The Magic of Mid-Face Fillers: Turning Back the Clock
Dermal fillers have revolutionized the rejuvenation of the midface, offering a minimally invasive treatment that can restore youthful volume in a subtle and natural way.
For patients who are concerned that their face looks sad, tired, or prematurely aged, strategically injected dermal fillers can dramatically refresh facial appearance in a way that neuromodulators cannot.
Aesthetic understanding concerning the process of lipoatrophy over the past decade has provided us with cutting-edge awareness that facial rejuvenation requires three-dimensional facial reshaping by restoring volume rather than filling in lines.
A youthful midface is characterized by an upside-down triangle which features high cheekbones, full cheeks and a firm jawline. When this triangle becomes inverted with age, nasolabial folds form, the cheeks appear sunken and jowls become apparent. Dermal fillers can go a long way to restoring the triangle of youth, helping to restore fullness to the cheeks and lift to the midface.
In this article, we’ll explore midface rejuvenation using dermal fillers, and reveal tips and techniques to help you achieve fantastic results for your patients.
Identifying patients who may benefit from dermal fillers in the mid-face
Midface aging is most apparent in the periorbital and mid-cheek zones, and is characterized by four anatomical elements:
- Skin sagging (ptosis) and loss of elasticity
- Weakened facial muscles with less tone
- The descent of malar fat pads
- The degeneration of bone structure
Patients presenting with any or all of these features are likely to be excellent candidates for mid-facial rejuvenation using dermal fillers, so long as the ptosis is not excessively pronounced.
Filler treatments for the mid-face must be based on a sophisticated understanding of facial anatomy, particularly sub-dermal fat, and the changes that occur through aging. Prior to treatment, the injector needs to determine:
- The anatomical causes for the patient’s aged appearance (Is it ptosis, hypotrophy or hypertrophy?)
- The locations that the filler should be injected so it addresses both the cause and the effects of the aged mid-face: for example, accentuating cheek prominence also often reduces heaviness around the jowls and smooths out the nasolabial folds.
Fillers can be injected into the superficial or deep dermal layers to restore volume or achieve projection. The result is a more youthful, refreshed look that can take decades off a patient’s appearance.
Dermal fillers for the superficial and deep layers of the midfacial region
The subcutaneous fat of the face is not a single, uniform layer, but partioned into segments that are either superficial or deep. Superficial fat compartments are located between the skin and the Superficial Muscular Aponeurotic System (SMAS) plane, while the deeper fat layers lie beneath the SMAS and adhere to the periosteal plane.
Superficial fat compartments of the midface include:
- Infraorbital fat
- Medial cheek fat
- Nasolabial fat
- Middle cheek fat
- Lateral temporal-cheek fat
- Superior jowl fat
- Inferior jowl fat
Deep fat compartments of the midface include:
- Medial sub-orbicularis oculi fat (Medial SOOF)
- Lateral sub-orbicularis oculi fat (Lateral SOOF)
- Deep medial cheek fat (DMCF)
- Buccal fat
- Superficial fat compartments
- Infraorbital fat
In the deeper layer, volume loss tends to take place in the lateral and medial sub-orbicularis regions and the deep medial cheek compartment. In the superficial layer, volume loss generally takes place in the lateral compartments and the medial and middle fat of the cheek fat pad.
Diagram sourced from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645140/
Injecting dermal fillers into the superficial layers
The aging process of superficial fat is mostly characterized by ptosis and hypertrophy. When treating patients lacking in superficial fat, the injector must be careful to avoid adding too much volume or there may be an increase in sagging. Fillers injected into the superficial layers of the midface should be able to spread easily through the connective tissue to sit smoothly and evenly in the upper layers of the skin.
Injecting dermal fillers into the deeper sub-periosteal layers
For improved longevity of results, it is essential to target the deep fat layers of the midface. Treatment of the deep subdermal layers requires a filler than provides excellent volume and projection, and doesn’t spread too easily through tissue. Fillers injected into deep fat compartments help these regions to regain lost volume, and have a subsequent effect on superficial fat compartments.
Which dermal fillers for the midface?
It is essential to understand how dermal fillers behave when injected into a particular compartment or layer of the skin. Once injected, fillers can shear, become vertically compressed or stretched from muscle movement, compression, or gravity. Practitioners need to understand how fillers behave when injected into a particular area or depth of the skin, and and choose a filler that is capable of achieving the best aesthetic result for the targeted area.
In 2015, hyaluronic acid (HA) dermal fillers represented more than 92% of all filler treatments in the U.S. In 2016, there were over 2.4 million HA dermal filler treatments performed in the US alone. For new injectors, hyaluronic acid fillers are commonly favored because of their excellent safety profile, reversibility, efficacy and ease of administration. Most HA fillers use cross-linking technology to improve durability.
The deep malar plane benefits from heavier HA gels that:
- Are highly cohesive
- Have a high elastic and viscous moduli
- Can withstand deformation and are capable of achieving maximum lift with a limited quantity of gel.
HA fillers commonly used for the midface include Juvederm Voluma, Belotero Volume and Restylane Lyft.
In addition to HA fillers for the mid-face, there are also deeper stimulatory fillers such as Radiesse, which is composed of 30% calcium hydroxylapatite microspheres, or Sculptra, which contains Poly-L-lactic acid (PLLA) to stimulate the body’s own production of collagen. These can be injected along the cheekbones and the lateral face for more enduring results.
Mid-face dermal filler injection technique
- Deeper injections
The preperiostal bolus technique is most often used for injection into the deeper mid-face fat compartments. The bolus technique is ideal for the treatment of single compartments because it ensures anatomical precision of injection without dispersal in other locations. The path of the needle through the soft tissues is as short as possible, and the number of injections needed is limited, which reduces the possibility of bleeding or bruising.
- Superficial injections
The micro cannula is most commonly used for more superficial mid-face injections. The microcannula has an atraumatic design than allows it to glide through the fat compartment in multiple directions without inflicting damage on the vessels or nerves. When inserted, the cannula slides above the SMAS plane, allowing the filler to spread evenly within the compartment. Avoid over-injecting within the superficial compartments: the proximity to the outermost layer of the skin can result in excessive volume during facial animation
The final word on mid-face dermal fillers
For patients looking for midfacial rejuvenation, dermal fillers offer a safe, minimally invasive method of rejuvenation with no downtime. Awareness of the position of the superficial and deep fat compartments in the mid-face, and the way fat loss and descent presents in the face is essential to administering dermal filler injections that provide optimal results for your patients.