Midface Descent and Malar Support

The Clinical Problem ( Fig. 8.1 )

Rejuvenation of the midface was formerly limited to a lower lid blepharoplasty in conjunction with some form of a face lift. Neither adequately addresses the nasojugal groove (also referred to as the tear trough) or the nasolabial fold. Furthermore, a traditional lower lid blepharoplasty would frequently include resection of herniated lower lid fat, which in turn could produce a gaunt, deflated lower lid that does not appear youthful.

Recently, more attention has been given to restoring a youthful look to the midface by volumizing the face and avoiding resection of lower lid fat as we have recognized the loss of periorbital fat as part of the aging process.

The Aesthetic Problem

Our patients present complaining of “looking tired,” “bags under my eyes,” or “dark circles under my eyes.” What they are describing in popular terms are the classic aging changes that are manifest in the lower lids and middle third of the face. These include the following:

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  Loss of skin laxity, leading to excess lower eyelid skin and fine wrinkles

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  Midface descent and ptosis of the malar soft tissues

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  The appearance of two aesthetic units—that is, the lower lid and cheek are demarcated by the tear trough, where there was only one in the person's younger years

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  Increase in the vertical dimension of the lower lid—lid margin to tear trough distance

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  Fat herniation

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  In its most severe form:

  • Lateral canthal dystopia

  • Scleral show

  • Poor lower lid tone, ectropion