Why Does My Midface Look Flat? Understanding Midface Projection in Asian Faces

You may notice it most in photographs taken straight on. Or from the side, where the middle of your face seems to sit further back than you expected. You may even have been told you have good cheekbones, and still feel that your face looks flat.

The usual explanation is that the cheeks lack volume. That may not be the reason.

A midface can look flat because the face is broad for its depth, because the area beneath the eyes or beside the nose sits further back than the cheekbone, because the nose and chin come forward less, or because of how the face is lit and photographed. Lack of volume is one possibility among several.

So the first useful question is not how much volume to add. It is what the eye is reading as flat.

What is midface projection?

Midface projection is how far the middle of the face comes forward, in three dimensions, relative to the structures around it.

The midface is the region between the lower eyelids and the upper lip: the cheeks, the area beneath the eyes, the area beside the nose and the base of the nose. Its projection is set mainly by the upper jaw (the maxilla) and the cheekbones (the zygomatic bones), and modified by the fat, muscle and skin over them.

Because projection is a forward dimension, it is easier to appreciate at an angle or from the side than in a mirror, which shows the face from the front.

"Flat midface" is not a medical diagnosis. It is an everyday description of a middle face that seems to come forward less than expected, and on its own it does not say which structure is responsible.

Width, projection and volume are not the same thing

Three words are often used as if they meant the same thing. Anatomically, they describe different dimensions of the face:

• Width: how broad the face is from side to side. At the level of the cheekbones, it is measured between the outermost points of the cheekbone arches, the bars of bone that run back towards the ears.
• Projection: how far a facial structure comes forward, in three dimensions, relative to the structures around it.
• Volume: the amount of soft tissue, such as fat, and where it sits: high or low, forward or to the side.

Because they are separate, a face can be generous in one and modest in another. A face can be wide without being strongly projected. A face can have substantial soft-tissue volume without strong forward projection, if that tissue sits low or to the side.

And adding volume does not necessarily change the structural relationship that made a face look flat. It may, when the volume sits where projection is lacking. It may not, when the flatness comes from width or from a neighbouring feature.

From the front, width combined with modest projection tends to read as flat, because the frontal view shows width more clearly than depth. That is a clinical observation about how faces are read, not a measured finding.

Width is how far a face extends. Projection is how far it comes forward. Volume is what fills it.

This changes the question. "My cheeks are flat" may describe missing volume. It may equally describe a face whose width is easy to see and whose depth is not. At the cheekbone itself, the same distinction separates a prominent cheekbone from a wide one, as High Cheekbones vs Wide Cheekbones explains.

Why can a face with good cheekbones still look flat?

Because projection is read across the whole middle of the face, not at one point. A cheekbone can sit well forward while the structures around it sit further back, and the overall impression can still be flat.

Four neighbouring areas shape how the midface reads. This is a clinical way of organising what is examined, not a validated scientific classification.

Beneath the eyes

The face looks flat or tired beneath the eyes, even where the cheeks are full lower down.

Beneath the eye, a rim of bone supports the lower eyelid and the top of the cheek. Seen from the side, clinicians compare how far the front of the cheek sits relative to the front of the eye. When the cheek sits behind the eye, the relationship is called a negative vector. Clinically, the eye can then look more prominent and the area beneath it less supported.

In a CT study of 224 Japanese adults at one Tokyo centre, the front of the cheek in those aged 20 to 39 sat, on average, slightly behind the front of the eye. The scans were taken lying down, and the finding describes that sample rather than East Asian faces in general. In that sample, the relationship was already present in early adulthood.

How a hollow beneath the eye differs from a bag is covered in Under-Eye Bags Versus Under-Eye Hollowing.

Beside the nose

The cheekbones look fine, but the centre of the face looks sunken, with shadow beside the nostrils.

Beside the nose, the upper jaw curves back towards the bony opening of the nose. In cadaver dissections, Rohrich and colleagues found a deep layer of cheek fat here, part of it against the edge of that opening and part lying directly on the upper jaw. From that anatomy, they concluded that adding volume to this deep layer increases how far the cheek projects forward. That is a conclusion drawn from dissection, not from a treatment study.

When this area sits back, the centre of the midface can look recessed even beneath prominent cheekbones, and the base of the nose can sit in shadow. That is clinical reasoning. The Asian Facial Aesthetics Expert Consensus Group, a panel of clinicians, described recession beside the nose and a concave central midface among the features of the Asian face. The panel said its description includes characteristics of ethnic Koreans and Chinese, and it is an expert description, not a measurement.

The nose and the chin

The face looks flattest from the side.

The midface is seen between the nose in front of it and the chin below it. A nose that comes forward less gives the centre of the face less depth, and a chin that sits further back gives the lower face less, so the same cheeks can read as flatter. This is clinical reasoning rather than a tested finding.

At Singapore General Hospital, Aung and colleagues used three-dimensional scans to measure the noses of ninety East Asian subjects. Compared with values for other groups, these noses were broader relative to their height and had less tip projection relative to their height and width. In a comparison of Korean and European-American adults selected for well-balanced faces, Hwang and colleagues found a less prominent chin in the Korean group. Both describe samples, not individuals. How the profile is read as one line is the subject of What Makes an Asian Face Look Balanced From the Side?

Width

The face looks flat and broad, mainly from the front.

The same forward projection is easier to see on a narrower face than on a broader one, where more of what the eye takes in from the front is width. This is clinical reasoning rather than a measured finding. How facial width is measured, and how photographs change it, is explained in Why Does My Face Look Wide?

A cheekbone can be prominent and the face can still look flat. Projection is read across the midface, not at a single point.

Is a flat midface an East Asian trait?

Not as a rule. Some studies report average differences in facial width between Asian and European samples, and an expert panel has described differences in skeletal projection. That is a different statement from saying that East Asian faces are flat, and the difference matters.

As anatomy, projection depends on where bone and soft tissue sit, and both vary widely between individuals in every population.

In measured samples, the findings are specific. Le and colleagues measured 60 Chinese, 60 Vietnamese and 60 Thai young adults and found greater width across the cheekbones than in 60 North American Caucasians; they measured width, not projection. The Tokyo CT study found the cheek sitting, on average, slightly behind the eye in younger Japanese adults; its comparison with a Caucasian group was too small to support conclusions about differences between populations. The 2016 consensus panel, 21 experts from 11 Asia-Pacific countries, described the Asian skull as wider than the Caucasian skull at the temples, cheekbones and jaw, and as less projected at the front, including beneath the eyes and beside the nose. The panel said that its description includes characteristics of ethnic Koreans and Chinese. It is expert opinion, not a measurement.

Clinically, greater width with less forward projection is the combination described earlier as tending to look flat from the front. That link is interpretation; none of these studies measured how flat a face looks. The same panel also described fuller lips, with the jaws and teeth set further forward, so a face can be flat through the cheeks and still convex around the mouth.

As a matter of preference, whether more projection is desirable is not an anatomical question at all. The consensus panel itself noted that beauty is influenced by customs, traditions and trends.

Two cautions follow. "Asian" is not one face. The Chinese, Malay, Indian, Eurasian and other faces seen every day in Singapore do not share one midface, and the studies here measured Chinese, Japanese, Korean, Vietnamese and Thai samples, with none of Malay or Indian faces. And findings from samples can provide population-level context, but they do not define the appropriate projection for an individual face.

Why can the same face look flat from one angle and not another?

The face looks flat in photographs, and better in person or at an angle.

Because projection is depth, and each view shows depth differently.

The frontal view shows facial width most clearly. Projection is harder to judge from the front, where it is read largely from light and shadow: where the front of the cheek catches the light, and where shadow falls beneath and beside it.

Oblique and profile views make projection, and the relationships between structures, easier to appreciate. At an angle, the midface is seen in outline: a curve that rises beneath the eye, passes over the front of the cheek and turns inward below it. In profile, it is read against the forehead, nose, lips and chin.

Light changes the same contour. Light from directly in front, such as a phone flash or a ring light, fills the shadows by which depth is judged, and a face can look flatter; light from the side models it. That is an observation about how form is seen, not a finding from a facial study. Close-range selfies add a distortion of their own: in one study, they made the nose measure on average about 6% longer than clinical photographs did.

So a face can look flatter in a mirror or a flash photograph than it does at an angle in daylight.

The front view shows width most clearly. Projection is easier to appreciate at an angle.

Does the midface become flatter with age?

The face looks flatter than it did in photographs from ten years ago.

It can change, but not in one uniform way, and the evidence does not all point in the same direction. The studies below compared different people at different ages rather than following one face over time.

In bone, CT studies comparing age groups found a smaller angle at the front of the upper jaw beneath the cheek in older Caucasian and Korean adults, a difference usually interpreted as that part of the bone sitting further back. In a Korean study, the area of the upper jaw beside the nose was more concave in older adults. Differences like these may contribute to a deepening beside the nose over time, although no individual was followed to show it.

Other findings differ. In a separate Korean CT study, Kim and colleagues found no significant difference between people in their twenties and their forties in the angle between the front wall of the upper jaw and the floor of the eye socket. In the Tokyo study, the cheek sat further forward relative to the eye in older age groups, not further back, and its authors suggested that in their Japanese sample, the cheek's position behind the eye was largely present from youth. These studies measured bone or soft tissue in different populations, so they do not all answer the same question.

In soft tissue, the midface does not simply empty. In CT scans of 60 Asian women, the fat beneath the eye and beside the nasolabial fold tended to be thicker in older women. The superficial cheek fat and the inner part of the deep cheek fat tended to be thinner, while the outer part of the deep cheek fat was thicker.

Read together, this suggests a change in relationships rather than a uniform loss. When some areas become fuller while their neighbours thin, the transitions between them change, and the midface can look less evenly projected without having lost volume overall. That is clinical interpretation.

Flatness that has always been there and flatness that has developed are different findings, and earlier photographs can help to tell them apart. Why the midface tends to show change early is discussed in Collagen and the Midface, and the wider sequence of facial ageing in The Architecture of Loss.

Can filler improve midface projection?

Filler can add volume to the midface. Whether that volume reads as projection, and whether the face looks more balanced, depends on where it is placed and on what was making the face look flat.

The two randomised trials cited here, both in Chinese adults, measured volume. In each, hyaluronic acid filler increased midface volume compared with no treatment. In one, midface volume measured on three-dimensional images rose by 1.83 ml against 0.11 ml at six months. In the other, 76% of treated participants and 8% of controls improved by at least one grade on a four-point scale that runs from "fairly full" to "substantial loss, clearly apparent hollowing". Both trials included authors from the filler's manufacturer. Neither was designed to ask whether the face looked more projected in profile, or more balanced as a whole.

That is not a criticism of the trials, which measured what they set out to measure. It is the reason volume and projection should not be treated as the same outcome.

Placement matters. The 2016 Asian consensus panel reported placing filler mainly in the inner part of the cheek and rarely in the outer part, where it could widen a midface that is already wide. That is expert opinion, not a measured outcome. In a face that already looks broad, volume added to the side may make it wider without making it look less flat.

Filler changes soft tissue, not bone. Placed in the cheek, it does not change the nose or the chin. Where flatness comes from beneath the eyes, beside the nose, the profile or the width of the face, the cheek may not be where the answer lies. Filler is a medical procedure with risks of its own.

Volume is measured in millilitres. Projection is read against the face around it.

Two people, one complaint

Consider two people who say exactly the same thing: "My midface looks flat."

The first is in her late twenties. Her face is broad at the cheekbones, and she notices the flatness mostly in photographs taken straight on. Seen at an angle, her cheeks come forward well. What she is noticing may be mainly width, made more visible by the camera.

The second is in his late forties. He notices it in the mirror, as a flatness beneath the eyes and a shadow beside the nose that was not there ten years ago. His facial width has not changed. What he is noticing may be a change in the relationship between the area beneath the eyes, the area beside the nose and the fullness lower in the cheek.

Their words are identical. Their architecture is not. Adding cheek volume would mean something different in each face, and might not change what either of them actually sees. These are illustrations, not case histories.

The table sets out more of the patterns that sit behind the same phrase. It is not a self-test. Many faces combine more than one, and telling them apart takes an examination.

The Asian Facial Architecture™ perspective

Asian Facial Architecture™, Dr. Gan Lee Ping's framework for reading each face against its own structure, starts from a simple observation: flatness is rarely something a single feature lacks. It is something the eye reads across the face.

A flat midface is a relationship, not a quantity.

That changes what an assessment asks. Width, projection and volume are separated before anything else. The midface is then read against the structures around it: the width of the face, the eyes above it, the nose beside it and the chin below it. And what is being noticed is placed in time: whether it has always been part of that face, or has appeared with age. This organises a clinical assessment; it is not a validated scientific classification.

Only then does the question of change arise. The answer may be one well-placed change, a referral, or nothing at all. Adding volume to the cheek addresses one dimension in one place, and the relationship that makes a face look flat may lie elsewhere.

What does a midface assessment look at?

In practice, those relationships are assessed by looking at the face, not by measuring a single feature:

• The face from the front, at an angle and in profile: the front view shows width most clearly, while the angled and side views make projection and the relationships between structures easier to appreciate
• Where the face is widest, and how that width relates to how far the midface comes forward
• Where the front of the cheek sits relative to the eye, and how the lower eyelid meets the cheek
• How deep the area beside the nose is, and how the base of the nose sits
• How far the nose and chin come forward relative to the midface
• Where the soft tissue sits: high or low, forward or to the side
• The face at rest and when smiling, because expression changes the contour of the midface
• Earlier photographs, where they exist, to separate what has always been there from what has changed

Several of these cannot be judged reliably in a mirror or a single photograph. Where the cause is skeletal or dental, a surgeon or an orthodontist may be the right person to see first.

Assessing a flat midface in Singapore

If you recognise yourself in one of the patterns above, or in more than one, the useful next step is not choosing a treatment. It is finding out which relationship you are seeing.

If you are unsure whether it is facial width, loss of projection, soft-tissue distribution or a relationship between several features, an individual assessment can help distinguish them. In assessing the midface in Singapore, Dr. Gan Lee Ping looks at projection in relation to facial width, the eyes, nose and chin, and at whether what the patient is noticing reflects longstanding anatomy or changes that have appeared with age.

Sometimes the answer is one precise change. Sometimes it lies outside the cheek, or with a surgeon or orthodontist. And sometimes the midface is already in proportion for that face, and the most useful finding is to leave it as it is.