis mus-
cle (ie, the sub-SMAS) as they traverse medially.
This path may traverse the supra-SMAS plane in
the philtrum or central lower lip in a smaller per-
centage of people.20–24 Owing to this principle,
many lip injections are performed in the supra-
SMAS plane in the upper lip, philtrum and lower
lip. The idea behind this approach is to maximize
the return on the investment of volume and topo-
graphic alteration while attempting to avoid
vascular complications.25 Authors have described
potential spaces in the subvermillion (ie, supra-
SMAS) of the upper and lower lip that can
be readily accessed with cannulas for lip
augmentation.11,26
The inferior labial artery comes off the facial ar- Fig. 8. Topographic markings for inferior labial, supe-
tery within an area 2.4 cm from the oral commis- rior labial, and facial artery. Note the superior labial
sure and 2.4 cm superior to the lower border of courses cephalic to the white roll for the lateral two-
thirds of the ipsilateral upper lip and then traverses
the mandible traversing submucosal to the
caudal to the white roll into the medial tubercle of
midline. The path of the artery is variable; the
the lip in the proximal third at an average depth of
main trunk can travel as low as the labiomental 3 mm. Then, a philtral artery branches vertical and su-
crease or has high as the vermillion cutaneous perior toward the columella. The facial artery travels
junction.20,21 The superior labial artery is not al- medial to the nasolabial fold and then crosses
ways a bilateral structure. Studies have shown beneath the fold at the proximal third at an average
that up to 43% of subjects had 1 superior labial depth of 5 mm.
608 Surek

injections on the bone in the anterior cheek and in- in thickness, density, and demarcation. Three
tradermal or immediate subdermal injection in the distinct boundaries define the subcutaneous
nasolabial fold. Additionally, studies recommend boundaries of the perioral region: the nasolabial
exercising caution in superficial injections in the sulcus, the labiomental sulcus, and the submental
peripyriform shadow because the depth of the sulcus. Volume augmentation in this region should
angular artery at this level seems to be variable be approached carefully and product selection is
and less predictable.16,33 To summarize, in the paramount, given the dynamic interplay of muscle
anterior cheek staying supra-SMAS in the nasola- and skin with animation.3
bial fold and sub-SMAS in the pyriform region are
likely to be safe planes to help decrease the inci- JAWLINE AND CHIN
dence of vascular injury (Fig. 9). Sub-SMAS (Subsuperficial
The main deep fat compartment of interest in the Musculoaponeurotic System)
upper lip is the retro-orbicularis oris fat. As the
name suggests, this compartment resides deep The sub-SMAS jawline contains the deep
to the orbicularis oris muscle. It has been postu- medial and lateral chin compartments as well
lated that this fat compartment loses turgor with as the mandibular osteocutaneous retaining
age and authors have postulated volumization of ligament (MOCL) and platysma mandibular liga-
this compartment for perioral rejuvenation.11 ment (PML). Similar to the midface, these liga-
ments can act as boundaries of injection when
Supra-SMAS (Suprasuperficial performing volume correction of the prejowl
Musculoaponeurotic System) sulcus.11
Superficial fat compartments of the lip have been The PML is located approximately 5 cm distal to
described; however, given the strong fibrous the gonial angle and acts as a fulcrum of stability
network between the perioral skin and the underly- for the platysma as it contracts over the jawline.
ing musculature, this fat can be dispersed and vary The PML is analogous to the zygomaticocutane-
ous ligaments in that it possesses a hammock-
like effect to help prevent injected volume to
descend below the jawline into the neck. Addition-
ally, the PML is analogous to the orbital retaining
ligament owing to its stabilizing function on the
platysma muscle (Fig. 10).34
The MOCL resides 5.6 cm distal to the gonial
angle and 1 cm above the mandibular border. The

Fig. 9. Cadaveric dissection demonstrating blue dyed Fig. 10. Pertinent sub-SMAS anatomy of the jawline.
hyaluronic acid filler within the deep pyriform space The mandibular osseocutaneous ligament, PML,
and adjacent anatomic structures. Note the location deep medial, and deep lateral chin fat compartments.
and path of the latex injected angular artery vessels. (Courtesy of Levent Efe, CMI, Melbourne, Australia.)
 Facial Anatomy for Filler Injection 609

ligament has been described as spanning 3.6 mm TEMPLE

in width and interdigitates with the depressor anguli Sub-SMAS (Subsuperficial
oris muscle. Therefore, the MOCL contributes to Musculoaponeurotic System)
the lower marionette fold and is a transition point
The temple remains a controversial topic in the
between the anterior jowl and marionettes.34
current realm of facial injections. To date, the
The deep chin fat contains medial and lateral
question remains as to what is the best plane to
compartments. The medial compartment lies on
inject. Certain authors target deep on the bone,
the mentum deep to the mentalis muscle and func-
others target superficial fat and, in some in-
tions as a suitable target for deep chin augmenta-
stances, intermediate targets are discussed.11,37
tion. The deep lateral chin fat compartment lies
A chronic issue with temple anatomy is that there
deep to the depressor anguli oris muscle, facili-
are several different names for the same structure.
tating muscle glide and has been described as a
Studies have attempted to simplify this.38,39
key injection target for volume correction of the
The etiology of the temple hollow has been well-
prejowl sulcus (see Fig. 10).11,12
studied and research shows that the anterior–
Several approaches to the prejowl have been
inferior trough is the deepest part of the temporal
described. The author’s preferred approach is
fossa. In youth, this trough is camouflaged by
through a paramedian port via cannula injecting
bulky soft tissue; however, as the face ages, thin-
cephalic to the PML and caudal to the MOCL to
ning of this soft tissue exposes the temple hollow,
volumize the deep lateral chin fat compartment.
creating an aesthetic deformity.40
For injectors who prefer a more direct approach
The deepest layer of fat in the temple is the tempo-
with a sharp needle, be mindful of the facial artery,
ral extension of the buccal fat pad (aka the deep
which ascends over the jawline through the antigo-
temporal fat pad), which lies deep to the deep tem-
nial notch, delivering vessels within or along the
poral fascia. Wedged between the 2 layers of deep
undersurface of the depressor anguli oris muscle
temporal fascia is the intermediate temporal fat
and then continuing cephalic to give off the inferior
pad. Interestingly, the bulk of this quadrangular fat
labial artery11 (see Fig. 10; Fig. 11).
pad is focused in the anterior–inferior trough and
studies show a volume loss with age in this compart-
Supra-SMAS (Suprasuperficial ment is a key component of aging the temple hollow.
Musculoaponeurotic System) The intermediate temporal fat pad receives its
The supra-SMAS jawline contains the superior and
inferior jowl compartments which are separated
from the submandibular compartment by the cuta-
neous insertion of the PML. With aging, repeated
gliding of the platysma over the mandible results
in counter-clockwise shift of the compartments
around the ligaments with gradual inferior descent.
This leads to the commonly described stigmata of
lower facial aging.3,35,36

Fig. 12. Pertinent anatomy of the temple. Note the

Fig. 11. Cadaveric dissection demonstrating green fat compartments of the temple and associated fascial
dyed hyaluronic acid filler deep lateral chin fat layers along with the demonstration of the superficial
compartment. Note the relationship of the superficial temporal artery coursing within the temporoparietal
jowl fat, depressor anguli oris and the facial artery fascia (ie, SMAS). (Courtesy of Levent Efe, CMI,
branches relative to this sub-SMAS injection target. Melbourne, Australia.)
610 Surek

vascular supply from the maxillary artery system retention era in upper blepharoplasty the desire
(Fig. 12). and necessity of infrabrow volumization is
A potential space lies between the deep tem- increasing.41 However, detailed depictions of the
poral fascia and the superficial temporal fascia periorbital vascularity are sparse. Actually, one
titled the upper temporal space. This space is can travel back to 1986 and credit Barry Zide
bordered superiorly by the superior temporal and Glenn Jelks42 with providing one of the first
septum (STS) and inferiorly by the inferior tempo- descriptions of tributaries stemming from the su-
ral septum. A commonly described method of praorbital and supratrochlear vessels. These tribu-
deep temporal augmentation is the use of an taries can possess direct connections between
intersection point 1 cm superior along the the central retinal artery, the forehead and temple
STS and then 1 cm posterior to the STS with vasculature.
an injection directly on bone. Others have sug- Anecdotally, many skilled surgeons demon-
gested adjusting this marking to 1.5 cm superior strate beautiful results from infrabrow injection.
along the STS and 1.5 posterior to the STS37 However, the question remains: What is the key
(Fig. 13). to these surgeons avoiding vascular problems?
A common port site is the lateral tail of the
Supra-SMAS (Suprasuperficial brow. The vessel that is in closest proximity to
Musculoaponeurotic System) this port site is the supraorbital vasculature. In
cadaveric dissection on a limited sample there
The superficial temporal fascia is the SMAS equiv- appears to be an intimate relationship of the su-
alent in the temporal region. The superficial praorbital tributary and the orbicularis muscle
temporal artery travels within this fascia and often (Figs. 14 and 15). The SMAS envelopes the orbi-
communicates with the orbital vascular system up cularis on its anterior and posterior surface.11 As
to 70% of the time. This relationship between the is seen in other parts of the face, the vessels
superficial temporal artery and orbital vasculature tend to run in and around this posterior lamella
is very important for each injector to understand of SMAS. Therefore, the common description of
as this has implications in vascular occlusions hugging the orbital rim on the bone during infrab-
that can lead to blindness. The superficial tempo- row injection places the injection in a sub-SMAS
ral (subcutaneous) fat pad lies superficial to the su- plane and conceivably in a plane that may
perficial temporal fascia and is a common target decrease the incidence of vascular injury. This is
for temporal volumization in the subcutaneous an important pearl considering the possible
plane (see Fig. 13). adverse sequelae of vascular compromise in this
region (ie, blindness). However, more anatomic
ORBIT and clinical data is needed regarding the efficacy
and safety of infrabrow volumization.
Periorbital injection is a hot topic in the current
literature. As the specialty of plastic surgery transi-
tions from a volume reduction era to the volume

Fig. 13. Cadaveric dissection demonstrating blue dyed

hyaluronic acid filler within the upper temporal space Fig. 14. The relationship of the SMAS, supraorbital ar-
and adjacent anatomic structures. Note the location cade, retro-orbicularis fat compartment and galeal fat
of the superficial temporal artery traveling within pad. (Courtesy of Levent Efe, CMI, Melbourne,
the temporoparietal fascia (ie, SMAS). Australia.)
 Facial Anatomy for Filler Injection 611

5. DeLorenzi C. Complications of injectable fillers, part

2: vascular complications. Aesthet Surg J 2014;
34(4):584–600.
6. Lee D, Yang H, Kim J, et al. Sudden unilateral visual
loss and brain infarction after autologous fat injec-
tion into nasolabial groove. Br J Ophthalmol 1996;
80(11):1026–7.
7. Ozturk C, Li Y, Tung R, et al. Complications following
injection of soft-tissue fillers. Aesthet Surg J 2013;
33:862–77.
8. Park T, Seo S, Kim J, et al. Clinical Experience with
hyaluronic acid complications. J Plast Reconstr Aes-
Fig. 15. Cadaveric dissection demonstrating green thet Surg 2011;64:892–6.
dyed hyaluronic acid filler within the retro orbicularis 9. Mitz V, Peyronie M. The superficial musculo-
oculi fat compartment and adjacent anatomic struc-
aponeurotic system (SMAS) in the parotid and
tures. Note the location of the latex injected supraor-
cheek area. Plast Reconstr Surg 1976;58(1):80–8.
bital vessel arcade running with the SMAS on the
undersurface of the orbicularis oculi muscle. 10. Cosmetic corner interview with Joel Pessa MD,
2017. Available at: https://academic.oup.com/asj.
11. Lamb J, Surek C. Facial volumization: an anatomic
SUMMARY approach. 1st edition. New York: Thieme Medical
Publishers; 2017.
Facial volumization with filler and/or fat can serve 12. Pessa J, Rohrich R. Facial topography: clinical anat-
as a finishing touch to compliment surgical omy of the face. St. Louis (MO): Quality Medical
repositioning of aging soft tissue. The depth of in- Publishing; 2012.
jection and anatomic awareness are paramount to 13. Surek C, Beut J, Stephens R, et al. Pertinent anat-
help avoid vascular, lymphatic and other undesir- omy and analysis for midface volumizing proced-
able sequalae. Each aesthetic subunit can be ures. Plast Reconstr Surg 2015;135(5):818e–29e.
approached in a systematic fashion to target 14. Surek C, Beut J, Stephens R, et al. Volumizing via-
sub-SMAS or supra-SMAS structures including ducts of the midface. Aesthet Surg J 2015;35(2):
fat compartments and potential spaces. This 121–35.
method can help the injector to obtain safe, accu- 15. Surek C, Vargo J, Lamb J. Deep pyriform space:
rate and aesthetically pleasing facial volume anatomical clarifications and clinical implications.
correction. Plast Reconstr Surg 2016;138(1):59–64.
16. Scheuer J, Sieber D, Pezeshk R. Facial danger
ACKNOWLEDGMENTS zones: techniques to maximize safety during soft tis-
The author would like to thank the Department sue filler injections. Plast Reconstr Surg 2017;
of Anatomy at Cleveland Clinic, specifically Dr. 139(5):1103–8.
Richard L Drake PhD and Dr. Jennifer McBride 17. Gierloff M, Stohring C, Buder T, et al. Aging changes
PhD. The author would like to acknowledge Levent of the midfacial fat compartments: a computed
Efe CMI for his hard work on the beautiful medical tomographic study. Plast Reconstr Surg 2012;
illustrations. 129(1):263–73.
18. Shoukath S, Taylor I, Mendelson B, et al. The lymphatic
REFERENCES anatomy of the lower eyelid and conjunctiva and corre-
lation with post-operative chemosis and edema. Plast
1. Richards B, Schleicher W, D’Souza G, et al. The role Reconstr Surg 2017;139(3):628–37.
of injectables in aesthetic surgery: financial implica- 19. Yang H, Lee J, Hu K, et al. New anatomical insights
tions. Aesthet Surg J 2017;37(9):1039–43. on the course and branching patterns of the facial
2. 2017 procedure statistics. American Society for artery: clinical implications of injectable treatments
Aesthetic Plastic Surgery. to the nasolabial fold and nasojugal fold. Plast Re-
3. Cotofana S, Lachman N. Anatomy of the facial fat constr Surg 2014;133(5):1077–82.
compartments and their relevance in aesthetic 20. Tansatit T, Apinuntrum P, Thavorn P. A typical pattern
surgery. J Dtsch Dermatol Ges 2019;17(4): of the labial arteries with implication for lip augmen-
399–413. Published by John Wiley & Sons LTD; tation with injectable fillers. Aesthetic Plast Surg
1610-0379. 2014;38:1083–9.
4. Lazzeri D, Agostini T, Figus M, et al. Blindness 21. Edizer M, Magden O, Tayfur V, et al. Arterial anatomy
following cosmetic injections of the face. Plast Re- of the lower lip. Plast Reconstr Surg 2003;111(7):
constr Surg 2012;129:995–1012. 2176–81.
612 Surek

22. Lee S, Gil Y, Choi Y, et al. Topographic anatomy of multidisciplinary perspectives. Plast Reconstr Surg
the superior labial artery for dermal filler injection. 2015;136(33):9S–10S.
Plast Reconstr Surg 2015;135(2):445–50. 34. Huettner F, Rueda S, Oztruk C, et al. “The relation-
23. Crouzet C, Fournier H, Papon X, et al. Anatomy of ship of the marginal mandibular nerve to the
the arterial vascularization of the lips. Surg Radiol mandibular osseocutaneous ligament and lesser lig-
Anat 1998;20(23):273–8. aments of the lower face”. Aesthet Surg J 2015;
24. Pinar Y, Bilge O, Govsa F. Anatomic study of the 35(2):111–20.
blood supply to the peri-oral region. Clin Anat 35. Lambros V. Observations on periorbital and midface
2005;18:330–9. aging. Plast Reconstr Surg 2007;120(5):1367–76.
25. Loukas M, Hullett J, Louis R, et al. A detailed obser- 36. Lambros V, Amos G. Three-dimensional facial aver-
vation of variations of the facial artery, with emphasis aging: a tool for understanding facial aging. Plast
on superior labial artery. Surg Radiol Anat 2006;28: Reconstr Surg 2016;138(6):980–982e.
316–24.
37. Lamb J, Martin A, Walker R, et al. Three
26. Pensler J, Ward J, Perry S. The superficial muscu-
dimensional CT validation of supraperiosteal
loaponeurotic system in the upper lip: an anatomic
temple volumization with hyaluronic acid filler
study in cadavers. Plast Reconstr Surg 1985;75(4):
techniques. Plast Reconstr Surg Glob Open
488–92.
2018;(9 suppl):166.
27. Furukawa M, Mathes D, Anzai Y. Evaluation of the
38. O’Brien J, Ashton M, Rozen W, et al. New perspec-
facial artery on computed tomographic angiography
tives on the surgical anatomy and nomenclature of
using a 64-slice multidetector computed tomogra-
the temporal region: literature review and dissection
phy: implications for facial reconstruction in plastic
study. Plast Reconstr Surg 2013;131(3):510–9. Dis-
surgery. Plast Reconstr Surg 2013;131(3):526–35.
cussion by Knize D. on 523-25.
28. Nakajima H, Imanishi N, Aiso S. Facial artery in the
upper lip and nose: anatomy and clinical applica- 39. Moss C, Mendelson B, Taylor G. Surgical Anatomy
tion. Plast Reconstr Surg 2002;109(3):855–61. of the ligamentous attachments in the temple and
29. Beer G, Manestar M, Mihic-Probst D. The causes of peri-orbital regions. Plast Reconstr Surg 2000;105:
the nasolabial crease: a histomorphological study. 1475–90 [discussion: 1491–98].
Clin Anat 2013;26:196–203. 40. Vaca EE, Purnell CA, Gosain AK, et al. Postoperative
30. Rubin L, Mishriki Y, Lee G. Anatomy of the nasolabial temporal hollowing: is there a surgical approach that
fold: the keystone of the smiling mechanism. Plast prevents this complication? A systematic review and
Reconstr Surg 1989;83:1–10. anatomic illustration. J Plast Reconstr Aesthet Surg
31. Pessa J, Brown F. Independent effect of various 2017;70(3):401–15.
facial mimetic muscles on the nasolabial fold. 41. Surek C. The SMAS is not Just for Facelifting Presen-
Aesthetic Plast Surg 1992;16:167–71. tation at the Annual Meeting of the American Society
32. Barton F, Gyimesi I. Anatomy of the nasolabial fold. of Aesthetic Plastic Surgeons. New Orleans, May 18,
Plast Reconstr Surg 1997;100(5):1276–80. 2019.
33. Fagien S, Fitzgerald R, Matarasso A. Soft tissue 42. Zide B, Jelks G. Surgical anatomy of the orbit. 1st
fillers and neuromodulators: international and edition. New York: Raven Press; 1985.