Starting in the Middle

New products and evolving techniques have put midface filling front and center for noninvasive facial rejuvenation.
Fillers for midface rejuvenation

The middle third of the face extends from the infraorbital rim to the upper lip and includes the zygomatic arch and maxilla. Age-related volume loss in this area is influenced by genetics, general health and dentition—among other factors—resulting in sagging fat pads, deepening nasolabial folds, and a host of hollows and wrinkles. Until the turn of the 21st century the only way to correct these problems was plastic surgery, a solution available to only a few.

The introduction of hyaluronic acid (HA) fillers in 2004 allowed cosmetic practitioners to offer more affordable, if temporary, solutions to age-related changes in the face. Today, the ability to subtly correct midface volume loss with fillers is a burgeoning art, allowing millions of women and men to retain more youthful faces well into their 40s and 50s.

“Aging shows itself in our mid-20s, when we begin to lose volume in the cheeks and around the eyes,” says Rod J. Rohrich, MD, founding partner of Dallas Plastic Surgery Institute and chair of the Dallas Rhinoplasty Symposium. “HA fillers are a safe way to reverse these signs of aging and maintain a more youthful appearance.”

Early practitioners tended to use fillers as the name implies—to fill wrinkles and folds. Pioneers like Dr. Rohrich soon began experimenting with fillers as a way to reposition and restore aging facial structures.

“The hallmark defect of midface aging is volume loss in the deep malar fat pad below the zygomatic arch,” he says. “The goal of filler injections is to reshape the cheek, to lift and soften it. The outcome is all about highlights. For women, the cheeks need to be higher and wider than in their male counterparts.”

In some cases, filler techniques in the midface mimic those used in surgical procedures. “I often place fillers in the same vector as I would place a suture when performing a facelift,” says Melissa S. Doft, MD, founder of Doft Plastic Surgery in New York City and clinical assistant professor of surgery at Weill Cornell Medical College. “I place the fillers along the periosteum of the zygoma to define the cheek bone and create a lift and, more superficially, in the cheek to add volume.”

Refining Technique

With their ability to fill lines and create structure, soft tissue fillers are allowing practitioners to address multiple concerns and create highly customized treatment plans. “The approach to midface rejuvenation is more individualized now. It’s about harmonizing facial features at all ages,” says Hema Sundaram, MD, director of Sundaram Dermatology, Cosmetic & Laser Surgery Centers in Rockville, Maryland, and Fairfax, Virginia. “To achieve this, we must take into account the congenital baseline for each face—and the acquired disharmonies, which are most commonly due to the aging process, but can also be the result of injury or other external causes. Volume loss is a cardinal feature of aging. To make the best use of the new soft tissue fillers that are in the U.S. or on the horizon, cosmetic practitioners need to understand their unique scientific properties—how these properties influence their clinical behavior and how to combine and layer fillers for the most natural results.

“The new concept is to think dynamically,” she continues. “We need to move away from injecting clumps of filler down over the bone and into the deep subcutis and toward a more even dispersal that reflects the multi-level pattern of age-related volume loss.”

“The best treatment depends on the patient’s needs,” agrees Mitchel P. Goldman, MD, medical director of Cosmetic Laser Dermatology in San Diego. “Nasolabial folds respond to full face filling but often also require some direct filler placement. However, too much filler in this area can produce a ‘simian’ appearance.”

When mapping her treatment plan, Lorrie Klein, MD, founder of OC Dermatology in Laguna Niguel, California, looks for areas that are not reflecting light or those where shadows form. “This may include sunken eyes/tear trough hollowness, sagging cheeks, malar grooves (cheek diagonal linear depression), jawline sagging and malar festoons (bags in upper cheeks), as well as nasolabial fold lines,” she says.

One of Dr. Klein’s favorite techniques is to inject 1cc to 2cc of Juvéderm Voluma XC (Allergan) periosteally in 0.1cc to 0.2cc aliquots over several sites across the cheekbone. “This improves the appearance of the eyes, cheeks, nasolabial folds and the jawline in most patients,” she says. “My other favorite area for filler correction is under the eyes, where I use Restylane-L (Galderma) periosteally to correct the tear trough deformity and hide undereye bags.”

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