How does the midface change as we age?

The midface is defined as the area between two hypothetical horizontal lines on the face; one passing between the upper and lower eyelids, and the other passing between the upper and lower lips. The midface is one of the first facial areas to show signs of ageing, and patients often choose to have wrinkle treatment to alleviate this.

There are four main ways by which this part of the face is affected by ageing; decent of tissues, changes in facial skin, loss of facial fat, and loss of facial bone volume. It is important to understand how the face ages in order to determine which wrinkle treatment, or method of cheek augmentation, will best achieve a patient’s desired outcome.

Beneath the skin there is a layer of tissue called SMAS (superficial musculoaponeurotic system) that provides structural support for the muscles and skin of the midface. This layer is attached to the underlying bone by ligaments; these elongate with age and cause descent of the skin and underlying fat.

The descent of facial tissues causes many common aesthetic concerns for patients. Ageing results in a hollowed out appearance below the lower eyelids and this in turn exaggerates the appearance of protruding fat below the eyes, commonly known as ‘bags’ under the eyes. The folds of skin that run from either side of the nose to the corners of the mouth, the nasolabial folds, also become more prominent as the midfacial tissues descend.

The facial skin becomes thinner as we age and photoageing occurs. This is premature ageing of the skin, particularly that of the face, due to ultraviolet light exposure, often visible in the form of wrinkles and discolouration of the skin. The skin becomes less elastic and more amenable to wrinkle formation.

As we age there is a reduction in facial fat, leading to a hollowed out and gaunt appearance of the cheeks, temple, and around the eyes. The loss of volume is an important principle to consider when thinking about cheek augmentation. The areas of fat just below the lower eyelids have been found to maintain their fullness and may increase in size with ageing. In combination with surrounding areas of fat loss and tissue descent, this can lead to the appearance of ‘bags’ below the eyes.

Facial bones also undergo volume loss. Relevant to the midface is deflation of the cheekbones, resulting in a less full appearance, an increased hollowed out area beneath the eyes, and enhanced nasolabial folds.

Understanding the principles behind ageing of the midface empowers patients to choose, with guidance from their clinician, wrinkle treatments and methods of cheek augmentation which will best achieve their desired cosmetic outcome.