Midface Restoration in the Management of Lower Eyelid

Authors: Dr. Cory Yeh and Dr. Edwin F. Williams 

     Rejuvenation of the aging face has undergone significant transformation over the past 20 years. Collective understanding of the physiologic forces of aging on skin, soft tissue, and facial bony structures has permitted the development of various surgical and nonsurgical treatments to correct or limit these effects. Further, increased understanding of the importance of volume restoration in facial rejuvenation has improved the results of interventions and addressed a critical component of aging that was previously ignored.

     Although almost all aspects of facial plastic surgery have significantly evolved during this time, restoration of the aging midface has been particularly rewarding for most surgeons and patients. This article seeks to describe the importance of midface restoration, the evolution of various treatments that have been developed, a synopsis of the authors’ current approach to rejuvenation of the midface complex, and the role midface restoration in the management of the aging lower lid.

     The authors’ think that complete rejuvenation of the middle third of the face can be achieved by addressing the aged lower lid and midface complex together as a single unit. These 2 regions are geographically confluent, and benefit from comprehensive analysis and simultaneous management. Isolated surgical restoration of ptotic soft tissue and fat pads is as likely to be inadequate as volume restoration with dermal fillers alone, because most patients demonstrate combined gravitational descent and volume loss. By combining the subperiosteal midface lift with autologous lipotransfer, the authors’ aesthetic results have significantly improved, and patients have benefited from reliable, long-lasting results.

     Dermal fillers such as Restylane, Radiesse, and Sculptra have a place in midfacial rejuvenation, particularly for those patients who are unwilling to undergo a surgical procedure and who desire the potential of a limited recovery phase. Even so, in the authors’ experience autologous fat seems to provide more long-lasting results, allowing for a lower financial cost to the patient in the long term compared with sequential volume enhancement with dermal fillers on a periodic basis. In addition, the easily availability of additional fat permits the precise placement into volume-deficient areas without the concern of using a limited supply of a dermal filling agent.

     There are many possible techniques and approaches to achieve effective midfacial rejuvenation. To ignore either the gravitational descent of the soft tissue and fat pads or the loss of facial volume will lead to consistent suboptimal results. The key is to perform a thorough facial analysis and establish the degree of ptotic descent and volume loss, so that a comprehensive treatment plan may be developed. The most natural results may occur by using a balanced approach that appropriately addresses the individual contributing components of midfacial aging.

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