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Mally et al1 have examined subjects in an upright and supine position, smiling and in repose. Observing that many of the signs of aging—cheek flattening, prominent nasolabial folds, malar bags, tear troughs, and steatoblepharon—were reduced by lying supine (recumbent) and smiling ( P = .0001), they conclude that the effects of gravity must therefore have caused these aging signs. They contend that because altering the direction of gravity’s pull by 90 (not 180) degrees makes the face look improved, the force of gravity must have created these changes of aging.If the question at hand is the effect of gravity and its reversal on the soft tissues of the midface, then one would expect to compare the upright face with the upside-down face. If so, there is a clear gravitational opposite, a model that might shed some light or at least some informed discussion on the question. By placing the patient in a recumbent position, the force of gravity pulls posteriorly on the face. This is an altogether different proposition.The soft tissues of the face are quite mobile2; a finger can push the skin of the face in ovals of various sizes, regardless of age. In an upright position, the face generally sits at its lowest limits of excursion, except for over the jowl, where there might be a few millimeters of give. When recumbent, the soft tissues slide posteriorly, much as a breast will slump laterally when supine.3 It is no accident that the authors found that the smile as well as recumbency had similar effects on the face. By the vagaries of evolution, the smile muscles have …

Commentary on: The Role of Gravity in Periorbital and Midfacial Aging