Facial Aging: A Quantitative Analysis of Midface Volume Changes over 11 Years

I read with great interest Boehm et al.’s study entitled “Facial Aging: A Quantitative Analysis of Midface Volume Changes over 11 Years.”1 Anatomical studies have identified separate superficial and deep facial fat compartments, leading some to theorize that volume loss from the deep midface causes overlying superficial fat pseudoptosis. Unfortunately, there is a paucity of evidence regarding whether the facial fat volume is truly lost with age and, if so, whether it is lost equally or differentially from the superficial and deep compartments. Boehm et al. performed a longitudinal analysis of midfacial fat volume over a mean period of 11.3 years and provided clear evidence supporting the volume-loss theory of midfacial aging—specifically, the pseudoptosis theory, in which a preferential loss of deep volume reduces midface projection, creating a “ptosis” of overlying superficial fat and a deepening of the nasolabial fold.2 However, certain issues are highlighted. First, the region of interest was divided into thirds, based on anatomical landmarks, to evaluate volume changes in the cranial, middle, and caudal thirds of the midface. However, specific anatomical landmarks have not been clarified. In addition, the results showed that subjects lost significant volume from all thirds at approximately equal rates. Aging leads to inferior migration of the midfacial fat compartments and an inferior volume shift within the compartments.3 However, all computed tomographic imaging in this study was performed with the patient in the supine position, which may not accurately evaluate the vertical descent of midface fat. Second, there is no explicit anatomical definition of the buccal fat pad’s position in this study. The results showed that the buccal fat maintains its volume with age, and its relative contribution to the total volume of the midface increases, which may explain the increasing fullness in the lower half of the face with age. However, deflation of the buccal extension of the buccal fat exists with aging, which aggravates the midfacial fat compartment’s inferior migration.3 This may be explained by the fact that the study interval of 11.3 years was too short to capture a significant change in midfacial fat. Third, previous studies have proven that the midfacial and paranasal fat is arranged in two independent anatomical layers each.3 In this study, superficial and deep fat in the midface was defined according to the superficial musculoaponeurotic system and the plane of the zygomaticus major muscle. Volume calculations were performed for total midface, superficial and deep fat only, and superficial fat only. However, the specific boundary between the superficial and deep fat in the midface was not explicit in either the cross-sectional image or the three-dimensional volume rendering. More detailed information concerning the calculation process of each region would be helpful to better understand the method. Boehm et al.’s efforts have clarified the important aspects of this topic and hence contribute significantly to the literature on midface volume changes. DISCLOSURE The author has no conflicts of interest regarding the publication of this communication. No funding was received for this work. Jing Liu, M.D.Department of Cleft Lip and PalatePlastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing, People’s Republic of China