38, F, midface descent on profile - blepharoplasty or midface lift first? (Photos)

Question

38F, 5'4", slim/thin-faced, Raleigh NC. I'm attaching a profile photo which shows my main concern — flat midface where cheek projection has dropped. Front photos look relatively normal but the profile shows the soft tissue descent clearly. Background: I have a history of bad filler placement— cheek filler made me look overfilled and "Handsome Squidward," and midface filler in 2022 caused a puffy shelf effect. I dissolve well but my face reacts dramatically to any volume. I've done Botox (forehead/11s) with good results. I also have upper eyelid hooding affecting my outer corners — I can no longer do winged liner as it looks droopy. My questions: 1) Based on profile, am I a candidate for endoscopic midface lift at 38 given my filler history? 2) Would you prioritize blepharoplasty over midface work given my profile? 3) Would you consider fat grafting instead of filler for my face type? I want to avoid anything that causes facial fat loss (so cautious about Ultherapy/Morpheus8). Sculptra also concerns me due to irreversibility.

Pasha Mostofi, MD, DMD · Answer

You’re asking very thoughtful questions, and your concerns make sense given your past experiences with filler. From what you’ve described, the core issue sounds like midface descent (loss of cheek support and projection), with the eyelid heaviness being a secondary effect of that. In cases like yours, addressing the foundation first, the midface, often leads to a more natural and balanced improvement overall. A subtle midface lift can restore cheek position and support the lower eyelid area, which may even reduce the need for aggressive eyelid surgery or change how much is needed.
Blepharoplasty can certainly help with the outer upper eyelid hooding you mentioned, but if done alone without addressing the descent below, it can sometimes make the midface hollowing more noticeable. That’s why many surgeons would either start with the midface or combine conservative eyelid work with midface repositioning, depending on your anatomy and goals.
Given your history of not tolerating filler well, your hesitation is completely valid. Fat grafting can be a good alternative in the right hands, it tends to look softer and more natural, but it’s still volume, and in very thin faces it needs to be done conservatively. The advantage of a lift is that it repositions what you already have rather than adding bulk, which may suit you better.
Overall, based on your description, I would lean toward prioritizing structural support (midface lift) first, then fine-tuning the eyelids if needed. The best plan, though, comes from an in-person exam where skin quality, ligament laxity, and eyelid anatomy can be assessed together. Hope this helps!

38, F, midface descent on profile - blepharoplasty or midface lift first? (Photos)

Answers (1)

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