Advances in the understanding of the pathophysiology of aging and the facial anatomy has led to a paradigm shift from focusing on individual wrinkle treatment and lift procedures to a holistic paradigm that considers the entire face and its structural framework. The appearance and restoration of the midface, spanning from the orbital rim to the upper lip, is particularly critical in volumetric structural rejuvenation as this region greatly manifests the signs of aging. Recession of the bony support and descent of the fat pads create sagging of the mid face and produce prominent nasolabial creases. Superficial and deep volume loss can lead to the manifestation of wrinkles, folds, and lines, and methods aimed at restoring the lost volume in both the superficial and deep structural supportive features may provide benefit in impeding the facial aging process. Using a structural rejuvenation approach with new generation volumetric fillers, true facial restoration can be achieved resulting in natural, long lasting clinical outcomes.

Strategies for augmenting lost volume in the soft tissues require the use of new generation fillers that provide lift and volume. Thin fillers are ideal for tweaking superficial areas and lines but cannot yield the structural support of volumetric fillers. These include injectable HA fillers such as Voluma that has a higher proportion of lower molecular weight HA, and Vycross™ technology, that provides more efficient and tight cross-linking between the HA molecules within the gel, Radiesse [calcium hydroxylapatite (CaHA)], Sculptra [injectable poly-L- lactic acid (PLLA)], and Bellafill [polymethyl methacrylate (PMMA)]. Aside from restoring volume, PLLA, CaHA and PMMA have been shown to have biostimulatory properties, which means they stimulate endogenous fibroblasts to produce collagen thus improving the quality and texture of the facial skin.

The methodology we developed for volumetric structural rejuvenation of the midface is called bimodal trivector approach. The first step involves supraperiosteal injections of the volumetric filler to restore lost volume in the deep structural layers of the midface face and to provide a structural platform. The supraperiosteal placement is used to mimic the volume lost in the supportive preauricular lateral cheek, mid-cheek, and mandibular fat pads and to address musculoskeletal atrophy.

The novel technique minimizes patient discomfort through the use of three injection access points: (1) the temporal fossa to address forehead atrophy and brow ptosis, (2) the midface to treat the tear-trough, infranasal, and malar fat pad areas, and (3) the jaw line to address the mandibular angle, maxilla, and marionette lines. The amount of product may vary for the depot injections, but in general, a small face with moderate volume loss requires a 1–2-ml temple, a 2–4-ml cheek, and a 1–2-ml perioral area. The total amount of product can be divided into aliquots for the depot injections.

Once the structural platform has been reinforced using the trivector approach, areas of dermal lipoatrophy are treated via deep dermal/subcutaneous injections in the next step of the bimodal technique. The goal of these injections is full customization of the volumetric filling in accordance with individualized desired outcomes and patient preferences. The injections should be performed using a 27-gauge needle (0.5, 1.0, or 1.5 in.) at a 30–40° entry angle. The filler (0.1–0.2 ml per injection site) should be deposited at the subdermal junction, avoiding areas above hypermobile muscles. To ensure even product distribution, the injected area should be massaged after every two or three injections and at the end of treatment, and patients should be instructed to massage the injected areas for 5 min five times per day for 5 days after the procedure.

Treatment of the middle third of the face is the cornerstone of aesthetic rejuvenation. The discussed overall approach to facial aging treatment can lead to natural-appearing results, minimal downtime, a high level of patient satisfaction, increased cost effectiveness, and safety with minimal complications. A combination approach with non-invasive procedures can enhance the effect and, in many cases, may be the best solution for the aging face. Interventions that include laser resurfacing, toxins and topical products can all help to improve the appearance of this area. Thus when treating the mid face, it is important to have an integrated approach and to use multiple modalities to ensure optimal outcomes.