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Mid-facial rejuvenation 14 September 2015 Advancements in our understanding of the anatomy and the pathophysiology of ageing, as well as an increased aesthetic awareness of the three-dimensional changes in the curves and contours of the lower eyelids and the tissues of the cheek beneath them, have led to the development of multiple techniques to rejuvenate this area, writes Dr Gabriel Doucas. The concept of addressing the ageing midface in aesthetic surgery is less than three decades old. It is imperative to comprehend midface ptosis (descent) and volume loss in the overall morphology of facial ageing. The  specialist plastic surgeon or aesthetic physician, who believes midfacial concerns can be addressed only by facelift surgical  options, or through volumisation techniques of the nasolabial fold, the tear trough and cheek must be very careful of the  multifactorial processes at work. These changes are often the first ones that bring patients into the aesthetic surgeon’s office,  and a complete understanding of all the options open for correction in this region is a necessity for any practicing aesthetic  surgeon. Anatomy and ageing A sound working knowledge of the bones, muscles, innervation, vasculature, retaining ligaments, fat depots and skin of the face is the cornerstone to precise, reproducible and aesthetically-pleasing rejuvenation results. Anatomically, the midface is bordered superiorly by a horizontal line drawn from the medial to the lateral canthus and inferiorly  by a line drawn from the inferior border of the tragal cartilage to the lateral edge of the oral commisure. It can be divided into  anterior and lateral components by a line drawn from the lateral orbital rim to the lateral oral commisure. The midcheek refers  to the triangular area of the anterior midface between the lower eyelid and nasolabial fold. Supero-medially, the cheek abuts  the nose. The lateral border of the midcheek is the point where it extends over the zygomatic arch.  Facial ageing is a multifactorial, three-dimensional process with anatomic, biochemical and genetic influences. Many exogenous (solar exposure, smoking, alcohol, medications, gravity) and endogenous factors (body mass index, genetics, endocrine status)  can significantly impact cutaneous and subcutaneous ageing. The contour of the midface changes over time – starting as early as the middle of the fourth decade of life. In youth: the midface is full, uniform and plump. The malar prominence is triangular in shape, with the apex at the junction of  the maxilla and zygomatic bones – conveying a heart-shaped appearance. With ageing: degenerative changes occur in nearly every anatomic component of the midface and include cranial bone  remodeling, tissue descent, fat atrophy and deterioration in the condition and appearance of the skin. The midface deflates,  leading to a double convexity of the cheek. Treatment solutions As with most cosmetic concerns, the options available for the improvement and even correction of the midfacial ageing battle  can be divided into surgical and non-surgical solutions. Each treatment option carries advantages and disadvantages. The midface is an area of relative controversy. Many of the procedures that have been innovated over the past 20 years are  complex and are associated with steep learning curves with serious, and often, difficult to manage complications. Some  surgeons are skeptical of the longevity of the procedures designed to correct changes in this area. Additionally, it was noted  that after surgery the patient’s face looked tighter, but not necessarily younger. Surgical Trans-eyelid composite and subperiosteal approaches are designed to achieve the correct vertical vector of pull that achieves  the best aesthetic rejuvenation results. These interventions require skill, expertise, experience and a well-educated patient  willing to endure the inevitable downtime associated with them.   Of great importance has been the realisation of volume loss in ageing and volume replacement in cosmetic surgery. As a result,  it has become evident that by making small corrections to the midface, big changes are realised in the final result. Synergy  results in the situation when the total is greater than the sum of the parts; this phenomenon is common with simple midfacial  augmentation.  Midface augmentation  The main advantage of implants is that they are a permanent option when compared with fillers and lifting procedures. The  cheek midface implants lie in the subperiosteal plane, tight to the bone, and are not subject to the soft tissue changes of the  more superficial planes. They are available in a vast array of anatomical sizes and shapes to customise augmentation. They are  easily placed; the recovery is minimal, and the complication rate is low. They can be performed as an individual procedure or  part of other facial or non-facial aesthetic interventions. The silicone structure (Silastic versus tissue integrated options) renders them very biocompatible and they are not subject to degradation seen with fillers and fat grafts. Very importantly, they are  reversible. Finally, with computer-assisted design/computer-assisted manufacturing technology, customised facial implants can be  fabricated to personalise the augmentation as well as to correct defects and asymmetries. Fat transfer – autologous fat injection of the midface is a viable and lasting remedy for midface soft tissue loss and has become  a mainstay in facial rejuvenation. This serves as either a stand-alone technique or as an adjunct to other restorative lifting and  repositioning techniques depending on patient needs. Although the use of fat grafting carries the inherent concern for  resorption and a need for additional augmentation in the future, correct technique and patient education can assist in better  and more reliable graft take. It is considered a fairly safe, easy and quick solution to midface ageing. Non-surgical Injectable synthetic fillers are further subdivided into permanent and temporary fillers. It is strongly advised to steer away from  the permanent products due to the potential for early and late complications that can have devastating consequences. These soft tissue fillers are injected into the skin and/or subcutaneous tissues to help fill in facial wrinkles, restoring a smoother appearance and more youthful contours. The effect lasts for about six months or longer but for more successful results, it is  important to have healthy skin, a skillful doctor administering the product, and, of course, the right type of filler. Barbed sutures were initially promising and approved by the FDA for mid-face procedures but are no longer available for  midface lifting. Silhouette Sutures (Silhouette Lift, Corona, California) may reverse this and provide long-term success. Polylactic Acid (PLA) is  the principal component of these, and, it is biocompatible with human beings – also completely biodegradable. Once the suture  has been applied, the PLA acts on the deeper layers of the skin and helps increase the volume of saggy areas, restoring  shapeliness to the face, gradually and naturally. We await long-term studies of patients treated with these devices and more  clinical experience needs to be published. Botulinum Toxin Type A (neurotoxin) is used to temporarily lessen the appearance of facial wrinkles, and, in this area the ones  around the eyes – ‘crow’s feet’ lines. Dermaceuticals – skincare products may not give volume but they can definitely offer skin rejuvenation that goes hand in hand  with midface and overall facial rejuvenation. They contain antioxidants and other plant-based or natural treatments (alpha-  hydroxy acid, salicylic acid and hyaluronic acid) that can counter free radicals that damage skin cell DNA. Conclusion It is often said that if a problem has more than one technique or solution, that no one procedure works definitively. Despite the  variety of techniques described, we do not feel this way about midfacial rejuvenation. Success in this area of the face can be  attained with many different techniques combined or on their own.  There will no doubt be many other techniques, procedures, implantables, and devices in the future that will come and try to  establish their dominance in midfacial rejuvenation. It is therefore imperative that we continue our careful scrutiny and  cautious application of these for the safety of our patients. Dr Gabriel Doucas MBChB (UFS), FC Plastic Surgery (SA) is a plastic and reconstructive surgeon based at Netcare Linksfield Hospital in Johannesburg. His areas of focus are cosmetic surgery, non-surgical aesthetics, skin lesion surgery, head & neck reconstruction and lipodystrophy-related surgery. He is a co-founder of Pure Aesthetics and a full member of APRSSA.
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