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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.

The authors of the manuscript “Volumizing Viaducts of the Midface: Defining the Beut Techniques” reveal their mastery of fat compartments and anatomical spaces by providing a comprehensive approach to midface rejuvenation.1 The discussion will focus on the ports, techniques, and concepts inherent in the authors’ approach to facial augmentation. The authors’ technique is a noteworthy departure from earlier attempts at midface rejuvenation that relied on en bloc repositioning of soft tissue. Rather than visualizing the midface as “malar fat,” the authors view the midface as a set of independent compartments and spaces, each of which contributes to overall morphology. Their use of ports or viaducts is a direct extension of this concept. Three ports enable access to the compartments and spaces that may require augmentation. This approach to facial rejuvenation by augmentation specifically addresses shape, support, and structure prior to augmentation of folds and creases. The authors suggest this approach improves the final dynamic result. In addition, augmentation of key regions as a preliminary step may decrease the volume required to improve some creases. The example of deep cheek fat augmentation and the nasolabial crease supports an approach directed primarily at support and secondarily at creases and wrinkles. This approach may also help to limit one of the most common unsolved problems in facial augmentation: prolonged refractory edema. If one dissects either the nasolabial crease or the vermillion white roll carefully under high power magnification, large lymphatic vessels will be noted to travel parallel within these structures. This is in keeping with the concept that creases do not occur sporadically nor in an arbitrary manner, but rather form over subsurface structures, including lymphatic vessels. Malar edema after injection of the nasojugal crease is …