Facial Soft-Tissue Spaces and Retaining Ligaments of the Midcheek

BACKGROUND: This anatomical study was undertaken to define the soft-tissue spaces, retaining ligaments, and their relations in the midcheek. METHODS: Sixty fresh hemifaces were dissected. The retaining ligaments and facial spaces were defined and their dimensions recorded. The course of the key vessels and branches of the facial and infraorbital nerves were defined and their anatomical relations noted. RESULTS: The preseptal and prezygomatic spaces underlie the lid-cheek and malar segments of the midcheek. A previously undocumented soft-tissue space, the premaxillary space, was found to underlie the nasolabial segment. The retaining ligaments of the midcheek are the tear trough-orbicularis retaining ligament complex in the upper midcheek and the zygomatic and maxillary ligaments in the lower midcheek. The tear trough-orbicularis retaining ligament complex separates the preseptal space above from the prezygomatic and premaxillary spaces below. Facial nerve branches in the midcheek are closely associated with the zygomatic ligaments located outside the lower boundary of the prezygomatic space and are protected so long as the dissection is kept within this space. The infraorbital nerve is protected by the floor of the premaxillary space, formed by the levator labii superioris and, at the inferior boundary of the space, by the close relation with the maxillary ligaments. CONCLUSIONS: This study completely defined the spaces and retaining ligaments of the midcheek. Knowledge of this anatomy is key to safe and atraumatic suborbicular dissection for effective midcheek lifts.