TThe mid-third of the face spans the infra-orbital rim to the upper lip. Anatomically, the most significant feature of this region is the scaffolding of the zygomatic arch and maxilla as well as the infra-orbital fat pads. Recession of the bony support and descent of the fat pads create sagging of the mid face and produce prominent nasolabial creases. Volume loss in this region is a significant hallmark of the aging face; restoration of volume will help to improve the appearance of the area. Photodamage also creates problems for the mid face, but treatments to alleviate this can help rejuvenate this zone.
Bone loss and recession are significant contributors to mid-facial aging. There are many other contributing factors, including skin type (darker skin will tend to have better bone structure and less bone loss), treatments for osteoporosis, genetics and dental hygiene. Volume loss depends on genetics, disease, ideal body weight, dietary factors and a host of other considerations. Regardless of the cause, both of these deficits can now be treated with a series of injections, and the materials used will likely to continue to improve over the next few years.
Injecting to Lift the Mid Face
Injections into the zygomatic arch have long been used to lift the face. When these injections are properly placed and injected in a supero-lateral vector, they can lift the face up and out. When improperly placed, they increase the forward projection of the face and make the person look like a monkey. Thus, placement, lifting capability and quantity of product are critical components of injections at this location.
Products used to lift the mid face should have lifting capability. Perlane, Radiesse and several products available in Canada and Europe, including Voluma, have the physical qualities needed to lift the face. Injecting thin products will not lift because they will simply deform under the load imparted by facial structures.
Experienced injectors will inject products in a deep plane, including just above the periosteum. Injections of thick products into the superficial or mid dermis should be avoided because they will result in lumps and bumps. If the product injected is opaque, such as Radiesse, and it is placed superficially, it will produce visible white bumps that are problematic. In general, for mild to moderate mid face descent, injections of 2 mL to 3 mL of filler into this area can produce significant improvement. When injecting this area in patients who have never been injected in this location, correct gradually to ensure patient satisfaction. If you have access to 3D photography, it is worth taking photos before and after to show the changes that these injections can produce. Patients are frequently amazed by the improvements of the nasolabial crease achieved with zygomatic injections.
As previously mentioned, care should be taken to avoid injections into the anterior of the cheeks. Overzealous injections into the anterior cheeks will push the lower eyelid superior and produce proportions that are not anatomically correct.
Although injections of the zygomatic area will help improve the appearance of the nasolabial crease, they are not always sufficient enough to correct these lines. Injections of hyaluronic acid and calcium hydroxylapatite (CAHA) can be used to fill this area. Depending on the skin’s thickness and the wrinkle’s depth, a host of products may be utilized.
For thin-skinned patients with superficial lines, I tend to use Restylane and Juvederm. Thicker skin or moderate lines are best treated with Restylane, Perlane or Juvederm Ultra Plus. Deep lines may be treated with either thick hyaluronic acid or CAHA depending on the patient and the experience of the physician. One other technique that can be helpful in this area is to reconstitute the fillers with saline or lidocaine and decrease the viscosity. These reconstituted products may be used to etch out small, superficial lines.
Restoring Volume Loss
Poly-L-lactic acid (PLLA, Sculptra) has been approved for the treatment of volume loss for many years. It is wonderful for restoring volume to the mid face. The ideal regimen for this area remains to be elucidated, but, in general, I prefer to use three bottles of material and a 9 mL dilution. Clinical trials to verify this are needed.
Many patients in their mid 50s and older have volume loss that will create mid facial deficits. Whereas injections of filler can lift the face and reduce the appearance of discrete lines, they are not great for volume restoration. In my practice, I utilize PLLA in an increasing number of patients to replace volume. Patients tend to be very pleased when they see their youthful proportions return and their cheeks reinflate. In addition to the volume correction induced by PLLA, there is an improvement in skin tone and texture that patients also appreciate.
Resurfacing Techniques to Improve Photodamage
Correcting volume deficits and etching out lines are important, but fixing these and leaving a photodamaged surface will not produce optimal outcomes. Resurfacing the mid face will produce significant improvements in overall appearance and should be part of any comprehensive treatment of this area. Included in this resurfacing is some post-treatment regimen to maintain or enhance the outcomes.
Fractional non-ablative resurfacing and fractional ablative resurfacing are exceptionally good for improving the surface of the skin. Chemical peels including TCA, salicylic acid and many others can also help but will not deliver the results with the same degree of precision afforded by a laser. I recommend incorporating one of these for most patients who are seeking improvement in the mid face. Treatment of the dyspigmentation associated with photodamage should include intense pulsed light and/or photodynamic therapy depending on the patient’s degree of damage and tolerance for down time.
Topical products are essential in treatment of the mid face. Tretinoin is the easiest product to recommend and it should be included in almost every patient’s skin care regime. Vitamin C, glycolic acid, hyaluronic acid and retinol are also important ingredients to look for. Whatever regimen that you decide to use, become familiar with it and try to monitor your patients’ progress to make sure they are happy with their appearance.
An Integrated Approach
Treatment of the middle third of the face is the cornerstone of aesthetic rejuvenation. Interventions that include resurfacing, fillers, volumizers and topical products can all help to improve the appearance of this area. If you are new to treating this area, proceed cautiously and use products that are reversible. If you have experience in treating this area, try to expand your horizons. Whatever the case, when treating the mid face, it is important to have an integrated approach and to use multiple modalities to ensure optimal outcomes.
Dr. Beer is in private practice in West Palm Beach, FL. He is also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University and Director of the Cosmetic Bootcamp meeting.
Disclosure: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for Medicis, 3M, Sanofi Aventis, Bioform Medical, Allergan and Stiefel. He is also a Director of the Cosmetic Bootcamp meeting.
TThe mid-third of the face spans the infra-orbital rim to the upper lip. Anatomically, the most significant feature of this region is the scaffolding of the zygomatic arch and maxilla as well as the infra-orbital fat pads. Recession of the bony support and descent of the fat pads create sagging of the mid face and produce prominent nasolabial creases. Volume loss in this region is a significant hallmark of the aging face; restoration of volume will help to improve the appearance of the area. Photodamage also creates problems for the mid face, but treatments to alleviate this can help rejuvenate this zone.
Bone loss and recession are significant contributors to mid-facial aging. There are many other contributing factors, including skin type (darker skin will tend to have better bone structure and less bone loss), treatments for osteoporosis, genetics and dental hygiene. Volume loss depends on genetics, disease, ideal body weight, dietary factors and a host of other considerations. Regardless of the cause, both of these deficits can now be treated with a series of injections, and the materials used will likely to continue to improve over the next few years.
Injecting to Lift the Mid Face
Injections into the zygomatic arch have long been used to lift the face. When these injections are properly placed and injected in a supero-lateral vector, they can lift the face up and out. When improperly placed, they increase the forward projection of the face and make the person look like a monkey. Thus, placement, lifting capability and quantity of product are critical components of injections at this location.
Products used to lift the mid face should have lifting capability. Perlane, Radiesse and several products available in Canada and Europe, including Voluma, have the physical qualities needed to lift the face. Injecting thin products will not lift because they will simply deform under the load imparted by facial structures.
Experienced injectors will inject products in a deep plane, including just above the periosteum. Injections of thick products into the superficial or mid dermis should be avoided because they will result in lumps and bumps. If the product injected is opaque, such as Radiesse, and it is placed superficially, it will produce visible white bumps that are problematic. In general, for mild to moderate mid face descent, injections of 2 mL to 3 mL of filler into this area can produce significant improvement. When injecting this area in patients who have never been injected in this location, correct gradually to ensure patient satisfaction. If you have access to 3D photography, it is worth taking photos before and after to show the changes that these injections can produce. Patients are frequently amazed by the improvements of the nasolabial crease achieved with zygomatic injections.
As previously mentioned, care should be taken to avoid injections into the anterior of the cheeks. Overzealous injections into the anterior cheeks will push the lower eyelid superior and produce proportions that are not anatomically correct.
Although injections of the zygomatic area will help improve the appearance of the nasolabial crease, they are not always sufficient enough to correct these lines. Injections of hyaluronic acid and calcium hydroxylapatite (CAHA) can be used to fill this area. Depending on the skin’s thickness and the wrinkle’s depth, a host of products may be utilized.
For thin-skinned patients with superficial lines, I tend to use Restylane and Juvederm. Thicker skin or moderate lines are best treated with Restylane, Perlane or Juvederm Ultra Plus. Deep lines may be treated with either thick hyaluronic acid or CAHA depending on the patient and the experience of the physician. One other technique that can be helpful in this area is to reconstitute the fillers with saline or lidocaine and decrease the viscosity. These reconstituted products may be used to etch out small, superficial lines.
Restoring Volume Loss
Poly-L-lactic acid (PLLA, Sculptra) has been approved for the treatment of volume loss for many years. It is wonderful for restoring volume to the mid face. The ideal regimen for this area remains to be elucidated, but, in general, I prefer to use three bottles of material and a 9 mL dilution. Clinical trials to verify this are needed.
Many patients in their mid 50s and older have volume loss that will create mid facial deficits. Whereas injections of filler can lift the face and reduce the appearance of discrete lines, they are not great for volume restoration. In my practice, I utilize PLLA in an increasing number of patients to replace volume. Patients tend to be very pleased when they see their youthful proportions return and their cheeks reinflate. In addition to the volume correction induced by PLLA, there is an improvement in skin tone and texture that patients also appreciate.
Resurfacing Techniques to Improve Photodamage
Correcting volume deficits and etching out lines are important, but fixing these and leaving a photodamaged surface will not produce optimal outcomes. Resurfacing the mid face will produce significant improvements in overall appearance and should be part of any comprehensive treatment of this area. Included in this resurfacing is some post-treatment regimen to maintain or enhance the outcomes.
Fractional non-ablative resurfacing and fractional ablative resurfacing are exceptionally good for improving the surface of the skin. Chemical peels including TCA, salicylic acid and many others can also help but will not deliver the results with the same degree of precision afforded by a laser. I recommend incorporating one of these for most patients who are seeking improvement in the mid face. Treatment of the dyspigmentation associated with photodamage should include intense pulsed light and/or photodynamic therapy depending on the patient’s degree of damage and tolerance for down time.
Topical products are essential in treatment of the mid face. Tretinoin is the easiest product to recommend and it should be included in almost every patient’s skin care regime. Vitamin C, glycolic acid, hyaluronic acid and retinol are also important ingredients to look for. Whatever regimen that you decide to use, become familiar with it and try to monitor your patients’ progress to make sure they are happy with their appearance.
An Integrated Approach
Treatment of the middle third of the face is the cornerstone of aesthetic rejuvenation. Interventions that include resurfacing, fillers, volumizers and topical products can all help to improve the appearance of this area. If you are new to treating this area, proceed cautiously and use products that are reversible. If you have experience in treating this area, try to expand your horizons. Whatever the case, when treating the mid face, it is important to have an integrated approach and to use multiple modalities to ensure optimal outcomes.
Dr. Beer is in private practice in West Palm Beach, FL. He is also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University and Director of the Cosmetic Bootcamp meeting.
Disclosure: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for Medicis, 3M, Sanofi Aventis, Bioform Medical, Allergan and Stiefel. He is also a Director of the Cosmetic Bootcamp meeting.
TThe mid-third of the face spans the infra-orbital rim to the upper lip. Anatomically, the most significant feature of this region is the scaffolding of the zygomatic arch and maxilla as well as the infra-orbital fat pads. Recession of the bony support and descent of the fat pads create sagging of the mid face and produce prominent nasolabial creases. Volume loss in this region is a significant hallmark of the aging face; restoration of volume will help to improve the appearance of the area. Photodamage also creates problems for the mid face, but treatments to alleviate this can help rejuvenate this zone.
Bone loss and recession are significant contributors to mid-facial aging. There are many other contributing factors, including skin type (darker skin will tend to have better bone structure and less bone loss), treatments for osteoporosis, genetics and dental hygiene. Volume loss depends on genetics, disease, ideal body weight, dietary factors and a host of other considerations. Regardless of the cause, both of these deficits can now be treated with a series of injections, and the materials used will likely to continue to improve over the next few years.
Injecting to Lift the Mid Face
Injections into the zygomatic arch have long been used to lift the face. When these injections are properly placed and injected in a supero-lateral vector, they can lift the face up and out. When improperly placed, they increase the forward projection of the face and make the person look like a monkey. Thus, placement, lifting capability and quantity of product are critical components of injections at this location.
Products used to lift the mid face should have lifting capability. Perlane, Radiesse and several products available in Canada and Europe, including Voluma, have the physical qualities needed to lift the face. Injecting thin products will not lift because they will simply deform under the load imparted by facial structures.
Experienced injectors will inject products in a deep plane, including just above the periosteum. Injections of thick products into the superficial or mid dermis should be avoided because they will result in lumps and bumps. If the product injected is opaque, such as Radiesse, and it is placed superficially, it will produce visible white bumps that are problematic. In general, for mild to moderate mid face descent, injections of 2 mL to 3 mL of filler into this area can produce significant improvement. When injecting this area in patients who have never been injected in this location, correct gradually to ensure patient satisfaction. If you have access to 3D photography, it is worth taking photos before and after to show the changes that these injections can produce. Patients are frequently amazed by the improvements of the nasolabial crease achieved with zygomatic injections.
As previously mentioned, care should be taken to avoid injections into the anterior of the cheeks. Overzealous injections into the anterior cheeks will push the lower eyelid superior and produce proportions that are not anatomically correct.
Although injections of the zygomatic area will help improve the appearance of the nasolabial crease, they are not always sufficient enough to correct these lines. Injections of hyaluronic acid and calcium hydroxylapatite (CAHA) can be used to fill this area. Depending on the skin’s thickness and the wrinkle’s depth, a host of products may be utilized.
For thin-skinned patients with superficial lines, I tend to use Restylane and Juvederm. Thicker skin or moderate lines are best treated with Restylane, Perlane or Juvederm Ultra Plus. Deep lines may be treated with either thick hyaluronic acid or CAHA depending on the patient and the experience of the physician. One other technique that can be helpful in this area is to reconstitute the fillers with saline or lidocaine and decrease the viscosity. These reconstituted products may be used to etch out small, superficial lines.
Restoring Volume Loss
Poly-L-lactic acid (PLLA, Sculptra) has been approved for the treatment of volume loss for many years. It is wonderful for restoring volume to the mid face. The ideal regimen for this area remains to be elucidated, but, in general, I prefer to use three bottles of material and a 9 mL dilution. Clinical trials to verify this are needed.
Many patients in their mid 50s and older have volume loss that will create mid facial deficits. Whereas injections of filler can lift the face and reduce the appearance of discrete lines, they are not great for volume restoration. In my practice, I utilize PLLA in an increasing number of patients to replace volume. Patients tend to be very pleased when they see their youthful proportions return and their cheeks reinflate. In addition to the volume correction induced by PLLA, there is an improvement in skin tone and texture that patients also appreciate.
Resurfacing Techniques to Improve Photodamage
Correcting volume deficits and etching out lines are important, but fixing these and leaving a photodamaged surface will not produce optimal outcomes. Resurfacing the mid face will produce significant improvements in overall appearance and should be part of any comprehensive treatment of this area. Included in this resurfacing is some post-treatment regimen to maintain or enhance the outcomes.
Fractional non-ablative resurfacing and fractional ablative resurfacing are exceptionally good for improving the surface of the skin. Chemical peels including TCA, salicylic acid and many others can also help but will not deliver the results with the same degree of precision afforded by a laser. I recommend incorporating one of these for most patients who are seeking improvement in the mid face. Treatment of the dyspigmentation associated with photodamage should include intense pulsed light and/or photodynamic therapy depending on the patient’s degree of damage and tolerance for down time.
Topical products are essential in treatment of the mid face. Tretinoin is the easiest product to recommend and it should be included in almost every patient’s skin care regime. Vitamin C, glycolic acid, hyaluronic acid and retinol are also important ingredients to look for. Whatever regimen that you decide to use, become familiar with it and try to monitor your patients’ progress to make sure they are happy with their appearance.
An Integrated Approach
Treatment of the middle third of the face is the cornerstone of aesthetic rejuvenation. Interventions that include resurfacing, fillers, volumizers and topical products can all help to improve the appearance of this area. If you are new to treating this area, proceed cautiously and use products that are reversible. If you have experience in treating this area, try to expand your horizons. Whatever the case, when treating the mid face, it is important to have an integrated approach and to use multiple modalities to ensure optimal outcomes.
Dr. Beer is in private practice in West Palm Beach, FL. He is also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University and Director of the Cosmetic Bootcamp meeting.
Disclosure: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for Medicis, 3M, Sanofi Aventis, Bioform Medical, Allergan and Stiefel. He is also a Director of the Cosmetic Bootcamp meeting.
