Balanced Restoration: Optimizing Midface Rejuvenation Using Hyaluronic Acid Fillers

Currently available hyaluronic acid filler technologies concentrate on reflation of the aging midface primarily with the use of fillers to reinflate the deep fat compartments. However, filler technology has evolved, which allows us to reconsider how to address midface volume loss more appropriately. We propose that balanced restoration, a multilayered technique, should be the contemporary approach to midface revolumization with hyaluronic acid fillers, as it is based on an advanced understanding of anatomy and can achieve natural-looking outcomes that maintain dynamic facial expression. The midface comprises 2 distinct fat layers, superficial and deep, with different morphological and mechanical attributes that reflect the different functions that fat tissue plays in each layer. Because of the more dynamic nature of the superficial fat layer over the more static deep fat layer, and its roles in providing facial contours and permitting skin mobility and facial expression, multilayered techniques for balanced restoration involve selecting appropriate products that match the viscoelastic properties of the fat that is being replaced. Reflation of the superficial fat compartments requires fillers with cohesivity and more dynamic properties than deep fillers to enable adaptation to facial movement and to provide natural outcomes. Here, we summarize the advances in the understanding of the anatomical considerations for midface rejuvenation and provide guidance on how to differentiate superficial fat loss from deep fat loss and on how to select the most appropriate injectable hyaluronic acid fillers to achieve balanced restoration in patients requiring midface rejuvenation.