The Mid-Face and Cheek
When we glance at a person for a first impression, our eyes first gravitate to the middle of their face. By gazing at this area from the eyelids to the upper lips, our brains decipher whether a person looks old, tired, mad, sad or youthful.
Several things contribute to middle face aging. “Gravitational descent” occurs early and often affects even younger women. In other words, the ligaments of the face that hold the facial structures to the underlying bone loosen and the fat and muscles of the face fall downward. 4
Loss of volume of the mid-face is also a factor and can exacerbate gravitational descent. So if the face loses volume, it can fall due to less of an infrastructure to hold it up. Likewise, if there is gravitational descent, the facial fat and volume can fall over the folds in the middle of the face, producing the illusion of less volume.
It is important that a patient with a drooping face work with a physician who can use all of the methods to treat the mid-face. “If you have a hammer, everything looks like a nail” is an adage that applies if a physician only has non-invasive, minimally invasive, or surgical approaches to use for the drooping mid-face. All of the options for a patient have their place and indication, and can, sometimes, even be combined to achieve a natural result.
The options for a patient to restore their youthful, natural appearance in the mid-face and cheek are many. Most of these fall into the “cheek lift” or filler category. Many of these are minimally invasive techniques, though there are some that require less invasive procedures. I’ll describe these in detail below.
Gravitational descent of the face occurs when the ligaments of the face that hold the fat pads of the face upward weaken and the “face falls”. When this happens, the fat pads often fall over the folds that run from the nose to the mouth, and these folds “deepen”. With the separation of the fat pads of the cheek, a groove or “tear trough” develops from the middle corner of the eye obliquely downward. As the fat pad drops downward on the cheek, the distance from the eye lashes to the bottom of the apparent eyelid increases.
A pioneering French plastic surgeon, Tessier, characterized the face as a “mask” held up on the facial bones by ligaments. By lifting the mask, he (and we) could reverse the downward fall and restore a “drooping” face.
Repositioning of the fat pads upward to restore them to their natural position can make a patient appear “rested” and “younger”. The cheeks do not look over-filled, and the middle face architecture can be restored to its natural position.
There are several minimally invasive ways to reposition the mid-face. I have a great experience with these methods and have innovated and worked on the development of many of the techniques in use today.
The Endotine mid-face or cheek lift is a procedure that I helped to develop in its current form.5,6 It is a variation of Tessier’s original procedure, but is made much less invasive with the Endotine device. I can install this dissolvable device with local anesthesia or twilight anesthesia. There are “tricks” to installing this device, but we achieve almost 100% favorable results. This “under the lining of the bone” cheek lift is, in my experience, the longest lasting cheek lift of the fallen “mask” of the face.
InstaLift can reposition the fat pads, cheek, and jowl (and to some degree, the neck) with dissolvable threads that are installed with local anesthesia as an office procedure. We have used this procedure for two years, and it lasts approximately 11/2 to 2 years, according to the manufacturer.
I have performed the gore-tex cheek lift as a local anesthesia procedure. This procedure usually lasts 3-8 years, and we have further refined the procedure over the last 15 years. I published this procedure and, as a result, it was carried on Good Morning America. I have seen patients from 15 years ago, and some of them still look better than at their initial procedure, though they were much younger then.
“Filling the face” is a less invasive way to camouflage the fallen cheeks. Any number of injectable fillers (juvederm, restylane, belotero, voluma, etc) are available to camouflage the tear troughs, fill in the nasolabial folds, and slightly lift the cheeks.
While the procedure is advertised as a volume replacement, the lack of volume in the cheeks is often because gravitational descent has occurred, and the cheek volume has “gone South” or downward, and the fill is replacing that volume that has fallen.
These procedures can be quite effective for many patients, but their effect is temporary. They can be overdone, and a puffer fish look can result with the subsequent “overfilling”. Satisfaction rates are high, and they can provide a result when procedures are not indicated or desired.
The “Vampire Lift” uses the patients own platelet rich plasma to stimulate collagen and fill in the fallen areas. The technique is quite effective, and seems to last for a year. It is especially useful for patients who have had reactions or lumps with filler. The Vampire lift avoids reactions and lumps.
Fat injections or micro-liporeinjections are often used to fill volume in the face and midface. We have performed these techniques since 1984, but the techniques, in the best of hands, are not totally reliable, as only 32% of patients in studies had results that lasted more than 6 months.
In our experience, longer lasting fat injection techniques require multiple injections with multiple recovery periods and bruising to achieve results that last longer than the newer fillers. We abandoned the technique under and around the eyes since we have had to correct problems of other physicians such as lumps that were not amenable to anything but surgical removal. Fat injections do contain stem cells that help to rejuvenate the skin, though products, such as DefenAge, can duplicate the skin rejuvenation with at home applications.
A variant on these techniques for mid-facial rejuvenation is “stem cell facelift”. In this technique, collagenase or rapid spinning in a centrifuge concentrates mesothelial stem cells, fibroblasts, macrophages and other cells into a “stromal vascular fraction”. An alternate technique is to derive the stromal vascular fraction from the bone marrow (a painful technique).
So far, there is no or minimal evidence that, in the face, there is any advantage of stromal vascular fraction over fat injection alone, and there are Russian experiences that, injected IV, it can cause cancers. In fact, the FDA has sued or shut down several clinics for fraudulent claims and harm to patients. While we have the equipment and techniques, we have, so far taken a “wait and see” on these techniques. Stromal vascular fraction has, however, gained traction in Orthopedics.
Scultptra, similar to fat injections, is a filler that stimulates collagen in growth, and can last up to three years. It does need to be injected three times to achieve lasting results, and there is a recovery period from bruising and swelling. “Sculptomas”, or lumps from Sculptra can be difficult to eradicate.
Finally, a more permanent solution to facial volume loss is cheek implants. We have performed these surgeries for many years, but feel that they are mainly indicated for patients with thin, narrow faces, or patients who desire the look of a more refined cheek. Patients with facial asymmetries may also benefit. These implants are tolerated well, and patients who have had them installed for 20-30 years are without problems.
Peterson MF, Eckstein MP.. Looking just below the eyes is optimal across face recognition tasks. P Natl Acad Sci USA. 2012;109:E3314-E23
Barton JJ Radcliffe N, et al. Information processing during face recognition: the effects of familiarity, inversion, and morphing on scanning fixations. Perception. 2006;35:1089-105.
Henderson JM, Williams CC, Flk RJ. Eye movements are functional during face learning. Mem Cognit. 2005;33:98-106.
Furnas DW. The retaining ligaments of the cheek. Plast Reconst Surg 1989;83:11-16. (one of the original articles; many since)
Heffelfinger R, et al, Keller G (senior author); A simplified approach to mid-face aging. Arch Facial Plast Surg (AMA publication). 2007;9:48-55.