Patients who seek surgical treatment for facial COSMETIC. Some Anatomical Observations on Midface Aging and Long-Term Results of Surgical Treatment

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1 COSMETIC Some Anatomical Observations on Midface Aging and Long-Term Results of Surgical Treatment John Q. Owsley, M.D. Christa L. Roberts, M.D. San Francisco, Calif. Background: Controversy exists as to whether the changes of midface aging (elongation of the lower eyelid caused by infraorbital hollowing, flattening of the malar eminence, and increased prominence of the nasolabial fold) are attributable to gravitational migration of the check fat or to fat atrophy. Methods: The anatomical explanation of the gravitational migration of the malar fat pad is based on previously reported magnetic resonance imaging studies of the midface cheek fat in young and older subjects and histologic studies of the superficial fascia in face-lift patients. Results: Clinical and laboratory observation of the midface malar fat pad suggests that, during repeated movements of animation, levator muscle contraction and shortening produces tissue expansion pressures within the overlying cheek fat pad that cause the acutely prominent nasolabial fold of animation. Conclusions: Over time, chronic recurrent tissue expansion of the skin of the lower anterior cheek combined with stretching of the supporting intrafat pad fascial septa results in downward migration of the malar fat pad, causing infraorbital flattening and permanent prominence of the nasolabial fold. Although not the primary cause of facial aging changes, fat atrophy may contribute secondarily in those individuals whose faces become thinner as they age. (Plast. Reconstr. Surg. 121: 258, 2008.) Patients who seek surgical treatment for facial aging commonly complain about prominent nasolabial folds. In the recent past, photogrammetric studies of the midface in youthful and older subjects have demonstrated that with aging there is anterior and inferior displacement of the soft-tissue cheek mass that results in deepening of the nasolabial fold. 1 Magnetic resonance imaging studies of the cheek and nasolabial fold reported in 1996 confirm that dynamic changes in the subcutaneous cheek fat pad occur with facial animation such as smiling, and that with aging there is a permanent redistribution of the superficial cheek fat mass that creates the prominent nasolabial fold. 2 Associated with this redistribution of From the Division of Plastic Surgery, University of California, San Francisco and the Aesthetic Institute of CPMC Davies. Received for publication April 28, 2006; accepted August 24, Presented in part at the Annual Meeting of the American Society of Plastic Surgeons, in Philadelphia, Pennsylvania, October 9 through 13, Copyright 2007 by the American Society of Plastic Surgeons DOI: /01.prs bb cheek fat, a decrease in the prominence of the infraorbital superior margin of the fat pad was observed. A more recent report on volumetric magnetic resonance imaging studies of the midface by the same author suggests that with aging there is also hypertrophy of the cheek fat in the mid and superior portion of the cheek fat pad. 3 This could be attributable to relative weight gain by the older subjects studied, or perhaps the localization of the hypertrophy in the mid and superior portion of the fat pad can be accounted for by the position of the subjects (prone with the head propped up 30 degrees) during the magnetic resonance imaging examination. Confusingly, the 1996 report stated that the facial magnetic resonance imaging scans were obtained with the subjects in the supine position. We are uncertain of the significance of the apparent fat hypertrophy in the 2005 studies, Disclosure: Neither of the authors has a financial interest of any kind associated with the creation of this article

2 Volume 121, Number 1 Midface Aging but our own observations would continue to support the description of fat redistribution that was reported in the 1996 magnetic resonance imaging studies. Clinically, while in the upright position, the aging midface of individuals of normal weight is characterized by prominent nasolabial folds and loss of subcutaneous fullness in the infraorbital region that extends out over the malar eminence. The severity of these changes varies, depending on the relative thinness or obesity of the individual. With advancing age, the lateral border of the descended malar fat pad becomes visible in the midcheek below the midlateral orbital location. When the aging midface is observed while moving to a supine position, the lateral border of the cheek fat pad moves superolaterally in a fluid motion, creating a more triangular malar fat pad with decreased prominence of the nasolabial fold, less infraorbital flattening, and improved soft-tissue covering of the malar eminence. This abrupt volumetric renewal of the youthful appearance of the midface while in the supine position suggests that fat migration rather than atrophy is the principal cause of the typical midface aging changes. In the past 5 years Lambros, using sophisticated morphing computer technology, has demonstrated the sequence of midface aging changes in photographs of individuals taken over a period of 20 to 40 years. 4 He has observed that the skin landmarks such as nevi in the infraorbital location show minimal descent with aging. He concludes from his observations that the cheek skin does not sag significantly in the midface but rather it is atrophy of the cheek fat that produces a deflation of the cheek skin envelope that causes the aged appearance. We submit that although atrophy of the cheek fat can and does occur, it is equally possible for cheek fat to hypertrophy if there is weight gain with aging, which is so common in our population. We believed that in the great majority of individuals with average cheek fat volume there is a gradual redistribution of that fat that is independent of vertical skin sagging. The previously mentioned studies with magnetic resonance imaging support the concept of translocation of the cheek fat with aging. The purpose of this report is to provide an anatomical explanation of the structural changes that occur in the mid face with aging that allow the downward migration of the cheek fat into an expanded nasolabial fold without an observable elongation of the skin of the infraorbital region of the mid face. The youthful cheek varies in the volume of fat, but typically there is a gently rounded malar mound that overlies the zygomatic maxillary area, producing an aesthetically pleasing contour to the oblique profile. From the front, the cheek fat or malar fat pad is approximately triangular in configuration, with the apex at the malar eminence of the zygoma and the base lying along the nasolabial crease, which is the paralabial line of adherence between the skin dermis and the underlying superficial subcutaneous fascia. At the infraorbital lid cheek junction, there is an abrupt transition between the thin eyelid skin lacking subcutaneous fat and the cephalic edge of the subcutaneous cheek fat. Medially, this transition zone is accentuated by the insertion of the orbitomalar septum, creating the nasojugal groove of varying depth that starts medially at the orbital rim just below the site of the medial canthal ligament. The orbitomalar septum is the principal mechanism for support of the infraorbital soft tissue and skin and also separates the lymphatic drainage system of the lid and infraorbital area from that of the cheek 5 (Fig. 1). As the insertion of the orbitomalar septum extends caudally in the lateral half of the lid-cheek junction, the insertion curves upward, lateral to the outer canthus, to outline the caudal margin of an elliptical portion of the superior lateral cheek fat called the malar mound. This site varies individually in prominence but tends in certain persons to become accentuated, presumably because of lymphatic stasis. The malar bag may atrophy with aging, resulting in the appearance of festoons of lax infraorbital malar skin hanging over the discrete fixed line of the orbitomalar septal insertion. In the youthful face, the cephalic margin of the malar fat pad actually reaches up beneath the caudal orbicularis oculi muscle to the level of the orbitomalar septum, which separates it from the sub orbicularis oculi fat above (Fig. 2). The superior edge of the malar fat pad and the adjacent sub orbicularis oculi fat blend and contour the youthful lid-cheek junction. Caudal to the orbitomalar septum, the malar fat pad is supported in its youthful location by multiple fibroelastic fascial septa that extend through the fatty cheek mass originating from the underlying superficial fascia that invests the mimetic muscles to insert into the overlying cutaneous dermis. Extending down from the nasoalarcheek junction to the level of the oral commissure, the anterior cheek skin is supported tightly by the firm superficial fascia-dermal insertion of the su- 259

3 Plastic and Reconstructive Surgery January 2008 Fig. 1. Drawings of the anatomy of the orbitomalar septum that extends from the arcus marginalis of the inferior orbital rim through the caudal portion of the orbicularis oculi muscle to insert into the skin in a curving arc defining the inferior margin of the infraorbital skin. Fig. 2. The superior fullness of the fat pad is seen in relationship to the orbitomalar septum and the sub orbicularis oculi fat (SOOF) pad. The supporting fascial septa within the malar fat pad extend from the superficial musculoaponeurotic system (SMAS) to the overlying dermis of the cheek skin. perficial musculoaponeurotic system (SMAS)-invested levator muscles at the nasolabial crease. Aging of the skin is histologically characterized by loss of the dermal elastic fibers that are gradually replaced by collagen of a fibrotic nature. 6 Alterations in dermal elasticity have been chiefly credited for the changes in appearance that occur with facial aging. 7 Recently, the microstructure and mechanical properties of the SMAS have been studied and compared with those of the 260

4 Volume 121, Number 1 Midface Aging Fig. 3. Drawings based on an illustration from Gosain et al. (A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: Implications for facial rejuvenation and facial animation surgery. Plast. Reconstr. Surg. 98: 622, 1996) depicting a magnetic resonance image of the cheek fat pad at rest and in animation. Contraction of the levator muscles results in forward expansion of the lower portion of the cheek fat pad to create the prominent nasolabial fold of animation. Fig. 4. Drawings based on Gosain et al. (A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: Implications for facial rejuvenation and facial animation surgery. Plast. Reconstr. Surg. 98: 622, 1996) illustrating the magnetic resonance image of the cheek fat pad at rest in the youthful and in the aging face showing how the temporarily prominent nasolabial fold associated with animation in the youthful face becomes the permanent nasolabial fold in the older aging face caused by the permanent increased thickness of the lower cheek fat observed with aging. skin. Har-shai et al. in 1996 reported on the histologic examination of skin and superficial fascia specimens obtained during 20 primary and four secondary face-lift operations in a group of patients of unspecified age. 8 They observed that the SMAS and the dermal portion of skin have a similar composition of collagen and elastic fibers. Mechanical testing showed similar viscoelastic stretch properties in the SMAS and skin, with the viscoelastic stretch of the SMAS being somewhat less pronounced. The article did not include any observations relative to tissue elasticity in patients of different ages. Stimulated by this report, a small study of skin and SMAS histology was performed by a pathologist at my hospital, using specimens from a group of my face-lift patients ranging from 40 to 75 years of age (T. Eiman and J. Q. Owsley, unpublished 261

5 Plastic and Reconstructive Surgery January 2008 Fig. 5. Drawing of the midsagittal anatomy of the youthful midface showing the contraction and shortening of the midface levator muscles, with animation causing an acute expansion effect in the lower cheek, producing the nasolabial fold (NLF) of animation. Tension on the supporting fascial septa is greatest in the lower third of the cheek skin, where the shortening of the levator muscles is maximal and the expansion force is greatest. Fig. 6. Drawing of the midsagittal anatomy of the midface at rest, demonstrating the descended malar fat pad that produces the permanent nasolabial fold (NLF) of the aging face. data). It was observed that both elastic fibers and nonelastic collagen were present in the specimens of SMAS and skin, with somewhat less elastic tissue in the SMAS. The relative quantity of elastic fibers in both the SMAS and skin was decreased in the older patients. It seems likely that the degenerative loss of elastic tissue in both the skin and the superficial fascia contributes to the development of the alterations of facial aging. In the lateral cheek, where the SMAS attachment to the zygoma supports the platysma of the lower face and neck, the plane of descent of gravitational aging is the anatomical cleft between the superficial and deep fascia. 9 In the study of living subjects, both young and old, using magnetic resonance imaging to observe dynamic changes in the midface soft tissues during facial animation and with aging, it was found that there was consistent observable shortening of the mimetic midface muscles with smiling. 2 This shortening was associated with moving the muscle body closer to its originating point on the zygomaticmaxillary bones (Fig. 3). The muscle shortening was accompanied by a redistribution of the overlying cheek fat, creating an increased thickness of the lowest portion of the fat pad, producing a prominent nasolabial fold in young subjects. This is described as the nasolabial fold of animation. In older subjects, the prominent nasolabial fold became a permanent feature at rest that increased in thickness with smiling (Fig. 4). It was of note that there were no significant alterations in the position or dimension of the facial muscles that occurred with aging. Because the midface levator muscles have firm bony origins in the infraorbital location, there is no descent of these muscles with aging. The plane of aging descent in the midface is at the subcutaneous level just above the superficial fascia investing the mimetic muscles. This can be characterized as a gradual redistribution of the cheek fat caused by downward migration with loss of thickness in the infraorbital location and increased thickening of the fat at the nasolabial fold. To understand how the cheek fat migrates down largely independent from the overlying skin, we can analyze the dynamics of midface animation. During smiling, the zygomaticus and le- 262

6 Volume 121, Number 1 Midface Aging vator muscle group shorten, with contraction drawing the oral commissure and the nasolabial crease in a superior lateral direction (Fig. 5). This abruptly reduces the dimension of the deep surface of the malar fat pad that overlies the SMASinvested levator muscles. Reducing the dimension of the base of the fat pad increases the tension and pressure within the semifluid mass of cheek fat, which is transmitted to the most readily yielding portion of the fat container, which is the overlying fibroelastic skin. Superiorly, the skin is supported and the cheek fat contained by the firm orbitomalar septum. Inferomedially, the limiting line is the tight SMAS insertion at the nasolabial crease. The greatest shortening of the muscles occurs toward their insertion at the modiolus of the oral commissure. The increased pressure within the overlying fat pad produces acute radial expansion pressure to the overlying elastic skin that creates the immediately prominent nasolabial fold of animation. The pressure dynamics are quite similar to the effect of acute filling of a saline-silicone tissue expander. In addition to the expansion of the surface skin, linear tension is placed on the multiple supporting fibroelastic septa that extend within the fat pad between the SMAS and the dermis. The expansion pressures gradually result in permanent elongation of the septa. Loss of the intrafat pad septal support allows the semifluid cheek fat to gradually descend with gravity into the expanded skin envelope at the lower end of the cheek above the nasolabial crease. Over years of animation, the skin in the region of the nasolabial fold is expanded to create a permanently prominent nasolabial fold filled with displaced cheek fat (Fig. 6). Superiorly, where the orbitomalar septum firmly retains the infraorbital and upper cheek skin, there is little if any apparent elongation of the skin, confirming Lambros observations of local nevi. In summary, the following points are concluded: 1. The upper anterior cheek skin is firmly supported by the orbitomalar septum that allows little or no downward migration with aging. 2. Midface levator muscle shortening with animation is greatest near the insertion at the lower nasolabial crease and modiolus causing greatest pressure expansion of the lower anterior cheek skin that causes the nasolabial fold of animation in youthful faces. 3. Chronic tissue expansion with stretching of the fascial dermal septa within the malar fat pad results in loss of support for the cheek fat, producing gradual downward migration into the expanded lower cheek skin that creates the permanent nasolabial fold associated with facial aging. CASE REPORTS The following case reports illustrate experience with face-lift patients in the past 14 years since the technique of lifting the malar fat pad to correct prominent nasolabial folds was first described in 1992 and subsequently published. Case 1 A 45-year-old woman was seen in consultation for facial and eyelid surgery in August of She had had a breast augmentation performed 17 years prior and cosmetic eyelid surgery 15 years previously. The patient expressed concerns about the appearance of her tired look around the eyes and the signs of aging in her face and neck (Fig. 7). She had recently stopped smoking an average of a half pack of cigarettes per day. Later in August of 1991, under general anesthesia, the patient underwent a coronal forehead lift, bilateral lower blepharoplasty, and a face and neck lift including the SMAS-platysma rotation flap, submental liposuction, and limited undermining in the malar area. This surgery was before the addition of the malar fat pad lift to the face-lift technique. She had an uneventful recovery and returned to her home in another state. She was seen 6 months after surgery, when she was photographed and expressed satisfaction with the outcome of her operation (Fig. 8). She was next seen in consultation in June of 2004, 13 years after her face lift. At that time, examination revealed beginning recurrence of facial and neck laxity, with prominent nasolabial folds and infraorbital hollowing, platysmal banding, and prominent fat in the lateral pockets of the lower eyelids, with a modest amount of redundant skin, and some lateral hooding of the brow (Fig. 9). The secondary face-lift surgery with the other ancillary procedures was performed in September of The face lift included a secondary elevation of the SMAS-platysma flap and rotation lift of the lower face and neck. This time, the midface was approached with complete elevation of the malar fat pad under direct vision to the line of the nasolabial crease and oral commissure followed by a suture suspension of the apex of the fat pad to the fascia in the malar area. This corrected the prominent nasolabial fold and infraorbital hollowing by repositioning of the malar fat pad. Except for a small area of superficial skin necrosis in the right subsideburn area that healed uneventfully, her postoperative course was uncomplicated. She returned home and was seen approximately 6 months later, at which time she was photographed (Fig. 10). 263

7 Plastic and Reconstructive Surgery January 2008 Fig. 7. Preoperative views of the 45-year-old woman who requested surgery to improve the signs of facial aging in Fig. 8. Appearance of the patient 6 months after undergoing a coronal forehead lift, bilateral lower blepharoplasty, and face and neck lift. Examination and comparison of her preoperative and postoperative photographs before and after the first face lift indicate that there was relatively little change in the appearance of the midface infraorbital and nasolabial fold location following the operation performed in 1991 in which the midface undermining was stopped at the malar location below the lateral orbital rim. Significant improvement in the appearance of the jawline and submental area was achieved. Although the 13-year postoperative follow-up photograph indicates recurrent laxity of the submental area and jawline with platysmal banding, the degree of laxity in the lower face and neck is still less than existed at the time of her first face lift at age 45. The nasolabial fold 264

8 Volume 121, Number 1 Midface Aging Fig. 9. The same patient s appearance in June of 2004, 13 years after the initial cosmetic facial surgery. Fig. 10. Thesamepatientisshown6monthsafterasecondfacelift, thistimeincludingamalar fat pad undermining and suture suspension as part of the secondary SMAS-platysma face lift. Lateral brow lift and revisional lower blepharoplasty were also performed. It is apparent that the malar fat pad lift has significantly improved the appearance of the nasolabial fold and that of the lid-cheek junction, in contrast to the midface contour after the first face lift in which only lateral cheek undermining was performed. and midface shows increased descent of the cheek malar fat pad. There is a significant improvement of the appearance of the midface apparent following the second face lift in which the malar fat pad dissection and suture suspension were performed. The prominence of the 265

9 Plastic and Reconstructive Surgery January 2008 nasolabial fold in both the front and lateral photographs is significantly decreased, and the improvement of the lid-cheek junction appearance as a result of elevation of the superior margin of the fat pad is apparent. Using enlarged preoperative and postoperative photographs that were matched in size by measuring lip length and earlobe length, the position of the lid-cheek junction and height of the lower lid were measured. Significant elevation of the lid-cheek junction and lower lid shortening by several millimeters were demonstrated (Figs. 9 and 10). Case 2 The second patient is one of two sets of twins who were selected to have face-lift surgery performed by four different surgeons on the occasion of the annual University of California, San Francisco, Aesthetic Surgery Symposium in She and her sister were seen in consultation in January of 1995 at age 50, when the examination revealed transverse forehead and glabellar frown lines with moderate drooping of the brows, baggy upper and lower eyelids, and laxity of the face and neck, with infraorbital hollowing, prominent nasolabial and labiomandibular folds, and submental and anterior neck laxity. She described herself as an occasional smoker (Fig. 11). Her operation was performed on March 24, 1995, on live video, at which time under general anesthesia a coronal brow lift, upper and lower blepharoplasty, and face and neck lift with submental liposuction were performed. The face lift included a SMAS-platysma rotation flap for correction of the neck, jawline, and lower face and a midface complete dissection of the malar fat pad to the nasolabial crease and oral commissure followed by suture suspension of the apex of the malar fat pad to fascia overlying the malar eminence. Her postoperative course was smooth, with uncomplicated healing, and since the operation in 1995, she has been followed and photographed yearly with her twin sister for comparative purposes. The 10-year postoperative appearance of the patient, at age 60, is seen in 2005 (Fig. 12). The appearance of her midface area including the lower eyelid cheek junction demonstrates well-maintained correction of the preoperative aging midface changes. There is maintained improvement of the periorbital, nasolabial, and labiomandibular fold locations, and the jowl area. It is apparent that the patient has developed some laxity in the submental location associated with platysma banding, but overall she looks more youthful at 60 than she did at age 50. She demonstrates excellent long-term maintenance of the midface malar fat pad suspension. DISCUSSION The clinical significance of this discussion regards selection of the best therapy for changes of aging in the infraorbital and midface location. If atrophy is the primary cause of aging changes, it seems appropriate to consider treatment with fat replacement by onlay graphs or fat injections. 10 In contrast, if downward migration of a normal volume of cheek fat has occurred, surgical repositioning of the malar fat pad can predictably accomplish an effective long-term cheek and infraorbital rejuvenation. 11,12 The significant difference between the two methods of midface rejuvenation regards the pre- Fig. 11. Front and lateral preoperative views of a 50-year-old woman who underwent an endoscopicbrowlift,upperandlowerblepharoplasty,andfaceandnecklift,includingasmas-platysma rotation flap and malar fat pad dissection and suspension suture in

10 Volume 121, Number 1 Midface Aging Fig.12. Thefrontalandlateralappearanceofthesamepatientin2005atage60,10yearsafter facial surgery, demonstrating well-maintained improvement in the nasolabial fold and elevation of the lid-cheek junction after midface malar fat pad lift. dictability of the result and the potential longevity of the improvement. These distinctions are important because of the widespread and intensive marketing by nonsurgical cosmetic specialists in the public media about the benefits of fat or other injectables as a noninvasive alternative to surgical treatment. Our observation of the results of fat injections in the cheek and infraorbital area is that the recovery time is long and the outcome is frequently unattractive during an overcorrected phase that is undertaken to enhance the amount of graft take. The concept of a long-term permanent buildup by recurrent fat injection treatments is frequently advocated, but we are unaware of any scientific documentation of this phenomenon. Disappointingly, the correction initially achieved with injected fat in the cheek and periorbital area gradually disappears in a relatively short time. A single notable exception is the occasional long-term persistence of firm clumps of fat injected into the nasojugal groove that can turn out to be a cosmetic liability requiring surgical revision. It is certainly appropriate for younger patients with beginning signs of facial aging to postpone surgery until they are psychologically ready. When we look at the beginning stage of midface aging, the earliest evidence of the gravitational fat migration is at the infraorbital area when the superior border of the malar fat pad descends centrally like the catenary of a sagging clothes line, as the apex of the malar fat pad moves medialward because of loss of support. At this time, careful fat injections or the use of hyaluronic acid products can correct the infraorbital hollow contour nicely for the short term. However, when both the infraorbital and paralabial areas show evidence of midface aging, a partial or complete maintenance type face lift with malar fat pad undermining and suspension can be recommended as an effective long-term correction. The suture suspension accomplishes simultaneous correction of the infraorbital hollowing by tightening the sagging catenary of the superior border of the malar fat pad while repositioning the cheek fat to reduce the prominence of the nasolabial fold. Experience has shown that, on average, after malar fat pad elevation with a face lift, patients return to a normal appearance and activity within a follow-up period of 2 to 3 weeks. 13 This is considerably sooner than the patients who have undergone significant cheek and periorbital fat injections. More recent publications on midface surgery have emphasized the benefits of periorbital rejuvenation combining blepharoplasty with a vertical cheek lift, which is certainly a useful procedure in younger patients who request a blepharoplasty and may not be candidates for a face lift. 14,15 Hamra has emphasized a composite approach for facial rejuvenation, combining a vertical vector of the midface by means 267

11 Plastic and Reconstructive Surgery January 2008 of his blepharoplasty with a simultaneous lateral tensioning vector provided by a face lift. The necessary disruption of the orbital malar septum with the composite technique is probably a significant factor associated with the prolonged midface ecchymosis and edema that has been reported with this operation. 16 John Q. Owsley, M.D. 45 Castro Street, Suite 111 San Francisco, Calif owsley@drjohnowsley.com REFERENCES 1. Yousif, N. J., Gosain, A. K., Sanger, J., Larson, D. L., and Matloub, H. S. The nasolabial fold: A photogrammetric analysis. Plast. Reconstr. Surg. 93: 70, Gosain, A. K., Amarante, M. T., Hyde, J. S., and Yousif, N. J. A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: Implications for facial rejuvenation and facial animation surgery. Plast. Reconstr. Surg. 98: 622, Gosain, A. K., Klein, M., Sudhakar, P. V., and Prost, R. W. A volumetric analysis of soft tissue changes in the aging mid face using high resolution MRI: Implications for facial rejuvenation. Plast. Reconstr. Surg. 115: 1143, Lambros, V. Facial aging: What really happens as we grow old. Presented at the Annual Meeting of the American Society of Plastic Surgeons, Philadelphia, Pennsylvania, October 9 13, Pesa, J. E., and Garza, J. The malar septum: The anatomic basis of malar mounds and malar edema. Aesthetic Plast. Surg. 17: 11, Kligman, A. M., Zheng, P., and Lavker, R. M. The anatomy and pathogenesis of wrinkles. Br. J. Dermatol. 113: 37, Pasquali-Ronchetti, I., and Baccarani-Contri, M. Elastic fiber during development and aging. Microsc. Res. Tech. 38: 428, Har-Shai, Y., Bodner, S. R., Egozy-Golan, D., et al. Mechanical properties and microstructure of the superficial musculoaponeurotic system. Plast. Reconstr. Surg. 98: 59, Owsley, J. Q. Aesthetic Facial Surgery. Philadelphia: Saunders, Coleman, S. R. Structural fat grafts: The ideal filler? Clin. Plast. Surg. 28: 111, Owsley, J. Q. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast. Reconstr. Surg. 91: 463, Owsley, J. Q., and Filala, T. G. Update: Lifting the malar fat pad for correction of prominent nasolabial folds. Plast. Reconstr. Surg. 100: 715, Owsley, J. Q., and Zweiffler, M. Midface lift of the malar fat pad: Technical advances. Plast. Reconstr. Surg. 110: 674, Moelleken, B. The superficial subciliary cheek lift, a technique for rejuvenating the infraorbital region and nasojugal groove: A clinic series of 71 patients. Plast. Reconstr. Surg. 104: 1863, Hester, T. R., Jr., Codner, M. A., McCord, C. D., Nahai, F., and Giannopoulos, A. Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: Maximizing results and minimizing complications in a 5-year experience. Plast. Reconstr. Surg. 105: 393, Hamra, S. T. Composite rhytidectomy. Plast. Reconstr. Surg. 90: 1,