M i d f a c e A n a t o m y, A g i n g ,

and Aesthetic Analysis

Andre Yuan Levesque, MDa, Jorge I. de la Torre, MDb,*

KEYWORDS
! Midface anatomy ! Facial aging ! Aesthetic analysis ! Malar fat pad ! Sub–orbicularis oculi fat

KEY POINTS
! The midface is the region between the upper and lower thirds of the face. Within the midface there is
an anterior portion referred to as the midcheek and the posterior portion referred to as the lateral
cheek.
! The changes with aging tend to affect the midcheek structures with laxity of the soft tissue support-
ing ligaments (orbitomalar, zygomatic, and masseteric), bony atrophy, decreases in skin thickness
elasticity, and subcutaneous fat resorption.
! Goals in midface rejuvenation are to produce midcheek fullness and smooth transition into adjacent
areas of the lower lid and lower face.

DEFINITION OF THE AREA With aging, the midcheek divisions become

apparent with development of a nasojugal fold
The midface is commonly used to describe the medially, palpebral malar groove superolaterally,
central third of the face because it is commonly and a midcheek furrow inferolaterally in the shape
divided into the upper, middle, and lower face. of a Y in between the 3 components of the mid-
The upper border of the midface extends from cheek (Fig. 3).2,3 The youthful midcheek typically
the superior helix along the upper zygomatic blends into the lower lid, nose, nasolabial, and
arch to the lateral canthus and then along the lateral facial regions without demarcation and
lower lid to the nose. The lower border extends has uniform fullness and volume.1,2
from the lower tragus to the oral commissure and With further anatomic study the superficial fat of
along the nasolabial fold to the nose (Fig. 1).1,2 the cheek itself has been shown to have 3 sepa-
The midface can further be divided by a line from rate fat compartments: the medial, middle, and
the lateral canthus to the commissure. Anterior to lateral temporal compartments, which all have
the line is the midcheek and posterior is the lateral separate septae.4 In addition, the sub–orbicularis
cheek. oculi fat (SOOF) located in the lid-cheek division
The midcheek and can further be divided into has also been shown to have 2 separate fat com-
lid-cheek, malar, and nasolabial components partments. The medial component of the SOOF
(Fig. 2). The palpebral malar crease separates extends from the medial limbus to the lateral
the lower lid and malar fat divisions. The nasojugal canthus along the orbital rim and the lateral
crease separates the lower lid and nasolabial divi- component extends from the medial fat pad to
sions. The midcheek furrow separates the malar the temporal fat pad.5
and nasolabial divisions.2
facialplastic.theclinics.com

Disclosure: None of the authors have any pertinent financial disclosures related to the content of this article.
a
Division of Plastic Surgery, University of Alabama at Birmingham, 1158 Faculty Office Tower, 510 20th Street
South, Birmingham, AL 35210, USA; b Division of Plastic Surgery, Birmingham VA Medical Center, University of
Alabama at Birmingham, 1102 Faculty Office Tower, 510 20th Street South, Birmingham, AL 35210, USA
* Corresponding author.
E-mail address: jdlt@uab.edu

Facial Plast Surg Clin N Am 23 (2015) 129–136

http://dx.doi.org/10.1016/j.fsc.2015.01.002
1064-7406/15/$ – see front matter ! 2015 Elsevier Inc. All rights reserved.
130 Levesque & de la Torre

Fig. 2. The portions of the midcheek divided into lid-

cheek (blue), nasolabial (red) extending into the jowl,
and malar (green) separated by the palpebral malar
Fig. 1. The superior border of the midface lies along a crease, nasojugal crease, and midcheek furrow.
line from the root of the helix to the lateral canthus to
medial canthus along the side of the nose. The inferior
border can be thought of as a line from the inferior allows the separate functions of eye closure, smil-
border of the tragus to the lateral commissure along ing, and chewing.
the nasolabial fold to the nose. The midcheek (blue) In the midcheek region immediate superficial to
lies anterior to a line from the lateral canthus to the maxilla and zygoma lies the deep fat compart-
commissure and posterior lies the lateral cheek (green). ment, with preperiosteal fat and the buccal fat pad.
This fat lies deep to the zygomaticus muscles and
INTERNAL ORGANIZATION/LAYERS OF THE
AREA
The layers in the midface are similar to those in the
upper and lower face with skin, subcutaneous fat,
a musculoaponeurotic layer, loose areolar layer,
and periosteum/bone (Figs. 4 and 5).2
The bony framework consists of the zygoma and
the maxillary bones with a small component of the
lacrimal bone.6 Important attachments to the bony
framework are the mimetic muscles, the zygo-
maticus major and minor, and the zygomatic liga-
ment arising between and around the zygomaticus
major and minor and minor muscles. There is
limited bone available for attachment of soft tissue
because the oral cavity mucosal reflexion oc-
cupies a large portion of the anterior maxilla. In
addition, the prezygomatic space with the orbito-
malar ligament superior and zygomatic ligaments Fig. 3. Note superomedial nasojugal folds (blue),
inferiorly also limits direct soft tissue attachment superolateral palpebral malar groove (green), infero-
to the zygomatic bone.2 This arrangement allows lateral midcheek furrow (red), which form the shape
gliding of the soft tissues over the spaces and of a Y on anterior view.
 Midface Anatomy, Aging, and Aesthetic Analysis 131

in the lateral cheek region and becomes less

distinct into the anterior face or midcheek region.
Laterally the SMAS is more distinct separate
from the parotid fascia and is continuous with
the platysma inferiorly and the temporoparietal
fascia superiorly.8 The SMAS also separates fat
into a superficial fat compartment that contains
septae and a deeper fat compartment without
septae. In the midcheek region this is analogous
to the SMAS/mimetic muscle layer separating
the malar fat pad from the buccal fat pad. The
exact relationship of the SMAS with the parotid
fascia and mimetic muscles is not clearly shown
in all studies, but most studies agree that the
Fig. 4. Cadaver dissection showing separation of skin, SMAS is most distinct in the parotid region and be-
subcutaneous fat, superficial musculoaponeurotic comes thin and less substantial moving anterior
system (SMAS), and deeper structures. into the midcheek region.8–11
The subcutaneous layer in the midface includes
levator labii superioris, and within the fat pad are the malar fat pad, which can be further subdivided
terminal branches of the zygomatic and buccal into 3 separate compartments (medial, middle, and
nerves that pass more superficially to innervate lateral), and each can age differently.4 Superior
their muscle targets in the musculoaponeurotic and deep to the malar fat pad is the SOOF,12 which
layer.7 This layer allows gliding of the mimetic occupies the prezygomatic space between the or-
muscles (zygomaticus major and minor, levator bitomalar ligament and zygomatic ligament with
labii superioris) with facial expressions. The zygo- the roof of the space being the orbicularis oculi
matic nerve innervates the zygomatic muscles on muscle.1,2,5 The SOOF is separate and distinct
their deep surface but more medially innervates from the malar fat and adherent to the deep sur-
the levator superioris on its superficial surface. face of the orbicular oculi muscle, whereas the ma-
The superficial musculoaponeurotic system lar fat pad is superficial to the SMAS.
(SMAS), often credited to Mitz and Peyronie,8 is
a distinct layer in the face that is more developed
SURROUNDING AREAS
The lower lid has distinct function and anatomy
and can be treated in isolation or with the midface.
The orbital malar ligament serves as the dividing
layer with the midcheek and the lower lid struc-
tures above. In the lower lid, the layers can be
separated into 3 lamellae. The anterior lamella
consists of the skin and orbicularis oculi muscle,
the middle lamella is the orbital septum and fat.
The posterior lamella contains the tarsus, conjunc-
tiva, and lower lid retractors.13 The lower lid orbital
fat has 3 compartments with the medial, central,
and temporal fat pads (Fig. 6). The inferior oblique

Fig. 6. The lower lid orbital fat is separated into 3 com-

Fig. 5. Relationship of the orbital fat, orbitomalar lig- partments: medial, central, and temporal. The inferior
ament (blue), SOOF, zygomatic ligament (green), and oblique muscle separates the medial and central com-
malar fat with surface bulges and creases. partments and can be damaged inadvertently.
132 Levesque & de la Torre

muscle separates the medial and central fat pads

and can inadvertently be damaged during
surgery.14
Development of a jowl is a result of descent of
cheek soft tissues from attenuation of the mas-
seteric ligaments.15 The described lower premas-
seteric space can be useful in describing the
changes involved in developing a jowl. The roof
of the space is the platysma and SMAS and the
inferior border is a membranous connection from
the SMAS layer to the mandible that anteriorly
connects to the mandibular ligament. With aging,
the development of laxity in SMAS, platysma, infe-
rior border of the space, and lower masseteric lig-
aments allows the roof to slide and the superficial Fig. 8. Cadaver dissection showing the zygomatic lig-
fat to descend beneath the level of the mandible, aments (red arrow), the masseteric ligaments (green
arrow), and the mandibular ligament (black arrow)
producing the jowl (Fig. 7).16
at the anterior border of the masseter deep to the
SMAS.
LIGAMENTS
The idea of retaining ligaments of the face or
sub-SMAS dissection there are safe planes of
connection from bone or fascia to the dermis
dissection overlying the masseter, divided into the
was proposed and demonstrated by Furnas.17 It
upper, middle, and lower premasseteric spaces,
was further developed by Mendelson,1 Rohrich
to reach the anterior space as described by Mendel-
and Pessa,4,18 and others. The important liga-
son and colleagues16 and Mendelson and Wong.19
ments within the midface are the zygomatic liga-
ments, orbitomalar ligament, and masseteric
ligaments. The confluence of the 3 cheek fat com- BLOOD SUPPLY
partments has commonly been described as the The blood supply to the midface arises from the
zygomatic ligament. In addition, the confluence external carotid artery and its branches via the
of the medial and middle cheek compartments facial artery and transverse facial arteries. The
has been described as the masseteric ligaments maxillary artery supplies the muscles and deeper
(Figs. 8 and 9).4
Between the ligaments there is minimal attach-
ment of the soft tissue to the underlying skeleton
allowing movement and facial expression. This
minimal attachment also provides an opportunity
for repositioning of tissue through surgical manipu-
lation and a safe, expeditious plane of dissection. In

Fig. 7. Development of jowl with laxity of the roof of

the premasseteric space SMAS/platysma and masse- Fig. 9. Blood supply to the midface. The blood supply
teric ligaments (red stars) with persistent fixation of derives from the external carotid largely by way of the
the mandibular ligament (black star). The labioman- facial, maxillary, and transverse facial arteries and
dibular fold is outlined in green. veins.
 Midface Anatomy, Aging, and Aesthetic Analysis 133

structures of the face via the buccal and infra- lead to prolonged swelling either from direct tran-
orbital arteries. Venous drainage accompanies section or from pressure on the lymphatic system
the arteries as separately named veins as well as from filler materials.24,25 Swelling can be most
vena comitans, and ultimately draining into the in- visible superior to the orbital malar ligament
ternal jugular system.6 because the ligament is largely impermeable and
The anterior portion of the midface is supplied serves as a barrier for fluid, blood, or lymph to
via musculocutaneous perforators through the accumulate and form festoons, malar mounds,
facial mimetic muscles arising from the facial ar- malar edema, and periorbital ecchymosis.23
tery system through the facial mimetic muscles.
The lateral portion of the midface is typically pro-
INNERVATION
vided via fasciocutaneous perforators from the
transverse facial artery.20,21 The anatomy of the facial nerve is described in
many publications but, specific to midface anat-
LYMPHATICS omy, the depth and location of the terminal sec-
tions of the zygomatic and buccal branches are
The lymphatics of the midface drain to the sub- important to understand to avoid injury. The zygo-
mental and submandibular nodes but form a rich matic and buccal branches emerge from the pa-
plexus of lymphatics more dense than that of the rotid beneath the deep investing parotid fascia
scalp. The lymphatics begin in the subcutaneous and travel more superficially as the nerve pro-
space as lymph capillaries and drain into precol- gresses more anteriorly.26 The branches then lie
lecting lymph vessels, collecting lymphatics, and immediately deep to the SMAS layer until inner-
then the first-tier lymph nodes. The first-tier lymph vating their muscle targets on the deep surface
nodes are generally situated deep along the deep (zygomaticus major and minor, orbicularis oculi)
veins of the face and neck.22,23 and then through the SMAS layer to innervate
The facial lymph nodes are the infraorbital, the levator labii superioris (Fig. 11). Dissection
buccinator, and maxillary nodes, which most
commonly drain to the submandibular nodes
(Fig. 10). Disruption of the lymphatic system can

Fig. 10. Lymphatic system within the midface. Typically

following the venous system, the important lymph no- Fig. 11. The course of the extratemporal facial nerve
des are the infraorbital, buccinator, and maxillary no- in the face. The zygomatic and buccal branches are
des, which drain to the submandibular nodes. the important branches for midface rejuvenation.
134 Levesque & de la Torre

within the subcutaneous space should be safe at the literature for the details of the individual
all times except when overlying the levator mus- procedures.28,30–33
cles, but care must be taken with sub-SMAS
dissection to avoid the zygomatic and buccal IMAGING
branches that traverse the sub-SMAS space.
Similarly, a deeper plane of dissection also pro- Computed tomography scan or plain radiographs
tects the facial nerve branches, as in a subperios- typically have little utility in preoperative planning
teal approach to the midface. In the midface in for rejuvenation of the midface; however, excel-
particular there are significant cross-innervations lent standard reproducible photographs should
between zygomatic and buccal nerves, with about be the goal. Close-up views of the face should
50% cross-innervations, and damage to one be obtained with anterior, oblique, lateral, upward
branch is likely to result in no functional gaze, closed eyes, and worms-eye views. Full-
consequence.27 face photographs should also be obtained in
Sensation to the midface skin is provided mainly anterior, oblique, and lateral views. We also like
by branches of the infraorbital and zygomaticofa- to take an animation photograph with the patient
cial nerves. In addition, there are minor contribu- smiling for midface anaylsis.34,35
tions from the zygomaticotemporal nerve,
infratrochlear nerve, auricular temporal nerve, SUMMARY
and buccal nerve.6 Attention to the changes within the midface is crit-
ical to achieve a harmonious facial rejuvenation.
SURGICAL ANATOMIC CONSIDERATIONS Global changes in all layers of the midface occur
to produce signs of aging. The bony framework un-
The critical structure of the midface with respect to dergoes resorption with time, especially in edentu-
midface rejuvenation is the malar fat pad. The lous patients.36–42 The orbitomalar, zygomatic,
malar fat pad is located between the SMAS and and masseteric ligaments all develop laxity and
the skin and is firmly attached to the skin.28 The allow descent of the attached soft tissues. There
youthful position of the malar fat pad is character- is also typically some loss in fat and skin thickness.
ized by positioning over the zygomatic arch with Surgical correction of the midface should be
the superior portion covering the orbital portion directed at all layers and particular care given to
of the orbicularis oculi muscle and inferior portion blending changes into the adjacent regions of the
at the nasolabial fold with no bulging anterior to lower lid and lower face. The anatomy, although
the fold.29 With appropriate repositioning of the complex because of the small spaces involved, is
malar fat pad in a superior vector, the lower lid ver- well described and with appropriate study surgical
tical distance is decreased and hollowness is elim- correction of the midface can be safe and effective.
inated in the infraorbital region.
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