Are We Underestimating Zygomaticus Variability in Midface Surgery?

The zygomaticus major and minor (ZMa/ZMi) are key determinants of smile dynamics and midface contour, yet they exhibit substantial morphological variability-including bifid or multibellied bellies, accessory slips, and atypical insertions. Such variants can alter force vectors, fat-compartment boundaries, and SMAS planes, increasing the risk of asymmetry, contour irregularities, or "joker smile" following facelifts, fillers, thread lifts, and smile reconstruction. To our knowledge, this is the first review to integrate the Landfald classification of ZMa/ZMi variants with a standardized dynamic imaging-based workflow for aesthetic and reconstructive midface procedures. We conducted a narrative literature synthesis of anatomical and imaging studies. Bifid or multibellied variants have been reported in up to 35% of cadaveric specimens. We synthesize anatomical, biomechanical, and imaging evidence (MRI, dynamic US, 3D analysis) to propose a practical protocol: (1) focused history and dynamic examination, (2) US/EMG mapping of contraction vectors, (3) optional high-resolution MRI for complex cases, and (4) individualized adjustment of surgical vectors, injection planes, and dosing. Procedure-specific adaptations are outlined for deep-plane releases, thread-lift trajectories, filler depth selection, and muscle-transfer orientation. We emphasize that standardizing preoperative dynamic mapping and adopting a "patient-specific mimetic profile" can enhance safety, predictability, and preservation of authentic expression, ultimately improving patient satisfaction across diverse midface interventions.