This article examines the increasing role of injectable fillers to treat midface aging and our approach to decision making regarding the use of fillers versus surgery. We discuss the volume changes of the aging midface and advocate taking an anatomic approach to correct these changes. We discuss our approach to patient selection and injection technique. Finally, we review potential complications from injectable fillers and discuss the management of complications.
Key points
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The understanding of midface aging has evolved in recent years with an emphasis on anatomically revolumizing the face over suspension alone.
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The fat of the midface is highly compartmentalized into deep and superficial compartments which lose volume and redistribute in an inferior direction with age.
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Injectable fillers offer a versatile, safe, and effective means to create an aesthetically pleasing midface/periorbital complex.
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Both surgical midface lifting with fat transfer and injectable fillers to the midface share the common goal of creating a youthful eyelid/cheek contour.
Overview
Since 1995, the senior author (E.F.W.) has been a strong proponent of midface lifting using an extended minimal incision approach suspending the entire midface as a single anatomic unit. Approximately 1200 procedures have been performed over this 15-year period. Beginning in 2004, the senior author began incorporating fat transfer as a complementary component to the midface lift, and currently performs fat transfer in 95% of all midface lifting procedures. The use of fat transfer in conjunction with the midface lift is to augment midface volume and address hollowness in the tear trough/infraorbital complex, which creates a more aesthetically pleasing result than midface lifting alone. Although this remains an effective and reliable procedure, we have seen a significant shift in our practice to less-invasive treatments for the midface and tear trough. The understanding of the pathophysiology of midface aging has evolved in recent years with an emphasis on anatomically revolumizing the face over suspension alone. We have found that, in most patients, injectable fillers offer a versatile, safe, and effective means to create an aesthetically pleasing midface/periorbital complex. The injectable fillers are appealing for patients because of less downtime and less cost than traditional surgery. Particularly with a younger patient population seeking midface/periorbital rejuvenation, injectable fillers are a viable option for these patients who neither need nor want a surgical procedure.
In this article, we explore the reasons for the increasing use of less-invasive procedures for midface rejuvenation and how fillers are changing traditional approaches to the midface.
Overview
Since 1995, the senior author (E.F.W.) has been a strong proponent of midface lifting using an extended minimal incision approach suspending the entire midface as a single anatomic unit. Approximately 1200 procedures have been performed over this 15-year period. Beginning in 2004, the senior author began incorporating fat transfer as a complementary component to the midface lift, and currently performs fat transfer in 95% of all midface lifting procedures. The use of fat transfer in conjunction with the midface lift is to augment midface volume and address hollowness in the tear trough/infraorbital complex, which creates a more aesthetically pleasing result than midface lifting alone. Although this remains an effective and reliable procedure, we have seen a significant shift in our practice to less-invasive treatments for the midface and tear trough. The understanding of the pathophysiology of midface aging has evolved in recent years with an emphasis on anatomically revolumizing the face over suspension alone. We have found that, in most patients, injectable fillers offer a versatile, safe, and effective means to create an aesthetically pleasing midface/periorbital complex. The injectable fillers are appealing for patients because of less downtime and less cost than traditional surgery. Particularly with a younger patient population seeking midface/periorbital rejuvenation, injectable fillers are a viable option for these patients who neither need nor want a surgical procedure.
In this article, we explore the reasons for the increasing use of less-invasive procedures for midface rejuvenation and how fillers are changing traditional approaches to the midface.
Volume changes in the aging midface
The fat of the midface is compartmentalized into a deep and a superficial layer. The deep layer is composed of the deep cheek fat and the sub-orbicularis oculi fat. The superficial layer, or “malar fat,” is composed of 3 fat compartments: the nasolabial, superior medial cheek, and inferior infraorbital fat ( Fig. 1 ). The aging midface experiences volume loss not only of the deep and superficial fat compartments but also in other components of the face, including skin, muscle, and bone. In a study of computed tomography scans, Shaw and colleagues demonstrated that the bony structures of the orbit undergo morphologic change with a widening of the orbital aperture that likely contributes to the change in the appearance of the overlying soft tissue envelope of the aging periorbital complex. They also found that the maxillary angle significantly decreased with age. The decrease in maxillary angle may lead to decreased skeletal support for the malar fat pad, which may allow the nasolabial crease to become more prominent with age. In another study of computed tomography scans, the midface fat compartments were analyzed for aging changes. The study further clarified facial fat anatomy and developed concepts of age-dependant changes in midfacial fat compartments: an inferior migration of the fat compartments and an inferior volume shift within the compartments in addition to volume loss. The investigators found that the inferior migration of midface fat compartments is due not only to gravity but is also a consequence of volume loss of the buccal extension of the buccal fat pad. A deflation of this fat compartment will lead to lack of support of the medial cheek and the middle cheek fat. Additionally, the fat within each compartment was found to redistribute in an inferior direction. Therefore, as we plan our rejuvenation of the midface (either surgically or with fillers) we must consider both soft tissue volume loss and bony loss.
Treatment goals
Both surgical midface lifting with fat transfer and injectable fillers to the midface share the common goal of creating a youthful eyelid/cheek contour. When deciding which approach to use, we consider the following factors ( Fig. 2 ):
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Severity of soft tissue ptosis
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Degree of volume loss
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Presence of significant brow ptosis
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Patient age
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Patient willingness for downtime
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Cost
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Patient preference
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Patient’s surgical candidacy
Patient selection
Most patients are viable candidates for injectable fillers. The patients for whom surgery is encouraged are those
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With significant midface and brow ptosis (our technique for midface lifting is done in conjunction with a browlift )
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With extensive facial volume loss who would benefit more from panfacial fat transfer
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Who desire a longer-lasting result
The remainder of patients are candidates for filler injection, although the ideal patient would be young (in their 40s) with good skin tone with mild-moderate midface volume loss, tear trough deformity, and nasolabial folds ( Fig. 3 and [CR] demonstrating midface and tear trough injection).
Pretreatment planning
Planning begins with a thorough facial analysis.
When considering the midface, we first evaluate its bony structure. The malar eminence (the most prominent portion of the zygomatic bone) is identified and palpated. The location of the malar eminence may not be prominent or symmetric on both sides of the face. It is often helpful to mark out the location of the malar region using a standard technique, such as the Hinderer method.
Mark the Malar Region
The Hinderer method helps locate the malar eminence at a point of intersection of 2 lines. The first line connects the nasal ala to the tragus and the second line connects the commissure of the lip to the lateral canthus ( Fig. 4 ). The area posterior and superior to the crossing of Hinderer lines is the most prominent part of the midface, and where the lines intersect usually identifies the area of maximal malar flattening. We find it helpful to mark these areas out on the patient’s face before injection. Once the malar eminence and the area of maximal malar flattening are identified, then the region for injection is marked out in a “triangular” shape ( Fig. 5 ).
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The apex of the triangle is at the malar eminence
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The corner of the upside-down triangle is superomedial (just inferior to the infraorbital rim)
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The third point is just superior to the middle of the nasolabial fold
By using a combination of direct palpation of the soft tissue and bony constituents of the malar eminence and marking out Hinderer lines, the areas for injection are delineated.
Assess Ptosis and Volume Loss
Next, the degree of ptosis and volume loss in the deep and superficial fat compartments of the face are assessed to determine how much filler will be needed. The deep medial fat is important to augment to increase anterior projection, improve the tear trough, and diminish the nasolabial fold.
Choice of Filler
We typically perform this with a thicker filler, such as calcium hydroxylapatite (Radiesse; Merz/Bioform, San Mateo, CA). However, other choices include poly- l -lactic acid (Sculptra; Sanofi-Aventis U.S. LLC, Bridgewater, NJ), which is a collagen stimulator as opposed to a filler. Poly- l -lactic acid’s effects are usually subtler than calcium hydroxylapatite (Radiesse, Merz/Bioform) and multiple treatment sessions are required to achieve a comparable effect. However, the duration of poly- l -lactic acid (Sculptra, Sanofi-Aventis U.S. LLC) is longer than most fillers, lasting up to 2 years. Another option is a hyaluronic acid filler, such as Juvederm Ultra Plus (Allergan Inc, Irvine, CA) or Perlane (Medicis, Scottsdale, AZ). We usually use hyaluronic acid fillers for more superficial injections or fine-tuning after a deeper injection has been performed. When using hyaluronic acid fillers in a deeper plane, we have found that a greater volume of product is necessary to achieve an effect comparable to a more substantial filler like calcium hydroxylapatite (Radiesse, Merz/Bioform). In general, hyaluronic acid fillers are the best choice for injecting in the subdermal plane; however, we do feel that primary correction of significant midface volume loss should not focus on the superficial layer alone. If excess hyaluronic acid is placed subdermally in the midface, it tends to give the face a doughy appearance with an unnaturally thick superficial layer.
Assess Tear Troughs and Midface as Single Unit
After injection of the midface, the tear troughs are again assessed. It is important to consider the midface and tear troughs as a single unit. To address one without consideration of the other will usually lead to a less then optimal result. The tear troughs may be significantly corrected following midface injection, particularly if the deep medial fat was injected ( Fig. 6 ). Deep midface injections tend to shift the shadow of the hollowed infraorbital rim in an upward direction, which effectively shortens the length of the lower lid and improves its appearance. If the tear troughs remain hollowed after midface injection, then they may be filled judiciously with a hyaluronic acid filler (Restylane, Medicis).
