Clinical Decision-Making
in the Midface
FOAD NAHAI
CHAPTER 35
F
or most individuals, aging of the lower lid and midface is intrinsically interre-
lated; therefore the best treatment options rejuvenate both areas. There are many
surgical and nonsurgical options for rejuvenation of the midface. The role of in-
jectable fillers and fat continues to evolve but for most of us, rejuvenation of the mid-
face is a surgical procedure.
Restoration of volume and repositioning of the malar fat pad is the foundation of
midface rejuvenation. Approaches for surgical elevation of the malar fat pad include
the following:
Temporal approach
Transpalpebral approach
Standard or modified face-lift approach
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Part VII Midfacial Rejuvenation
Although all of these approaches elevate the midface, with the exception of the
transpalpebral approach, the vector is usually diagonal. A true vertical vector of el-
evation is achieved only through the lower lid.
Temporal Approach
The temporal approach entails an incision in the temporal area and endoscopic dis-
section into the midface. Elevation and fixation of the midface are accomplished
through long suspension sutures or fixation devices, such as the Endotine device (see
Chapter 38).
Transtemporal
Eyelid
Face-lift incision
The advantage of the temporal approach is that the scar is well hidden within the
hair. It is effective for elevating the midface (malar fat pad) and affords some blending
of the lid-cheek junction. However, it only produces a diagonal vector for elevation
of the midface and does not address aging of the lower lid or of the lower face. The
temporal approach is best for individuals with isolated midface aging. It can be com-
bined with blepharoplasty and a lower face lift in individuals with panfacial aging.
Transpalpebral Approach
This approach affords not only a diagonal vector but also the only true vertical vec-
tor for elevation of the midface, combined with lower lid rejuvenation. The major
concern about this approach involves lower lid retraction. The approach can be mod-
ified to minimize the risk.
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Chapter 35 Clinical Decision-Making in the Midface
If manipulation of the lower eyelid fat is planned, a full-length skin-muscle incision
is made and the skin-muscle flap elevated for access to the periorbital fat. The risk
of lid retraction is minimized through the routine application of lid-anchoring tech-
niques and a diagonal vector on the orbicularis oculi muscle to add extra support
to the lower lid in addition to the aesthetic improvement.
Muscle
sutured
to deep
temporal
fascia
Muscle
sutured
to deep
temporal
fascia
If fat manipulation is not planned, a very limited incision is made laterally in the or-
bicularis, and midface mobilization is accomplished either with an endoscope, a
headlight, or a small lighted Aufricht retractor. This alternative approach in which
the orbicularis is not divided along the entire length of the lid carries a lower risk
of lid retraction while offering the same vertical and diagonal vectors as the full open
approach.
Face-Lift Incisions
Through the standard face-lift incision or the modified prehairline incision, the SMAS
is easily accessed and can be manipulated to elevate the midface.
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Part VII Midfacial Rejuvenation
Surgical Options
The high SMAS technique
The extended MACS lift
SMASectomy and SMAS plication
Fixation vectors
The High SMAS Technique
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Chapter 35 Clinical Decision-Making in the Midface
The incision in the SMAS at or above the level of the zygomatic arch combined with
adequate mobilization of the SMAS facilitates effective elevation of the midface and
malar fat pad with blending of the lid-cheek junction in a diagonal direction. When
performed in isolation, it is not effective in dealing with the aging lower lid; it does,
however, reliably rejuvenate the midface, lower face, and jaw line.
The Extended MACS Lift
The third and highest of the purse-string sutures described with the extended MACS-
lift (see Chapter 42) effectively and diagonally elevates the midface with some blend-
ing of the lid-cheek junction. Tonnard and Verpaele combine this procedure with a
skin pinch blepharoplasty to rejuvenate the aging lower lid.
Horizontal
release to
zygomatic
retaining
ligaments
Oblique loop
Vertical loop
Malar loop
Mobilization for complete cheek
and eyelid rejuvenation
Mobilization for jowls
and neck only
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Part VII Midfacial Rejuvenation
SMASectomy
The upper part of the diagonal SMAS, when excised and sutured or plicated, does
effectively elevate the midface with some blending of the lid-cheek junction. To fully
rejuvenate the lower eyelid, the surgeon must perform a blepharoplasty to deal with
the eyelid, skin, and orbicularis muscle.
Choosing the Best Option
For patients who require a blepharoplasty to address the skin, orbicularis muscle,
and fat pads, the transpalpebral route offers midface lifting and full rejuvenation of
the lower lid. If the lower lid rejuvenation requires only lid-cheek blending without
extensive skin, muscle, or fat manipulation, the temporal and face-lift approaches
are suitable options.
Lateral SMASectomy
extends from tail of
parotid to lateral canthus
Vectors
Vertical
Diagonal
Eyelids
Midface
Lower Face
Jaw Line
Transpalpebral
—
—
Transtemporal
—
Face-lift approach
Choosing the Best Option
Rejuvenation/Lift
Although the transpalpebral approach affords a more direct midface lift with un-
limited opportunities for eyelid rejuvenation, it is also the only approach that poses
a risk of eyelid retraction and its consequences. Some surgeons think that this risk
is not adequately offset by the advantages. The eyelid approach also involves longer
recovery, as does any complex procedure in this area.
Alternative approaches involving the percutaneous insertion of barbed sutures have
been advocated, but their efficacy and long-term outcomes remain in question.
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Cheek Lift
JOEL J. FELDMAN
CHAPTER 36
M
y approach to facial rejuvenation is a regional one. Out of 100 patients, I will
perform a cheek lift without a neck lift in about 20, because these patients ei-
ther do not need or do not want a neck lift. A good many will have already had the
neck tended to one way or another, and now it is just the cheek that is in need of at-
tention. Others simply find that for the first time a nasolabial or labiomandibular fold
has become unacceptable, while the signs of aging in the neck still remain tolerable.
Then there are others with only a small amount of soft tissue laxity in the submen-
tal neck that might well snug up nicely to an isolated cheek lift if it is done well.
On the other hand, in approximately 50 of every 100 patients that I operate on for
facial rejuvenation, I will perform a neck lift without a cheek lift—the so-called iso-
lated neck lift—because, in the same way, these patients do not need or do not want
a cheek lift. Then in the remaining 30 patients, I will do a combined cheek lift and
neck lift—a more conventional undertaking—commonly referred to as a face lift. In
this chapter I will describe my approach to cheek-lifting—either done alone or as
part of the cheek-neck combination. Either way, the surgical maneuvers I employ are
the same. I have not included management of the neck in this chapter, because that
material has been published in detail elsewhere.
Brief mention should be made here regarding the difference between a cheek lift, a
midcheek lift, and a lower cheek lift. A cheek lift is, at its best, capable of correct-
ing soft tissue laxity in all areas of the face—upper, central, medial, lower, and lat-
eral. In that regard, a more accurate term for the subject of this chapter might well be
the complete cheek lift. It is, of course, performed through a preauricular incision.
The midcheek lift, on the other hand, is usually performed through a lower eyelid
incision, and its surgical objectives are considerably more modest—namely, a resus-
pension of the slumping perimalar tissues in the area of the lid-cheek junction and
upper nasolabial fold. That procedure would not be expected to produce very much,
if any, improvement beyond the upper cheek. The lower cheek lift, as I envision it,
is aimed primarily at improving the lower nasolabial fold and labiomandibular fold.
It is often combined with a neck lift in patients who do not want or do not need an
accessory lower eyelid lift or temporal lift (discussed later), so in those patients,
I may do a little less flap undermining in the uppermost areas of the cheek.
Evolution of Technique
The Extensively Undermined Point-Tensioned Subcutaneous
Cheek Lift
I completed my plastic surgery residency in 1976, the year that Mitz and Peyronie
published their seminal paper on the anatomy of the SMAS, and only a few years af-
ter Skoog of Sweden had dazzled the attendees at the 1973 Baker-Gordon Sympo-
sium in Miami with a live demonstration of his new and revolutionary sub-SMAS
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Part VII Midfacial Rejuvenation
face-lift operation. Those two events produced a seismic change in the basic as-
sumptions of face-lifting, and the old-fashioned subcutaneous flap technique that
I had been taught became more or less passé. Most plastic surgeons thought that an
undermining and lifting of the SMAS would make for a better face lift.
Soon, however, there were two kinds of SMAS lift procedures to choose from—a
two-flap model and a one-flap model. The two-flap method employed a separate
skin flap and a separate SMAS flap, each carrying about half the thickness of the
subcutaneous fat. The assumption was that it was better to lift the malar and jowl
fat attached to the SMAS in a more vertical direction than the skin with its attached
fat, which was best lifted along the traditional vector, perpendicular to the nasolabial
crease. That concept made sense to me, so a few years after starting out in practice,
I decided to try the two-flap SMAS lift technique. I tried out several versions over a
period of several years and found that with all of them, a thin SMAS flap often tore
easily when I tried to suture it under tension. In addition, a thin skin flap in a thin
patient at times had a precarious blood supply, particularly in patients who smoked.
What’s more, having two slightly different vectors of lift, one for the skin flap and
one for the SMAS-fat flap, produced little if any noticeable benefit in my hands.
Then I tried the one-flap SMAS lift procedure, better known as the deep plane face
lift, a technique developed by Hamra. I really liked that operation. The sub-SMAS
dissection plane was nice and dry, with very little intraoperative bleeding and a very
low incidence of postoperative hematoma, even after I had done an extensive medial
undermining, which I learned was important in terms of consistently producing a
high-quality result. In my modified version of the deep plane lift, I started the deep
plane dissection 1.5 cm preauricularly. Then, along the lateral border of the zygo-
maticus major muscle in the upper cheek, where the SMAS becomes the invisible
epimysium of that muscle, I entered the subcutaneous plane again to continue the
dissection almost to the sidewall of the nose in the upper medial cheek and over to the
nasolabial crease in the central medial cheek. In the lower half of the cheek, after re-
leasing the sub-SMAS masseteric-cutaneous ligaments, I would break through the
medial SMAS to enter the subcutaneous plane and then continue the dissection over
to the corner of the mouth and the side of the chin. That change of tissue planes
from superficial to deep and then back to superficial left the cheek flap with only a
narrow jawline-based peninsula of SMAS on its underside. In reality, my deep plane
lift had in large part become a subcutaneous lift.
However, the deep plane flap was thicker than the usual subcutaneous flap, provid-
ing a robust blood supply that allowed me to anchor it safely at multiple points un-
der considerable tension—which I did—because I had become increasingly appre-
ciative of the importance of holding the well-mobilized flap securely in the lifted
position during the 6 to 8 weeks needed for solid healing to begin. Overall, my re-
sults with this modified deep plane lift were quite good, so I continued to use it in
most cases for more than 20 years.
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Chapter 36 Cheek Lift
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Part VII Midfacial Rejuvenation
During that time, however, I also occasionally performed a subcutaneous cheek lift—
mostly on patients with chubby cheeks on whom I wanted a wide-open access for
thinning of the subcutaneous fat and in patients who had had a previous sub-SMAS
face lift and who at the time of a secondary lift were found to have a deep plane that
was too scarred or distorted to allow me to continue safely at that level. But unlike the
subcutaneous lift that I had done many years earlier, the subcutaneous lift that I was
by then using incorporated three elements that I had learned from doing the deep
plane lift were critical to a first-rate result.
One of those important factors was a very extensive flap undermining, as seen here,
which was done to release all of the skin and fat-retaining ligaments and filaments
in the medial cheek that might inhibit the unrolling of a nasolabial fold or labio-
mandibular fold (marked in red and green in the illustration below).
Orbicularis retaining ligaments
Accessory malar ligaments
Intrafold filaments
Mandibular ligament
Malar ligaments
Masseteric-cutaneous ligaments
Skin-SMAS ligaments
SMAS–parotid fascia ligaments
Platysma-auricular ligaments
Platysma-mandibular ligaments
The second important factor needed for a consistently good result using the subcu-
taneous cheek lift was a very secure fixation of the lifted flap to counteract, as much
as possible, both the stress relaxation and viscoelastic creep of stretched skin, and
the pull of gravity, which urged the flap to slide downhill along a yet-to-heal dissec-
tion plane.
The third important element was having a single point of flap fixation situated pre-
cisely at the convergence of all the important vectors of lift required for a complete
cheek lift—the vectors needed for improvement of the upper and lower nasolabial
fold, the labiomandibular fold, the jowl, and the jawline. That specific fixation point
was located at the immobile periosteum over the lateral zygomatic arch just in front
of the upper ear (circled X)—a particularly safe place for a deep anchoring suture,
well behind the frontal branches of the facial nerve. At that one point of flap fixa-
tion, a controlled amount of tension could be applied to the body of the flap—enough
to hold the flap up securely—but not so much that it would compromise the blood
supply of this skin flap that has a less-robust blood supply than the deep plane flap.
Equally important, none of the tension on the flap itself was transferred to the skin
incision line closure, so there was no forward traction on the ear, earlobe, or tragus,
and the incision scars were able to heal kindly. In contradistinction to what some
plastic surgery colleagues imagined, I found that placing a moderate amount of ten-
sion on the cheek skin flap did not at all produce a flattening of the facial plane.
After having acquired considerable experience using both the extensively undermined
point-tensioned subcutaneous lift and the deep plane lift, a few years ago I thought
it would be interesting to compare my results between those two methods. I looked
at hundreds of preoperative and postoperative photographs of patients I had oper-
ated on using one method or the other, and although the analysis was far from sci-
entific in its methodology, I came away with an unambiguous conclusion: at 1 or
more years after surgery, I could not tell the difference between the results in the two
groups of patients.
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Chapter 36 Cheek Lift
For example, the patient above and the one shown on p. 1085 are shown before and
3 years after surgery. The first patient (above) had a subcutaneous lift, and the second
patient (p. 1085) had a deep plane lift. To my eye, the results are of equal quality.
However, the two procedures did differ in some other ways. Compared with the deep
plane lift, the subcutaneous lift was a little easier for me to perform, and because the
facial nerve branches were less vulnerable, the subcutaneous lift was also potentially
a little safer (even though I never had a facial nerve injury using the deep plane
method). And because the subcutaneous flap was not attached to the mandibular
periosteum the way the SMAS-platysma layer usually is, it was often easier for me
to smooth out the tissues along the jawline when performing the subcutaneous lift.
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Part VII Midfacial Rejuvenation
Furthermore, once I had adopted two simple technical maneuvers, the subcutaneous
lift became nearly as “dry” as a deep plane lift, with a very low incidence of post-
operative hematoma. With these considerations in mind, a few years ago I switched
to the subcutaneous lift as my primary method of cheek-lifting.
One of the two simple hemostatic tactics I incorporated into the subcutaneous lift
was to use electrocautery for a good deal of the flap dissection. The other tactic was
aimed at avoiding the late rebound bleeding that is encountered when the local anes-
thetic solution contains epinephrine in the usual dilution of 1:200,000 to 1:400,000,
which at times leads to the development of recurrent bleeding and possible expand-
ing hematoma formation after the skin incisions have been closed. For that reason,
for several years I completely eliminated the use of epinephrine (as advocated by Drs.
Barry Jones and Rajiv Grover), which I found beneficial. Recently, however, I have
begun to use epinephrine again, but now in a very dilute concentration of 1:4,000,000
(1 to 4 million), which seems to provide just enough vasoconstriction for an ac-
ceptably bloodless flap dissection, along with a short enough duration of vasocon-
striction to allow secure hemostasis before the skin incisions have been closed.
1085
Chapter 36 Cheek Lift
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Part VII Midfacial Rejuvenation
When the cheek is lifted upward and backward, excess skin often piles up in the lower
eyelid and pretemporal areas. To blend the lifted cheek smoothly with the tissues in
the periorbital area, and to prevent the so-called lateral sweep that Hamra described,
I often perform an auxiliary lower eyelid lift and temporal lift.
When performing a subcutaneous cheek lift, occasionally I will imbricate the sub-
cutaneous fat or the platysma-SMAS layer to fill in a volume-deficient area, such as
a hollow submalar zone, or to improve the neck and jawline when I perform a cheek
lift without a neck lift, as Little does routinely. However, in most cases, I do no pli-
cation of the subcutaneous fat or SMAS in the cheek. I have found that sutures that
gather tissue together under the skin of the cheek can at times produce visible bumps
and irregularities, distort the corner of the mouth, or create an asymmetry between
the two sides of the face. At a recent symposium, Little and Baker, who both do no
sub-SMAS flap dissection in the cheek, concurred that a subcutaneous fat or SMAS
plication may produce a better-looking and longer-lasting result in many patients
and that the disappointing track record of subcutaneous plication observed by
Aufricht, Tipton, and others many years ago could be attributed to the use of sutures
that were too few in number, or too small in diameter, or were put in the wrong
place. That said, perhaps I will do more subcutaneous plication in the future.
Adjuncts to the Cheek Lift: The Subgaleal Lower
Eyelid Lift and the Subgaleal Temporal Lift
This patient is an example of a cheek lift that was done with a complementary tem-
poral lift and a lower eyelid lift. The temporal lift, in addition to preventing pretem-
poral skin bunching, nudged up the tail of the eyebrow and corrected the small
amount of lateral upper eyelid hooding that the patient had. The lower eyelid lift
consisted of nothing more than a simple skin excision superficial to the orbicularis
oculi muscle and a transconjunctival removal of the excess lower eyelid fat. Because
nothing in the eyelid was actually lifted, the apparent elevation of the lid-cheek junc-
tion (seen on oblique and lateral views) might better be termed a virtual lift.
I have come to appreciate that almost anything that I do that smoothes out the sur-
face or the contours of the lower eyelid will make it appear as if the eyelid had been
vertically shortened—whether through removal of excess eyelid skin alone, or a sim-
ple redraping of the eyelid skin without removing any skin, or a transconjunctival
removal of excess fat alone, or a transconjunctival fat transposition alone to simul-
taneously improve puffiness and tear troughs, or some combination of those things.
This observation is an important one, because for years now, many plastic surgeons
have said that to elevate the lid-cheek junction, the surgeon must vertically lift the
malar soft tissues as part of a SMAS face lift or as part of a transblepharoplasty mid-
cheek lift, and I do not think that is necessarily true.
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Chapter 36 Cheek Lift
That said, there are many patients in whom I do a real vertical lifting of the lower
eyelid by actually shortening and tightening the lateral orbicularis oculi muscle us-
ing a muscle hitch stitch or two. At times, I also tighten the lid margin horizontally
with a double-loop muscle-tuck canthopexy. I will illustrate both of those maneu-
vers in the section on operative technique (p. 1118). But whether the eyelid lift is a
real or virtual one, it is often an important component of a truly successful rejuve-
nation of the face.
As for the temporal lift, whose purpose is simply to lift the pretemporal skin and the
skin at the tail of the brow and lateral orbital area, the question that is frequently
asked is: why do it, as I do, by way of a subgaleal dissection, when a subcutaneous
dissection would be more direct and more efficient? My answer has five parts. First,
if the scalp incision were to be placed behind the hairline and a subcutaneous dis-
section were to be done, there is a small but real risk of alopecia. Second, I prefer to
avoid a skin incision along the temporal or frontal hairline, where it may leave a vis-
ible scar. Third, excising hair-bearing scalp behind the hairline (which I rarely do
with my temporal subgaleal lift) can noticeably elevate the hairline. Fourth, the sub-
cutaneous plane in the forehead may not be an easy plane of dissection, and it is al-
ways well-vascularized. Obtaining a satisfactory hemostasis can take a good bit of
time, and should a hematoma develop under a thin forehead skin flap, there is some
risk to the flap’s blood supply. Fifth, the sensory nerves in the lateral forehead lie on
the surface of the frontalis muscle, and they can be easily injured during a subcuta-
neous dissection.
The subgaleal temporal lift that I do is quick and easy. It is performed under direct
vision without the endoscope and takes about 15 minutes on each side. Alopecia,
numbness, flap viability, and incision scar visibility are of little concern, and because
I rarely remove skin, the position of the hairline is minimally altered.
Preoperative Evaluation and Indications
Making the case for a cheek lift is an interaction of subjective patient aspirations
and objective physical findings that is done on a case-by-case basis. From my point of
view, there are nine indications—each alone may be reason enough for a lift, but
they often appear, naturally, in some combination: a bothersome nasolabial fold; an
unattractive labiomandibular fold; wrinkled, sagging cheek skin; inferior displace-
ment of the soft tissues from over the malar eminence; an age-related submalar hol-
low; increased visibility of the lateral infraorbital rim; a cluttered appearance to the
jawline; a pronounced jowl; and a chubby lower cheek. Of course, the cheek lift may
be combined with a neck lift, a temporal lift, a small-incision brow lift, a blepharo-
plasty, or some other ancillary procedure.
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Part VII Midfacial Rejuvenation
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Chapter 36 Cheek Lift
Patient Profiles
This 48-year-old woman was bothered by mild nasolabial folds and short labio-
mandibular folds. When I lifted her cheeks with my hands during the preoperative
examination to simulate the effects of a cheek lift, something I always do, those early
signs of medial cheek relaxation were completely eliminated without producing an
associated bunching up of the skin in the lower eyelid or pretemporal area. Her neck
needed no intervention. Together we decided on isolated small incision cheek lifts
and upper blepharoplasties.
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Part VII Midfacial Rejuvenation
This 64-year-old patient was quite certain that she wanted a cheek lift without a
neck lift because of the perceived complexity of the combined procedure. However,
her lower eyelids were puffy and tired looking, so she acquiesced to having them re-
juvenated at the same time. Because the preoperative simulated cheek lift produced
skin bunching in the pretemporal area, I felt that a temporal lift was mandatory, as
was an undermining of the skin of the neck just below the earlobe to prevent a ver-
tical skin fold from forming there (see the description of the pushup maneuver in
the section on the cheek-lift skin incision), both of which the patient also accepted.
She understood that the cheek lift would not improve the wrinkle lines in her lips at
all. The procedure that was done for her was an isolated subcutaneous cheek lift,
along with a temporal lift, and a lower eyelid lift (a transconjunctival fat removal, a
vertical muscle hitch, and a skin strip excision). The jawline skin was undermined
2 fingerbreadths below the lower mandibular border so the jowl could be trimmed
under direct vision. She is shown 1 week (top right) and 1 year (bottom right) after
surgery. All of the improvement in her neck resulted simply from lifting the skin in
her cheek.
Preoperative
1 year postoperatively
Preoperative
1 week postoperatively
In the 5 years preceding her consultation, this 52-year-old woman observed a grad-
ual downward drift of the tissues in her brows, eyelids, cheeks, jawline, and neck,
which together bestowed a tired appearance. I performed a subcutaneous cheek lift,
along with small incision endobrow lifts, upper blepharoplasties with ptosis correc-
tion, lower eyelid lifts, and a neck lift. The cheek lift restored a youthful fullness over
the malar eminence, which can be seen as a more generous ogee curve (yellow ar-
row) on the postoperative oblique view. Although the cheek was actually lifted
obliquely upward toward the upper preauricular fixation point along a vector per-
pendicular to the nasolabial crease, it seems as if the malar fat pad actually had been
lifted vertically upward. The small jowl that was present preoperatively (white ar-
row) was also lifted obliquely upward as part of the cheek flap. However, I have
found that if the jowl is any bigger than this small one, the most effective and stable
treatment is a surgical trim of the excess jowl fat under direct vision, as was done
for the previous patient.
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Chapter 36 Cheek Lift
This 58-year-old woman disliked her lower nasolabial folds and labiomandibular
folds, her jowls, and the small wattle under her chin, but she was content with the
appearance of her upper cheeks and periorbital areas. When I lifted her lower cheeks
during the preoperative examination, the lower eyelid and upper cheek did not dis-
play a lateral sweep. Therefore a lower cheek lift was done in conjunction with a
neck lift. No temporal lift and no lower eyelid skin excision were necessary—only a
transconjunctival removal of some excess lower lid fat. A lower cheek lift is done us-
ing the same incision as that used for a full cheek lift, except that a bit less under-
mining is done across the upper malar zone and lid-cheek junction over toward the
side of the nose than I usually do for a full cheek lift.
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Part VII Midfacial Rejuvenation
In some patients, recontouring the subcutaneous tissues is the component of the
cheek lift that is most responsible for rejuvenating the face. In this patient, a care-
fully tapered excision of excess lower cheek and jowl fat was done under direct vi-
sion, which transformed the patient’s lower face from a square shape to a more at-
tractive and youthful-appearing oval.
At the preoperative consultation, patients often ask, “How long will the lift last?”
I tell them, “The most unpredictable part of any face lift is the durability of the flat-
tening of the nasolabial fold or the labiomandibular.” In my practice, the average
time is 8 years—but it can be as short as 2 to 3, or as long as 10 to 15. That’s be-
cause there are three factors at play, and I can influence only one of them—which is
how the surgery is done. The other two factors are genetically determined and out
of our control: how easily the skin stretches back after it has been tightened, and
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Chapter 36 Cheek Lift
how well the scar bond that glues everything back together holds up. In some people
that bond is tight and does not allow the tissues to slide downward again easily. But
in other people, that scar is thin and slippery. So I turn the clock back, but then it
starts to tick again, and how long it takes to get back to where we started is anyone’s
guess. That said, you’ll still always look better and younger having had the lift than
if you had not. For example, I may make you look 50 instead of 60, so when you’re
70, perhaps you’ll look 60; when you’re 90 maybe you’ll look 80. But I do not freeze
you at 50.” Most patients then say, “Okay, I get it.”
One last comment regarding the indications for various methods of cheek-lifting. If
the patient is a smoker or has diabetes or some other kind of microangiopathy, or
if there are scars on the patient’s cheek that might interfere with the blood supply to
the flap, then at the least I would perform a less-extensive undermining of the cheek
flap and anchor the flap under less tension than I usually do. Or I might play it even
safer, and elect to do a deep plane lift.
Sequencing the Procedures
I find it convenient to perform the temporal lift or endobrow lift first, before the
cheek lift. If a procedure is to be done on eyelids, I first complete the cheek lift and
neck lift to minimize the bruising around the eyes. A light dressing and/or cold com-
presses are applied to the periorbital area immediately after the surgery is completed.
Planning
The Cheek-Lift Skin Incision
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Part VII Midfacial Rejuvenation
With rare exception, I use the same skin incision in every female and male patient.
At the level of the lateral canthus, the marked incision runs barely above the lower
edge of a short sideburn, or through a longer sideburn, in a lazy-S fashion that fol-
lows the natural sinuous curve of the hairline. I always place the lateral centimeter
of the incision along the very top edge of the little hairless triangle that separates the
sideburn from the front of the upper ear—not a little farther down, where some sur-
geons place it, because that little bit lower can make the scar visible if the hair there
is pulled up. Placing the incision no higher than the lower edge of the sideburn rather
than running it up into the temporal scalp prevents the sideburn and the hairless tri-
angle from being shifted upward, which is an unnecessary and often undesirable re-
sult. With the design described, the cheek lift can be repeated any number of times
with the sideburn and its hairline remaining in their original position.
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Chapter 36 Cheek Lift
Incorrect
Correct
It is best generally to avoid using the word “never” when talking about aesthetic sur-
gery. However, in regard to cheek-lift incisions, there are some things I never do. In
a first-time cheek lift in a woman, I never draw and cut the incision as a straight line,
as seen here (left), which has produced a sawed-off, unnatural appearance. A straight
incision can be acceptable in a male patient, either because the scar is hidden within
an endless sideburn and would not determine its final shape, or because most men
shave their cheeks in a way that purposely leaves a straight rather than curvy edge.
In a female patient, a high, flat border seems artificial, and since it is just as easy to
leave the patient with a nice U-shaped sideburn, as suggested in the photo (right),
why not do that?
I also never put a new incision at the front of the sideburn—not even a little—un-
less there is one there already. One or 2 years after surgery, a mature scar along the
front of the sideburn often will have turned white in color, making the scar visible
and possibly bothersome to the patient, as it was for the two patients seen here. Be-
cause the direction of hair growth in the sideburn is backward, the hair there can-
not naturally conceal a pale scar. I find that cutting a zigzag incision edge and plac-
ing it a bit behind the hairline for camouflage is not particularly helpful. And while
other maneuvers, such as beveling the incision and foregoing the electrocautery to
protect the hair follicles and melanocytes, thinning the trimmed edge of the overly-
ing skin flap to allow the hair to more easily grow through the scar, and avoiding
tension on the closure, do produce inconspicuous scars in some cases, those ma-
neuvers are not always successful. For that reason I think it is best to avoid a scar at
the front of the sideburn in every case, since there are other technical maneuvers that
can be used that entirely obviate the need for an incision there.
1096
Part VII Midfacial Rejuvenation
I avoid a scar at the front of the sideburn by doing two things. First, I rely on the
temporal lift to clear away any excess skin that the cheek lift may deposit in front of
the sideburn (left). Second, I compromise just a little on the amount of vertical lift
I apply to the cheek flap by adjusting the flap’s swing around its pivot point at the
anterior end of the incision at the lower edge of the sideburn (white X in the photo,
right). This sometimes shifts the flap’s dog-ear from the front of the sideburn to the
base of the earlobe, but I would rather chase the dog-ear behind the ear, where a
short scar in the sulcus will be completely hidden, than chase the dog-ear to the front
of the sideburn, where the scar might be visible.
1097
Chapter 36 Cheek Lift
The incision may end at the anterior base
of the earlobe or in the postauricular sulcus.
Below the sideburn, the incision continues downward, tightly hugging the front edge
of the upper ear. Then it dips just behind the crest of the tragus (not on the crest)
where it will not be seen. Even when I am doing a secondary or tertiary cheek lift,
I almost always try to end up with a retrotragal incision scar. Usually I can create a
small superiorly based transposition flap from the excess skin in front of the earlobe
to swing over the tragus in reoperative cases. Pretragal scars may at times be hard to
see, but they may also be noticeable—it’s a roll of the dice. If a nice pretragal de-
pression is created, and if the tragal flap is cut to fit, properly thinned, and set in
place under absolutely no tension, a retrotragal scar is a much better choice than a
pretragal scar in almost every case. Once in a while I will see a male patient for a
secondary face lift who had a pretragal incision positioned along the posterior edge
of his whisker line in front of the ear—something I personally would not do. But if
that scar happened to heal imperceptibly, with an excellent color match, I probably
would use that same incision again for the patient’s secondary procedure to preserve
the glabrous strip in front of the ear, but that is an unusual situation.
At the lower apex of the tragus the incision jogs out at a right angle for a few mil-
limeters to create a definite visual endpoint to the tragus (an important detail de-
scribed by Bruce Connell), and then the incision nestles into the crease at the top
end of the earlobe. If I am performing an isolated cheek lift (that is, a cheek lift with-
out a neck lift), the incision ends either at the anterior base of the earlobe or behind
the earlobe in the lower postauricular sulcus.
Preoperative Pushup Maneuver
1098
Part VII Midfacial Rejuvenation
In this particular case,
the isolated cheek lift incision ends here
I can determine exactly where the isolated cheek-lift incision needs to end behind the
ear using a simple preoperative test that I call the pushup maneuver. I put a finger
on the lower cheek just above the angle of the jaw and push upward, simulating the
effect of the cheek lift on the skin around the ear. Usually that pushup produces a
vertical skin fold below the earlobe (white arrow). I draw a circle on the skin around
that fold, which indicates the additional area of skin that I will need to undermine
in continuity with the undermined cheek flap to redistribute the skin there (center).
That will prevent a skin fold from forming below the ear when the cheek is actually
lifted. It is obvious then to see how far up behind the ear the skin incision will need
to run to easily and adequately release and redrape the skin within the outlined cir-
cular area.
Sometimes the preoperative pushup maneuver produces no skin fold below the ear-
lobe, usually in a younger patient who has relatively snug cheek and neck skin to be-
gin with, or in a secondary cheek lift case. In that situation, the cheek-lift incision
can end at the anterior base of the earlobe without extending around behind the ear,
which makes for a real short-scar cheek lift.
OPERATIVE TECHNIQUE
Temporal Lift Incision
1099
Chapter 36 Cheek Lift
5 cm
3.5-4 cm
4 cm
3.5-4 cm
Deep branch of the
supraorbital nerve
Line of fusion
Orbital
ligament
Dissection caudal to
supraorbital rim
On
periosteum
On temporal
muscle fascia
Galeal
fat pad
Sentinel vein
Frontal branches
of CN VII
The area of the subgaleal dissection is highlighted above in white. To adequately re-
lease the tail of the brow for lifting, the dissection must break through the galeal at-
tachments to the periosteum along the lateral orbital rim to enter the retroorbicu-
laris oculi fat (ROOF) of the upper eyelid below the rim. The dense orbital ligament
at the junction of the superior and lateral orbital rims should also be divided. The
frontal branches of the facial nerve run within the galeal fat pad that hangs down
from the ceiling of the dissection pocket. Therefore the lower portion of the pocket
dissection should be done under direct vision, with the dissecting scissors staying
The temporal lift incision is 3.5 to 4 cm long and is placed 2 to 3 cm behind the tem-
poral hairline, with the central point located 5 cm from the superior otobasion, which
places the medial end of the incision just lateral to the line of fusion and the path of
the deep branch of the supraorbital nerve. The hair is parted but not shaved.
Subgaleal Dissection
1100
Part VII Midfacial Rejuvenation
Galea
The local anesthetic solution I use for the face and neck is 0.25% lidocaine with ep-
inephrine 1:4 million. The anesthetic I use everywhere in the forehead is 0.25% li-
docaine with epinephrine 1:4,000,000 (1 to 4 million). I inject the solution into the
subgaleal plane of the area to be dissected as well as into the skin and subcutaneous
fat along the incision line and directly down to the periosteum along the lateral half
of the supraorbital rim and the lateral orbital rim. The incision is made with the scalpel
and then deepened down through the subcutaneous tissue and galea with micronee-
dle tip electrocautery.
I undermine a few centimeters behind the incision (left) so the scalp can shift up-
ward slightly to accommodate the lifted flap when it is hiked up, thereby avoiding a
transverse hump, because I will be removing no scalp skin with this procedure. I then
start the dissection downward (right) just on top of the temporal muscle fascia, us-
ing the little blunt-tipped iris scissors to push and cut through the wispy innominate
fascia that lies between the galea and the white fascia covering the muscle.
right on the surface of the white temporal muscle fascia and lateral forehead peri -
osteum. The surgeon should appreciate that once the so-called sentinel vein has been
reached, the scissors are close to, but also beyond, the facial nerve branches.
The little iris scissors are pushing and cutting through the line of fusion onto the lat-
eral forehead periosteum. The extent of blind undermining is shown (right) about
halfway down toward the supraorbital rim, but no farther, to avoid possible injury
to the frontal nerve branches. Farther caudally, I dissect under direct vision until
I reach the orbital rim.
1101
Chapter 36 Cheek Lift
Line of fusion
Area of blind
undermining
Temporal branches
of CN VII
Temporal muscle fascia
Temporal
muscle fascia
Thin layer of galea
covering galeal fat pad
Innominate
fascia
With the back of the operating table tilted up, a long, narrow Deaver retractor in-
serted, and a xenon headlight for illumination, I gently spread horizontally and ver-
tically with the long Metzenbaum scissors directly on the surface of the temporal
muscle fascia, keeping the galeal fat pad above the tips of the scissors.
I also watch for the sentinel vein (left) so that I do not inadvertently cause it to bleed.
It is usually seen 1 cm above the upper lateral corner of the orbital rim. In most cases
I preserve the vein and work around it, but if it gets in the way, I cauterize and di-
vide it. Farther medially in the pocket (right), I cut through the line of fusion, which
I progressively divide as I extend the pocket downward over the lateral forehead to
the bony rim.
1102
Part VII Midfacial Rejuvenation
Galeal fat pad
Orbital ligament
released here
Sentinel vein
Cutting the
line of fusion
Retroorbicularis
oculi fat
Galeal
fat pad
Sentinel
vein
Orbital
ligament
Supraorbital
rim
When I reach a point just above the supraorbital rim, I proceed with the dissection,
looking down at the patient from outside the pocket. I spread the scissors open hor-
izontally to tear through the galeal attachments to the periosteum along the lateral
half of the supraorbital rim to enter the ROOF of the upper eyelid (left). Then I look
into the pocket (right) to confirm the break-through. The long cautery tip indicates
the location of the orbital ligament, which needs to be divided if the tail of the brow
is to be lifted.
Sometimes I use the long cautery device under direct vision to open through the
galea–periosteal adhesion and the orbital ligament with the aid of a thin suction can-
nula to aspirate the smoke so I can easily visualize the inside of the pocket. More of-
ten, I simply spread and cut blindly with the scissors over to the outside corner of
the orbital rim and then around the corner (right) to be certain that any attachments
there that could inhibit the lift have been adequately released. However, if the in-
tention of the temporal lift is just to prevent lateral orbital and pretemporal skin
bunching produced by a cheek lift while maintaining the position of the tail of the
brow where it is, then of course, I do little if any dissection at the lateral orbital rim.
1103
Chapter 36 Cheek Lift
I always insert a suction drain. Then I grab the galea and a little fat securely with a
small Kocher clamp, evert the flap over my fingertip, and take a nice deep bite of galea
and subcutaneous tissue with a 2-0 PDS suture on a taper SH needle in the midpor-
tion of the flap about 2 cm from the edge. I find that it is easiest for me to put this
stitch in backhand. Then I pass the suture a second time so that I have a generous
double-loop bite of tissue that will not tear out when the suture is tied up under
tension.
Next I take a big transverse bite of the temporal muscle fascia cephalad to the double-
loop bite in the flap; then I tie this horizontal mattress suture up very tightly. To do
this I grasp the short end of the first throw of the knot with a small needle holder
and pull it straight upward toward the top of the head, while applying countertrac-
tion straight downward at the knot with the tip of my other thumb. When that first
throw has been cinched up as snug as I can make it, my assistant grabs the knot with
the tips of a smooth needle holder so it will not slip before I add the nonslip second
square throw. Three more square throws follow. I have found that in most patients
it is hard to overdo this temporal lift, because there is always a little downward set-
tling of the tail of the brow as time goes on.
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Part VII Midfacial Rejuvenation
I put in one or two more simple nonmattress sutures laterally between the galea and
temporal muscle fascia to increase holding power. For the closure (right), the cut
edges of the galea are approximated with a running 3-0 Vicryl suture that is hemo-
static and prevents scar widening, then the skin is closed with a running 4-0 plain
catgut intradermal suture. The suction drain is usually removed after 24 hours. I have
found that use of a drain significantly reduces periorbital ecchymosis.
Cheek Lift
Anesthesia and Markings
1105
Chapter 36 Cheek Lift
3 cm
2 cm
Next I move on to the cheek lift itself. I inject a solution of 0.25% lidocaine with
epi nephrine 1:4,000,000 (1 to 4 million) along the incision lines and into the sub-
cutaneous tissues of the cheek. Of course, I also inject the subcutaneous tissues of
the neck if I am going to be working on the neck. I then draw two vertical lines on
the cheek, the first line 2 to 3 cm in front of the ear and the other line dropped down
from the lateral orbital rim to the jawline. I use the cautery to elevate the flap out to
the first line, then dissect with small scissors out to or somewhat beyond the second
line. Beyond that, I use a combination of cautery and scissors dissection into the far
medial cheek.
Flap Elevation
After lightly scoring the incision lines with the scalpel, I use the microneedle tip elec-
trocautery on coagulating current to elevate the flap out to the first blue line with-
out bleeding in the subcutaneous plane superficial to the SMAS; in the process the
tragal cartilage is skeletonized and a pretragal depression is created.
Next I undermine down to or somewhat below the jawline with the cautery, taking
care to stay superficial to the SMAS-platysma layer. Then I extend the pocket supe-
riorly with the cautery, staying just superficial to the orbicularis oculi muscle, which
brings me well up into the territory of the lower eyelid.
In the zone between the two vertical lines, where the skin is held down rather tightly
by the lateral and central cheek-retaining ligaments, I use the little curved, blunt-
tipped iris scissors (left) to first cut a little into the superficial subcutaneous fat un-
der direct vision, then I perform the rest of the dissection using the blind push-cut
technique (right), seeing the tips of the scissors through the skin, which keeps me
from dissecting too deeply or too superficially. I have used this push-cut method of
flap dissection for 35 years and find it to be the safest, easiest, and quickest way to
elevate the flap.
1106
Part VII Midfacial Rejuvenation
It takes only a few minutes with the
Yankauer suction and the long needle-
tip cautery to obtain good hemostasis.
Orbicularis
oculi muscle
1107
Chapter 36 Cheek Lift
Scissors
Cautery
Temporal
lift
Scissors
Cautery
Temporal
lift
The overlay map (left) shows what has been done so far with the cautery and with the
scissors. Then I use either short iris scissors or long Metzenbaum scissors to blindly
make a series of tunnels just under the skin into the medial cheek (right), which again
keeps me from dissecting too deeply or too superficially.
These tunnels extend almost to the side of the nose, nasolabial crease, corner of the
mouth, and side of the chin.
Trimming Jowl Fat
1108
Part VII Midfacial Rejuvenation
Jowl fat
If there is jowl to be trimmed, I undermine the skin for about 2 fingerbreadths be-
low the jawline with the scissors, leaving a 2 to 3 mm cushion of fat on the under-
side of the skin; then the excess jowl fat can be removed with the cautery after the
medial cheek dissection has been completed.
To complete the medial dissection of the flap, I connect the scissors-made tunnels
with the cautery while looking inside the pocket and controlling whatever bleeding
was instigated by the scissors dissection. The overlay dissection map above shows
how the completed dissection is usually accomplished with cautery and scissors for
an isolated cheek lift. Occasionally, however, if the subcutaneous fat in the medial
cheek is soft and opens up easily and safely with cautery, I may do most, if not all,
of the medial cheek dissection with electrocautery alone. At other times, I may do
almost all of the medial cheek dissection with scissors, using the push-cut technique
without first making disconnected tunnels.
Jowl fat
Isolated cheek lift
Scissors
Cautery
Temporal
lift
When I perform a cheek lift with a neck lift, I usually wait to do the medial cheek
dissection until after I have elevated the neck flap and joined the subcutaneous pocket
in the neck with the subcutaneous pocket in the lateral two thirds of the cheek across
the jawline. Once that has been done, the cheek flap tents up much more easily (right),
allowing me to quickly and safely dissect all of the medial cheek using just the cautery,
with no scissors. Thus there is no bleeding at all, even when the fat of the medial
cheek contains a lot of fibrous tissue and is quite vascular.
1109
Chapter 36 Cheek Lift
Scissors
Cautery
Temporal
lift
Undermined
neck flap
Combined cheek-neck lift
This overlay map summarizes the dissection done with the cautery and scissors for
a combined cheek-neck lift.
Flap Fixation and Incision Closure
My final assessment for hemostasis is done with the patient’s blood pressure at or
above his or her preoperative systolic baseline. If it is below that level as I near the
end of the operation, titrated amounts of ephedrine are given intravenously until the
patient’s normal or supranormal level has been reached.
Scissors
Cautery
Temporal
lift
Cautery
Undermined
neck flap
Regardless of how dry the wound may seem after that last look, I always leave a suc-
tion drain in each cheek. If I am performing an isolated cheek lift without a neck lift
that does not require skin undermining below the earlobe or below the jawline, the
TLS drain (size 10 Fr) that I use exits through the lower temporal scalp above the
front of the ear and lies obliquely under the cheek flap with its end close to the cor-
ner of the mouth. If I do undermine the skin below or behind the ear or below the
jawline with an isolated cheek lift, I place a second drain into the small infraauric-
ular pocket that exits through the skin of the upper postauricular sulcus behind the
ear. I’ve found that using one long drain that curls upward above the jawline to also
drain the cheek area, placed into the small pocket below the ear, does not work very
well. If either area should develop a collection of blood or a hematoma, resulting in
occlusion of the single drain, the other area would also be deprived of drainage. Two
separate drains are alway better than one. When I perform a combined cheek and
neck lift, I always use one drain for the cheek and another separate drain for the neck
on each side. Cheek-lift drains are often removed 24 hours after surgery. Neck-lift
drains, on the other hand, usually need at least 48 hours before removal.
I have listed here the objectives and considerations that I have in regard to the fixa-
tion of the cheek flap. Put simply—I want it tight, but not too tight:
Capture the benefit of the extensive flap undermining.
Counteract elastic skin stretch-back and flap slippage.
Hold the lift until solid healing has taken place.
Place tension on the flap, but none on the skin closure.
Avoid compromising the blood supply of the flap.
1110
Part VII Midfacial Rejuvenation
For the flap fixation, a 2-0 PDS suture on an SH taper needle is used. As shown (left),
I take a deep bite where the blue line has been drawn, which should catch something
solid, so that when I lift up on the suture (right), the ear does not move and I can
tell that I am into periosteum and not just deep fascia.
The cheek flap is grasped with both hands, thumbs under the flap, index fingers on
top. I pull the flap firmly backward and upward in a direction that makes the jaw-
line and medial cheek tissues look their best, and I mark the place where the flap
touches the fixation point with the tip of my left index finger. Then I turn the flap
over, and at the tip of my index finger I take a small but solid bite of fat, along with
a little deep dermis. I have found that I do not need a big bite of tissue here to keep
the suture from tearing out when it is tied under tension.
1111
Chapter 36 Cheek Lift
An economical bite of tissue is taken into the lining of the flap (arrow). Because
I make both passes of the suture needle in a forehand direction—one pass into
periosteum at the fixation point, and the other into the flap—this suture is really a
figure-of-eight stitch. I tie that suture so that the flap is pulled up quite snug, but
I never cinch the knot down all the way. As can be seen (right), I purposely leave
some space under the knot to prevent strangulation of the small blood vessels in the
surrounding skin and to retain some play for final positioning of the flap, which
I will want when I close the skin incision to avoid a dog-ear in front of the sideburn.
In both photos above, notice that the cheek drain was placed under the flap before the
fixation suture was inserted.
The needle holder has been placed beneath the tied suture loop (left). This one fix-
ation suture functions as a very short leash—it does all the work of holding up the
flap. I always release the tissue a little just under the skin edge in front of the upper
ear with the cautery (right) to ensure that the ear has not been pulled forward at all
by the anchoring stitch.
1112
Part VII Midfacial Rejuvenation
The skin incisions have already been closed, as shown, but before that, I examined
the flap to see whether a skin dimple had been created by the fixation suture. A shal-
low dimple, like the one seen here (arrow), will not compromise the blood supply
to the flap and will disappear in a few months as the fixation suture dissolves. If there
had been a deep dimple or a blanched line in the skin radiating downward from the
dimple, I would have known that I had either tied the suture too tightly, or taken
too deep a bite of tissue on the underside of the flap. A deep dimple will often result
in some superficial skin necrosis in its depth, leading to crusting and a little scarring,
while a blanched line in the skin may well portend more extensive tissue loss. That
being the case, if I see a deep dimple or a blanched line, I cut out the suture and in-
sert a replacement, taking a bite in the flap that grabs less fat and dermis, then I tie
the suture down less tightly, leaving a bigger loop below the knot. I have learned that
a little less tension on the flap can avoid problems and will not noticeably diminish
the quality of the result. Because this is a skin flap, not a thicker composite flap or
SMAS flap that is hidden from sight, it cannot be safely tied up as tightly.
Before beginning the closure, I inject all of the exposed skin edges and the subcuta-
neous tissue on the underside of the flap a few centimeters in from of the flap edge
with the lidocaine-epinephrine solution so there will be very little bleeding when
I cut and trim the flap.
1113
Chapter 36 Cheek Lift
A small Kocher clamp grasps the top point of the flap and a second clamp grasps
the upper crest of the small flap that once covered the tragus. The two clamps are
fanned out and the flap rotated upward as much as possible without creating a dog-
ear—not even a small one—at the front of the sideburn. A dot is made on the skin
at the cephaladmost point of the preauricular incision (arrow, left), and the flap is
cut down to that point. A curved line is then drawn on the skin (or in the surgeon’s
mind) that mimics the undulating lower edge of the sideburn, and the excess flap
overlying the sideburn is trimmed along that line. The electrocautery is used to seal
new bleeding vessels along the cut edge.
A 4-0 Prolene tacking skin suture has already been placed at the superior otobasion
(left), and the excess flap overlying the earlobe is being carefully cut over to the lower
apex of the tragus at the front of the ear so that there will be enough flap skin ro-
tated upward to cover the tragus, while also leaving some excess flap at the base of
the earlobe to allow a perfectly tailored inset.
Two or three small crescents of skin are carefully and incrementally carved from the
flap just below and just in front of the earlobe (left) to allow the earlobe to sit com-
fortably in its normal position with the raw skin edge at its base abutting the raw
skin edge of the just trimmed cheek flap without the help of any sutures. Nonetheless,
I usually insert a stabilizing 5-0 PDS subcuticular suture there (not shown in the pho-
tos). Then the excess skin flap overlying the front of the ear is splayed out and pulled
gently backward with the two small Kocher clamps, and while peering under the
flap, I make a dot on the skin at the upper apex of the tragus, then cut the flap care-
fully down to that point, making small course corrections as I go. I do not want to
overcut past the notch at the upper end of the tragus, because I do not want to cre-
ate any tension at all on the skin closure at the front of the tragus.
1114
Part VII Midfacial Rejuvenation
The skin flap that will cover the tragus is then turned back and thinned by excising
most of the underlying fat almost down to the dermis.
Small bleeding vessels under the thinned flap are judiciously controlled with the
cautery, and a 5-0 nylon skin suture is placed above and below the tragus. I never
use a buried suture at the front of the tragus to hold the flap into the pretragal de-
pression; that suture could easily jeopardize the blood supply to the little flap and is
entirely unnecessary. The flap will settle and stick down nicely on its own into the
excavated hollow I made for it there. A small, curved skin flap is then designed and
cut to drape over the tragus without tension. After I remove the excess skin there,
I grasp any fat poking out from under the back edge of the tragal flap with a small
forceps, and as I gently pull the fat out from under the flap, I trim it off with the
small iris scissors while lightly pressing the blades of the scissors up against the un-
dersurface of the flap. This thins the little flap safely just a bit more. Then the re-
maining excess skin flap draped over the front of the upper ear is trimmed away.
1115
Chapter 36 Cheek Lift
The entire periauricular incision line is then closed with a single running 4-0 plain
catgut intradermal suture with the knots tied outside. If these catgut knots have not
fallen away on their own by the first postoperative office visit 1 week after surgery,
I snip them off at that time and remove the 5-0 nylon skin suture above and below the
tragus and the 4-0 Prolene suture at the top front of the ear.
Lower Eyelid Lift
Now that the cheek lift has been completed, and perhaps a neck lift as well, I want
to illustrate the lower eyelid lift that I so often do with the cheek lift. I have used in-
traoperative photos of several different patients for this sequence to ensure that each
step is clearly demonstrated. However, I am not going to describe here how I manage
excess lower eyelid fat, except to say that it is usually done by a transconjunctival re-
moval; nor how I treat a bothersome tear trough at the lid-cheek junction, except to
say that it is usually managed with a transconjunctival fat transposition. As a gen-
eral rule, if I work on the eyelid fat, I approach it through the conjunctiva, and if
I work on the eyelid skin or the orbicularis oculi muscle, I do that without cutting
into the orbicularis oculi, not because I think that denervates the pretarsal muscle (I
do not think that it does), but because empirically I have experienced a lower inci-
dence of postoperative lid retraction problems if the integrity of the muscle is strictly
maintained.
Estimating Amount of Lower Lid Skin Excision
1116
Part VII Midfacial Rejuvenation
I like to estimate preoperatively the amount of skin that I am likely to excise. Lifting
the lower eyelid skin with my fingers creates a skin fold just under the eyelash mar-
gin, indicating the required length of the subciliary incision. I then draw out that
subciliary incision line, along with a short lateral limb that extends beyond the lat-
eral canthus in one of the crow’s-feet lines. The lateral eyelid skin is again pinched
and lifted, and the excess skin is rolled under. Where the upper edge of the rolled-
under skin touches the lateral canthal point, I make a dot with the marking pen
(black dot at the arrow). Then the medial and lateral ends of the subciliary incision
are connected with a gently curved second lower line that runs through the lower
black dot.
Anesthesia and Incision
1117
Chapter 36 Cheek Lift
Festoon
I use a solution of 1% lidocaine with epinephrine 1:100,000 for local anesthesia
when performing a blepharoplasty. All eyelid procedures are performed with corneal
shields temporarily in place. The lateral segment of the skin incision is lightly scored
with the scalpel and the subciliary segment cut with small sharply pointed scissors
superficial to the underlying orbicularis oculi muscle. A suture is placed laterally
along the lid margin for countertraction, and the separation of the muscle from the
skin is begun—at first under direct vision (right), and then by seeing the tips of the
scissors through the eyelid skin—which is a good way to dissect quickly under the
thin skin without creating a buttonhole.
Dissection
I always dissect beyond the blue estimation line, freeing up the skin as far caudally
as needed to eliminate all of the skin wrinkling. If there is a malar festoon present,
I separate the skin from the muscle down to the upper edge of the festoon.
1118
Part VII Midfacial Rejuvenation
Hemostasis is obtained with the electrocautery on a low setting.
Lateral Canthopexy
If the patient has a hypotonic lower eyelid, often manifested by a downward round-
ing of the lateral lid margin or some degree of increased scleral show, I perform a
lateral canthopexy—one that I call the double-loop muscle-tuck canthopexy—which
tightens the pretarsal muscle and the lid margin in a horizontal direction. For this,
a permanent 4-0 Prolene suture on a taper SH needle is used. With my assistant’s fin-
gers gently pulling the mobile soft tissues at the lateral orbital area upward and out-
ward, I locate the inside edge of the lateral orbital rim with the tips of the forceps.
Assistant’s
finger
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Chapter 36 Cheek Lift
I then insert the needle into the orbicularis oculi muscle just below the skin of the
lateral lower eyelid margin and just medial to the lateral canthus, catching hold of
the periosteum on the inner edge of the lateral orbital rim at or just slightly above
midpupillary level. The tip of the needle can be seen emerging through the perios-
teum and muscle laterally (arrow). When I pull up on the suture (right), it should
feel solidly engaged in the periosteum.
I pass the needle a second time exactly the same way, creating a double-loop of the
suture. When this suture is tied, the muscle within the double-loop is gathered and
tucked up against the bone just inside the lateral orbital rim, where it is meant to
heal securely. It is important that the needle pass through the periosteum on the in-
ner edge of the lateral orbital rim both times, not the outer edge, to avoid an “air
space” between the lateral lid margin and the globe. It is also important that the su-
ture not pass through the tarsus, which could kink the lateral lid margin when the
suture is tied. This is a muscle-tuck canthopexy, not a tarsal-tuck canthopexy.
My first tie is a surgeon’s knot, followed by two more square throws. The ends of
the suture are cut flush with the knot. Usually the lid margin above the knot is puck-
ered or pulled down a little by having the muscle crimped just below it. It is very im-
portant that I correct that distortion, even if it is minor, by snipping just above the
knot with the little scissors to set the lid margin back in a perfectly normal position.
Muscle Hitch Procedure
I do a vertical tightening of the lateral orbicularis oculi muscle, a muscle hitch, for
one of several reasons: if I simply sense that a muscle lift will impart a smoother
appearance to the lower eyelid or the lid-cheek junction; if the lower eyelid seems
hypotonic—characterized by a lateral rounding of the lid margin or an increase of
scleral show; if I want to increase the stability and security of the muscle-tuck can-
thopexy; or if I want to correct a malar festoon, which is often a combination of skin
laxity and muscle laxity.
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Part VII Midfacial Rejuvenation
The muscle hitch is a horizontal mattress suture anchored to the immobile perios-
teum of the lateral orbital rim. The amount of vertical muscle lift obtained depends
on how far below the rim the suture is placed into the muscle. The more the lift that
is desired, the farther downward the skin will need to be separated from the muscle.
Just a little lift requires just a little undermining of the skin. More lift means more
undermining—often 1 to 1.5 cm below the lateral canthal area.