Anatomy of the Cheek: Implications for Soft Tissue

Augmentation
ULRIKE PILSL, MD,* FRIEDRICH ANDERHUBER, MD,* AND BERTHOLD RZANY, MD†

The authors have indicated no significant interest with commercial supporters.

W hy is the knowledge of anatomy important?

Because it helps us to become better injec-
tors by avoiding preventable adverse effects and by
ameliorating our aesthetic results.
Regions of the Cheek
The cheek extends superiorly to the zygomatic
arch, inferiorly to the margin of the mandible, pos-
teriorly to the ear, and anteriorly to the corner of
the mouth (Figure 1).
In topographic anatomical descriptions, the cheek
is divided into an infra-orbital region, a buccal
region, a zygomatic region, and a parotid-masse-
teric region. From the dermatologic-aesthetic point
of view, regarding volume augmentation, the ante-
rior part of the cheek is partitioned into the mid-
face and the infraorbital hollows. To equate these
two classifications, one can say that the infraorbital
hollow is equal to the anatomical infraorbital
region, and the aesthetic anterior midface is equal
to the buccal region.
Facial Muscles of the Cheek
The facial muscles are important because their size
and activity—in addition to the thickness of the
skin and the fat compartments—determine the visi-
bility of the mimic wrinkles and folds. They are
the targets for treatment with botulinum toxin A.
When injecting fillers, one should be aware of the
muscles, because for example, a too-superficial
injection of the filler might give the midface a
lumpy appearance when the midface muscles are
activated.
The facial muscles are arranged in two layers
(Figure 2). In the region of the cheek within the
superficial layer are the orbicularis oculi, the leva-
tor labii superioris, the levator labii superioris alae-
que nasi, the depressor anguli oris, the platysma,
the risorius, and the zygomaticus minor and major
muscles. The zygomaticus major muscle originates
from the zygomatic bone near the temporozygom-
atic suture and inserts into the upper lip and the
labial angle. The zygomaticus minor muscle also
originates from the zygomatic bone medially from
the zygomaticus major muscle and from the orbic-
ularis oculi muscle and has the same insertion as
the major. This muscle is found most superficially.
The orbicularis oculi muscle consists of three parts:
the palpebral, which originates from the medial
palpebral ligament and the anterior wall of the lac-
rimal sac; the orbital, which originates from the
frontal process of the maxilla, the anterior lacrimal
crest, and the medial palpebral ligament; and the
lacrimal, which comes from the posterior lacrimal

*Institute of Anatomy, Medical University of Graz, Graz, Austria; †Division of Evidence-Based Medicine,
Clinic for Dermatology, Medical University of Berlin (Charité), Berlin, Germany

© 2012 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2012;38:1254–1262  DOI: 10.1111/j.1524-4725.2012.02382.x

1254

Figure 1. Regions of the cheek: (A) infra-orbital, (B) buccal,
(C) zygomatic, (D) parotid-masseteric.
Figure 2. Facial muscles of the cheek. Superficial layer: (i)
zygomaticus major, (ii) zygomaticus minor, (iii) orbicularis
oculi, (iv) levator labii superioris, (v) levator labii superioris
alaeque nasi, (vi) nasalis, (vii) depressor anguli oris, (viii)
risorius. Deep layer: (ix) buccinator.
crest, the posterior wall of the lacrimal sac, and
the medial palpebral ligament. The levator labii
superioris muscle originates from the infra-orbital
margin superiorly to the infra-orbital foramen and
inserts into the upper lip. The levator labii superi-
PILSL ET AL
oris alaeque nasi comes from the frontal process of
the maxilla and from the infra-orbital margin and
reaches to the nasal wing and the upper lip. The
nasalis muscle originates from the alveolar yokes
of the canine and the lateral incisor and inserts
into the dorsum of the nose. The depressor anguli
oris originates from the mandible inferior to the
mental foramen and inserts into the lower and
upper lip. The platysma originates from the dermis
above the pectoralis major muscle at the level of
the second rib. Its medial fibers insert into the
mandible and unite with the platysma of the oppo-
site side. Its lateral fibers spread into the region of
the cheek, cover the masseter muscle and the paro-
tid gland, and intertwine with the mimic muscles
in the region of the labial angle. In most cases, the
risorius muscle originates from the platysma and
the masseteric fascia and inserts into the labial
angle and upper lip.
In the deep layer of facial muscles of the cheek,
we find the levator anguli oris muscle, which origi-
nates from the maxilla inferiorly to the infraorbital
foramen and inserts into the labial angle. The
buccinator muscle has its origin in the maxilla, the
mandible, and the pterygomandibular raphe and
inserts into the labial angle and the upper and
lower lip. It forms the basis of the cheek.
Blood Vessels of the Cheek
Why is knowledge of blood vessels important? The
reasons are twofold: first to decrease the risk of
downtime by hematomas and second to avoid the
rare but severe adverse events after the compres-
sion or occlusion of an artery.1 Arterial occlusion
with necrosis is not frequently reported for the
cheek, but several cases of alar necrosis after aug-
menting the nasolabial fold have been reported.2,3
Furthermore, one case of a retinal branch artery
occlusion after the injection of a hyaluronic acid
filler in the glabellar and cheek area has been docu-
mented.4 An occlusion of the facial artery that runs
in the depth near the nasolabial fold may explain
these adverse events.
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 ANATOMY OF THE CHEEK
Figure 3. Arteries of the cheek: (i) external carotid artery,
(ii) facial artery, (iii) superficial temporal artery, (iv) trans-
verse facial artery, (v) zygomatico-orbital artery. (Specimen
of Institute of Anatomy Graz.)
The blood supply of the cheek comes from
branches of the external carotid artery, including
branches of the two terminal trunks of the external
carotid artery: the superficial temporal and the
maxillary artery (Figure 3).
The facial artery arises from the external carotid
artery in the region of the carotid triangle and runs
across the inferior margin of the mandible anteri-
orly to the insertion of the masseter muscle. The
pulse can be felt at the anterior edge of the masse-
ter muscle. Then the artery runs across the cheek
deep to the zygomaticus muscles and ends in the
medial canthus as the angular artery. An occlusion
of the angular artery (e.g., by placement of too
much volume of filler specifically in the perialar tri-
angle), if not treated immediately, may lead to alar
necrosis.2,3 The projection of the facial artery on
the surface of the face can be imagined by a line
drawn from the anterior margin of the masseter
muscle to the medial canthus. The facial vein,
which runs behind the artery, accompanies the
facial artery.
1256 DERMATOLOGIC SURGERY
The infra-orbital artery, a branch of the maxillary
artery, runs through the infra-orbital canal in the
bottom of the orbit and reaches the face through
the infra-orbital foramen. Here it anastomoses with
the facial artery. The infra-orbital vein joins the
facial vein. When correcting the infraorbital
hollow, these vessels are frequently severed with
sharp needles, leading to sometimes quite visible
hematomas.
The superficial temporal artery runs upward within
the parotid gland between the temporomandibular
joint and the external acoustic meatus over the
root of the zygomatic arch. Then it is found on the
temporal fascia, where it branches out into its ter-
minal vessels. The retromandibular vein, which
gathers the facial vein and ends in the internal or
external jugular vein, accompanies the artery. The
superficial temporal artery releases two branches
for the cheek: the transverse facial artery and the
zygomatico-orbital artery. The parotid gland ini-
tially covers the first of these, which runs approxi-
mately 1 cm inferiorly to the zygomatic arch
across the masseter muscle deep to the branches of
the facial nerve. The zygomatico-orbital artery is
found superior to the zygomatic arch parallel to
the transverse facial artery and runs over the tem-
poral fascia to the orbicularis oculi muscle. The
same-named veins accompany the arteries.
Nerves of the Cheek
Why is the knowledge of the nerves of the cheek
important? Mainly to give the exact location of the
injection point for a local anesthetic when a nerve
block is intended before the injection of a filler.
Hypoesthesia or dysesthesia after the injection of a
filler is an unlikely event, but there are a few as of
yet unpublished reports of dysesthesia after a filler
injection in the area of the infraorbital nerve.
The sensory innervation of the cheek comes from
the branches of the maxillary and mandibular divi-
sions of the trigeminal nerve. The sensory nerves
initially lie in the deepest layer of the cheek and

Figure 4. Nerves of the cheek. Sensory nerves: (i) infra-
orbital nerve, (ii) mentalis nerve, (iii) auriculotemporal
nerve, (iv) buccal nerve. Motor nerves: (v) facial nerve, (vi)
temporal branches, (vii) zygomatic branches, (viii) buccal
branches, (ix) marginal mandibula branch. (Specimen of
Institute of Anatomy Graz.)
then penetrate the plane of the motor nerves to
reach the level of the skin (Figure 4).
The infra-orbital nerve is the only branch of the
maxillary nerve for the cheek. It runs—accompa-
nied by the same-named blood vessels—in the
infra-orbital canal in the bottom of the orbit and
reaches the skin of the anterior cheek through the
infra-orbital foramen. Injection of filler material in
the area where the nerve exits the infra-orbital
foramen should be avoided. The infra-orbital fora-
men can be identified in the mediopupillar-line a
maximum 1 cm inferior to the infra-orbital mar-
gin. It can be palpated through the skin, the super-
ficial fat, the inferior extension of the orbicularis
oculi muscle, the suborbicularis oculi fat (SOOF),
and the levator labii superioris muscle.
The following three sensory nerves in the region of
the cheek are branches of the mandibular nerve.
The auriculotemporal nerve is located at the pos-
terior border of the cheek. It originates in the
infratemporal fossa and runs laterally behind the
neck of the mandible. Then it runs upward
PILSL ET AL
together with the superficial temporal artery and
innerves the skin of the ear and the temple. It has
no branches for the skin of the cheek.
The mental nerve is the terminal part of the infe-
rior alveolar nerve. The nerve runs—together with
the same-named blood vessels—through the man-
dibular canal and ends as the mental nerve, which
appears in the mental foramen at the level of the
second premolar. It innerves the skin of the lower
lip and chin.
The buccal nerve comes from the deep region of
the face (infratemporal fossa) and appears in the
cheek at the anterior border of the masseter mus-
cle, superficial to the buccinator muscle. It inner-
vates the main part of the skin of the cheek.
The motor nerves for the mimic muscles are
branches of the facial nerve. They run transversely
to the sensory nerves and appear at the anterior
margin of the parotid gland. The motor nerves are
located between the superficial and deep layers of the
mimic muscles and run superficially to the arteries.
The temporal branches leave the region of the
cheek and run over the zygomatic arch to the
mimic muscles above the palpebral fissure. The
zygomatic branches run upward obliquely to the
mimic muscles between the palpebral fissure and
the oral fissure. The buccal branches run horizon-
tally to the buccinator muscle and to the muscles
around the mouth. The marginal mandibular
branch runs anteriorly at a variable distance from
the inferior margin of the mandible (maximum
3 cm caudally) and innerves the mentalis and the
depressor labii inferioris muscle and the platysma.
Connective Tissue of the Cheek
The connective tissue appears in the form of the
superficial muscular aponeurotic system (SMAS)
and the retaining ligaments. What roles do these
ligaments play? First, they help us to understand
the different compartments of the cheek; second,
38:7 PART II:JULY 2012 1257
 ANATOMY OF THE CHEEK
Figure 5. Histologic section of left cheek (hematoxylin and
eosin). PG, parotid gland; M, mandible; MM, masseter
muscle; TM, temporalis muscle; LAO, levator anguli oris
muscle; MF, maxillary fat pad; MAL, malar fat pad; SF,
superficial fat. Red arrow shows septum subcutaneum par-
otideomassetericum. Black arrow shows superficial muscu-
lar aponeurotic system.
ideally, we fill the space between the ligaments;
and third, when we use the cannula we can feel
certain ligaments when we pass through them dur-
ing injection. What fillers cannot do is to tighten
these ligaments. It is claimed that other methods
such as radiofrequency do so, but the evidence for
this is scarce.
The SMAS is a sheet of connective tissue located
deep to the dermis and superficial to the facial
motor nerves (Figure 5). It is thickest in the paro-
tid-masseteric region, where it is attached to the
parotid sheath.5 In the anterior cheek region, it
comes in contact with the superficial facial mus-
cles, which are enveloped by the SMAS. In this
region, the SMAS is no longer formed as a continu-
ous layer of connective tissue but splits and dis-
perses into the surrounding tissue.
The retaining ligaments of the cheek are classified
into true and false retaining ligaments.6,7 The true
retaining ligaments originate from the periosteum,
especially in the region of sutures. The false retain-
ing ligaments come from the superficial fascia or
the SMAS. Both types of ligaments insert into the
dermis (Figure 6).
True retaining ligaments in the region of the cheek
are the zygomatic ligaments (McGregor’s patch),
1258 DERMATOLOGIC SURGERY
Figure 6. Retaining ligaments of the cheek. True retaining
ligaments: (i) zygomatic ligaments, (ii) orbital retaining lig-
aments, (iii) maxillary portion of buccomaxillary ligaments,
(iv) mandibular ligaments, (v) platysma-mandibular liga-
ments. False retaining ligaments: (vi) platysma-auricular
ligaments, (vii) septum subcutaneum parotideomasseteri-
cum, (viii) buccal portion of buccomaxillary ligaments, (ix)
masseter-cutaneous ligaments.
which originate from the temporozygomatic suture
and from the zygomatic arch. The orbital retain-
ing ligaments (orbitomalar septum) arise from the
infra- and supraorbital margin and penetrate the
orbicularis oculi muscle. They are strongest in the
region of the frontozygomatic suture. The maxil-
lary portion of the buccomaxillary ligaments origi-
nates from the zygomatico-maxillary suture and
inserts into the dermis of the nasolabial fold. The
mandibular ligaments originate approximately
1 cm cranially to the inferior margin of the man-
dible at the lateral edge of the depressor anguli
oris muscle. The platysma-mandibular ligaments
arise from the periosteum of the mandible behind
the mandibular ligaments and penetrate the
platysma.
Among the false retaining ligaments are the plat-
ysma-auricular ligaments, which arise from the
SMAS and the parotid-masseteric fascia at the
posterior edge of the platysma. The subcutaneous
parotid-masseteric septum8 originates from the

SMAS in the region of the parotid gland and runs
in an anterior and lateral direction into the dermis
of the cheek. The buccal portion of the buccomax-
illary ligaments originates from the buccal mucosa,
penetrates the buccinator muscle, and inserts into
the dermis of the nasolabial fold. The masseter-
cutaneous ligaments arise from the deep SMAS at
the anterior edge of the masseter muscle.
Relationship Between Connective Tissue and
Facial Muscles
The facial muscles do not form a continuous layer.
Between the muscles, we find fatty and connective
tissue. The epimysium envelops the muscles. They
do not show a real fascia. Fibers of connective tis-
sue perforate some of them. Strands of connective
tissue run from the muscle into the dermis in an
anterolateral direction (Figure 5).
Superficial Fat Compartments of the Cheek
In the aging process, the connective tissue starts to
loosen, and fat usually diminishes. Injecting fillers
in the fat compartments, which the retaining liga-
ments separate, allows us (in case there is not
enough elastosis) to restore the lost features from
youth, but reconstruction needs to be done care-
fully. The goal is to achieve natural corrections
that fit into the respective face. Creating “balloon
heads” by augmenting all compartments is possible
but not desirable.
In the region of the cheek, five superficial fat com-
partments are found: the lateral-temporal, the mid-
dle and medial cheek, the nasolabial, and the
labiomandibular (Figure 7). The compartments are
separated mainly by the aforementioned retaining
ligaments.9–12
The lateral-temporal and middle cheek compart-
ments have common upper and lower borders.,
The zygomatic ligaments delimit both compart-
ments superiorly (McGregor’s patch), and the
platysma-mandibular ligaments delimit them
PILSL ET AL
Figure 7. Superficial fat compartments of the cheek. Violet,
lateral-temporal; red, middle; green, medial; yellow, naso-
labial; orange, labiomandibular. (Yellow, below the middle
cheek compartment, is the jowl compartment; blue, chin
compartment.)
inferiorly. The platysma-auricular ligaments form
the posterior border of the lateral-temporal com-
partment, and retaining ligaments only partially
form the anterior limitation of the middle compart-
ment: in the upper zone the zygomaticus major
muscle and in the lower zone the masseter-cutane-
ous ligaments. Between the lateral-temporal and
middle compartments we find the subcutaneous
parotid-masseteric septum (Figure 5). As this
septum runs anteriorly and laterally into the dermis
of the cheek, the lateral-temporal compartment par-
tially overlaps the middle compartment.
The medial cheek compartment is mostly shaped as
a triangle with its apex downwards. The orbital
retaining ligaments (orbitomalar septum) form its
superior limitation. The zygomaticus major muscle
delimit the compartment laterally. Strands of con-
nective tissue run from the epimysium of the mus-
cle into the dermis. The maxillary portion of the
buccomaxillary ligaments forms the medial border
of this compartment.
The nasolabial fat compartment is located laterally
to the nasolabial groove, which forms the medial
38:7 PART II:JULY 2012 1259
 ANATOMY OF THE CHEEK

border of this compartment. The facial muscles,

which insert into the upper lip, and the depressor
anguli oris muscle form the nasolabial groove.
Two ligamentous structures delimit the compart-
ment laterally: in the upper zone the maxillary por-
tion of the buccomaxillary ligaments and in the
lower zone the buccal portion of these ligaments.
The skin insertion of the maxillary portion of the
buccomaxillary ligaments is responsible for the tear
trough.

The labiomandibular compartment is located

anteriorly to the inferior part of the middle
cheek compartment. The labiomandibular groove
forms its medial border. The groove begins at
the labial angle and follows the medial margin
of the depressor anguli oris muscle onto the
origin of the mandibular ligaments. The
masseter-cutaneous ligaments delimit the compart-
ment laterally and the mandibular ligaments
inferiorly.

Because retaining ligaments mostly delimit the

fat compartments, these ligaments have an impor-
tant role in keeping the injected fillers in its
position.
Deep Fat Compartments of the Cheek
Figure 8. Sagittal section of a 66-year-old, non-lipotrophic
male anatomic specimen: (i) orbicularis oculi muscle, (ii)
superficial fat (medial compartment), (iii) SOOF, (iv) levator
labii superioris muscle, (v) malar fat pad, (vi) levator anguli
oris muscle, (vii) maxillary fat pad, (viii) buccal fat pad.

Four deep fat compartments, arranged in different
layers, are found in the region of the cheek
(Figure 8).
The SOOF is located underneath the orbicularis
oculi muscle and protrudes from the inferior mar-
gin of the muscle. It rests on the zygomaticus
major and the levator labii superioris muscle. The
malar fat pad is located deep to the SOOF. It lies
in a layer between the levator labii superioris and
the levator anguli oris muscle. There also exists a
very deep fat pad, the maxillary fat pad, located
deep to the levator anguli oris muscle. It is the
smallest of the deep fat pads and is found in the
canine fossa above the superior fornix of the oral
vestibule.
The buccal fat pad (Bichat) lies on the buccinator
muscle and has its own capsule. The main body of
this fat pad is located medially to the mandible in
the deep facial region and has extensions into the
temporal and buccal region (temporal and masse-
teric process). Injections of fillers in this fat pad
might be done using an interoral approach, too,
but this is not a routine injection mode and should
not be done by less-experienced colleagues.
Content of the Regions of the Cheek
Essentially, three regions of the cheek can be
found. Although the regions are discussed sepa-
rately, treatment usually refers to all three regions
(Figure 9).

1260 DERMATOLOGIC SURGERY


Figure 9. Regions of the cheek: (i) parotid gland, (ii) mas-
seter muscle, (iii) facial artery and vein, (iv) malar fat pad.
Parotid-Masseteric Region (Posterior Part of
the Aesthetic Midface)
The lateral region is more an add-on region for
cheek augmentation. Most injections are done in
the anterior part of the cheek. Nevertheless, this
region should not be forgotten when treating the
cheeks.
In this region, which is—in aesthetic terms—equal
to the posterior part of the midface, directly under-
neath the skin we find the superficial fat in the
form of the lateral-temporal and middle compart-
ments (Figure 7), separated from each other by the
subcutaneous parotid-masseteric septum. Below the
superficial fat lies the SMAS, covered by the plat-
ysma (Figure 5). Underneath the SMAS, we find
the parotid-masseteric fascia, which covers the par-
otid gland and the masseter muscle. The branches
of the facial nerve (Figure 4) (the zygomatic, the
temporal, the buccal and the marginal mandibula
branches), the auriculotemporal nerve, the superfi-
cial temporal artery, the transverse facial artery,
and the parotid duct (Figure 3) are found in this
region of the cheek. Correction in the lateral area
is usually done superficially, because the subcutane-
PILSL ET AL
ous fat layer is not very thick. Injecting fillers into
the parotid gland should be avoided.
Buccal Region (Anterior Part of the Aesthetic
Midface)
Aging affects this area most. Loss of fat will create
a hollow appearance; among other factors,
increased muscle activity is responsible for lines
and folds of various degrees. Fat reconstruction
requires deeper injections in this region, in contrast
to the correction of lines and folds, where a more
superficial injection is required.
The buccal region is equivalent to the aesthetic
anterior part of the midface. Underneath the skin,
the superficial fat is found in the form of the mid-
dle cheek, nasolabial, and labiomandibular com-
partments (Figure 7). The superficial fat covers the
platysma and the risorius muscle. The SMAS,
which is no longer a coherent sheet but is split in
this region, lies beneath these muscles (Figure 5).
The SMAS envelopes the zygomaticus major and
minor muscles and the depressor anguli oris mus-
cle. The branches of the facial nerve (the buccal
branches and the marginal mandibula branch) and
the parotid duct (Figure 4) run underneath the
SMAS. A line from the external acoustic porus to
the upper lip shows the course of this duct. We
find the facial artery and vein, which run over the
buccal fat pad (Bichat), deep to the branches of the
facial nerve. We find the buccal nerve and the buc-
cinator muscle underneath this fat pad.
Infraorbital Region
The infraorbital region is probably the most chal-
lenging region because all corrections need to be
made deeply, down to the level of periosteum.
Injections can be done using a tower technique
(e.g., penetrating the various layers) or more later-
ally, using a needle or cannula.
This region is equivalent to the aesthetic infraorbit-
al hollows. We find the superficial fat underneath
the skin in the form of the medial cheek and
38:7 PART II:JULY 2012 1261
 ANATOMY OF THE CHEEK
nasolabial compartments (Figure 7). The superficial
fat covers the orbicularis oculi (Figure 8) and the
zygomaticus minor muscles. The SOOF, which
covers the zygomaticus major and the levator labii
superioris alaeque nasi muscles, lies beneath these
two muscles. The branches of the facial nerve
(Figure 4) (the zygomatic and the buccal branches)
run underneath these two muscles. These nerve
branches run over the facial artery. We find the
levator labii superioris muscle, which covers the
malar fat pad, beneath the facial artery. The infra-
orbital nerve and artery, which lie on the levator
anguli oris muscle, run underneath this fat pad.
We find the maxillary fat pad beneath this muscle
(Figure 8).
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Address correspondence and reprint requests to:
Ulrike Pilsl, MD, Institute of Anatomy, Medical
University of Graz, Harrachgasse 21, 8010 Graz,
Austria, or e-mail: ulrike.pilsl@medunigraz.at