Inadequate projection of the midface skeleton results in midface concavity. Patients with this skeletal morphology tend to have prominent eyes and noses. Lack of skeletal support for the midface soft tissue envelope predisposes to premature cheek descent, resulting in palpebral fissure distortion and lower lid “bags,” an appearance of early aging. Concave midfaces can be made convex with two basic maneuvers performed through intraoral and periorbital incisions. Midface skeletal projection can be increased by augmenting the facial skeleton with alloplastic implants. Multiple implants are required to replicate the complex curvature of the midface skeleton and to avoid impingement on the infraorbital nerve.

Subperiosteal elevation of the midface soft tissues and repositioning provides cheek fullness and narrows the palpebral fissure while masking eyelid “bags.” The resultant midface concavity makes the eyes and nose appear less prominent. This procedure has been a safe and effective treatment for 14 patients treated over a 4-year period.