title: The Role of Gravity in Periorbital and Midfacial Aging.
abstract: BACKGROUND
  With respect to the pathogenesis of periorbital and midfacial aging, gravity may play a greater role than volume loss.
  
  
  OBJECTIVE
  The authors determined the effect of shifting from the upright to the supine position on specific attributes of facial appearance and ascertained whether facial appearance in the supine position bore any resemblance to its appearance in youth.
  
  
  METHODS
  Participants who showed signs of midface aging were positioned in the upright and supine positions, and photographs were obtained during smiling and repose. For each photograph, examiners graded the following anatomic parameters, using a standardized scale: brow position, tear trough length and depth, steatoblepharon, cheek volume, malar bags/festoons, and nasolabial folds. Some participants provided photographs of themselves taken 10 to 15 years earlier; these were compared with the study images.
  
  
  RESULTS
  Interobserver correlation was strong. When participants were transferred from upright to supine, all anatomic parameters examined became more youthful in appearance; findings were statistically significant. The grading of anatomic parameters of the earlier photographs most closely matched that of current supine photographs of the subjects smiling.
  
  
  CONCLUSIONS
  In the supine position, as opposed to the upright position, participants with signs of midface aging appear to have much more volume in the periorbita and midface. For the subset of participants who provided photographs obtained 10 to 15 years earlier, the appearance of facial volume was similar between those images and the current supine photographs. This suggests that volume displacement due to gravitational forces plays an integral role in the morphogenesis of midface aging.
authors.affiliation: Dr Mally is a clinical instructor, Department of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania.
authors.forename: Pooja
authors.initials: P
authors.lastname: Mally
authors.affiliation: Dr Czyz is an assistant professor, Division of Ophthalmology, Oculofacial Plastic and Reconstructive Surgery Section, Ohio University/OhioHealth Doctor's Hospital, Columbus.
authors.forename: Craig N
authors.initials: CN
authors.lastname: Czyz
authors.affiliation: Dr Wulc is a clinical instructor, Department of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania; an associate professor, Department of Ophthalmology and Otolaryngology, Abington Memorial Hospital, Abington, Pennsylvania; and an associate professor, Scheie Eye Institute, University of Pennsylvania, Philadelphia awulcmd@gmail.com.
authors.forename: Allan E
authors.initials: AE
authors.lastname: Wulc
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000375:Aging; D059925:Anatomic Landmarks; D005145:Face / Q000033:anatomy & histology*; D005260:Female; D006112:Gravitation; D006801:Humans; D008875:Middle Aged; D015588:Observer Variation; D056888:Patient Positioning; D010781:Photography; D015203:Reproducibility of Results; D012904:Smiling; D016683:Supine Position
keywords: facial aging; midface; periorbita; soft-tissue descent; volume loss