Facelift, Mid Face

Author: Adam J Cohen, MD, Eyelid and Facial Aesthetic and Reconstructive Surgery,
Diseases and Surgery of the Orbit and Lacrimal System, Cosmetic Laser Surgery
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Introduction
)he mid face is the area lying bet*een the bicanthal and oral commissure. )he mid face is one of
the first facial areas to sho* signs of aging. Individuals in their early /&s may have descent of
the malar fat !ad0 this may lead to the formation of infraorbital dar1 circles and dee!ening of the
nasolabial and naso2ugal 3tear trough4 creases. )hese changes occur earlier in the !resence of
!oor bony su!!ort and midface retrusion.
During the !ast '5 years, several techni6ues have been described to s!ecifically address the mid
face, since this area is not addressed *ith standard cervicofacial rhytidectomy. (resently,
restoration of chee1 contour and volume can be achieved by !erforming a sub!eriosteal,
vertically oriented lift *ith inde!endent sus!ension of the various chee1 structures. )he lift can
be !erformed *ith small and hidden incisions and su!!lemented *ith a chee1 im!lant if deemed
necessary.
History of the Procedure
Early in the authors7 !ractice, an e8tended o!en sub!eriosteal facelift *as !erformed, and the
intermediate tem!oral fascia 3see image belo*4 *as used to anchor the mid face. )o better
elevate the chee1, the sus!ension !oint *as changed to the suborbicularis oculi fat 3SOOF4.
)hese techni6ues usually *ere !erformed through a full ble!haro!lasty incision, but this resulted
in an unacce!table level of eyelid retraction.
Midface facelift !he dissection over the "y#omatic arch $%A& is challen#in# due to the
'ro(imity of the frontal )ranch of the facial nerve $F*& Dissection starts over the tem'oral
fascia 'ro'er $!FP& and 'roceeds inferiorly and anteriorly over the intermediate tem'oral
fascia Just )efore reachin# the "y#omatic arch, the fascia is incised and the intermediate
tem'oral fat 'ad $IFP& is divided !he IFP is raised in continuity with the 'eriosteum
overlyin# the %A !he masseter muscle $MM& is divided in line with its fi)ersJust a)ove
the 'lane of dissection lie the F* and the su'erficial tem'oral fascia $+!F& Directly
)eneath the 'lane of dissection lie the !FP and its underlyin# tem'oralis muscle !he dee'
tem'oral fascia $D!F& overlies the dee' tem'oral fat 'ad $DFP& !he lar#e arrow
re'resents the direction of dissection !he 'arotid #land is indicated )y P,
9 CLOSE :I;DO: <
Midface facelift !he dissection over the "y#omatic arch $%A& is challen#in# due to the
'ro(imity of the frontal )ranch of the facial nerve $F*& Dissection starts over the tem'oral
fascia 'ro'er $!FP& and 'roceeds inferiorly and anteriorly over the intermediate tem'oral
fascia Just )efore reachin# the "y#omatic arch, the fascia is incised and the intermediate
tem'oral fat 'ad $IFP& is divided !he IFP is raised in continuity with the 'eriosteum
overlyin# the %A !he masseter muscle $MM& is divided in line with its fi)ersJust a)ove
the 'lane of dissection lie the F* and the su'erficial tem'oral fascia $+!F& Directly
)eneath the 'lane of dissection lie the !FP and its underlyin# tem'oralis muscle !he dee'
tem'oral fascia $D!F& overlies the dee' tem'oral fat 'ad $DFP& !he lar#e arrow
re'resents the direction of dissection !he 'arotid #land is indicated )y P,
)he access incision then *as modified to a cro*7s foot incision, s!reading the orbicularis oculi at
the site of the incision *ithout disru!ting the muscle. )he orbital se!tum *as not violated. )he
infraorbital fat only *as resected in !atients *ith obvious !ro!tosis 35= of !atients4. :ith these
modifications, no !ermanent ectro!ion or eyelid mal!osition *as observed.
)he authors no* have eliminated the need to !erform any !eriocular incision. )he !eriosteum is
raised over the entire anterior malar area and the anterior t*o thirds of the >ygomatic arch.
)unnels are made over the >ygomatic arch, and inde!endent suture sus!ension of the SOOF,
inferior malar soft tissues, and ?ichat fat !ad is !erformed.
-tiolo#y
As individuals age, the bony s1eleton and soft tissues of the face lose volume, !roducing a
slightly *ider orbital a!erture and less anterior !ro2ection. )his decreases the overall !ro2ection
of the chee1 and diminishes bony su!!ort for the overlying soft tissue structures. )he !rese!tal
orbicularis oculi muscle loses tone, resulting in herniation of the intraorbital fat.
(tosis of midfacial adi!osity e8!oses the inferior orbital rim. Further descent of chee1 fat and
se!aration from the suborbicularis oculi fat 3SOOF4 can be heralded by a faint diagonal groove
in the infraorbital area !arallel to the nasolabial crease. Furthermore, descent of the ?ichat fat
!ad over the u!!er mandible can increase lo*er facial 2o*ling.
Indications
,id face lifting has the follo*ing aesthetic and reconstructive a!!lications"
Reversal of aging changes
Increasing the antero!osterior chee1 dimensions
Correction of asymmetries
Recruitment of anterior lamellar tissue of eyelid for eyelid mal!osition, cicatricial
changes, and reconstruction
Camouflage of im!lant materials for ma8illary augmentation
In all !atients, the suborbicularis oculi fat 3SOOF4 is sus!ended to the tem!oralis fascia !ro!er
3)F(4. )he sus!ension of the inferior malar soft tissues to the tem!oral fascia has some
imbrication effect, tending to increase the antero!osterior dimension of the chee1. If this is not
desirable, then this lo*er malar soft tissue suture is not !laced.
)he ?ichat fat !ad is a relatively mobile structure. It is a vasculari>ed fat !ad, *hich may be
moved to the area of !erceived deficit. For e8am!le, !atients *ith a *ide bigonial distance and a
smaller bi>ygomatic distance may benefit aesthetically from lateral !lacement of the fat !ad.
)hose *ith a malar deficit, *hich is more anterior, may benefit from anterior !lacement of the
fat !ad, *hereas the !atient *ith an obese or full face and a *ide bi>ygomatic distance may
benefit from removal of the fat !ad. )he fat !ad may be !laced over a chee1 im!lant, thus
disguising the edge of the im!lant and decreasing its !al!ability. Its sus!ension or removal
significantly im!roves the u!!er e8tension of 2o*ling. Autologous fat grafting is fre6uently used
as an ad2unct.
.elevant Anatomy
)he sub!eriosteal !lane is relatively bloodless and straightfor*ard to dissect. Chance of in2ury to
the facial nerve is minimal, although if a lo*er eyelid a!!roach is ta1en the infraorbital nerve
can be damaged.
)he suborbicularis oculi fat 3SOOF4 is a fibrous !ortion of se!tate, thic1 fat located at the
inferolateral 6uadrant of the orbital rim. )he SOOF descends as one ages because the lateral
canthus descends so that it comes to lie at a level inferior to that of the medial canthus. )his
dysto!ia leads to less lateral su!!ort and inferior and medial dis!lacement for the orbicularis
oculi muscle and *ea1ening of the orbital se!tum. )he result is !artial !rola!se of the !osteriorly
located SOOF.
)he buccal fat !ad is an enca!sulated structure. It has subunits e8tending to the buccal,
!terygoid, !arotid duct, and dee! tem!oral areas. )he !ad *eighs a!!ro8imately @ g in adults
and receives its main blood su!!ly from the ma8illary artery.
)he motor nerve su!!ly to the orbicularis muscle is mainly through the >ygomatic branches of
the facial nerve. )ransection of the orbicularis muscle during standard ble!haro!lasty leads to
denervation of the !retarsal !ortion of this muscle, *hich may be !ermanent, *ith resultant
eyelid retraction. Sensory innervation of the infraorbital and midfacial region is su!!lied by the
infraorbital and >ygomaticofacial nerves.
)he !ath of dissection ta1en to raise the !eriosteum of the >ygomatic arch starts over the
tem!oral fat !ad 3)F(4. )raveling inferiorly, the intermediate tem!oral fascia is crossed, *ith the
yello*+colored )(F beneath. )his !lane is continued until %+/ mm su!erior to the >ygomatic
arch. At this !oint, the intermediate tem!oral fascia is !ierced, raising the intermediate tem!oral
fascia and immediately the !eriosteum of the >ygomatic arch. )hese act as a cushion for the
frontal branch of the facial nerve.
?eneath the su!erficial musculoa!oneurotic system 3S,AS4 lies the !arotid gland. In the same
!lane as the !arotid gland, the facial nerve travels to*ard the tem!le 2ust beneath the
tem!oro!arietal 3su!erficial tem!oral4 fascia. In the >ygomatic arch and tem!oral region, a small
fat !ad is !resent beneath the su!erficial tem!oral fascia. )his is termed the su!erficial tem!oral
fat !ad. In the same !lane as the masseter muscle lie the >ygomatic arch and the intermediate
tem!oral fat !ad.
At the >ygomatic arch, *hat *as the masseter fascia belo* becomes the !eriosteum of the
>ygomatic arch and above it the intermediate tem!oral fascia. In other *ords, these / structures
are in the same surgical !lane. ?eneath the intermediate tem!oral fat !ad lies the dee! tem!oral
fascia, and beneath it lies the dee! tem!oral fat !ad. )herefore, beneath each tem!oral fascia lies
its corres!onding tem!oral fat !ad.
)he frontal nerve crosses the >ygomatic arch in its middle third at a !oint a!!ro8imately half*ay
bet*een the lateral canthus and the tragus. Dissecting the anterior and !osterior thirds of the arch
before dissecting the middle third is safest. )he tem!oral region contains / veins that
communicate bet*een the su!erficial and dee! systems, numbered tem!oral veins ', %, and /
from su!erior to inferior. )em!oral vein ' is located near the region of the >ygomaticofrontal
suture, tem!oral vein % is situated inferior and !osterior to the lateral canthus, and tem!oral vein
/ is located around the middle of the >ygomatic arch. )he >ygomaticotem!oral nerve may be
seen to either side of vein %.
Contraindications
)his !rocedure is contraindicated in !atients *ith !revious >ygomaticoma8illary fractures and
!atients *ith unrealistic e8!ectations.
!reatment
Preo'erative Details
Analy>e the mid face for asymmetries. ;ote the !osition of the lateral canthi, the amount
of anterior and lateral !ro2ection of the chee1, the de!th of the nasolabial creases, and the
volume of ?ichat fat !ads.
Determine *hether most of mid facial volume deficit lies laterally, medially, or in the
submalar region. )he fat !ads then can be !laced to address the deficient area and
im!rove asymmetry.
Determine if allo!lastic im!lants are needed.
A !hotogra!h of the !atient at a younger age is useful so the age+related changes can be
demonstrated to the !atient 3eg, !tosis of the lateral canthus, chee1 fat !ad, dee!ening of
the nasolabial fold, formation of the 2o*l, atro!hy of facial fat4. Aenerally s!ea1ing, the
younger !atient is more acce!ting of a higher lateral canthus and !sychologically can
acce!t a more radical change than an older !atient.
)a1e !reo!erative !hotogra!hs.
(reo!eratively, mar1 the !atient7s >ygoma8illary !oint defined as the !oint *here a
vertical line through the lateral orbital rim intersects the Fran1fort hori>ontal. )his is
usually the region of greatest !ro2ection in a !atient seen in a /+6uarter vie*.
,ar1 the nasolabial creases and the !osition of the ?ichat fat !ad and note asymmetry of
the mid face.
Intrao'erative Details
(re!are the !atient7s face. (re!are the mouth *ith !ovidone+iodine solution 3?etadine4
and in2ect the midface area *ith lidocaine &.5= *ith e!ine!hrine '"%&&,&&&.
,a1e a '%+mm tem!oral incision % cm behind the tem!oral hairline. )he central as!ect of
the incision lies !er!endicular to a line through the nasal ala and lateral canthus.
Identify and incise the su!erficial tem!oral fascia. )his is retracted by the assistant, and
dee! to this is an Bangel hair !astaB !lane 3subgaleal fascia4. )his area can be s!read
easily *ith the scissors, and dee! to this lies the )F(. A ;o. C !eriosteal elevator can be
used to e8!ose the )F( circumferentially.
Insert a !lastic !ort !rotector into the incision. If the need for a large vertical lift has been
determined !reo!eratively, then the dissection also is carried su!eriorly to*ard the
tem!oral line of fusion.
Enter the sub!eriosteal !lane at the tem!oral line of fusion *ith a ;o. D !eriosteal
elevator. )hen carry the dissection to*ard the mid line of the s1ull.
;e8t, continue the dissection to*ard the >ygomaticofrontal suture and do*n to*ard the
arch. After several centimeters of dissection, *ith the )F( lying beneath the dissector, a
color change is noted as the dissector !asses over the intermediate tem!oral fascia *ith
its underlying intermediate tem!oral fat !ad.
A!!roaching the >ygomaticofrontal suture, use a >ero elevator. )his has a rounded ti!
and does not damage the veins and nerves found in this area. (erform gentle dissection in
this area to isolate tem!oral vein '. )his vein often is divided. )raveling inferiorly along
the lateral orbital rim, vein % 3sentinel vein4 is encountered. )his is a large vein and
should be !reserved. Inferior to this, the >ygomaticotem!oral nerve may be found.
Once the anterior one third of the >ygomatic arch has been dissected, attention then is
turned to the !osterior one third. )his also is dissected through the tem!oral incision
using a ;o. @ elevator and traveling over the intermediate tem!oral fascia to 2ust above
the >ygomatic arch.
Lastly, dissect the middle one third in the same !lane. A!!ro8imately %+/ mm above the
>ygomatic arch, incise the intermediate tem!oral fascia using this !eriosteal elevator.
Raise this intermediate tem!oral fascia and some of the intermediate tem!oral fat !ad
su!eriorly.
Dissection continues in the !lane of the intermediate tem!oral fat !ad to the >ygomatic
arch. )hen, raise the !eriosteum of the >ygomatic arch u!*ard. )his !rovides a cushion
to the frontal nerve consisting of the intermediate tem!oral fascia and a !ortion of the
intermediate tem!oral fat. Several *indo*s can be made in this !lane through the
>ygomatic arch !eriosteum and into the masseter muscle lying belo*.
Dissect tunnels bet*een the >ygomaticotem!oral nerve and tem!oral vein /. Eein / is
found at a!!ro8imately the 2unction of the middle and !osterior thirds of the >ygomatic
arch.
At this !oint, the dissection of this area is halted. (lace e!ine!hrine+soa1ed !ledgets in
this region through the tem!oral incision and turn attention to the gingivobuccal sulcus.
Again !re!are the mouth *ith !ovidone+iodine solution and ma1e an inverted BEB
incision over the first !remolar tooth.
Incise the underlying muscle and use a ;o. @ !eriosteal elevator to elevate the !eriosteum
shar!ly and in a single !lane.
Continue this dissection almost to the !yriform a!erture and su!eriorly u! to the inferior
orbital rim. )his dissection can be !erformed *ithout the aid of the endosco!e u! to
malar bone.
)o dissect the >ygomatic arch, using an endosco!e and one of a series of narro* curved
!eriosteal elevators 3Ramire> ,inus Series4 is necessary. sing these !eriosteal
elevators, elevating the !eriosteum of the entire length of the >ygomatic arch *ithout a
!eriocular incision is !ossible.
Continue the dissection slightly inferiorly to raise the masseter fascia from the masseter
muscle for a!!ro8imately %+/ cm. )his is !erformed to allo* for a vertical translation of
the su!erficial soft tissues.
Redra!ing or removal of the orbital fat is !erformed at this time if indicated. )his also is
!erformed through the gingivobuccal incision. se a ;o. C !eriosteal elevator to dissect
the !eriosteum u! and over the inferior orbital rim.
At this !oint, the intraorbital fat can be identified, and the middle and lateral
com!artments carefully are freed *ith a s!reading motion using endosco!ic scissors.
Light !ressure on the globe !ermits !rola!se of these fat !ads. )hey then may be sutured
over the rim to the malar !eriosteumFSOOF using C+& !olydio8anone 3(DS4 suture.
(lace a suture in the SOOF through the gingivobuccal sulcus. ?ecause it is thin at this
!oint, and the suture may cause a dim!le, it is im!ortant to avoid gras!ing too su!eriorly
in the SOOF. )he authors !refer to !lace the suture at or slightly inferior to the
>ygoma8illary !oint and use /+& (DS suture. Feed the free ends of this over the
>ygomatic arch and e8it the tem!oral incision.
)he ne8t structure to be sus!ended is the inferior malar soft tissue. )his is a flimsy
structure, *hich is gras!ed in a tangential *eaving motion *ith C+& (DS. Of im!ortance,
do not include the multi!le small branches of the long buccal nerve. )rauma to these
branches may result in some !aracommissural numbness. ?oth free ends of this suture
also are !assed over the >ygomatic arch and e8it the tem!oral incision. )his suture lies
su!erior and medial to the SOOF sus!ension suture.
If a deficit is noted in the region of the malar bone or the submalar area, then the buccal
fat !ad may be released and re!ositioned to these areas. If additional augmentation is not
re6uired in the malar or submalar areas, the fat !ad may be released or resected as
necessary.
)he fat !ads may be reached through the same intraoral incision by dissecting bet*een
the !eriosteum and buccinator muscle. Aentle teasing of the buccal fat !ad can be
!erformed using t*o smooth+ti!!ed bayonet force!s. )he fat !ad can be teased gently
from the overlying fascia. Im!ortantly, do not tear the connective tissue covering of the
fat !ad *hile !erforming this maneuver. )his connective tissue carries the blood su!!ly
to the fat !ad and gives it structural integrity to su!!ort the sutures !laced in it.
Once the fat !ad has been released, it herniates. If it is to be removed, it may be clam!ed
and am!utated using cautery. If it is to be sus!ended, then a C+& (DS suture is *oven
through the connective tissue overlying the fat !ad and the fat itself.
(lacement of the free ends of this suture de!ends on the aesthetic goal. If more lateral
fullness is re6uired, !ass the suture over the >ygomatic arch medial and su!erior to both
other sutures. If more anterior fullness is desired, the suture holding the fat !ads may be
1notted around the suture holding the SOOF.
Retract the tem!oral incision inferiorly and suture the / sutures to the )F( in a !osition
inferior and anterior to the incision.
(lace the SOOF sus!ension suture most laterally and !lace the buccal fat !ad suture most
medial and su!erior. (lace the suture that sus!ends the inferior malar soft tissues bet*een
these t*o.
:hen !erforming the !rocedure on the second side, tension can be ad2usted as the sutures
are being tied to achieve symmetry *ith the first side.
?utterfly drains connected to Eacutainer tubes are !laced on either side through a
se!arate !uncture incision. Direct the free end of the drain over the >ygomatic arch and
into the mid face. )hen sus!end the su!erficial tem!oral fascia su!eromedially to the
)F(.
)he scal! is retracted in a su!eromedial direction by an assistant *hile the anterior edge
of the su!erficial tem!oral fascia is sutured. (lace t*o sutures of C+& (DS. Close the s1in
*ith interru!ted C+& gut sutures. (rior to closing the mouth incision, irrigate the cavity
*ith saline and then *ith antibiotic+containing solution.
)he E+sha!ed incisions are advanced su!eriorly and closed in a BGB configuration. )he
authors use C+& chromic hori>ontal mattress sutures. )his has the effect of everting the
*ound edges, creating a valve system and decreasing the !robability of saliva entering
*ithin the *ound.
Fat grafting is often used to augment facial volume or to correct asymmetry.
Posto'erative Details
Iced saline s!onges are a!!lied to the area %& minutes on and %& minutes off for the first
CD hours.
Advance the drain at %C hours and remove it at CD hours.
Continue !osto!erative antibiotics for 5 days.
As1 the !atient to avoid s*ishing li6uids and brushing the u!!er teeth, since this may
cause !articles and saliva to enter the gingivobuccal incision.
Instruct !atients to clean the incision *ith !ovidone+iodine solution s*abs t*ice daily for
' *ee1.
As1 !atients to 1ee! their heads elevated at all times and to avoid heavy che*ing for the
first *ee1. Li6uid and soft foods are given during this time.
Com'lications
)his is a safe !rocedure *ith fe* com!lications. ;o !ermanent instances of frontal nerve !alsy
have occurred. One e!isode of tem!orary inferior orbital !araesthesia occurred due to irritation
caused by a small hematoma ad2acent to the nerve. Infection is rare and tends to occur in !atients
in *hom an im!lant has been !laced. ?eaded nylon im!lants 3(ore84 are !laced in the
sub!eriosteal !lane. :hile these im!lants are more technically difficult to !lace, they do not
have !roblems *ith local tissue reactions and ca!sule formation. In addition, *hen these
im!lants become infected, they can be salvaged by o!ening the gingivobuccal sulcus and
irrigating the cavity *ith antibiotics. nli1e silastic im!lants, no bony erosion is associated.
Outcome and Pro#nosis
)he authors have !erformed the endosco!ic midface lift since '@@/. )his o!eration can !roduce
reliable and re!roducible results and can im!rove the tear trough, refine the !ro2ection of the
chee1, elevate the 2o*ls, and lift both the corner of the mouth and the lateral canthus of the eye.
Asymmetry of the chee1 mound also can be addressed by !lacing a larger volume of ?ichat fat
!ad to the smaller chee1. Fine+tuning of this area and of the nasolabial crease also can be
accom!lished using fat+grafting techni6ues.
For additional relevant images see the authors7 :eb site Scarless Facelift or the authors7 other
e,edicine article Facelift, Sub!eriosteal.
Future and Controversies
:hile this !rocedure is very a!!ealing to the !atient 3addressing the chee1 mound through %
small nonvisible scars4, it may not be as a!!ealing to the surgeon because of the stee! learning
curve. Once mastered, the techni6ue is safe and reliable. It is technically more challenging than
the endosco!ic forehead lift. Although it involves dissection millimeters a*ay from the frontal
branch of the facial nerve, it is much safer than the intermediate !lane techni6ues.