Doctor Isaac Wong > Blog > Ellanse > Mid-Face Aging – Where It All Starts

Mid-Face Aging – Where It All Starts

mid face aging

The mid-face is one of the biggest tell-tale areas when it comes to aging

Where is the mid-face? It’s anywhere between the level of the eyes to the level of the upper lip area. When we meet any stranger, our eyes automatically zoom onto the mid-face area after we have had a glance of the whole face – to subconsciously grade the person’s age, as that’s where the tell-tale signs of aging appear first.

mid face aging

Prominent cheeks in ladies are associated with youth, fertility and attractiveness (studies have shown that ladies with full, round, rosy cheeks have high levels of estrogen, and more likely to be fertile). When ladies are young, they have rosy, round, full cheeks. Just name any Asian actress and she most likely has rosy, round cheeks or 苹果肌. Some of them may be natural, but most of them have a fantastic aesthetic doctor/surgeon. Except Madonna’s. Madonna’s cheeks are over-filled, aka Pillow Face aka Overfilled Face Syndrome. Madonna’s face is a good reason why any lady needs to visit a skilled aesthetic doctor/surgeon to perform cheek fillers treatments.

Madonna when she was younger (left), as compared to Pillow Face or Overfilled Face Syndrome seen in recent years (right)
Madonna when she was younger (left), as compared to Pillow Face or Overfilled Face Syndrome seen in recent years (right)

The tell-tale signs of aging in the mid-face are:

  1. Obvious tear trough
  2. Sunken cheeks and cheekbone area
  3. Saggy cheek fat
  4. Deep Smile Lines (Nasolabial Folds)

Obvious Tear Trough

When we age, we start to lose fat, collagen and volume in the mid-face. It starts from around the eyes and progresses downwards to the cheeks. Loss of volume around and just below the eyes causes the tear trough line to become obvious and show up. You may not know what the tear trough is but you have probably heard of that phrase, “tired-looking eyes”. Obvious tear trough lines give us that ‘tired-looking’ look below the eyes.

Classification of the Tear Trough Deficiency

Sunken Cheeks/Cheekbones

The area at the cheeks and the cheekbones also begin to lose fat and volume, becoming flat looking. This is especially common in Caucasians – even young Caucasian ladies may tend to have a flat cheek/cheekbone area. That’s not to say that if you are chubby, you will not have this issue. Asian chubby ladies may also have this issue as the fat cheek sags downwards, leaving the immediate undereye to cheek/cheekbones area sunken.

Sunken cheeks give an aged look
Sunken cheeks give an aged look

Saggy Cheek Fat(Mid-Cheek Fat Pad Descent)

When we are young, our cheek fat stays firm and perky and stays around the apex of the cheek (around 1.5cm downwards from the outer corner of the eyes). As we age, the support for this mid-cheek fat pad worsens and thus it starts to slide downwards and also towards the nose.

aging midface

Prominent Smile Lines

At the same time, our skin also starts to lose elasticity due to slowed production of collagen to replace the lost collagen in the skin. It is also less hydrated. Thus, it becomes wrinkly-looking and lacks shine. As a result, the skin at the cheeks sags and is unable to stay in its original place. The remaining fats in the middle of the cheek slide downwards together with this lax skin as well, causing very prominent smile lines to form due to an ‘’overhang’’ effect. The smile lines also lose a lot of fat and collagen, worsening the issue.

Formation of Prominent Smile Lines (Naso-labial Folds aka NLF) as we age
Formation of Prominent Smile Lines (Naso-labial Folds aka NLF) as we age

Options available to treat the signs of aging in the mid-face

There’s no 2 ways about it – treating the signs of aging as listed above will require the treating of 2 main issues:

  1. Loss of Volume
  2. Fat Pad Descent

Treating Loss of Volume

How do we treat loss of volume in the mid-face? Restore the volume!

This usually consists of an injection of either hyaluronic acid, collagen-stimulating fillers or fat grafts into the area. My personal favourites are Collagen-Stimulating Fillers e.g Radiesse or Ellanse. (Hyaluronic Acid Fillers do not stimulate much collagen and leaves no collagen behind after 9-18 months; Sculptra may have varying results from patient to patient; Fat grafts involves liposuction surgery and has a very swollen effect for months).

The injection has to be skilfully done by placing the injected product/fat very deep, either on the cheekbones, or in the deep fat area. Superficial placement will result in a high chance of having a ‘lumpy’ cheek appearance. Also take note not to over-fill the cheeks or one will end up like Madonna and have a pillow-face (as seen in the earlier part of this post)!

Fillers / Fat Graft injected too near the surface gives an obvious weird-looking lump at the cheeks
Fillers / Fat Graft injected too near the surface gives an obvious weird-looking lump at the cheeks

Treating mid-cheek fat pad descent

Again, the answer is quite instinctive. To re-position the fat pad to where it’s supposed to be!

For mild sagging of the mid-cheek fat pad, high G prime fillers like Radiesse, Ellanse, Perlane can help to give it a lift.

For more severe sagging of the fat pads, the fillers are best combined with Silhouette Soft or Korean Threadlifts. The threads have suspension powers to reposition the fat and skin back to where they were supposed to be.

contours of the face


The first signs of aging start from the mid-face and the changes spread downwards. It is prudent to ALWAYS ADDRESS THE CHEEKS AGING FIRST, and not to treat the nasolabial folds, jowls, marionette lines as first measure. Doing otherwise will result in wastage of product with poor aesthetic results. Knowledge of anatomy is extremely important.

Take Note: A good aesthetic doctor/surgeon will not touch the nasolabial folds, jowls, marionette lines before treating the cheek area.

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