Surgical anatomy of the midcheek and malar mounds

The anatomy of the midcheek has not been satisfactorily described to adequately explain midcheek aging and malar mounds, nor has it suggested a logical approach to their correction or provided sufficient detail for safe surgery in this area. This cadaver study, which was complemented by many operative dissections, located a missing link: a glide plane space overlying the body of the zygoma. The space functions to allow mobility of the orbicularis oculi, where it overlies the zygoma and the origins of the elevator muscles to the upper lip. The space is a cleft between the sub-orbicularis oculi fat and the preperiosteal fat and is lined by a fine membrane. The anatomic boundaries are clearly defined by retaining ligaments, which correlate with the triangularity of the space. Several anatomic features provide the functional characteristics of the prezygomatic space, including the (1) absence of direct attachments between the orbicularis in the roof to the floor, (2) more rigid inferior boundary formed by the zygomatic ligaments, and (3) more mobile upper ligamentous boundary formed by the orbicularis retaining ligament (separating from the preseptal space of the lower lid). These components determine the characteristic aging changes that occur in this region and explain much about malar mounds. An appreciation of this anatomy has several surgical implications. The prezygomatic space is a junction area that can be approached from the temple, lower lid, and cheek. The zygomatic branches of the facial nerve to the orbicularis do not cross the space; rather, they course in the walls and in the sub-orbicularis fat within the roof of the space.