Lower Eyelid and Midfacial Rejuvenation

Abstract

Over the past two and a half decades, techniques for midfacial rejuvenation have evolved. Midfacial rejuvenation has gained significant popularity among many aesthetic surgeons, including the ophthalmic plastic surgeon. Yet rejuvenation of the midface remains a challenge for the aesthetic surgeon who seeks facial harmony. A variety of techniques and approaches are available, yet no single approach is ideal for all patients. It is clear that the age-related anatomic alterations that cause patients to seek rejuvenation vary from patient to patient, and that many patients have more than one anatomic alteration that must be addressed to rejuvenate the lower lid. The surgeon must address the individual needs of each patient for optimal results. It has also become clear that the lower eyelid and midface form a continuum that needs to be addressed in its entirety for optimal rejuvenation. To achieve this, the surgeon must understand the basic concepts important to lower eyelid and midface rejuvenation, which include an understanding of eyelid and midfacial anatomy, an understanding of aging changes of the lower eyelid and midface, and surgical approaches and nonincisional options. A full understanding of aging changes in the lower eyelid and midface is essential to successfully address midfacial rejuvenation. A harmonious facial appearance consists of a balanced relationship among all tissues of the face. With age, disturbance of this harmony among midfacial tissues occurs. The aging process of the midface encompasses the lower eyelid, malar fat pad and associated structures, melolabial fold, and lateral perioral region. Hester describes four important features of midfacial aging: (1) baring of the inferior orbital rim with creation of a hollow valley at the junction of the lower eyelid and cheek; (2) descent of the malar fat pad, with loss of malar prominence; (3) deepening of the tear trough; and (4) exaggeration of the nasolabial fold. The midface represents a crucial aesthetic unit of the face. It is bordered by structures that play major roles in the overall appearances of the face. The lower eyelid and tear trough toward the nose and the lateral canthus and crow’s feet at the superior lateral aspect frame the midface superiorly.