What exactly is mid face rejuvenation? In this Inside Cosmetic Surgery interview, we speak with Dr. Achih Chen, of The Georgia Center, about where the mid face lies, and why this area is so often overlooked. Dr. Chen goes into detail on why facial implants are so different from breast implants, and why filling the nasiolabial folds isn’t always enough.

He answers our questions on how long mid face implants last, why the implants never leak, how this procedure stacks up to fat transfer and other injectable fillers, and so much more. Listen to the detailed interview, or read through the transcript below to find out what you need to know about mid face rejuvenation.

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Sharon Odom (SO): Hi everybody, this is Sharon Odom from CosmeticSurgeryToday.com and welcome Inside Cosmetic Surgery. Our special guest today is Dr. Achih Chen, a board-certified facial plastic surgeon in Evans, Georgia. Hi Dr. Chen, how are you?

Dr. Achih Chen (DAC): Good, how about yourself?

SO: I am great. Well, thank you for joining us today to discuss midface rejuvenation, which when you suggested this as the topic, I never knew that it was such a specialized thing with midface rejuvenation. So first of all, where is the midface?

DAC: Well, the midface is at the area of the face that lies between the corner of the eyes and the corner of the mouth, and it’s an area that’s often overlooked in facial rejuvenation surgery. So the problems with the aging face often are recognized as just the jaw and the neck and maybe with the eyes, and so that kind of skips over the entire area of the face called the midface.

SO: Okay. So it’s the area between the corner of the eyes and the corner of the mouth.

DAC: Right. And some people will call that the cheek. The midface has had some attention drawn to it recently. Now, a lot of people will talk about the nasolabial fold or the filler companies will call it the “parenthesis.” That does lie within the midface, and so oftentimes people think that the rejuvenation of the midface really involves filling that nasolabial fold. So that’s kind of the extent of midface rejuvenation that most people will know about.

SO: Right. Well, let’s sort of backtrack. So what happens to the midface with age? As people age, bad things happen.

DAC: Well, with some good things. I mean, we gain wisdom.

SO: Right.

DAC: But with respect to our face, you can think of the youthful face as more like a grape, and so the grape is full in the sense that it has smooth transition from one facial area to another, so there aren’t cavities or indentations.

SO: Right.

DAC: What happens as we get older, conventional wisdom is that everything just falls. That’s only part of the truth. What happens is then is if you think of a young face as a grape, the grape becomes more like a raisin, and so as you let air out of a balloon, the balloon is going to sag.

SO: Right.

DAC: So yes, you can pull that balloon tighter or you can pull that raisin a little bit tighter, and at first that will look okay. But what happens is it continues to deflate, and so in the midface region, the soft tissue or the cheek area starts to deflate and it slides downhill and then that nasolabial fold starts to look deeper and deeper. That’s one of the reasons why people think that if you just fill that area, the nasolabial fold, that they will make the midface more youthful. But the actual problem is further uphill, kind of closer to the eye or what people call their cheekbones, and so that’s kind of what happens is there is an overall deflation of the face. That’s why when you look at a young face, it’s full, but when you look at an older face, it looks flatter and longer.

SO: Even if it’s been rejuvenated, then it ends up… what was that word you used to describe it? An over-tight-looking raisin.

DAC: Yes.

SO: I thought that was a very good visual.

DAC: So what happens is as we get older, we lose volume, and we lose volume in several ways. There have actually been CT findings of the aging facial skeleton and we actually lose bones in our midface and we lose bone in the jaw and our eye sockets get deeper. But beyond that, the overlying soft tissue, the cheek fat, that starts to go away, and so if you pull it tight, you will tighten the jaw line and you will tighten the neck, but you may not make someone look younger.

So all of us have seen that the really tight older person who doesn’t have a line on their face, but they just don’t look young, but they looked like somebody does some surgery on them and that’s what I’m referring to when I talk about the over tight raisin. So the object of making someone look younger isn’t to pull them tight as you can, it’s to reverse the clock so they look like themselves years before.

SO: Right. So why is it so important to address the midface as part of the facial rejuvenation process? Why is that so important?

DAC: Well, it kind of goes back to the trying to revolumize the face, and so, yes, it’s okay to tighten the jaw line and it’s okay to take care of the extra skin in the neck. In fact, that’s great. But you still haven’t accomplished the total goal, and really to make a face look younger, you have to put back things that were lost with time, and volume is the biggest thing that’s been lost with time.

It isn’t because we are thinner. Most of us actually gain a little bit of weight as we get older, but we tend to lose volume in the face. So to really create, I guess, a rejuvenated face rather than an operated-looking face, you have to create volume, and that’s the biggest thing about the midface.

So it isn’t so much that you want to lift the midface, it’s that as you create some volume and you revolumize it. It’s very much like filling up a balloon.

SO: Okay.

DAC: If you put more air in the balloon, that sagging balloon will rise and lift.

SO: Okay.

DAC: And that’s what we are trying to accomplish with the midface region.

SO: Great. So what are some of the methods of putting air back into the balloon in rejuvenating the midface?

DAC: Well, there are many ways. They range from the very simple to a kind of a little bit more complex, and the very simple ways are to put filler in there. You can do injectable fillers. There are a number of injectable fillers that people will use. Radiesse looks very well. There is Sculptra and various other fillers that are on the market, and they all work well. The downside is it’s temporary.

SO: Right.

DAC: But the upside is there is very little downtime and people can enjoy it right away with the exception of Sculptra which takes over a period of time. Some people just don’t want to have surgery. Now, the intermediate type of procedure is fat transfer or fat grafted, and that works pretty well in the sense that everybody loves the concept of taking fat from somewhere you don’t want it and putting it somewhere you like it.

SO: And putting it somewhere you do want it. Right, yes. That’s right.

DAC: It’s a very sexy topic.

SO: Yeah.

DAC: Because that’s like accomplishing several goals at the same time. Now, the downside of that is fat is a living tissue, so when you inject it, it has to get blood supply in order to live over the long term, so it’s a little bit unpredictable, and oftentimes, people would do a lot of fat transfers. We will actually tell all of our patients that it’s a two or more stage procedure because you have to overfill that area and then what happens to fat. It’s not going to live or gets absorbed almost like filler. You need to come back and fill again.

SO: Right.

DAC: So some people aren’t up for that kind of multiple procedures, and so the procedure of choice in my practice is using what’s called the midface implant.

SO: Okay.

DAC: And that equates to a small incision inside the mouth, and it’s different than a cheek implant in that a midface implant fits more towards the nose and creates volume more towards the middle. So we are not trying to create a different look. We are actually trying to just revolumize the midface, and so I like that because it’s reversible. It’s totally predictable and it’s easy to do, and so patients really like it because it’s not a multi-stage procedure. It’s a one-time shot and you can even reverse it if you want to.

SO: So where does the implant go, inside the mouth?

DAC: It does. So what we do is we make a little incision inside the mouth. It’s called the gingivolabial sulcus. So basically, it’s in that little valley that’s between the lips and the gums. We make a little incision underneath there and we actually lift the soft tissue off of the bone and the implant is placed right up against the bone. So it’s different than a breast implant. This is not a floating implant. It’s actually fixed right to the bone, and once it heals, you never feel it. Even if a surgeon is feeling for it, it would be very hard to feel.

SO: And what is the implant made out of? Is it saline, gel? Is that like a breast implant?

DAC: No, no. It’s actually nothing like a breast implant. It’s not a gel. It’s actually a soft, solid material. It’s made out of Silastic. It’s the same material that they put in that covers up like cochlear implants that’s used for hearing loss or around pacemakers.

SO: Okay.

DAC: It’s kind of the soft silicone, but it’s solid.

SO: Okay, all right, so no chance of leakage.

DAC: No, it can’t leak actually because it’s somewhat firm and it fits right. It’s not hard as a rock. I mean, it has some spring to it, but it can’t leak because it’s a solid material.

SO: Interesting. So the midface lift, that’s different from what you are talking about now, right? What is the midface lift?

DAC: Well, the midface lift is a little bit different procedure. It’s done by a very similar approach. So a midface lift involves an incision in the temporal region, basically in the scalp, and then what we do is we perform a little pocket and dissect down to the bone as we are coming across the corner of the eye and then what we do is we create a second pocket that we go inside the mouth with.

That pocket is created underneath the bone and then what we do is we anchor the cheek from below and we lift that superiorly, so then the whole cheek is lifted upward. Now, what happens is the whole cheek is actually detached from the bone or the midfacial structure and when it heals it will heal back to the bone in a higher position.

SO: Oh, I see. Okay.

DAC: Now, it’s a nice procedure for someone who has a full cheek to begin with. It’s not so nice of a procedure or not such a great procedure for someone who has volume loss because what you are really lifting is something that has kind of gone away, and so what I find is if somebody is kind of full faced and is kind of cheeky to begin with and you don’t want to give them more cheek, but you just want to lift it up, that’s a good way to go.

SO: Right.

DAC: But with most people, what happened is they’ve lost volume and that nasolabial fold is deepened because basically the soft tissue envelope is deflated.

SO: Okay, so the midface lift will still be good for someone who had lots of volume and cheeks already.

DAC: Right. When midface lifting first came about, it’s kind of like liposuction. Everybody thought that was the answer to everything, so everybody got midface lift, and what we find out is new techniques come and we learned more about them is that they are a good indication for them and then there are ones that are not so good, and so midface lifting is really great to rejuvenate the midface in a limited patient population that has a full cheek that’s kind of fallen over time and you just want to lift that cheek, but you don’t want to create a full cheek.

Now, augmenting in the midface, whether by a filler or an implant or fat, that works great for the most people because most people have actually lost volume in their midface.

SO: Right. So is that your preferred method of rejuvenating the midface with the implant?

DAC: It really is, and I’ve done fat transfer. Basically, I do all of the methods of midface rejuvenation. I do midface lift. I do fat transfer. I do filler and I do midface implants, and of all those procedures that we do, I find that midface implants are probably the best way to go, namely because they come in different sizes.

They are completely predictable. You put them in and that’s where they are going to be forever and ever until you take them back out again if you want to take them back out. The other thing that’s unlike a breast implant, if you form a capsule around the breast implant, it’s a disaster because they get stuck. I mean, it gets stuck against the chest wall.

SO: Right.

DAC: It makes for the unnatural appearing breast while on a facial implant, that’s the first thing you want to happen is when a capsule is formed, you want it to get stuck down to the bone and it always happens that way, and so the nice thing about a capsule and having it fixed to the bone is that the implant doesn’t move, that you can’t feel the implant, and if you want to reverse it at some point, you can. All you have to do is find the edge of the implant and it comes right back out. So it takes about ten minutes to reverse it.

SO: Okay.

DAC: Now, you are probably wondering why you would want to reverse it. Well, what happens is with patients, they get used to this fullness, and a lot of them will have fullness. They have this postsurgical fullness, and then what happens is that postsurgical fullness goes away and they are left with the fullness of the implant.

SO: Right.

DAC: And occasionally, you will get one or two who really like the fullness that they had when they had swelling from the surgery, and so when that fullness goes away and they just are left with the size of the implant, some want to upsize.

SO: Oh, I see, okay.

DAC: And so, you will occasionally will go back and actually put in a little bigger implant, and I think that’s probably the case with, although I don’t do breast implants, but I have friends that do and that’s often the case with them as they put in the implant and the patients like the size when they were swollen.

SO: Right.

DAC: And when it all settles, they kind of wish they were a little fuller.

SO: You are right. So the results then are permanent.

DAC: They are.

SO: So it doesn’t deflate. It doesn’t go away. It’s just with them forever unless they decide they want a bigger one.

DAC: Right. And the reason why fat transfer is still a very nice procedure or the reason why I like midface implants over fat transfer for the midface region is you don’t have this time of huge swelling where you have to overfill with the fat.

SO: Right.

DAC: Because you have to overfill with fat, kind of anticipation that some of it is going to them to work.

SO: Right.

DAC: And then the other is you don’t have to go back and do a second stage procedure trying to hit the size that you are hoping to hit, whereas with an implant, you’ve already picked out a size so you kind of know where you are going to be when the swelling has gone away.

SO: What type of anesthesia is required?

DAC: I think there are a variety of anesthetics that people will use in their office. We tend to prefer what’s called TIVA, Total IV Anesthesia, which is really I think the most stable with deep IV sedation. It’s a little deeper than Twilight. You are breathing spontaneously and that’s supplemented with local anesthetic. Now, there are surgeons that will prefer to use general anesthesia. That works perfectly well. I think sometimes the cosmetic patient prefers not to have that deep of anesthesia.

SO: Right.

DAC: I think straight local anesthesia will be a little bit tougher, just simply because I think there is an aversion to dental procedures and I think it’s similar to a dental procedure when someone is in your mouth putting an implant in place.

SO: Yeah, I think you would rather be asleep.

DAC: Right. Most of them prefer to use sleep for that type of procedure.

SO: Right. Do you have a patient story you like to share? I know that you sent me some pictures and I hope it’s okay to post them on the website because pictures, of course, is worth a thousand words and you can actually see the results. Well, is there a certain patient you like to tell us about?

DAC: Well, sure. And I would be happy to share some more pictures with you.

SO: Oh, excellent.

DAC: I think that your readers would have a better understanding of it. Let me think of a good patient story. Well, I’ll tell you a story about my wife. What my wife wants to say is, “The cobbler’s children have no shoes.” And so she has often kind of, and my wife is her early 40s, and boy, I’m going to be in trouble for sharing her age.

SO: We won’t tell her.

DAC: Okay. But she came in, and I don’t think she sees everything that we do, and so we were doing midface implants one day and I was putting the before and after pictures together, and she looked at that and it was like a light bulb went off in her head and she came in one day. Well, actually, she had the office schedule her under someone else’s name. And I was supposed to go and do filler in this young lady’s midface and it turned out to be my wife.

SO: Oh.

DAC: And so I think looking over my shoulders, she was so impressed with midface rejuvenation, and I think it’s an area of the face that’s really overlooked, and until people see before and afters on what the results provide, it’s really hard to picture because it’s actually a three-dimensional rejuvenation. Instead of just pulling someone tight, you are actually voluminizing it, and so it’s a little bit harder to conceptualize without actually seeing it. And so sometimes the proof is in the pudding when your own wife is asking you, “Hey, you know, that looks pretty good. Maybe I can come and have that done someday.”

SO: Really? Great. Okay, well, we will post pictures on the website. And people can see for themselves what the results could look like, so great. Well, would you like to tell our listeners about your practice and where you are located and your website?

DAC: Sure. My practice is located in Evans, Georgia. Evans is actually a suburb of Augusta, Georgia, and that’s best known for the Masters, but it’s also home of what some people know as the Medical College of Georgia, and recently it changed its name to the Georgia Health Sciences University, and so I have a hybrid practice. Ninety percent of my practice is cosmetics, but I’m also the chief of division of facial plastic surgery at the Georgia Health Sciences University.

SO: All right. Okay, so you are an educator as well.

DAC: I am. We train residents and we are going to have a fellow starting in July, so we train both sub-specialists and residents as well.

SO: Great. Well, what’s your website?

DAC: It’s www.thegeorgiacenter.net.

SO: Okay. We will have a link of that on the website, and well, thank you very much. This has been very useful. Is there anything else you would like to tell our listeners about the midface rejuvenation?

DAC: Well, I think that you will see more and more of it coming up. You are already seeing it. If you are like me, you watch TV and if you look at any of the actresses that are older than the age of 40, you will start seeing more volume in the midface and that’s because we are all starting to recognize that that is basically the icing on the cake in facial rejuvenation and it’s not just face lifting itself. So keep a close eye on all the actresses’ midfaces.

SO: Right, as they are aging.

DAC: Right.

SO: Now, we know why they look so youthful, right?

DAC: Right, right.

SO: Great. Okay, well, thank you, Dr. Chen.

DAC: Oh sure.

SO: It’s been a pleasure.

DAC: Well, thank you for having me.