The Anatomic Basis of Midfacial Aging

Facial aging is a multifactorial, three-dimensional (3D) process with anatomic, biochemical, and genetic correlates. Many exogenous and endogenous factors can signifi cantly impact the perceived age of an individual. Solar exposure [ 1– 3 ] , cigarette smoking [ 1, 2, 4, 5 ] , medications [ 1 ] , alcohol use [ 1 ] , body mass index [ 2 ] , and endocrinologic status [ 1, 6, 7 ] have all been implicated as factors that accelerate cutaneous and subcutaneous aging. These factors act in concert to create a variegated spectrum of facial morphologic aging changes, and thus, Mme. Chanel was partially correct in her statement from the last century. Most of the aging changes that occur in the midface, however, occur predictably in the majority of individuals. Stigmata of midfacial aging typically appear by the middle of the fourth decade. Degenerative changes occur in nearly every anatomic component of the midface and include cranial bone remodeling, tissue descent secondary to gravity, fat atrophy, and deterioration in the condition and appearance of the skin. The lower eyelids and adjacent tissues are often the initial areas of patient concern. This chapter reviews the morphologic changes that occur in the aging midface and discusses the pathogenesis of midfacial aging based upon its anatomic components. An integrated theory of facial aging will be presented. A. E. Wulc , MD, FACS ( ) Associate Clinical Professor of Ophthalmology , University of Pennsylvania