The arsenal of practicing surgeons is constantly updated with various tools for correcting functional and cosmetic problems in the midface. Among them: lifts of varying degrees of aggressiveness, blepharoplasty to correct the position of the lower eyelid and preserve its youthful shape, removal and reposition of fat in the lower eyelid area, various implants for the zygomatic and orbital zones, volume replenishment using autologous fat tissue and fillers available on the market. However, the surface of the skin remains a separate task - wrinkles and sagging skin require action on the surface of the skin in order to compress collagen and tighten the skin. Laser and radiofrequency devices are successfully used for this purpose. In this article, Dr. Fred Fedok, a plastic surgeon from the USA, talks about procedures for correcting the middle third of the face: the lower eyelid.
Correction of the middle third of the face: anatomy of age-related changes
When considering the mechanisms of aging of the midface, which must be taken into account when choosing procedures for correction, the doctor pays attention to three main anatomical zones:
- lower eyelids;
- connection of the lower eyelids and cheeks;
- directly to the cheeks.
The movement and structural integrity of this area are interrelated: aging causes several negative changes to occur simultaneously in the structures mentioned above.
Various dynamic factors that influence the aging of the midface include:
- decreased skin elasticity;
- stretching of the retaining ligaments in the cheeks and eye sockets, which are connected to the skeleton, muscles and the skin itself;
- involutional changes in fatty compartments, which are a consequence of the weakening of their supporting structures and direct atrophy of adipose tissue.
All these processes occur against the background of bone loss in the orbital area and structural loss of projection.
As a result of the above changes, drooping of the eyelid margin is observed, the orbicularis oculi muscle lengthens vertically, resulting in folds under the eyes, and the fat pad of the cheek moves downwards (Fig. 1).
Rice. 1. Age-related changes in the lower eyelid and middle third of the face
The nasolabial fold becomes more pronounced, but not due to its deepening, but due to the displacement of the zygomatic tubercle downward, closer to the nasolabial fold. Thus, due to the contrast, the fold visually appears more pronounced.
At the junction of the lower eyelid and cheek, a characteristic deformation appears - a double bulge of the lower eyelid and the junction of the middle part of the face (Fig. 2). This deformation is a consequence of changes in the volume of bone and soft tissue in the periorbital and zygomatic region, as well as ptosis of soft tissue.
On a young face, this anatomical area has smooth contours and is presented as a gradual transition from the contour of the lower eyelid through the orbital ridge to the cheek. With age, these structures separate from each other, and their contours become more noticeable.
The above changes are more pronounced in patients with insufficient bony projection of the orbital rim and midface, resulting in the formation of a negative vector (Fig. 2). Signs of aging in the midface appear earlier in these patients. Insufficient support of periorbital structures leads to the appearance of:
- unaesthetic appearance of the lower eyelids;
- skeletonization of the orbital ridge;
- functional eyelid retraction;
- ectropion.
Rice. 2. (Left) A characteristic double bulge is a deformation at the junction of the lower eyelid and cheek. (Right) “Negative vector” of facial anatomy. The projection of the pupil is larger than the projection of the cheek.
Conversely, in patients with good bony projection in the midface (or positive vector), the periorbital structures are less prone to downward displacement due to age-related stretching of the cheek retinaculum muscles.
Goals of correction of the angles of the lower jaw with fillers
The general perception of a person’s face lies in the details; many people focus their gaze on certain specific areas, but if they are not harmonious with the rest, then you should not count on an impressive appearance.
The angles of the lower jaw can be simply smoothed, not expressive, and this makes the face softer. For men, this can result in a lack of masculinity and decisiveness in appearance; for women, this can result in a lack of some “vampirism” and coquetry. It is believed that a pronounced lower jaw is a sign of “breed”, which can affect society’s perception of a person.
Correction of the angles of the lower jaw with fillers is often carried out not as a single manipulation, but as a component of a complex for correcting the entire oval of the face. If the defect in the contour of the lower jaw is not too large, then cosmetologists recommend using fillers with hyaluronic acid.
After their introduction, the following problems are solved:
- the jaw becomes clearly defined;
- the face acquires a correct and proportional shape;
- a protruding chin becomes less noticeable (if such a defect occurred);
- if the chin is too sunken, then it acquires the correct size (visually enlarges);
- the double chin disappears if the person is of normal weight;
- your appearance will be harmonious and attractive.
It is also very important that the procedure for introducing fillers into the corners of the lower jaw solves problems of a psycho-emotional nature - a person does not feel like a “gray mouse”, he gains confidence in his own attractiveness. A striking example of this can be famous personalities - Angelina Jolie, Tom Cruise and others.
The price of introducing 1.5 ml of filler into the corners ranges from 28,000 rubles. If you need to use a larger volume of the drug for correction, then the cost of the procedure will fluctuate within 40 thousand rubles. Considering that clinics and private cosmetologists regularly hold promotions, you can get great discounts and take advantage of reduced prices for manipulation.
They are much cheaper - around 20,000 rubles for a complete correction of the angles of the lower jaw. But you should not trust your own health and beauty to unknown persons - according to statistics, infectious, inflammatory processes and uneven distribution of the drug under the skin, allergic reactions are diagnosed precisely after the procedure is carried out in inappropriate conditions and by an inexperienced specialist.
We suggest you familiarize yourself with a lump on the leg near the ankle: hygroma
Modern methods for correcting signs of aging in the middle third of the face
Understanding of age-related anatomical changes, the popularization of new techniques and the development of new biomaterials have led to a change in the approach to midface correction. As a result, doctors are able to obtain better facial rejuvenation results compared to traditional facelift techniques. Due to the significant influence of this anatomical region on the appearance of the entire face, plastic surgeons pay special attention to rejuvenating the middle third. Modern cosmetic surgeons have a wide selection of instruments to solve a whole range of anatomical problems associated with age-related changes. These include:
- restoration of volume with fillers or autologous fat;
- blepharoplasty;
- lifting;
- correction of bone tissue.
BEAUTIFUL AND NATURAL LIPS
Belotero Lips Shape
is an injectable hyaluronic filler ideal for increasing the volume of the upper and lower lips. It improves the appearance of lips by adding shape, structure and volume.
The drug effectively copes with:
- correction of wrinkles around the mouth caused by age-related changes or the influence of negative factors (unfavorable environment, smoking, habit of chewing gum, facial expressions, and so on)!
- violations of the proportions of the upper and lower lips!
- lip asymmetry!
- a slightly pronounced curve of the upper lip!
The result of the correction lasts 6–12 months, which depends on the individual characteristics of the body and compliance with all conditions of the recovery period.
Belotero Lips Contour
— the filler is intended for lip contour correction and anti-aging therapy in the perioral area.
The drug allows in 1 procedure:
- eliminate age-related changes (flabbiness, loss of elasticity) and superficial wrinkles around the mouth!
- improving the contour of the red lip line!
- elimination of lip asymmetry!
- modeling the natural shape of the upper and lower lips!
- improving the proportion of the lip section!
The effect lasts up to 1 year. Does not cause rejection or allergic reactions, does not migrate in tissues, immediately provides the desired volume, does not require additional correction.
Volume restoration for correction of the middle third of the face
The problem of soft tissue volume reduction and skeletonization, which lead, for example, to deformation of the tear trough, is in most cases solved with the help of fat and fillers.
It is volume restoration that is the most common method of correcting the middle third of the face, especially in younger patients. Both injections of your own fat and fillers available on the market provide excellent results. But fillers are used more often because their injection procedure is non-surgical and less expensive.
Based on the patient's anatomical changes, the appropriate procedure for correcting the midface can be selected. In case of slight changes, it will be enough to just replenish the volumes:
- In patients with slight excess skin and wrinkles (without eyelid displacement), slight protrusion of fat in the lower eyelid area, mild skeletonization and downward displacement of the malar fat pad, the author injects filler along the eye ridge (Fig. 3).
- To work with patients who experience more pronounced changes with a noticeable downward displacement of the malar fat pad, a slightly different volume replenishment strategy is chosen. As in the previous case, the filler is injected along the orbital ridge, but the contour of the cheekbones itself is also changed. Here, volume replacement is performed to elevate the buccal cusp. Improving the malar contour also helps reduce the severity of the nasolabial fold. Carefully introduced filler will smooth out the skeletonization of the orbital ridge, as well as the deformation of the tear trough.
Rice. 3. (Left) before and (right) after injection of HA filler along the infraorbital margin to correct tear trough deformity and skeletonization of the orbital ridge.
HA fillers, which distribute very well and have a slight lifting effect, are ideal for injection into the orbital area: they provide volume without the need for bone support; we self-align in the tissues, which reduces the risk of lumpiness in the injection area.
In the midface and lateral cheeks, it is better to use HA with a greater lifting effect and less spreading ability to restore volume and provide structural support. Such materials are introduced deeply, above the level of the periosteum. With proper assessment of the anatomy and choice of insertion technique, this procedure is performed safely, painlessly and with minimal risk of complications.
Autologous fat can also be injected into the malar region (Fig. 4). Deep fat injection makes the procedure simple, painless and safe.
Injecting fat into the tear trough should ideally only be carried out by experienced professionals, otherwise lumps of fat will be visible through the relatively thin skin of the eyelids and can only be removed surgically.
The safety of volume replacement for correction of the middle third of the face depends on the chosen technique of drug administration and the correct assessment of anatomical changes.
The author typically injects HA fillers and the patient's fat into the midface using a blunt cannula, which reduces the risk of bruising, as well as intravascular injection.
Rice. 4. Before (left) and after (right) fat grafting to correct tear trough deformity and restore cheek volume
Beauty in questions and answers
How do you know which procedure to choose to improve your appearance?
The choice of a specific beauty method depends on a large number of factors. First of all, these are your complaints. What you don’t like about yourself is what needs to be corrected. The surgeon can suggest which techniques are suitable in a particular case. And here the choice will depend on the degree of trauma of the intervention, the duration of postoperative rehabilitation, the durability of the result and, last but not least, the price. For example, injection beautification is much easier to tolerate than plastic surgery to improve appearance and does not require special training or rehabilitation. At the same time, its result is unstable and requires constant repeated corrections, which means constant financial investments. If we compare how much surgical facial rejuvenation and filler injections cost, the difference disappears after just a few years of constant injections, and after ten years the total cost of permanent corrections will greatly outweigh the cost of the operation. Prices for some interventions, for example, endoscopic beautification, are unreasonably high, especially in Moscow, where the publicity of the service is of great importance.
What to choose - facial rejuvenation or beauty?
Again, it all depends on your complaints. There is no need to come to the surgeon with a ready-made solution - “I need a face lift” or “I want beautification.” Like any other doctor, a plastic surgeon needs to hear what exactly is bothering you. Based on your complaints, the doctor will offer you correction options, and together you will find a solution that suits you. We said above that rejuvenation and correction of facial proportions often go hand in hand, and it is likely that the elimination of age-related signs in your case will be combined with one or another option for improving your appearance.
Blepharoplasty for correction of the middle third of the face
Excess soft tissue and laxity in the area in question can be corrected through various surgical techniques:
- blepharoplasty;
- blepharoplasty with fat reduction;
- lifting (both transpalpebral and transtemporal).
Blepharoplasty should be performed in case of more pronounced signs of aging: excess skin on the eyelids, a large amount of protruding fat and displacement of the eyelid.
There are many techniques for performing blepharoplasty. According to the author, it is best to choose a transconjunctival or transcutaneous approach for the operation. The choice of approach is based on the patient's anatomy and history of blepharoplasty. The author, as a rule, performs lower blepharoplasty transconjunctivally with removal of excess tissue. According to the author, this is the best way to preserve the function of the orbicularis oculi muscle.
If it is necessary to perform a midface lift, correct eyelid retraction, ectropion, or install an implant, the author in most cases is inclined to transcutaneous blepharoplasty.
Transcutaneous incisions are typically made below the eyelid, at least 4 mm from the lash line, to preserve the pretarsal region of the orbicularis oculi muscle. The younger the patient, the closer the incision is made to the eyelash line. The medial part of the incision should be limited in order to preserve the innervation of the orbicularis oculi muscle.
Until the mid-90s, the surgical approach to rejuvenation of the periorbital area was limited to lower blepharoplasty with lifting the soft tissues of the eyelid, removing excess skin and excess orbital fat. Later, blepharoplasty for correction of the middle third of the face began to be performed with reposition of orbital fat (as a biological internal implant) onto the orbital rim.
In the case of a large amount of visually noticeable orbital fat, a certain part of it must be removed. If there is significant deformation of the tear trough, the author removes the lateral fat pad and repositions the nasal and central fat pads over the orbital rim.
How to recover quickly and correctly
To avoid complications, each patient is informed about the rules of rehabilitation. These include:
- on the first day, do not touch your face at the injection sites;
- Do not use foundation, blush or loose powder for 3 days;
- Do not wash your face for 24–48 hours, but only wipe your face with cleansing lotions;
- 7 days do not visit swimming pools, saunas and baths, do not take a hot bath;
- Avoid aggressive physical activity for 10 days.
We invite you to familiarize yourself with the benefits of hyaluronic acid for facial skin.
But immediately after correction with fillers, you can and should use cold compresses, wipe the skin with decoctions of medicinal plants (chamomile flowers, calendula, sage, thyme).
Lifting options for correcting the middle third of the face
There are different techniques for performing lifting procedures to tighten the midface. Most often, surgeons use a transtemporal endoscopic approach to perform this procedure. Some lifting correction techniques are performed together with blepharoplasty through transcutaneous or transconjunctival access. The goal of a midface lift is to correct the contour and position of the lower eyelid, as well as improve the eyelid-cheek connection and reposition the malar fat pad (Figure 5).
Rice. 5. Before (left) and after (right) transtemporal/transpalpebral lift with double convexity correction and cheek tubercle lift
Violation of proportions and loss of volume
Depending on the structure of the skull, as well as on age, a person may lack volume in some areas of the face. At the first glance at you, an experienced cosmetologist will immediately determine whether you have enough. Most often, people need to restore the volume of the chin, the cheek-zygomatic area, the volume of the temporal area and sometimes the volume of the lips - all with the help of fillers. A simple example: a lack of volume in the cheek-zygomatic area can make the face “tired” - and this is what can “age” much more than wrinkles.
