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Table 1 Midface aging type classification Type 1
Hypotrophic (aging caused by hypotrophy)
There is widespread hypotrophy in all the maxillary fatty tissues, prevalently of the deep compartments (medial and lateral SOOF and DMCF). The region appears flat or concave all over. The nasolabial fold is caused by ‘pseudoptosis’ of the skin, which, no longer supported by the underlying soft tissue, is redundant. The cheek is concave due to hypotrophy of the middle cheek fat.
Type 2
Hypotrophic/ptotic (aging caused prevalently by hypotrophy but with a secondary ptotic component)
There is hypotrophy prevalently in the deep fat compartments (medial and lateral SOOF, DMCF). The region appears concave in the suborbital portion while the section closest to the nasolabial fold is slightly convex due to ptosis of the nasolabial compartment. The nasolabial fold is determined again by skin ‘pseudoptosis’ but appears more accentuated due to nasolabial fat ptosis. The cheek is slightly
convex due to ptosis of the middle cheek fat.
Type 3 Ptotic/hypertrophic (aging caused mainly by ptosis but with a secondary hypertrophy component)
The fatty tissue of the maxillary region dislocates downwards due to ptosis of the superficial fat compartments. The infraorbital region appears flat or slightly concave due to hypotrophy of the medial SOOF and ptosis of the medial cheek fat compartment while the nasolabial region is convex due to hypertrophy of the nasolabial fat compartment. Nasolabial folds are caused by the sagging of the ptotic and hypertrophic
nasolabial fat. The cheek is convex due to the ptosis and hypertrophy of the middle cheek fat. The hollow of the posterior part of the cheek begins to be noticeable due to the hypotrophy of the lateral cheek fat.
Type 4
Hypertophic/ptotic (aging caused predominantly by hypertrophy but with a secondary ptotic component)
The fatty tissue of the maxillary region is hypertrophic and displaced downwards due to ptosis of the superficial fat compartments. The region appears concave only at the nasojugal groove while the central part and the nasolabial region are clearly convex. The nasolabial fold is determined by the sagging of the ptotic superficial fat compartment and accentuated by the hypertrophy. The hypertrophy and ptosis
of the middle cheek fat make the cheek convex and the demarcation with the hypotrophic lateral cheek fat is noticeable.
Nasolabial fat
Undergoes an inferior volume shift of fat tissue. In elderly patients, the sagittal diameter of the upper third is smaller and the sagittal diameter of the lower third is higher19
. This modification creates an overall As the malar fat pad
is loosely adherent to the SMAS plane, its aging is
hypertrophy of the lower part of the malar fat pad due to the ptosis and caudal migration of fat tissue. Aging of the malar fat pads can be described as ptotic/hypertrophic. The ptosis and the hypertrophy of these fat compartments contributes to the increase in the depth of the nasolabial fold17
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characterized by ptosis, caudal migration of fat, and hypertrophy.
Middle cheek fat As the malar fat pad is loosely adherent to the SMAS plane, its aging is characterized by ptosis, caudal migration of fat, and hypertrophy. These modifications produce an increase of convexity to the central portion of the cheeks.
Lateral temporal-cheek fat Located adherent to the parotid fascia without any deep fat compartment between it and the fascial plane. The aging determines a hypotrophic involution and it usually does not have any tendency for caudal migration.
Deep fat compartments Medial and lateral SOOF Both lie on the periosteum and have an aging characterized by hypotrophy with a low tendency for ptosis. The hypotrophic involution of medial SOOF produces the formation of the hollow in the infraorbital region. Reduction of the medial SOOF has been noted to increase the orbital cheek crease and the ‘V’ deformity of the lower-lid described by Mendelson et al13
. The medial
SOOF acts to support the palpebral tissues of the inferior eyelid, so its volume reduction increases the relaxation of the tissue of the inferior eyelid and of the intraorbital fat. The hypotrophy of lateral SOOF decreases the projection of the malar area and cheekbone, facilitating the ptosis of superficial fat compartments of the cheek.
Deep medial cheek fat This compartment undergoes a gradual and global decrease of volume and a caudal migration. The hypotrophy is greater in the upper two thirds and minor in the lower third where the caudal migration of fat compensates the hypotrophy.
Buccal fat The area of this fat compartment that influences the aesthetic of cheeks is the buccal extension. It seems to be mainly affected by hypotrophic aging. Several authors have observed a lower volume of buccal extension in older patients19,21
. The deflation of this fat compartment
leads consequently to a lack of support for the medial cheek and middle cheek fat, aggravating the descent of these compartments. Other authors22,23
have observed an
antero-inferior protrusion of buccal fat that increases the convexity of the cheeks and jowl ptosis.
Treatment planning Now the two pillars of the Anatomologic™ approach (anatomy and anatomy of aging) have been introduced, the physician should use this knowledge to plan the best filler treatments for different patient types. The knowledge of anatomical changes related to the aging process can guide the physican’s choice and suggest which fat compartments should be treated and volumized. This phase is crucial because if the physican chooses an inappropriate treatment the patient will probably have a partial or lacking result. If, however, the planning is correct, the results will be satisfactory.
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