Midfacial aging involves a complex interplay between the aging osseous skeleton, facial retaining ligaments, soft tissue envelope, facial fat compartments, and the overlying skin. The authors describe a classification of midfacial aging that can help direct the appropriate surgical technique for rejuvenation utilizing evidence based medicine. Procedures discussed include endoscopic midface lifting, autologous fat grafting, deep plane rhytidectomy, alloplastic midfacial implants, and lower blepharoplasty with fat transposition to the lid cheek junction.
Key points
- •
Changes that occur in individual distinct compartments of facial subcutaneous fat characterize the aging face.
- •
The complex interplay existing among osseous skeleton, facial retaining ligaments, soft tissue envelope, facial fat compartments, and the overlying skin leads to several patient-specific changes.
- •
The authors describe a classification of midfacial aging that can help direct the appropriate surgical technique for rejuvenation utilizing evidence based medicine.
- •
Procedures discussed include endoscopic midface lifting, autologous fat grafting, deep plane rhytidectomy, alloplastic midfacial implants, and lower blepharoplasty with fat transposition to the lid-cheek junction.
Introduction
Midfacial aging is one of the most challenging problems to address in facial rejuvenation surgery. A complex interplay exists between the osseous skeleton, facial retaining ligaments, soft tissues envelope, facial fat compartments, and the overlying skin, which leads to several patient-specific changes. In addition, genetic and facial anatomic differences can manifest throughout life at variable ages. Signs of midfacial aging can be apparent in the third decade of life for some patients, while for others changes begin as late as the sixth decade. The complexity in midface rejuvenation is evidenced by the variety of treatment approaches, from a myriad of face-lifting techniques (transtemporal midface lift [MFL], transblepharoplasty MFL, and rhytidecomy with midfacial repositioning) to volumization procedures (autologous fat grafting, midfacial implants, orbital fat repositioning, and bioabsorbable fillers), with no consensus as to which approach is the best.
Ptosis
Ptosis of the soft tissue envelope encompasses one component of midfacial aging. As it descends, the suborbicularis occuli fat (SOOF) falls below the bony infraorbital rim, with concomitant development of a tear-trough deformity. The malar fat pad continues to descend with subsequent production of deeper nasolabial folds, as the relatively thick cheek subunit abuts the thin and muscular perioral area. Later, with advancing age and hormonal changes, the facial retaining ligaments and overlying skin lose elasticity, accelerating midface ptosis and contributing to jowling of the lower face.
Volume Loss
A second distinct component of midfacial aging results from devolumization of the midface structures, including the soft tissue envelope, fat compartments, and the osseous skeleton. Esthetic surgeons have described changes in the facial fat compartments, which have recently been described in studies that show both descent of the tissue mass and overall volume loss. Specifically, Rohrich and Pessa showed, in cadaveric studies, that there are distinct partitions of facial subcutaneous fat. It is the changes that occur in these individual compartments that characterize the aging face. The importance of this work is in the understanding that the face does not age as one “confluent mass.”
Cheek fat compartments are identified as 3 separate entities that lie between the orbital retaining ligaments superiorly and the jowl fat inferiorly. These 3 fat compartments consist of the medial, middle, and lateral temporal cheek fat. There is a described zone of confluence where all 3 fat compartments meet and the zygomaticus major muscle is adherent; this is known as the zygomatic ligament. The importance in understanding that a dense fascial plane exists where the medial and middle cheek fat compartments meet is invaluable in face-lifting surgery. It is these dense fascial systems that can cause poor postoperative midface results if not adequately released.
Facial Skeletal Anatomy
A final consideration in midfacial analysis is relatively independent of patient age: skeletal anatomy, which determines malar projection. In youth, the fullness of the perimalar soft tissues can mask bony hypoplasia. As the attendant soft tissue volume loss and midface ptosis progresses with age, malar structural deficiency becomes apparent and contributes significantly to the aged appearance. In addition, patients with malar hypoplasia and/or a negative vector have premature midfacial descent from a lack of soft tissue support, which can be apparent by age 30. Conversely, patients with strong zygomatico-malar complexes (“high cheekbones”) tend to display midfacial ptosis later in life.
Involution of the facial skeleton does occur with age, but it is the authors’ belief that this is not as significant a contributor to midfacial ptosis as the cheekbone anatomic structure in youth. Shaw and Kahn describe a statistically significant derotation of the maxillary angle of 6.7° into the face when comparing young to middle age groups of patients via 3-dimensional computed tomographic studies. It is the authors’ belief that this degree of change, although statistically significant, matters most in patients who already have weak zygomatic-maxillary structure and likely would have benefited from early malar augmentation. Those with strong skeletal structure in youth are unlikely to need skeletal augmentation in older age, even with derotation of the maxilla.
As a result of the many anatomic components involved in midfacial aging, the authors proposed a classification system based on distinct anatomic factors to direct surgical treatment. In this article, the authors review their retrospective experience of 150 patients who underwent midfacial rejuvenation surgery. Their outcomes were analyzed in terms of midfacial aging classification, surgical approach used, and patient satisfaction with the midface rejuvenation. The techniques used included the following either as a single modality or combined treatments: autologous fat grafting, transtemporal midface lifting, deep plane rhytidectomy with release of zygomatic subcutaneous ligaments, cheek augmentation with implants, and lower eyelid blepharoplasty with fat transposition.
Midface classification
The authors assess midface anatomy and aging by physical examination and preoperative photography. The following 4 variables are used:
- 1.
Volume loss
- 2.
Midface ptosis
- 3.
Loss of elasticity
- 4.
Presence or absence of a negative vector or hypoplastic malar eminence
To determine adequate projection of the malar region, a line perpendicular to the Frankfort horizontal is drawn inferior from the glabella; if the most anterior portion of the midface is obviously posterior to this line, the patient is considered to have deficient midface projection, which is similar to the “negative vector” described for periorbital surgery. For men with a very prominent frontal bar, the nasion is used in place of the glabella.
The authors found that, using this classification scheme, patients fit into 1 of 3 general categories (class I, II, and III) based on severity of midfacial aging ( Table 1 ). Furthermore, patients in each group can be subclassified as having either (1) normal skeletal anatomy; or (2) deficient skeletal projection in the midface ( Fig. 1 ). Finally, it is important to note that people age differently, with genetic and environmental factors contributing uniquely. Strict age-based classifications are thus inadequate. As such, age for each class is presented as a suggested range, although outliers exist in each group.
| Midface Classification | Infraorbital or Malar Volume Loss | Midfacial Ptosis | Loss of Elasticity | Negative Vector or Malar Hypoplasia | Age Category, y |
|---|---|---|---|---|---|
| IA | + | − | − | − | <40 |
| IB | + | − | − | + | <40 |
| IIA | + | + | + | − | 40–55 |
| IIB | + | + | + | + | 40–55 |
| IIIA | ++ | ++ | ++ | − | >55 |
| IIIB | ++ | ++ | ++ | + | >55 |
Surgical procedures
Autologous fat grafting
Autologous fat grafting is performed in standard fashion, according to the algorithm presented by Coleman. Periumbilical abdominal fat is typically used as the donor tissue. Approximately 80 mL of raw fat can be harvested using a Tulip 2.1 SL cannula (Tulip Medical, San Diego, CA, USA). This raw fat is then centrifuged, washed with injectable normal saline, and centrifuged a second time to isolate the adipose tissue. The authors use a 0.9 SL Tulip cannula for micrograft placement overlying the zygoma, in the submalar region, along the infraorbital rim, and at the nasojugal groove. An average of 12 to 15 mL of processed fat is typically used per hemiface per case.
Malar implants
The authors use either Conform Terino Malar Shells or Combined Submalar Shells (Implantech, Ventura, CA, USA) for malar augmentation. Implants are placed exclusively via the transoral approach with a standard upper gingivobuccal sulcus incision and subperiosteal dissection. Implants are held in place with 2 transcutaneous sutures for 5 to 7 days postoperatively, at which time the sutures are removed.
Extended lower-lid blepharoplasty with orbital fat transposition
Lower eyelid rejuvenation is approached via an extended blepharoplasty dissection, according to the method outlined by Baker. Briefly, after elevating of a skin-muscle flap, dissection is carried out on top of the SOOF over the face of the maxilla to the level of the infraorbital nerve, allowing for manipulation of the SOOF and providing a recipient site for transposed orbital fat. The orbital septum is incised along the infraorbital rim, permitting visualization and isolation of fat pockets. Excess fat in the lateral pocket is typically resected, improving the contour at the lateral canthus. Fat from the middle and nasal pockets is isolated, bluntly dissected, and then rotated inferiorly as pedicled flaps over the orbital rim to fill in the tear trough medially and improve the lower lid-cheek contour centrally.
Endoscopic midface lift
The authors perform the endoscopic MFL as described by Quatela and Jacono. Briefly, dissection begins immediately on top of the deep temporal fascia overlying the temporalis muscle. At the zygomatic arch, the periosteum is incised and elevation is continued in a subperiosteal plane and below the masseteric tendon inferiorly. After release of the perisoteum over the zygomatic arch, the dissection continues inferiorly deep to the masseteric. The composite flap is resuspended in a superolateral direction to the temporoparietal fascia.
Deep-plane rhytidectomy
This procedure follows from the basic concepts introduced by Hamra. The authors’ technique evolved from Hamra’s approach and is called the minimal access deep plane extended (M.A.D.E.) vertical volumizing facelift. Like Hamra’s technique, the authors’ technique releases the zygomatic ligaments, which allows mobility of the ptotic medial and middle cheek fat compartments. However, the M.A.D.E. extends the deep plane below the angle of the mandible into the upper neck, releasing the platysma from its cervical fascial attachments to the sternocleidomastoid. The extended deep plane flap is suspended in a vertical vector, repositioning the cheek fat and volumizing the midface.
Introduction
Midfacial aging is one of the most challenging problems to address in facial rejuvenation surgery. A complex interplay exists between the osseous skeleton, facial retaining ligaments, soft tissues envelope, facial fat compartments, and the overlying skin, which leads to several patient-specific changes. In addition, genetic and facial anatomic differences can manifest throughout life at variable ages. Signs of midfacial aging can be apparent in the third decade of life for some patients, while for others changes begin as late as the sixth decade. The complexity in midface rejuvenation is evidenced by the variety of treatment approaches, from a myriad of face-lifting techniques (transtemporal midface lift [MFL], transblepharoplasty MFL, and rhytidecomy with midfacial repositioning) to volumization procedures (autologous fat grafting, midfacial implants, orbital fat repositioning, and bioabsorbable fillers), with no consensus as to which approach is the best.
Ptosis
Ptosis of the soft tissue envelope encompasses one component of midfacial aging. As it descends, the suborbicularis occuli fat (SOOF) falls below the bony infraorbital rim, with concomitant development of a tear-trough deformity. The malar fat pad continues to descend with subsequent production of deeper nasolabial folds, as the relatively thick cheek subunit abuts the thin and muscular perioral area. Later, with advancing age and hormonal changes, the facial retaining ligaments and overlying skin lose elasticity, accelerating midface ptosis and contributing to jowling of the lower face.
Volume Loss
A second distinct component of midfacial aging results from devolumization of the midface structures, including the soft tissue envelope, fat compartments, and the osseous skeleton. Esthetic surgeons have described changes in the facial fat compartments, which have recently been described in studies that show both descent of the tissue mass and overall volume loss. Specifically, Rohrich and Pessa showed, in cadaveric studies, that there are distinct partitions of facial subcutaneous fat. It is the changes that occur in these individual compartments that characterize the aging face. The importance of this work is in the understanding that the face does not age as one “confluent mass.”
Cheek fat compartments are identified as 3 separate entities that lie between the orbital retaining ligaments superiorly and the jowl fat inferiorly. These 3 fat compartments consist of the medial, middle, and lateral temporal cheek fat. There is a described zone of confluence where all 3 fat compartments meet and the zygomaticus major muscle is adherent; this is known as the zygomatic ligament. The importance in understanding that a dense fascial plane exists where the medial and middle cheek fat compartments meet is invaluable in face-lifting surgery. It is these dense fascial systems that can cause poor postoperative midface results if not adequately released.
Facial Skeletal Anatomy
A final consideration in midfacial analysis is relatively independent of patient age: skeletal anatomy, which determines malar projection. In youth, the fullness of the perimalar soft tissues can mask bony hypoplasia. As the attendant soft tissue volume loss and midface ptosis progresses with age, malar structural deficiency becomes apparent and contributes significantly to the aged appearance. In addition, patients with malar hypoplasia and/or a negative vector have premature midfacial descent from a lack of soft tissue support, which can be apparent by age 30. Conversely, patients with strong zygomatico-malar complexes (“high cheekbones”) tend to display midfacial ptosis later in life.
Involution of the facial skeleton does occur with age, but it is the authors’ belief that this is not as significant a contributor to midfacial ptosis as the cheekbone anatomic structure in youth. Shaw and Kahn describe a statistically significant derotation of the maxillary angle of 6.7° into the face when comparing young to middle age groups of patients via 3-dimensional computed tomographic studies. It is the authors’ belief that this degree of change, although statistically significant, matters most in patients who already have weak zygomatic-maxillary structure and likely would have benefited from early malar augmentation. Those with strong skeletal structure in youth are unlikely to need skeletal augmentation in older age, even with derotation of the maxilla.
As a result of the many anatomic components involved in midfacial aging, the authors proposed a classification system based on distinct anatomic factors to direct surgical treatment. In this article, the authors review their retrospective experience of 150 patients who underwent midfacial rejuvenation surgery. Their outcomes were analyzed in terms of midfacial aging classification, surgical approach used, and patient satisfaction with the midface rejuvenation. The techniques used included the following either as a single modality or combined treatments: autologous fat grafting, transtemporal midface lifting, deep plane rhytidectomy with release of zygomatic subcutaneous ligaments, cheek augmentation with implants, and lower eyelid blepharoplasty with fat transposition.
Midface classification
The authors assess midface anatomy and aging by physical examination and preoperative photography. The following 4 variables are used:
- 1.
Volume loss
- 2.
Midface ptosis
- 3.
Loss of elasticity
- 4.
Presence or absence of a negative vector or hypoplastic malar eminence
To determine adequate projection of the malar region, a line perpendicular to the Frankfort horizontal is drawn inferior from the glabella; if the most anterior portion of the midface is obviously posterior to this line, the patient is considered to have deficient midface projection, which is similar to the “negative vector” described for periorbital surgery. For men with a very prominent frontal bar, the nasion is used in place of the glabella.
The authors found that, using this classification scheme, patients fit into 1 of 3 general categories (class I, II, and III) based on severity of midfacial aging ( Table 1 ). Furthermore, patients in each group can be subclassified as having either (1) normal skeletal anatomy; or (2) deficient skeletal projection in the midface ( Fig. 1 ). Finally, it is important to note that people age differently, with genetic and environmental factors contributing uniquely. Strict age-based classifications are thus inadequate. As such, age for each class is presented as a suggested range, although outliers exist in each group.
| Midface Classification | Infraorbital or Malar Volume Loss | Midfacial Ptosis | Loss of Elasticity | Negative Vector or Malar Hypoplasia | Age Category, y |
|---|---|---|---|---|---|
| IA | + | − | − | − | <40 |
| IB | + | − | − | + | <40 |
| IIA | + | + | + | − | 40–55 |
| IIB | + | + | + | + | 40–55 |
| IIIA | ++ | ++ | ++ | − | >55 |
| IIIB | ++ | ++ | ++ | + | >55 |
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