Some Anatomical Observations on Midface Aging and Long-Term Results of Surgical Treatment

Division of Plastic Surgery, University of California, San Francisco, USA.
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 02/2008; 121(1):258-68. DOI: 10.1097/
Source: PubMed


Controversy exists as to whether the changes of midface aging (elongation of the lower eyelid caused by infraorbital hollowing, flattening of the malar eminence, and increased prominence of the nasolabial fold) are attributable to gravitational migration of the check fat or to fat atrophy.
The anatomical explanation of the gravitational migration of the malar fat pad is based on previously reported magnetic resonance imaging studies of the midface cheek fat in young and older subjects and histologic studies of the superficial fascia in face-lift patients.
Clinical and laboratory observation of the midface malar fat pad suggests that, during repeated movements of animation, levator muscle contraction and shortening produces tissue expansion pressures within the overlying cheek fat pad that cause the acutely prominent nasolabial fold of animation.
Over time, chronic recurrent tissue expansion of the skin of the lower anterior cheek combined with stretching of the supporting intrafat pad fascial septa results in downward migration of the malar fat pad, causing infraorbital flattening and permanent prominence of the nasolabial fold. Although not the primary cause of facial aging changes, fat atrophy may contribute secondarily in those individuals whose faces become thinner as they age.

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    • "In the aging face, deflation of the deep periorbital fat forms a relative concavity between the thin medial eyelid skin and thicker cheek skin, creating a nasojugal groove or tear-trough deformity.32 The smooth blend between the medial SOOF and the superior edge of the malar fat pad is lost, leading to a harsh transition between the lid-cheek junction.14 Understanding this mechanism, deep augmentation of the medial SOOF or DMC just superficial to the underlying periosteum has been shown to improve the tear-trough deformity.17,32,33 "
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    ABSTRACT: The recent identification of the facial fat compartments has greatly affected our understanding of midfacial aging. This article chronicles the discovery of these fat compartments including the shift of attention from a purely gravitational to a volumetric approach to facial aging and the series of methodologies attempted to ultimately define the anatomy of these compartments. The revived interest in volumetric facial rejuvenation including compartment-guided augmentation techniques is discussed. Lastly, the article discusses interesting distributional patterns noted in these fat compartments likely related to the different mechanical and biologic environments of the deep and superficial facial fat pads.
    Full-text · Article · Dec 2013
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    • "As the malar fat pad is compact and very adherent to the skin [21], it moves together with the skin and has a natural tendency to droop with it because of the distension of the orbicularis retaining ligament with aging [1, 2]. The characteristics of typical midface aging are sagging of the malar fat pads [23], formation of the malar bags [21], relaxation of the periorbital skin, and the external canthus. This 80-year-old subject (Fig. 8a) has however the malar fat well in place, no malar bag, and no relaxing of the periorbital skin. "
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    ABSTRACT: The malaris muscle is a superficial and fine facial muscle. It is not well known because of its inconsistency in Caucasians. It could play a role in midface aging prevention as that observed in subjects with prominent cheekbones like Asian people. The purpose of this study was to explain how the malaris muscle is able to produce an anti-aging effect on the midface. We first analysed a hundred pictures of human faces of different age sex and race to better comprehend identifying characteristics of aging in particular of the midface. Then anatomical dissections were done on fresh cadavers to identify the malaris muscle associated with radiological studies. Finally, in vivo experiments with botulinum toxin A (Botox) and lidocaine (Xylocaine) permitted to precise the action of the malaris muscle on the midface and principally on the malar fad pad. These anatomical and functional studies demonstrated that the malaris muscle acts as a dynamic link between the Superficial Muscular Aponeurotic System (SMAS) of the upper part of the face and the SMAS of the midface, producing a lifting effect of the soft tissues of the cheek particularly the malar fat pad. This action is the due to presence of the dermal terminations of the malaris muscle. The malaris muscle could be an anti-aging link of the midface. Our findings suggest a new approach for the comprehension of the global facial aging.
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    ABSTRACT: Treatment of the aging midface is an underappreciated element of overall facial rejuvenation. The anatomy of the midface and the pathophysiology of midface aging both remain somewhat controversial. The quest for ideal long-lasting midfacial rejuvenation continues. The purpose of this paper is to outline the latest progress in the field of midface rejuvenation. The complexity of midface anatomy has sparked many new investigations. Minimally invasive techniques such as threadlifts have shown promise but require further study. Volume augmentation with autologous fat and fillers is an important aspect of midface rejuvenation. Nonablative therapies offer an attractive concept, but the ideal modality still does not exist. Enthusiasm for cheek implants seems to be decreasing in favor of soft-tissue-based treatments. Open surgical treatment via suspension techniques continues to be an important option for surgeons when rejuvenating the aging midface. Cadaver dissection and clinical observation have recently been used to further define the complex anatomy of the aging midface. New developments in both minimally invasive and open surgical procedures continue to both advance and redefine the field.
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