Deep Pyriform Space: Anatomical Clarifications and Clinical Implications.

BACKGROUND: The purpose of this study was to define the anatomical boundaries, transformation in the aging face, and clinical implications of the Ristow space. The authors propose a title of deep pyriform space for anatomical continuity. 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 elevators. 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 pyriform 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 position of the angular artery in the roof of the space allows safe injection on the bone without concern for vascular injury.

Pertinent anatomy and analysis for midface volumizing procedures.

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.

Volumizing viaducts of the midface: defining the Beut techniques.

BACKGROUND: In nonsurgical facial rejuvenation, autologous fat and dermal fillers have become an effective method to achieve symmetry and balance of the midface. Nonsurgical techniques that target the dynamic anatomical relationships existing in the midface can improve rejuvenation outcomes in this commonly augmented region. OBJECTIVES: The authors described techniques for fat compartment and potential space volumization of the midface via a standardized and reproducible technique. They placed emphasis on access to anatomical spaces and compartments within the midface. METHODS: In 11 hemifacial cadavers, hyaluronic acid filler homogenized with red dye was injected via 3 midfacial ports that were anatomically designed to access the superficial fat compartments, deep fat compartments, or traverse the prezygomatic space. Specimens were dissected in a layered fashion to analyze relationships between the injected filler and midfacial anatomy. We have described 4 site-specific procedural techniques and created a video containing anatomical renderings of each targeted viaduct accompanied by technique demonstrations. RESULTS: We found that Beut techniques 1 through 4 can be performed through 3 midfacial viaducts. Port placement 1.5 cm inferolateral to the alar base in the nasolabial crease created a medial midface viaduct, suitable for access to the deep medial cheek fat, medial superficial fat compartment, premaxillary space, and adjacent superior nasolabial cheek compartment. Port placement within the nasojugal groove provided a middle midface viaduct to access the middle superficial fat compartment and medial suborbicularis oculi fat (SOOF). Port placement 1.5 cm inferolateral to the lateral canthus created a lateral midface viaduct to approach the pre-periosteal fat, prezygomatic space, lateral SOOF, and infraorbital fat compartment. CONCLUSIONS: Our findings indicate that anterior and lateral cheek projection, V-deformity correction, rhytid softening, and tear trough effacement can be achieved through the midfacial viaducts. Systematic assessment and site-specific nonsurgical rejuvenation of the midface may lead to increased safety, accuracy, and technique reproducibility in this commonly injected region.

Volume rejuvenation of the face.

Patient's desires for an un-operated look and shorter recovery times have lead to a blending of surgical and nonsurgical techniques to effect facial rejuvenation. Anatomical changes within the skeleton and soft tissue compartments are discussed. A brief review of adjunctive techniques to replace volume lost in aging is presented. These techniques (autologous fat grafting and injectable fillers) are contrasted with more involved surgical procedures (rhytidectomy and sub-periosteal mid-face lifting). In patients with mild jowling, the "liquid facelift" can approach the results seen in surgical face-lifting. In patients with significant jowling, the addition of volume replacement at the time of rhytidectomy enhances the rejuvenation. The addition of volume replacement at the time of rhytidectomy has the potential to allow less aggressive surgical dissections to accomplish a harmonious result.