Abstract
Aging of the midface has been described to involve soft tissue descent as well as volumetric change. A simplified grading system for midfacial ptosis ranging from mild to severe has recently been proposed. Midfacial ptosis results in exposure of the orbital rim and the creation of a more acute orbital rim angle, especially in conjunction with orbital fat pseudoherniation. In the authors' opinion, the best surgical approach to address severe midfacial ptosis is the transtemporal subperiosteal midface lift in combination with a fat-modifying transconjunctival lower lid blepharoplasty with skin pinch.
Highlights
Aging of the midface has been described to involve soft tissue descent as well as volumetric change
Using magnetic resonance imaging, Gosain et al showed a relative descent in cheek fat pad position in older faces (> 60 years) compared to younger ones (16-30 years) [5]
While Lambros noted the stability of lid-cheek junction and certain facial landmarks based on photographic evidence, the enlargement of the orbital aperture that occurs with aging was not addressed
Summary
Aging of the midface has been described to involve soft tissue descent as well as volumetric change [1]. Ligaments within the cheek that affix the dermis to the underlying fibro-osseous structures were described by Furnas in 1989 [3] The attenuation of these ligaments, age-related elastosis and the repeated animation of facial mimetic muscles were thought to contribute to midfacial soft tissue descent [4]. In contrast to the gravitational theory, Lambros described a volumetric theory of midfacial aging in 2007 In his analysis of 130 patients photographed 10-56 years apart, Lambros noted that the lid-cheek junction remained stable and the periorbital and upper midface skin landmarks did not descend. Lambros suggested that the changing morphology of the midface was the result of the relative deflation or atrophy of specific fat pads rather than gravitational soft tissue descent [6] This echoed Donofrio’s proposition that the periorbital, buccal, and perioral fat atrophy with aging [7]. While the involution and ptosis of the soft tissue paired with a larger orbital aperture give the appearance of a stable lid-cheek junction, a component of gravitational descent is present
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