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3.1 Vessels andNerves
as when a ller enters a blood vessel. A possible
nerve injury is a case where the pain persists by
injuring the sensory nerve with the end of a cannula or needle. In such cases, the pain usually
disappears within a few days, but in severe cases,
the pain can last for more than a month.
The sensation of our face is mainly innervated
by the fth cranial nerve (trigeminal) (Fig.3.3),
and the V1 branches of the supratrochlear nerve,
supraorbital nerve, emerge from the superomedial border of the orbital rim. Their course is
accompanied by an arterial structure of the same
name, but not always together. Also, the deep
branch of supraorbital nerve proceeds deep near
the periosteum in the medial 2 cm area of the
superior temporal septum, with the remaining
nerves emerging from the orbital rim and going
upward through the galea layer to the subcutaneous layer (Fig.3.4).
The infraorbital nerve of the V2 branch of the
trigeminal nerve, along with the mental nerve of
the V3 branch, are important nerves that are
responsible for the sensation of the skin surface
67
Fig. 3.3 Sensory nerves of the face
Fig. 3.4 Supercial and
deep branch of the
supraorbital nerve
Superficial
branch of
supraorbital
nerve
Deep branch of
supraorbital
nerve
68
3 Anatomical Considerations forFiller Procedures
of the mid- to lower-face area and are characterized primarily by the proximity of the midpupillary line (Fig. 3.3). The infraorbital nerve
usually emerges 1cm below the orbital rim and is
clinically important when treating around the
nasolabial fold, upper lip, and tear trough because
it gives off many branches in the inferomedial
direction. The mental nerve is associated with
lower lip and jaw surgery with a large amount of
branches toward superomedial areas.
In addition, there is an auriculotemporal nerve
which innervates the sensation of the temple or
lateral forehead area (Fig.3.3) and a great auricu-
Fig. 3.5
Auriculotemporal nerve
Great auricular
nerve
lar nerve for the sensation of the area around the
ear and mastoid (Fig.3.5).
It is very unlikely that the motor nerve will be
damaged during the ller injection. No matter
how sharp a needle is used, it is difcult to sever
the nerve, but, of course, some nerve damage can
occur if the cannula or needle is moved too much.
The motor nerve of the face is primarily innervated by the facial nerve (VII), and there are ve
branches from top to bottom: temporal, zygomatic, buccal, marginal mandibular, and cervical
branches (Fig. 3.6). The other four branches,
except the temporal branch of facial nerve, are all
Fig. 3.6 Motor nerves
of the face
Sternocleidomas
toid (SCM)
muscle
3.2 Fat Compartments andMuscles
69
located under the deep fascia on the face, but the
temporal branch of facial nerve goes up slightly
past the area 1cm above the zygomatic bone and
attaches to the bottom of the SMAS.Therefore, if
you inject a ller between supercial temporal
fascia and deep fascia, you will have to be aware
that the nerve is around this area.
3.2 Fat Compartments
andMuscles
Our face used to be conceptualized as a big balloon which needs a procedure to ll in (if it is not
enough) or to extract (if it is excessive). While
there is no signicant difference in this concept
nowadays, studies of facial anatomy have shown
that the fat layers on our faces are not a large
mass but rather a combination of subdivided fat
segments. These local compartments can be
thought of in large terms as supercial fat compartments and deep fat compartments. The supercial fat compartment has a relatively large fat
cell size, and the overall fat increases as age progresses. In contrast, deep fat compartments are
small in size, and the amount of fat decreases as
aging progresses. It has also been found that the
fat inside all local compartments, regardless of its
depth, tends to migrate downward over time due
to the inuence of gravity.
Some doctors claim that it is not clinically signicant to consider these fat layers as complex
and divide them into regional divisions. In fact, it
is also true that local compartmentalization cannot be distinguished with the naked eye. It is difcult and meaningless to target the correct local
compartment every time a ller procedure is performed. However, in order to plan the amount to
inject before the procedure, it is necessary to
understand as much as possible the combination
of structures such as fat compartments, retaining
ligaments and skin. The results of the procedure
can be different from those who understand and
treat the cause of wrinkles with an analytical perspective, from those who only see the wrinkle
itself.
Figure 3.7 is a representation of the supercial
fat compartments, and the right side is a representation of the deep fat compartments. Of course,
not all anatomists have a consensus on this classication. Moreover, the layer of fat found during
facelift surgery or dissection of cadavers are not
as distinct as in the picture. All fat layers are
intertwined with surrounding structures such as
muscles, nerves, and blood vessels looking like
composing structures. However, looking at
Fig. 3.7 Supercial and deep fat compartment
70
3 Anatomical Considerations forFiller Procedures
Fig.3.8, one can understand why many consider
these local distributions as distinct. Figure 3.8
shows the supercial and deep fat compartments
and pink lines of wrinkles on the surface of the
face. The forehead folds and the glabella wrinkles found in the upper face area do not seem to
have much connection with the fat compartments.
Of course, anatomists like Pessa claim that the fat
layer around the glabella is again subdivided into
several parts, named and related. However, in a
larger context, it may not be that important. If
you look closely at other wrinkles, you can see
that they have some, if not perfect, relationship to
local compartments. In particular, SOOF, deep
medial cheek fat, and submentalis fat are associated with the midcheek crease, nasolabial fold,
and mentolabial sulcus, respectively. Interestingly
enough, while the boundaries of the supercial
fat compartments correspond to the creases, the
deep fat compartments are not conned by these
creases, but extend beyond them. In other words,
deep layer ller injection in these areas can have
the effect of reducing wrinkles.
There is labiomandibular fat on the medial
aspect of the labiomadibular fold and superior/
inferior jowl fat on the lateral aspect of the fold.
Anatomy studies have shown that the amount of
labiomandibular fat decreases with age, while the
jowl fat increases. For this reason, the fat on the
outside of the crease is effectively removed or
raised by liposuction or lifting procedures, while
the depleting fat layer inside the crease is replenished through ller or fat injection.
There is buccal fat in areas deeper than the
deep fat, which is about 10cc in volume. There
are still differences of opinion on the exact
boundary or distinction of the buccal fat, as some
describe it as the buccal extension of the buccal
fat. This region extends up to the temple, giving a
temporal extension called the deep temporal fat
pad. It also plays an important role in forming a
sunken cheek because it supports all the soft tissue of the surface from deep below the zygomatic
arch. The buccal fat also reduces friction during
the sucking process (such as suckling in infants
and babies) and protects important structures
such as nerves and blood vessels by cushioning
them. However, its function decreases as it
becomes more muscular in nature in the form of
the masseter muscle. By about 50years of age,
fat increases slightly, and after 50 years of age,
the volume of fat decreases with age, which is
similar to the change in deep fat compartments.
Sunken cheeks are thought to be the main reason
for the decrease in the buccal fat, but direct ller
or fat injection in the buccal fat can be dangerous
since blood vessels, nerves, and parotid ducts
pass through it.
3.3 Retaining Ligaments
In Fig. 3.8, the areas shown in black are the
retaining ligaments of the face, and the pink line
indicates the wrinkles and folds on the face. The
forehead and the glabella wrinkles are usually
less associated with the retaining ligament
because they are caused by muscle movements,
but the middle face shows a close connection
between the retaining ligaments and the surface
wrinkles.
The retaining ligament can be divided into two
main groups: true retaining ligaments which run
from bones to skin and false retaining ligaments
which originate from middle layers of connective Fig. 3.8 Relationship between compartments
3.3 Retaining Ligaments
tissue, such as muscles and fat layers.
Traditionally, orbital retaining ligaments, zygomatic ligaments, maxillary ligaments, and mandibular ligaments were regarded as true retaining
ligaments, while the rest were regarded as false
retaining ligaments. The retaining ligament can
be clearly distinct from the surrounding tissue,
while other times it can be observed as a bundle
of rigid soft tissue. The distinction between
“true” and “false” is changing gradually. More
importantly, which wrinkles on the face are
caused by which retaining ligaments and how do
we correct them?
Not all facial wrinkles are closely related to
retaining ligaments, but the midcheek crease and
labiomandibular fold (also known as the called
the marionette crease) are highly associated with
the retaining ligament.
There are many causes contributing to a tear
trough deformity, such as differences in skin
thickness around the eyelid and cheek, changes
in the fat compartments, and changes in the
boundary of the orbitalis oculi muscle. However,
the largest contributing cause can be the tear
trough ligament. These ligaments can be thought
of as part of an orbital retaining ligament and are
connected by a ber from the bone to the skin.
Similarly, the outer part of the orbitomalar ligament creates an orbitomalar groove, but this part
has thicker soft tissue and a double layer of support, so the frequency and severity of the wrinkle
is less than the tear trough.
The wrinkle leading to the inferolateral part of
the tear trough is called the midcheek crease,
which is closely related to the zygomatic ligament. Reading a textbook or journal is likely to
cause confusion about the zygomatic ligament,
which some describe as the zygomatic cutaneous
ligament. In some cases, it may be shown only at
the intersection of the T-shape where the zygomatic and the masseteric cutaneous ligaments
meet in Fig.3.9. In some cases, it may be displayed only on the lateral aspect with the zygomatic arch. Recent views have often indicated
that all sections extending from the anterior to
lateral face are marked as the zygomatic ligament
and that this retaining ligament shows great supporting power at the T-intersection where they
71
Fig. 3.9 Relationship between retaining ligaments and
surface creases
meet the masseteric cutaneous ligament at the
front.
The maxillary ligament in Fig.3.9 on the lateral side of the nasolabial fold is sometimes
described by some as a bucomaxillary ligament,
which is also divided into two parts: a buccal part
and a maxillary part. It has been known that the
buccal part is a false retaining ligament and the
maxillary part is directly referred to as the skin
from the maxilla as the true retaining ligament.
The reason for the formation of the nasolabial
fold can be explained by the fascial theory and
muscular theory. The fascial theory states that
wrinkles are caused by retaining ligaments such
as the maxillary ligament holding the skin in the
nasolabial fold. The muscular theory, on the other
hand, is a theory that muscles such as the zygomaticus major/minor muscles and levator labii
superioris directly hold the skin layer, which
gives rise to wrinkles. Although there is not a
complete consensus as of now, based on the studies near the nasolabial fold, comparing the support force of retaining ligaments, and by
histological ndings, the muscular theory is
slightly more persuasive than the fascial theory.
The labiomandibular fold, called the marionette line, originates directly inside the mandibu-
72
lar ligament, separating the inner and outer fat
compartments with strong support from the bone
to the skin, and blocks the inner movement of the
supercial fat to create a jowl. In addition, the
presence of a mandibular septum prevents soft
tissue on the top of the mandibular border from
migrating downward to create a jowl. On the
other hand, the superior temporal and inferior
temporal septi create the boundary of the space.
The masseteric cutaneous ligament provides a
reference boundary for the anterior and lateral
face and forms the outer boundary of the
pre- massteric space, creating a jowl if permitting
the buccal fat to protrude out.
3.4 Layer andSpace
3 Anatomical Considerations forFiller Procedures
Space is a virtual area surrounded by fat compartments, muscles, and retaining ligaments (such as
the fascia or SMAS). In fact, there is no empty
space like an air bag, but the meaning of space is
as follows. Space is located between supercial
and deep fascia allowing muscles to move independently without affecting the movement of
other layers of muscles. For example, when the
orbicularis oculi muscle or the orbicularis oris
muscle are contracting, the zygomaticus major
and minor muscles function by raising the corners of the mouth so that they are not affected by
each other. Also, blood vessels and nerves pass
through the boundaries of these spaces, so the
area inside the space is only relatively dangerous.
This makes it a safe passageway for stripping,
needles, and cannulas to pass through when they
enter. In addition to the space shown in blue in
Fig. 3.10, there are many other spaces on the
face.
The preseptal space also exists above the
orbital retaining ligament and can be easily
observed when lower blepharoplasty surgery is
performed. Although not called a space, there are
upper and lower temporal compartments in the
temple area. The upper border of prezygomatic
space is the orbital retaining ligament, and the
lower border is the zygomatic ligament.
Suborbicularis oculi fat (SOOF) is the roof of this
space. This space is connected to the lower tem-
Fig. 3.10 Relationship between retaining ligaments and
spaces
poral compartment through the temporal tunnel,
and the inside is blocked by retaining ligaments.
Care should be taken when injecting ller at the
midcheek crease since the ller is injected into
this area. If the ller volumizes the outside and
top of this crease, it may bulge, making the crease
look deeper. This mistake can also result in similar results if the ller spreads to the lower prezygomatic space when correcting the orbitomalar
groove.
The premasseteric space is a structure that is
formed by the masseteric cutaneous ligament on
the front, platysma muscle on the surface, masseter muscle posteriorly, and a mandibular ligament and septum on the bottom. The space is
small in front of the masseter muscle when
young, but as one ages, the space’s front, bottom,
and surface sagging causes the internal buccal fat
to ow medially and inferiorly. This phenomenon makes the jowl worse and contributes to the
thickening of labiomandibular fold. Recently, as
shown in Fig.3.10, this space is not one space,
but is technically divided into two spaces. The
top is called the middle pre-masseteric space, and
the bottom is called the lower pre-masseteric
space. Part of the buccal branch of the facial
nerve passes between the upper and lower spaces.
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
73
This pre-masseteric space is clinically meaningful as it can be a space for the ller to move when
injecting the ller and a safe layer when performing facial rejuvenation procedures within the
prezygomatic space.
Finally, the premaxillary space has not been
considered to be very important. This space is
located below the SMAS, nasolabial fat, and
orbicularis oculi muscle. The upper border is the
tear trough ligament, and the lower border is the
zygomatic ligament. On the outside, they face to
prezygomatic space. One interesting point is that
unlike normal venous and arterial movements,
the angular artery passes through the medial part
of the premaxillary space and the angular vein
passes through the lateral boundary of the space.
The clinical signicance of this space is that the
ller often migrates over the top of the crease
when correcting the nasolabial fold. Therefore, it
is important to block with a nger while injecting
the ller so that it will not migrate superiorly.
3.5 Identication ofSubSMAS
Spaces oftheFace forFiller
Injection: Cadaver Studies
Using Stained Gelatin
The facial spaces for ller procedures can be said
to be virtual spaces surrounded and distinguished
by fat components, muscles, fascia, and ligamentous tissue. The purpose of dividing space can be
understood by considering the signicance of
space. First, the spaces of the face located between
the deep fascia and the supercial fascia allow the
muscles of the face in each space to move independently without interrupting or interfering with
the movement of other muscle layers. For example, when the orbicularis oculi muscle or orbicularis oris muscle in supercial layer contracts and
moves around the eyes or mouth, the zygomaticus
major and minor muscles can function to raise the
corners of the mouth without affecting the movement of the supercial muscles.
In addition, blood vessels and nerves mainly
pass through the boundary of the spaces on the
face, so the inside of the space is relatively safe.
Therefore, knowing these spaces well during
ller procedures helps to make the procedure
safer and easier.
To improve facial wrinkles and depressions,
soft llers are injected into subdermal tissues,
including the subcutaneous fat layer immediately
supercial to the skin. However, rmer llers
should be injected into the deeper layers. Thus, it
is important to locate the plane deep to the SMAS
layer where there is a smaller risk of neurovascular injury. In particular, compared to Caucasians,
Asians have thicker and heavier skin, and the
connective tissue and subcutaneous tissue, such
as the SMAS and retinacula cutis, are tougher
and rmer. Therefore, efcient facial volumization cannot be achieved by augmenting the subcutaneous fat layer in the subdermal region alone.
It is important to accurately identify the spaces in
the deeper subSMAS layer and augment the volume in those areas.
Different regions of the face contain different
anatomical structures called subSMAS adipofascial spaces. These structures consist of only fat
and soft tissues with boundaries dened by major
retaining ligaments and are safe injection zones.
Table 3.1 summarizes the treatment indications
that should be used when performing which ller
procedure along with the boundary of each space.
A cadaveric study using a stained gelatin ller
was performed to identify the anatomical structures of subSMAS adipofascial spaces. Before
dissecting the cadaver, injection points were
marked on the face as it is done before performing a ller or fat graft procedure on patients.
Subsequently, a cannula was used to inject a
small amount of stained gelatin into the subSMAS spaces. After allowing the gelatin to solidify, each injection region was carefully dissected,
layer by layer, to check whether the gelatin had
been accurately placed in the targeted subSMAS
adipofascial spaces. What is important when targeting the subSMAS adipofascial spaces is the
thickness of the SMAS as the thickness of the
SMAS is not uniform throughout the face. It is
thickest in the preauricular region and progressively becomes thinner toward the medial facial
region (Table3.2).
74
3 Anatomical Considerations forFiller Procedures
Table 3.1
Space Boundary Indication
Subgalea- frontalis space Area under the frontalis muscle Flat forehead
Interfascial & pretemporalis space Compartment between STF & DTF,
Subprocerus space Area under the procerus muscle Glabellar depression
Preseptal space Area that overlies the orbital septum
Suborbicularis space Area under the orbicullaris oculi
Subnasalis space Area under the nasalis muscle Flat nose
Prezygomatic space including
Sub-Orbicularis Oculi Fat (SOOF)
Premaxilary space including lateral
part of deep medial cheek fat
Ristow’s space (pyrifom space)
including medial part of deep medial
cheek fat
Preparotid & premasseteric space Area that overlies the parotid gland &
Prebuccal space Area that overlies the capsule of the
Subdepressor anguli oirs space Area including fat deposits under the
Premental space Area including fat deposits under the
Boundaries and indications of the possible subSMAS adipofascial spaces
Temple augmentation
STFP between the supercial & deep
layer of DTF
Sunken eyelid
below the orbital retaining ligament in
the upper eyelid
Infraorbital groove & hollowness
muscle (ROOF of the eyebrow, medial
part of the SOOF & lateral portion of
deep medial cheek fat)
Area that overlies the body of the
zygoma– Its oor covers the origin of
the zygomaticus muscle.
Area that overlies the maxilla boneIts oor covers the origin of the
levator labii superioris muscle.
Area that overlies the canine fossa
under the medial part of the DMCF in
the paranasal region
the lower half of the masseter
buccal fat pad medial to the anterior
border of the masseter
depressor anguli oris muscle
skin insertion of the mentalis muscle
Apple cheek
Anteromedial cheek hollowness
Paranasal depression & nasolabial
fold
Lateral cheek hollowness
Buccal cheek hollowness
Marionette line
Chin augmentation
Table 3.2
the facial regions
Progressive thinning from preauricular region to medial
facial region
1. Basic structure of preauricular region
Skin—Supercial fat layer with retinacular cutis
2. Basic structure of parotid region
Skin—Supercial fat layer—SMAS—Deep fat
3. Cheek region
Almost same with the basic structure of
4. Nasolabial fold region
Dim SMAS enveloping the mimetic muscles
Change of the SMAS thickness depending on
supercialis—Supercial fascia—Deep fat layer
with retinacular cutis profundus—Deep fasciaMasticatory muscle
layer—Parotid fascia—Parotid capsule- Parotid
gland
preauricular region
The varying thicknesses of the SMAS layer by
facial region is conrmed in the cadaver photos.
The SMAS appears as a white, tough fascia along
the side of the face, while it appears as a fat layer
with no white fascia in the midface region
(Fig.3.11). From such gross ndings, it was previously claimed that the formation of the nasolabial fold was due to the presence of a thick and
tough SMAS layer in the lateral aspect of the fold
and absence of a thick SMAS layer in the medial
aspect of the fold. However, actual histological
studies have conrmed the presence of the SMAS
in the medial aspect of the fold.
After the gelatin solidied, cadaveric skin was
removed to reveal supercial fat (Fig.3.12, left).
Gelatin that was injected into the subSMAS
AS
Superf
compar
Superficial fat Deep fat compartments
Stained gelatin
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
75
space below this layer cannot be seen. After the
supercial fat layer was removed, the SMAS
layer could be observed, and green gelatin
injected below the SMAS layer became partially
visible (Fig.3.12, right).
Let’s take a closer look at the subSMAS
spaces of each part of the face organized in
Table3.1.
SM
Fig. 3.11 Thick SMAS on lateral cheek region
3.5.1 Subgalea-Frontalis Space
In the forehead area, the subgalea-frontalis space
is present below the galeo-frontalis muscle,
which is a part of the SMAS in the midface area.
The supercial temporal artery, temporal branch
of the facial nerve (both enter from the lateral
aspect of the forehead), supraorbital artery and
nerve, and supratrochlear artery and nerve
(course in a superior direction in the central forehead) are present within or above the frontalis
muscle. When this area is dissected, the supraorbital artery and nerve and supratrochlear artery
and nerve exiting from the supraorbital foramen
and supratrochlear notch can be seen. Therefore,
adipofascial space where the gelatin was injected
is a safe region where the risk of injuring the
major vessels and nerves is minimal (Fig.3.13).
3.5.2 Interfascial andPretemporalis
Space
In temporal depression that is not too severe, it is
common practice to inject ller or place fat grafts
between the supercial temporal fascia (SMAS
icial fat
tments
Fig. 3.12 Stained gelatin in sub-SMAS spaces under supercial fat compartments
76
Galea-fr
muscle la
Stained gelatin
r
Lo
m
Fig. 3.13 Gelatin in
subgalea-frontalis space
3 Anatomical Considerations forFiller Procedures
Fig. 3.14 Upper and
lower temporal spaces
ontalis
yer
wer temporal space
Inferior temporal septum
Superficial fat laye
Upper temporal space Superior temporal septu
layer) and the deep temporal fascia. In the temple
are the upper and lower temporal spaces. The
upper temporal space is bounded by the superior
temporal septum (STS), an extension of the temporal ligament adhesion, and inferior temporal
septum (ITS). The boundaries of the lower temporal space are the ITS and zygomatic arch
(Fig.3.14).
The upper and lower temporal spaces refer to
the space formed in between the supercial temporal fascia (SMAS of the midface) and the
deeper deep temporal fascia. Important structures
do not pass through the upper temporal space.
However, the lower temporal space is an anatomically signicant triangular-shaped area through
which the supercial temporal artery, temporal
branch of facial nerve, and the medial and lateral
branches of the zygomatico-temporal nerve
(ZTN) course. Moreover, the sentinel vein penetrates vertically through the muscle and fascia,
while the middle temporal vein runs parallel to
and above the zygomatic arch. Therefore, caution
must be taken when injecting this area. The risk
of neurovascular damage can be minimized by
making the entry point at the intersection between
the zygomatic arch and lateral orbital rim.
Supercial temporal artery and the temporal
branch of the facial nerve, the key neurovascular
structures of the temporal region, are included in
the supercial temporal fascia or they run immediately deep to it. If ller is accurately injected
within the plane formed by the two fascia, neurovascular injury can be avoided (Fig.3.15).
For severe depressions requiring signicant
volumization, many clinicians believe that ller
should be injected in deep to the temporalis mus-