Removal of skin and fat around the eye exacerbates an already hollow, aged eye. The buccal region is critical in the appearance of the midface. An undercorrected midface still shows significant rejuvenation after the procedure and can easily be improved with a secondary procedure. Overcorrection is difficult to correct and leads to an unhappy patient. For isolated filling of lips and nasolabial folds, off-the-shelf fillers are a better alternative than autologous fat.
Key points
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Removal of skin and fat around the eye exacerbates an already hollow, aged eye.
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The buccal region is critical in the appearance of the midface.
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An undercorrected midface still shows significant rejuvenation after the procedure and can easily be improved with a secondary procedure. Overcorrection is difficult to correct and leads to an unhappy patient.
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For isolated filling of lips and nasolabial folds, off-the-shelf fillers are a better alternative than autologous fat.
Overview
The eyes are perhaps the most important area to rejuvenate; if the eyes remain tired and older in appearance after rejuvenation, little else matters. Traditional blepharoplasty principally robs the eye of its precious frame. Removal of skin and fat around the eye exacerbates an already hollow, aged eye. The authors advocate conservative transconjunctival lower blepharoplasty when needed combined with periorbital/midface fat transfer.
The authors have long maintained that the key to facial rejuvenation lies in understanding the visual cues that instantaneously and subconsciously trigger evaluation of a person’s appearance. Shadow patterns that brains associate with the appearance of aging are the primary determinant of this blink impression. The primary goal of facial rejuvenation with volume replacement is to convert these shadow patterns to highlights that are perceived as youthful ( Fig. 1 ).
Autologous fat transfer has proved the most effective treatment of addressing global volume loss in the midface and surrounding areas. Focal rejuvenation, such as filling the nasojugal hollow, can be accomplished with small-volume, off-the-shelf fillers, but for comprehensive midface rejuvenation, more volume is necessary and is best supplied by autologous fat.
Overview
The eyes are perhaps the most important area to rejuvenate; if the eyes remain tired and older in appearance after rejuvenation, little else matters. Traditional blepharoplasty principally robs the eye of its precious frame. Removal of skin and fat around the eye exacerbates an already hollow, aged eye. The authors advocate conservative transconjunctival lower blepharoplasty when needed combined with periorbital/midface fat transfer.
The authors have long maintained that the key to facial rejuvenation lies in understanding the visual cues that instantaneously and subconsciously trigger evaluation of a person’s appearance. Shadow patterns that brains associate with the appearance of aging are the primary determinant of this blink impression. The primary goal of facial rejuvenation with volume replacement is to convert these shadow patterns to highlights that are perceived as youthful ( Fig. 1 ).
Autologous fat transfer has proved the most effective treatment of addressing global volume loss in the midface and surrounding areas. Focal rejuvenation, such as filling the nasojugal hollow, can be accomplished with small-volume, off-the-shelf fillers, but for comprehensive midface rejuvenation, more volume is necessary and is best supplied by autologous fat.
Evaluation
The importance of facial shadows and highlights is most evident in the ease with which facial aging is depicted in 2-D art. People are subconsciously aware of the shadows that dominate the aging face and the highlights that typify a youthful face. The shadow pattern of the midface depression and the inferior orbital rim are the most important shadows of aging in the midface ( Fig. 2 A). These shadows are accentuated by the highlights of the lateral cheekbone and the fullness of the nasolabial fold as well as bulging orbital fat. In the youthful midface, a unified midface highlight is seen, with the only shadows of significance just under the lid margin and the shadow of the nasolabial fold (see Fig. 2 B). In the overall scheme of facial aging, the presence of a youthful unified cheek highlight that frames the lower orbital rim is probably the most powerful feature that is responded to. The buccal region is critical in the appearance of the midface. Faces typically transition from a rounder appearance of youth to a more angular aging shape. Patients often like the gentle hollowing of the buccal region, which occurs in the 20 to 40 age range. On seeking opinions for rejuvenation, they often emphasize a desire for a high cheekbone appearance, which should always be managed with an understanding that as the malar eminence is augmented it must be transitioned smoothly into the buccal region.
Bulging of the orbital fat in the inferior orbital rim needs to be assessed when rejuvenating the midface. Attempting to camouflage this fat by contouring alone can lead to overfilling the midface. The authors find that in most cases of bulging of orbital fat, a conservative transconjunctival blepharoplasty done prior to the fat transfer creates a smoother and more natural transition from the lower eyelid to the cheek ( Fig. 3 ).
Related posts:
An Algorithmic Approach to Multimodality Midfacial Rejuvenation Using a New Classification System for Midfacial Aging
Dark Circles
Transconjunctival Lower Lid Blepharoplasty with and Without Fat Repositioning
The Management of Festoons
The Transeyelid Midface Lift
Transtemporal Midface Lifting to Blend the Lower Eyelid-Cheek Junction
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