Anatomic predictors of unsatisfactory outcomes in surgical rejuvenation of the midface.

[OBJECTIVE] To aid the aesthetic surgeon in midface analysis and selection of treatment plans offering the greatest likelihood of success in midface rejuvenation.

[METHODS] We performed a retrospective review of all patients who underwent surgical midface rejuvenation by a single surgeon. We recorded demographics, history, procedures, outcomes, and complications. Results of physical examination and photography were used to classify patients by volume loss, midface ptosis, skin elasticity, and skeletal anatomy. Outcome was determined by patient satisfaction at the 12-month follow-up; unsatisfactory results were further analyzed by a blinded independent expert with more than 15 years' experience.

[RESULTS] We included 150 patients. Mean patient age was 51 years; 93.3% were women, and 20.7% had undergone previous procedures, including malar implants, autologous fat grafting, rhytidectomy, midface-lift, and extended lower blepharoplasty. Multimodality treatment was used in 34.0%. Patient dissatisfaction was encountered in 14.0% of cases; the expert concurred in each case. Autologous fat grafting alone demonstrated the greatest propensity for dissatisfaction (4 of 12 cases [33%]). Rate of dissatisfaction was significantly higher with malar hypoplasia (41% vs 7%; P < .001) or loss of elasticity (16% vs 3%; P = .01) but was not highly correlated with age (r = 0.15).

[CONCLUSIONS] Successful midface rejuvenation requires accurate diagnosis and avoidance of anatomic pitfalls. Many patients require multimodality therapy, including lifting and volumizing techniques. Unsatisfactory results are most common when midfacial aging is accompanied by skeletal insufficiency or loss of elasticity. Respective consideration of these defects should be given to placement of malar implants and rhytidectomy approaches targeting the midface.