Abstracts - Clinical Science

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    Surgical Management of Thoracic Disc Herniation Via a Modified Transfacet Approach
    P. Arnold and S. Kashyap
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Symptomatic thoracic disc herniation rarely resolves with conservative management. The gold standard in surgical management is the transthoracic approach, but in patients with significant comorbidities, this approach carries significant risk. Posterolateral approaches are less invasive and have been shown to be effective, but a best approach has not been established. The results are dependent upon a surgeon's experience, location and type of herniation, and health of the patient. A retrospective review of a collected database was conducted to evaluate the safety and efficacy of the modified transfacet approach in the management of single-level thoracic disc herniation. The charts of seventy-six patients with laterally herniated thoracic discs were reviewed to evaluate for improvement in their pain, Nurick Grade, and neurological symptoms up to 12 months postoperatively. Their estimated blood loss, length of hospital stay, hospital course, and postoperative complications were evaluated. All attempts at disc resection were successful. The majority of patients reported improvement in pain, sensory involvement, and strength. Nine patients had complete resolution of their symptoms while three patients had unchanged symptoms. Three patients experienced worsened paraparesis postoperatively. One patient experienced myelopathy during the postoperative period which resolved with steroid administration. The procedure was well tolerated with minimal complications. Thoracic disc herniation can be managed surgically through a variety of approaches. The selection approach should depend on a surgeon’s experience with an approach, the patient’s health, and the location of the disc. The transfacet approach is safe and efficacious approach that should be considered in surgical management.


    Text-Message Reminders Increase Patient Attendance at Outpatient Appointment Following ED Visits
    E. Burner, S. Terp, C. Lam, A. Nercisian, V. Bhatt, A. Ngan, L. Craft, R. Malanga, R. Ortizo, V. Iyer, G. Jhaj, S. Arora, and M. Menchine 
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Timely and appropriate outpatient follow up to ED visits reduces healthcare costs, inefficiencies within the system and improves health outcomes. These appointments are often made in the ED but attendance is low (less than 70% at LAC+USC). Patients most often report that they failed to attend scheduled appointments as a result of forgetfulness or confusion regarding the appointment. A simple text-message reminder system may be the key to resolving this clinical problem. Research Assistants approached a consecutive sample of ED patients prior to discharge to screen for eligibility. Patients were included if they had an appointment scheduled between 3 days and 4 weeks of the ED visit. Patients were excluded if they were critically ill, admitted from the ED, had no subsequent outpatient appointments, did not speak English/Spanish, did not own a mobile phone, know how to receive a text-message, or had an incompatible carrier. Patients were randomized to usual care versus the text reminder arm. Patients in the treatment arm received text message appointment reminders including date, time, and location 3 times prior to their appointment. Their attendance was collected by RAs 30 days after enrollment and analyzed. 2365 patients were approached, 1862 were excluded. Control and intervention group were similar in age, language and ethnicity. The intervention group attended 73.5% of outpatient appointments compared to 62.1% of the control group (p=0.027). In conclusion, a simple text-message reminder system increased patient attendance at outpatient appointments following ED visits, potentially improving health outcomes and inefficiencies in the system.


    Injury Profile of Mixed Martial Arts Competitors
    G. Grenier, A. Berry, R. McClain, R. Suminski, J. Wasserman, and C. Mayfield
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    PURPOSE/INTRODUCTION. Mixed Martial Arts (MMA) overall rate of injury between 23% and 29% of fight participations; boxing (~25%); kickboxing (~11%). Though informative, prior studies have: small sample sizes, exclude female fighters, use injury data from surveys of fighters and not physician assessment, and were conducted prior to the adoption of the Unified Rules of Mixed Martial Arts in 2009. The purpose is to provide a contemporary description of ringside physician diagnosed injuries during male and female, professional and amateur MMA competitions and formulate an injury prediction model. METHODS/MATERIALS. Cross-sectional design, with injury, bout, and demographic data obtained by one physician immediately after a bout; 1422 fight participations (fight participations = 711 bouts x 2 fighters/bout) between 2008 and 2012. Variables include: state, level, gender, number of rounds, and bout outcome. RESULTS. The overall injury rate was 8.5% of fight participations (121 injuries/1422 fight participations) or 5.6% of rounds (121/2178 rounds). Injury rates were similar between men and women, but a greater percentage of the injuries caused an altered mental state in men. The risk of being injured was significantly greater for bouts held in Kansas, at the professional level, lasting more rounds, and ending in a KO/TKO. Fighters also were more likely to be referred to the ER if they participated in longer bouts ending in a KO/TKO. CONCLUSIONS. The observed injury rate was lower than previously reported suggesting recent regulatory changes have made MMA a safer sport. Increased clinical awareness and additional research should be extended to head-related injuries in MMA.


    Shape of the Distal Articulating Surface of the First Metatarsal Head and its Relation to Hallux Valgus Deformity: A Cadaveric Study
    G. Grenier, B. Roe, M. Pfefer, and A. Olinger
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.
    INTRODUCTION. The shape of the distal articular surface of the first metatarsal head has been argued as a potential predisposing factor to hallux valgus formation. The present study aimed to measure and categorize the shape of the distal articular surface of the first metatarsal head and its relationship to the presence of pathological angles indicative of hallux valgus deformity. METHODS. Fifty-five adult embalmed cadavers underwent bilateral ankle disarticulation. Dorsoplantar radiograph images were taken of the sixty specimens; the x-ray beam centered on the middle of the third metatarsal was angled 15° from the vertical line in the sagittal plane. Gross dissection of the first metatarsophalangeal joint then occurred to visualize the articular surface. Measurement of the intermetatarsal (IMA), hallux vallgus (HVA), and interphalangeal (IP) angles occurred as well as the distal articular surface of the first metatarsal head. RESULTS. Utilizing a measurement and classification system to categorize the shape of the distal articular surface of the first metatarsal head as well as pathological values indicative of a hallux valgus deformity (IMA >15°, HAV >9°, and IP >5°) positive correlations were found between the shape of the articular surface and the presence of hallux valgus deformity in the specimens. CONCLUSIONS. Based on our cadaveric study, there is statistical significance indicating that the shape of the articular surface of the first metatarsal head is an additional anatomical variable that must be considered in the formation of hallux valgus deformities. Further cadaveric and radiological studies are required to verify our findings.


    Which Predictive Equation For Resting Energy Expenditure Can Help Determine Diet Recommendations In ALS Patients?
    J. Hubbard, P. Dube, and A. Wills
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disorder that affects motor neurons in the brain and spinal cord. Reduction in caloric intake and malnutrition are commonly seen in ALS patients as a result of the changes in motor neuron functioning, weakened esophageal muscles, and inability to swallow. Malnutrition also exacerbates the speed and severity at which skeletal and respiratory muscles atrophy. Despite the importance of providing adequate nutritional guidelines to ALS subjects to slow disease progression, there is limited evidence on the kilocalorie requirements for subjects with ALS. In fact, to date there have been no published recommendations for general kilocalorie needs in this patient population. Energy needs can be accurately determined from measuring resting energy expenditure (REE) data collected from indirect calorimetric methods. However, the equipment to conduct such research has proven prohibitively costly; therefore, predictive equations for REE have been developed to estimate this value. The purpose of this research is to compare the values of REE collected from indirect calorimetric methods in advanced ALS patients to eight validated predictive equations of REE in order to determine which equation best predicts calorie requirements in this patient population. Identification of an equation to accurately predict kilocalorie needs in ALS patients will prove to be an important measure in helping to determine treatment protocol.


    A Priority Approach to Donation after Circulatory Death (DCD)
    M. Jendrisak, M. Harmon, M. Skotnicki, A. Jendrisak, and A. Jamarillo
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106 and Gift of Hope Organ and Tissue Donor Network

    BACKGROUND. The DCD evaluation tool helps guide selection for donor candidacy based on a probability forecast of circulatory arrest within a 90 minute timeframe following withdrawal of support. Tool impact on missed donation opportunity and organ recovery resources saved is heretofore not well defined and is now examined. METHODS. The local Organ Procurement Organization database was queried and retrospective data analysis performed, comparing two consecutive eras of DCD practice. The first 36 month era featured routine use of the Tool in 214 cases followed by an 18-month era where the Tool was not used for 106 cases pursued so long as the donor was ventilator dependent and lacked spontaneous or purposeful movements. RESULTS. Respectfully, donor candidate exclusion (38% vs. 19%), and missed donation opportunity (18% vs. 0%) were significantly greater (p<.0001) with Tool use compared to without Tool use while failure to expire within 90 minutes was significantly greater (p<.036) for cases without Tool use (31% vs. 11%, respectively). The pattern of expiration and proportion of true donors with organs utilized in expired cases was not impacted by Tool use or omission. The mean number of persistent neurologic reflexes was significantly less (p<.0001) in the expired cases (2.5+/-1.7) compared to cases of failure to expire (4.6+/-1.8). CONCLUSION. The historic rate of 18% for missed donation opportunity employing the Tool in DCD practice was eliminated by Tool omission. The associated higher rate for failure to expire with this strategy in order to maximize donation of viable organs is justified.


    Comparison of the Carotid Bifurcation Angle in Relation to Plaque Buildup: A Cadaveric Study
    T. Kauffman and A. Olinger
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    INTRODUCTION. Atherosclerosis is one of the most prevalent diseases among Americans today. The carotid bifurcation is a common location for atherosclerotic plaque buildup. Previous studies have demonstrated anatomical differences at the carotid bifurcation to be a contributing factor of plaque buildup. This study aims to explore this relation from a gross perspective. METHODS. 35 embalmed cadavers and 10 unembalmed cadavers were used for this study. The Internal Carotid, External Carotid and Common Carotid Arteries were removed, intact, from each specimen. The carotid bifurcation angle and the internal carotid artery angle were measured, and the samples were placed in a decalcifying solution. The samples were then cut into 5mm sections and examined using a dissecting microscope. Images of the slices were taken and the area stenosis of each slice was measured using vessel analysis software. RESULTS. A total of 45 right and 45 left carotid bifurcations were examined. The results were plotted with data comparing normal atherosclerotic build up by age, weight and gender to rule out these variables. We observed a relationship between the carotid bifurcation angle and plaque buildup in both left and right samples. We also observed and even greater relationship between the ICA angle and plaque buildup in left and right samples. CONCLUSION. Based on this cadaveric study and other studies before it, the carotid bifurcation angle should be taken into account when determining patient risk for atherosclerotic disease and administering proper preventive treatments.


    Variation of the Radial Nerve, Ulnar Nerve and Axillary Nerve in Innervation of the Three Heads of the Triceps Brachii Muscle
    T. Kauffman and A. Olinger
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    The innervation of the triceps brachii (TB) muscle by the radial nerve has been refuted in recent studies. The innervation pattern of the TB muscle has clinical relevance for the surgical treatment of traumatic injury in the region. This study aimed to determine the innervation pattern of the medial, long and lateral heads of the TB muscle, and to correlate the distances from the insertion of the TB to where the innervating nerve branch enters the muscle belly. 154 limbs from preserved cadavers were dissected and examined. The innervation pattern of the heads of the TB was recorded. The distance from the insertion of the TB to the insertion of the innervating nerve was measured. The radial nerve was observed innervating all 3 heads of the TB in each limb examined. The ulnar nerve coursed through the medial head 20 times, but no branches were observed that would suggest they were innervating the musculature. The axillary nerve was not seen innervating any heads of the TB. The average distance from insertion of the TB on the olecranon to the point where the nerve branch enters the muscle belly for the medial, long and lateral was 128 mm, 183 mm and 170 mm respectively. Several studies have recently challenged the classic description that the radial nerve innervates the three heads of the TB, however, the findings of the current study suggest that the classical description of the TB innervation is more accurate than the these studies suggest.


    Diabetes and Incident Parkinson’s Disease: Results from the Atherosclerosis Risk in Communities (ARIC) Study
    V. Kishore, L. Kao, and N. Maruthur
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Diabetes is associated with neurologic complications including neuropathies and dementia. Prior cohort studies in Taiwan and Finland demonstrated an increased risk of Parkinson’s Disease (PD) in patients with type 2 diabetes (T2DM); however no studies have been conducted in a U.S. population. Therefore, we conducted a prospective analysis to examine the association between pre-existing T2DM and PD in the Atherosclerosis Risk in Communities study, a population based cohort study of 16,000 middle-aged adults from various U.S. communities. T2DM was defined by 1) self-report of physician’s diagnosis, 2) use of anti-diabetic medications, 3) fasting glucose ≥ 126mg/dL, 4) non-fasting glucose ≥ 200 mg/dL. PD was defined by medical records and physician confirmation. The Cox proportional hazards model was used to determine the independent risk of T2DM and PD. For the analysis, 15,291 individuals were included. At baseline, 1,823 (11.9%) individuals had T2DM. Over a mean follow-up of 19.8 years, 91 (30.02 cases/100,000 person-years) individuals developed PD. Incidence rates were similar between individuals with and without diabetes, 29.95 and 30.57 cases per 100,000 person-years, respectively (p=0.95). The unadjusted hazard ratio (HR) of PD associated with T2DM was 1.02 (95% confidence interval: 0.54-1.91,p=0.96). After adjustment for potential confounders the HR was 0.83 (0.29-1.81, p= 0.49). In conclusion, in a large U.S. population-based cohort, we found no evidence for an association between prevalent T2DM and the risk of PD. The inconsistencies observed in studies of T2DM and PD to date may be due to a lack of statistical power within any individual study or the definitions used for PD themselves.


    Pediatric Computed Tomography Dose Index Volumes: Comparison of Children's and Community Hospitals to ACR Recommendations
    J. Loeb, S. Nazeer, L. Lowe, and C. Keup
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    INTRODUCTION. The purpose of this study is to determine how the CT dose index volume (CTDIvol), dose length product (DLP), and scan phases at a children's hospital and surrounding community hospitals compare to the American College of Radiology (ACR) recommendations. MATERIALS AND METHODS. A retrospective review of CT Head (CTH) and CT Abdomen (CTA) CTDIvol’s, DLPs and number of scan phases from a children's hospital and surrounding community hospitals were compared to each other and ACR CTDIvol recommendations (< 20 mGy for pediatric CTA's and < 75 mGy for CTH's). Results: 97.10% of CTH and 97.48% of CTA CTDIvol's, respectively, at the children's hospital and 90.21% and 82.91% of CTH and CTA CTDIvol's, respectively, at the community hospitals were below ACR recommendations. CTA's at the children's hospital had a lower CTDIvol average in all age groups when compared to the community hospitals. CTH's at the children's hospital had a lower CTDIvol in the 5 to <10 year and 10 to <15 year groups. The average CTA DLP in all age groups one year or above at the children's hospital, was at least 50% lower, compared to the community hospitals. 99.20% of CTA's at the children's hospital were single phase compared to 68.20% at the community hospitals (p<0.0001). CONCLUSION: The children's hospital had a higher percentage of CTH and CTA scans performed within the ACR CTDIvol recommendations. The most significant difference between the children's hospital and the community hospitals, was the percentage of single-phase scans, specifically 99.20% vs. 68.20%, respectively.


    Clinical Validation of the QBC FAST Stain and ParaLens Advance System for Malaria Diagnosis
    S. Parsel, S. Gustafson, C. McArthur, and A. Shnyra
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Malaria is a significant world health burden leading to over 650,000 deaths annually. The high incidence of fatalities is partially linked to substandard diagnostic accuracy associated with lack of appropriate training and supervision of laboratory personnel. Previous studies showing improved accuracy in the diagnosis of tuberculosis using fluorescent techniques, prompted us to evaluate the diagnostic utility of the QBC FAST Stain with the ParaLens Advance fluorescent microscopy system over the standard Giemsa method in diagnostics of malaria. For this purpose, we collected 515 blood samples during routine care in Cameroon, West Africa. Blood smears were analyzed on location using microscopy with Giemsa stain and the FAST system by four technicians. In order to verify microscopic data, a two-step nested PCR assay was performed at our laboratory using primers for the genus Plasmodium. Of 223 samples analyzed to date there are 37 and 21 positive samples identified by Giemsa and FAST technique, respectively. PCR has confirmed only 6 positive samples in each group while revealing a high rate of discrepancy in diagnostic accuracy between individual technicians. However, the use of the FAST method significantly decreased the rate of false-positive readings attributed to the less experienced technicians confirming a long-standing notion that technician training and experience play a key role in accurate diagnosis of malaria. Collectively, our data show that the FAST technique decreased the rate of false positive results amongst inexperienced technicians thereby improving the interexaminer consistency in microscopic diagnosis of malaria.


    Chromatin Remodeling Resets the Immune System to Protect Against Autoimmune Diabetes in Mice
    T.Patel, V.Patel, R.Singh, S.Jayaraman
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106 and Loyola University, Chicago

    Epigenetic alteration of the genome has been shown to provide palliative effects in mouse models of certain human autoimmune diseases. We have investigated whether chromatin remodeling could provide protection against autoimmune diabetes in NOD mice. Treatment of female mice during the transition from prediabetic to diabetic stage (18-24 weeks of age) with the well-characterized histone deacetylase inhibitor, Trichostatin A effectively reduced the incidence of diabetes. However, similar treatment of overtly diabetic mice during the same time period failed to reverse the disease. Protection against diabetes was accompanied by histone hyperacetylation in pancreas and spleen, enhanced frequency of CD4+ CD62L+ cells in the spleen, reduction in cellular infiltration of islets, restoration of normoglycemia and glucose-induced insulin release by beta cells. Activation of splenic T lymphocytes derived from protected mice in vitro with pharmacological agents that bypass the antigen receptor or immobilized anti-CD3 antibody resulted in enhanced expression of Ifng mRNA and protein without altering the expression of Il4, Il17, Il18, Inos, and Tnfa genes nor the secretion of IL-2, IL-4, IL-17, and TNF-α proteins. Consistently, expression of the transcription factor involved in Ifng transcription, Tbet/Tbx21 but not Gata3 and Rorgt, respectively required for the transcription of Il4 and Il17, was upregulated in activated splenocytes of protected mice. These results indicate that chromatin remodeling can lead to amelioration of diabetes by employing multiple mechanisms including differential gene transcription. Thus, epigenetic modulation could be a novel therapeutic approach to block the transition from benign to frank diabetes.


    Identification of a Novel Pharmaceutical Target to Treat Iron Overloading

    M. Shah1, C. Gayer1, T. Nag1, M. Khan1, J. Steib, R. Kress, R. Patel, E. Von Ende, and R. White
     1These authors are equal contributors.

    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Hereditary hemochromatosis and transfusion-dependent diseases (sickle cell disease and beta-thalassemia) result in iron overloading that can lead to end organ disease. Current treatment for these diseases includes monthly phlebotomy and/or oral iron chelating therapy. Improving this treatment with pharmacologic approaches has been the highest priority. The care for these iron overloaded patients presents a cost and health burden to the United States. A hereditary iron deficient mouse model called flaky skin (gene symbol fsn) may provide a novel pharmaceutical approach to treating iron overloading since this mouse suffers from excessive urinary iron excretion and resultant anemia as homozygotes. The fsn mutation is in the Ttc7 gene whose function is unknown. Normal fsn/fsn homozygous mice, showing a completely rescued phenotype, were produced from the mating of the fsn parent strain, BALBc/J, to C3H/101H mice. Our hypothesis is that a modifier gene from C3H/101H is able to completely rescue the anemic fsn mutant. We are mapping and identifying this modifier gene in the mouse genome, whose discovery will likely help explain why the mutant fsn mice excrete excessive iron in the urine. Through the use of dinucleotide repeat genetic markers, we are going to determine the exact location of the modifier gene that is contributed by C3H/101H. Ultimately, this will allow us to understand the function of normal TTC7 protein in the body, and how a mutation in this protein allows excessive urinary iron excretion. This will lead to the identification of a novel pharmaceutical target for iron overloading.


    Examination for Safer Placement of Surgical Instruments in Thoracentisis and Video-Assisted Thoracic Surgery (VATS): A Cadaveric Study
    J. Sharp, D. Solomon, and A. Olinger
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Thoracentesis and VATS procedures can result in hemorrhage as a result of severing the collateral branches of the posterior intercostal artery. These collateral branches are most common in the 5th intercostal space, and tortuosity has been shown to be present in the third through eighth intercostal spaces. A group of investigators have recommended the 4th and 7th intercostal spaces, 120mm lateral to midline as a safe zone least likely to hit collateral branches when cutting or inserting an instrument into the intercostal space. The study aimed to investigate that safe zone as better entry points for procedures. METHODS. A total of 54 embalmed human cadavers were selected. With the cadavers in the prone positions, 2cm incisions were made at the 4th and 7th intercostal spaces 120mm lateral to midline bilaterally. The cadavers were then placed supine, and the posterior intercostal arteries were dissected out. Careful attention was paid to identify if any collateral branches were present and if they had remained intact after the initial incision. RESULTS. After thorough dissection of the 4th and 7th intercostal spaces surrounding each incision, it was shown that this location for incision resulted in very little damage to any of the posterior intercostal arteriers or to any additional collateral branches. CONCLUSIONS. Based on this cadaveric study, a 2cm incision at the 4th and 7th intercostal spaces 120mm lateral from midline resulted in infrequent severing of any collateral branches and would be a more suitable location for instrument placement in thoracentesis and VATS procedures.


    Quantification of the Distal Radial Artery for Improved Vascular Access
    E. Wessel, K. Hessel, A. Glaros, K. Stark, and A. Olinger
    Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO 64106.

    Transradial coronary artery intervention is a safe alternative to traditional catheterization techniques that utilize the femoral or brachial arteries. There is no consensus in the literature as to which point of the radial artery (RA) is the safest to introduce a catheter. The purpose of this study was to measure the diameter, tortuosity and branching patterns of the distal RA with respect to the radial styloid process (SP). 93 cadaveric RAs (46 male, 47 female) were dissected and measured. The diameter of the RA was measured at 2cm increments starting at the SP and moving proximally along lateral edge of the radius. The location and degree of tortuosity of the artery were recorded if > 35⁰. Lastly, branches of the RA were recorded with respect to their distance from the SP. In males, we found the average diameter of the RA at the SP was significantly larger than the diameter at 6 cm and 10 cm. In males, we observed typical RA branches at an average of 1.72 cm from the SP and tortuosity of the RA >35⁰ at 1.65 cm from the SP. In females, there were no significant changes in the diameter of the RA along its course. In females, branches and tortuosity greater than 35⁰ occurred on average at 1.98 cm and 2.93 cm from the SP respectively. Our data suggests that catheters could be safely inserted at distances greater than 3 cm from the SP to avoid excessive tortuosity or branches, and greater accessibility may be found 6 cm proximal from the SP in males.


    Dynamic Facial Rejuvenation Part 1: Midface Analysis
    C. Surek1, J. Beut2, R. Stephens3, J. Lamb1, and G. Jelks4
    1University of Kansas Medical Center, Kansas City, Kansas
    2Instituto Dr. Beut, Palma De Mallorca, Spain
    3Kansas City University of Medicine and Biosciences, Kansas City, MO
    4New York University, New York, New York

    Purpose: Construction of an anatomically inspired midfacial analysis to facilitate safe, accurate and dynamic non-surgical rejuvenation. Emphasis is placed on determining injection target areas and adverse event zones. Methods: Six hemifacial fresh cadaver specimens were dissected in a layered fashion. Dimensional measurements between midfacial fat compartments, mimetic muscles and neurovascular bundles were used to develop a topographic analysis for clinical injections. A gliding tissue pocket in the midface was anatomically mapped. A three-dimensional video rendering of the analysis was created. Results: The base of alar crease to the medial edge of the Levator Anguli Oris (LAO) [1.9 cm (1.7-2.5)], lateral edge of the LAO [2.6 cm (2.4-3.1)] and Zygomatic Major [4.6 cm (3.9-5.7)] partition the cheek into two aesthetic regions. A six-step facial analysis outlines five target areas, two adverse event zones and triangulates the point of maximum cheek projection. The lower adverse event zone yields an anatomical explanation to inadvertent jowling during anterior cheek injection. The upper adverse event zone localizes the palpebral branch of the infraorbital artery. Two inferior target areas isolate regions for anterior cheek projection and lateral cheek volumization. Three superior target areas highlight regions for lid-cheek blending, tear trough effacement, lateral cheek projection and a dynamic gliding pocket between the superficial and deep facial fat compartments. Conclusions: This stepwise analysis isolates target areas and adverse event zones to achieve midfacial support, contour and profile in the repose position while simultaneously achieving a natural shape during animation.