The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part VII  Midfacial Rejuvenation
And once again, I make sure that the skin edge is not distorted (left). With the com-
bination of two muscle hitch sutures, I have usually lifted and secured the muscle
just about as much as possible (right).
For me, eyelid skin excision or skin redraping is the last step—done as the one and
only lower blepharoplasty maneuver, or after a transconjunctival fat removal or fat
transposition, or after a muscle hitch and/or canthopexy. If there was just one place
in plastic surgery to exercise restraint, excising skin from the lower eyelid would be
that place. It is much better to leave a little bit of extra skin behind than to remove
a bit too much and risk even a hint of lid margin retraction.
For a smoother and more refreshed appearance, some wrinkled lower eyelids just
need to have the skin separated from the underlying muscle and then redraped with-
out removing any skin at all—even when more skin has been brought up into the
eyelid with a cheek lift. This is particularly true if the eyelid margin was lifted up-
ward with a muscle hitch and/or a canthopexy.
The freed skin flap of the lower eyelid is laid out without any tenting or tension. If
there is some excess to remove, it is conservatively marked and trimmed. In the pa-
tient on the left, that amounted to only a tiny triangle; in the patient on the right, it
was a good bit more. In most cases, the preoperative estimate will come close to the
new mark.

I close the subciliary incision with a 4-0 Prolene intradermal pull-out suture, taking
only tiny, wispy bites under the skin. The short medial and lateral tails of the pull-
out suture and the lateral crow’s-feet extension of the incision are covered with a
small piece of 1⁄4-inch Steri-Strip, and then 1⁄2-inch Steri-Strips are applied to the skin
of the lower eyelid to provide vertical support; in addition, the little bit of pressure
that the tapes apply to the skin somehow reduces postoperative bruising and swelling.
After the pull-out suture has been removed 1 week after surgery, with the patient sit-
ting upright, I place the tips of my thumbs under the lower edge of the lateral tarsal
plate on the left and right sides and push the lower eyelid margins straight up, some-
what forcefully, to stretch out the eyelid tissues. This simple maneuver corrects any
pleating along the eyelid margin that may have been produced by the running in-
tradermal suture, and this allows the lid margin to once again hug the globe.
Postoperative Care
My office operating suite is physically connected to an inpatient hospital, so I keep all
cheek-lift patients in the hospital at least 24 hours. If they also had a neck lift, the
patients stay for 48 hours, because that is when I usually remove the subcutaneous
drains. Occasionally, however, a patient will go home or to a hotel with a drain or
two left in and then return to my office a few days later to have the drains removed.
When told that leaving a drain in longer than expected means less bruising and less
swelling and a quicker recovery, most patients readily except the short period of in-
convenience.
If eyelid surgery was part of the face lift, cold compresses to the eyes are used for at
least 12 hours after surgery, and beyond that, only when the patient wishes to use
them for comfort. I remove the light wrap-around face-neck-forehead gauze dress-
ing the morning after surgery so that I can have a look at things, and also because
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Chapter 36  Cheek Lift

most patients are more comfortable without the dressing. At that time I clean all the
suture lines so they are crust free, including those along the lower eyelid margins.
The morning after surgery, the eyelashes of the upper and lower eyelids are often
stuck together, making it difficult for the patient to see. The nurses, understandably,
do not do a very good job of separating the glued-together top and bottom lashes,
so I do that myself with cotton swabs moistened with peroxide while the patient, at
first, keeps the eyes closed. At home, however, patients are told not to use peroxide,
but only warm water and perhaps a little Johnson’s Baby Shampoo—which will not
sting the eyes.
I tell patients that as soon as they get home, and as long as they do not feel dizzy,
they can get in the shower and wash their hair using any kind of shampoo and hair
conditioner, can also blow-dry their hair, and this can be done as often as they wish.
Nothing makes a patient feel better than a clean head, and the soap and water run-
ning over the incision lines helps to keep them crust free. Since the incisions are by
then nicely sealed, there is no increased risk of infection. I do not routinely have the
patients apply an antibiotic ointment to the suture lines: it is a bit messy and usually
unnecessary.
Most patients take a prophylactic oral antibiotic for 1 week after surgery. If they
have a history of ever having had a cold sore, they also take an antiviral medication
for 1 week, such as valacyclovir.
During the week after surgery, a walk around the block, some fresh air, or perhaps
a movie can all be good for the patient’s spirits. Of course, the usual admonition of
“keeping the head above the heart level” is recommended for 1 or 2 weeks, with no
strenuous exercise for at least 3 to 4 weeks.
Suture removal is done 1 week after surgery. The next office visit after that is usually
at 3 months, but if either the patient or I have any concern about anything, the pa-
tient is encouraged to return as often as necessary for treatment or reassurance.
The majority of patients are comfortable returning to work and most of their social
activities at 2 to 3 weeks after surgery, but an occasional patient will need longer.
Every patient is told that the amount and duration of postoperative swelling and
bruising is quite variable.
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Part VII  Midfacial Rejuvenation

Complications and Outcomes
The reason I particularly like the technique described in this chapter is that the in-
cidence of associated problems is quite low, while the quality of the results is con-
sistently good to excellent. In other words, the risk-to-benefit ratio is a very favor-
able one.
The incidence of postoperative hematoma has been kept well under 1% because a
good deal of the flap dissection and all of the fat excision is done with the electro-
cautery; late rebound bleeding is avoided for the most part by using a very dilute so-
lution (1:4,000,000) of epinephrine. Maintaining or regaining a normal or supra-
normal blood pressure during the final hunt for hemostasis before closure has helped
as well. The routine use of closed suction drainage for at least a day or two follow-
ing surgery has, for the most part, avoided the puddles under the flap that produce
swelling and ecchymosis.
To achieve an effective temporal brow lift, the necessary freeing of the soft tissues to
the periosteum along the supraorbital and lateral orbital rims has produced a 6%
incidence of temporary brow elevator (frontalis muscle) dysfunction, which may take
several months after surgery for complete resolution. All patients are apprised of this
possibility during the preoperative consultation. I have not had a single case of per-
manent frontalis muscle dysfunction. There have been no buccal branch, zygomatic
branch, or marginal mandibular branch facial nerve injuries, temporary or perma-
nent, associated with the subcutaneous flap technique in my hands.
A visible dimple in the skin in front of the upper ear is a frequent sequela of the skin-
to-bone method of skin flap fixation. The dimple is usually a shallow one that in
most cases can be camouflaged by the hair. Typically, the dimple disappears in 3 to
4 months as the absorbable fixation suture dissolves.
Because the small, crescent-shaped skin flap that is made to fit over the tragal carti-
lage has its subcutaneous tissue thinned almost to dermis, there have been some in-
stances of superficial skin loss along the edge of this little flap. An optimistic expec-
tation of outcome transferred to the patient, along with a dab of antibiotic ointment
and a little time, is all that is usually needed for the scar there to become unnoticeable.
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Chapter 36  Cheek Lift

Results
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Part VII  Midfacial Rejuvenation
For this 60-year-old woman, I did a subcutaneous cheek-neck lift and temporal lifts.
An extensive undermining of the cheek flap was done with a point-tensioned fixa-
tion of the flap. The jowls were trimmed under direct vision. Her more youthful-
looking complexion resulted from the skin lift alone. The postoperative photos were
taken 1 year after surgery, as were the postoperative photos in the other patient ex-
amples to follow. I operated on this patient many years ago, before I had come to
appreciate the value of a concomitant lower eyelid lift in improving the quality of
many cheek lifts. In this case, flattening, smoothing, and lifting the lower eyelids with
an apparent elevation of the lid-cheek junction would have further improved her
nice result.

This 48-year-old woman underwent a combined cheek and neck lift, along with tem-
poral brow lifts, a narrow skin strip excision from just the right lower eyelid, skin
redraping without skin excision in the left lower eyelid, and dermabrasion of the up-
per lip. The patient reported that even as a young woman she had full upper na-
solabial folds, and despite my having undermined beyond the folds over to the lower
sidewall of the nose and onto the lateral upper lip to release the intrafold filaments
that are often primarily responsible for maintaining the humped shape of the folds,
the shape of these particular folds persisted, because they were simply a mound of
localized fat that had always been there. Had the patient said to me at the preoper-
ative consultation that she would like to have her upper nasolabial folds diminished,
I would have done a closed liposuction there at the beginning of surgery before the
cheek flaps were elevated.
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Chapter 36  Cheek Lift

Aside from her full, firm, oblique neck, this 57-year-old woman was bothered mostly
by her chubby lower cheeks and prominent jowls. She had a subcutaneous cheek and
neck lift that included lower cheek subcutaneous lipectomies, buccal fat pad exci-
sions, and a jawline clean-up. For the neck, an extensive subcutaneous fat removal
was done, along with a subplatysmal fat excision, a perihyoid fascia release, a low
release of the anterior digastric muscles, partial resection of the right anterior di-
gastric muscle, partial resection of enlarged submandibular salivary glands, a corset
platysmaplasty, and correction of pixie earlobes. Temporal brow lifts prevented soft
tissue from bunching in the lateral orbital areas when the cheeks were lifted and also
corrected the slight ptosis of her lateral brows. Transconjunctival removal of excess
lower eyelid fat was done, and skin strips were excised from both the lower and up-
per eyelids. As with the previous patient presented, this woman also had unyielding
upper nasolabial folds caused by excess fat. In both cases, those folds could have
been reduced by narrow-cannula closed liposuction.
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Part VII  Midfacial Rejuvenation

At her consultation with me, this 63-year-old woman reported that 4 years earlier
she had had lower blepharoplasties and a perioral dermabrasion done elsewhere.
She was now discontented with the persistent puffiness in her lower eyelids, the de-
velopment of jowls, vertical webbing at the front of her neck, and soft tissue relax-
ation in the lower cheeks—especially the labiomandibular folds.
I performed a subcutaneous cheek-neck lift, jowl fat excision, temporal brow lifts,
bilateral transconjunctival fat excisions, and a unilateral right lower eyelid double-
loop muscle-tuck canthopexy to lift and tighten that one eyelid margin a bit. Today
I would have added a muscle hitch or two on top of that. I had thought that I would
also excise a very narrow skin strip from the lower eyelids as well, but at surgery
I found that both lower lids needed all of the existing skin, so the eyelid skin flap on
each side was simply elevated and then redraped.
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Chapter 36  Cheek Lift

This 54-year-old woman came to me still looking younger than her age—but a sub-
tle and yet discernible downward displacement of the soft tissues of her face had be-
gun to tell its tale. The fullness that once enriched her malar eminences had dimished.
Some portion of the mid cheeks had settled near the jawlines, leaving a shadowed
submalar hollow. Even the lower eyelids had lost a measure of tonicity, where a trace
of lateral rounding had become evident. Prominent glabellar frown lines imparted
an angry expression, particularly since they were paired with her actively arched lat-
eral brows—an expression that was not at all softened by a pursed-looking upper
lip with a stingy vermilion.
I performed a subcutaneous cheek-neck lift, along with low temporal lifts to prevent
skin bunching in the pretemporal regions, but done in a way that entirely avoided
lifting the lateral eyebrows—not even one millimeter. In the neck, a slim strip of up-
per midline interplatysmal fat was excised to make room for the joined platysma
edges rolled inward with a corset platysmaplasty. The excess neck skin was widely
undermined, allowing it to shrink and slide to the sides without the need for any
neck skin excision.
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Part VII  Midfacial Rejuvenation

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Chapter 36  Cheek Lift
For her thin and somewhat puckered upper lip, a direct vermilion lift was done to
create a more generous red lip topped by a much prettier cupid’s bow. She is seen
(right) 1 week after surgery.
In the lower eyelids, vertical tightening muscle hitches were used, along with the ex-
cision of a narrow bit of skin. Her glabellar frown lines were improved by transpalpe-
bral corrugator muscle resections. En route to the corrugators, a little excess fat in
the medial aspect of the upper eyelids was trimmed. Thin strips of preauricular SMAS
and fat were also tunneled under the dermis of the frown lines through tiny stab in-
cisions in the skin. Her appearance at 1 year after surgery displays a subtle im-
provement in all of the treated areas, which, taken together, provided her with a re-
juvenated appearance and a refreshed spirit.

Concluding Thoughts
In my thirty-fifth year in practice, I find myself having come full circle in my cheek-
lift technique, beginning with a subcutaneous lift, then moving on to various itera-
tions of a SMAS–included lift, before returning to a subcutaneous lift. Over the years,
however, I added some things that I believe make the procedure I do now more ef-
fective and the results longer lasting: a more generous flap mobilization, a sound
method of flap fixation, and an accessory lift to the lower eyelid and temporal zone.
This may be an easier, safer, and highly gratifying approach for other plastic sur-
geons as well.
Clinical Caveats
 Inclusion of the SMAS in a compound cheek-lift flap was found to offer no long-
term benefit.
 Far-reaching subcutaneous undermining is routinely done to release all of the skin
and fat-retaining ligaments that might inhibit successful unrolling of the nasolabial
fold and the labiomandibular fold and repositioning of sagging malar and jawline
soft tissues.
 Despite the extensive amount of tissue dissection, a very low incidence of postop-
erative hematoma is expected because a weak concentration of epinephrine is com-
bined with the local anesthetic, producing relatively weak vasoconstriction of rel-
atively short duration, and because a good deal of the dissection is done with the
electrocautery rather than with scissors.
 Tension on the flap takes up the slack, while a stable method of flap fixation coun-
teracts the elastic and gravitational forces working against the lift.
 The degree of tension must be gauged for safety. A deep dimple or a blanched line in
the skin at the site of the fixation suture indicates that less tension must be reapplied.
 The locus of flap fixation, high up and far out in the cheek, is ideally situated at
the point of covergence of all the vectors needed for a complete cheek lift.
 A temporal lift and lower eyelid lift are often done in conjunction with the cheek
lift to prevent pretemporal and lower eyelid skin bunching and the appearance of
a lateral sweep.
 The best short- and long-term improvement of a prominent jowl is obtained by
direct excision of excess or ptotic medial jawline fat.
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Part VII  Midfacial Rejuvenation

Annotated Bibliography
Friedland JA. The cutaneous rhytidectomy. In Bernard RW, ed. Surgical Restoration of the
Aging Face. Boston: Butterworth-Heinemann, 1996.
While most of his colleagues had adopted a SMAS flap face-lift technique, this experi-
enced surgeon stuck with a subcutaneous method, involving extensive undermining,
along with a superior and lateral cheek SMAS plication, because of its safety and effi-
cacy. The skin flap was “redraped under tension.”
Gillies H, Millard DR Jr. The Principles and Art of Plastic Surgery, vol II. Boston: Little Brown,
1957.
In regard to face-lifting, the senior surgeon noted “the necessity of wide undermining,”
saying that it should extend “over the cheek, outer portion of the upper and lower lips
and chin,” while observing that “the skin over the malar is often quite adherent and de-
mands a little more care.”
Gosain AK, Amarante MT, Hyde JS, et al. A dynamic analysis of changes in the nasolabial
fold using magnetic resonance imaging: implications for facial rejuvenation and facial
animation surgery. Plast Reconstr Surg 98:622-636, 1996.
This MRI study found that an increased prominence of the nasolabial fold over time
was caused by “progressive thickening of the dependent portion of the cheek fat pad
and overlying skin, with no appreciable change in the muscle plane” and concluded that
“to diminish the nasolabial fold, surgery for facial rejuvenation should be directed to
the skin and subcutaneous tissue planes.”
Hamra ST. The Facelift Letdown. New York: MDP, 2009.
The developer of the deep plane and composite face lift techniques has abandoned the
sub-SMAS dissection in the cheek, saying that “while I originally lifted the SMAS with
the cheek fat and eye muscle, I have concluded that it is best left untouched, as moving
it toward the ear actually inhibits upward motion of the cheek fat.” His current ap-
proach focuses on a strong vertical lift to the tissues of the upper cheek, periorbital area,
and lateral orbicularis oculi muscle, which is done through a lower eyelid incision—
along with a subcutaneous cheek-neck lift done through a periauricular incision.
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Chapter 36  Cheek Lift
 Small details of skin incision placement are emphasized to avoid postoperative
scar visibility and a dislocation of the hairline.
 This cheek lift can be done as an independent short-scar procedure without a neck
lift, or as part of a combined cheek-neck lift.

Hoefflin SM. The extended supraplatysmal plane face lift. Plast Reconstr Surg 102:2513,
1998.
In this letter to the editor, the author says the following: “I do not feel that a platysma
aponeurosis or SMAS dissection is necessary and, at times, I think it is contraindicated.
Long-term results much too frequently show SMAS banding, overlying ‘sweep,’ and an-
imation abnormalities. These problematic results, often seen and published, caused me
to pursue techniques other than a subplatysma technique. I believe that the platysma
aponeurosis (SMAS) has a very important function in not only uniformly supporting,
but also finely coordinating, the facial mimetic muscles and normal facial animation.
Although many excellent surgeons continue to successfully use a two-level dissection,
I do not.”
Lambros VS. The superficial musculoaponeurotic system rhytidectomy. In Bernard RW, ed.
Surgical Restoration of the Aging Face. Boston: Butterworth-Heinemann, 1996.
The author observed that “the results of a SMAS face lift, a skin face lift, or a combi-
nation lift may be indistinguishable.”
Mayer DM, Swanker WA. Rhytidoplasty. Plast Reconstr Surg 6:255, 1950.
This was the very first article on face lift surgery to appear in Plastic and Reconstruc-
tive Surgery. The authors stated that “the longevity of the result is directly proportional
to the extent of the undermining.”
Suggested Readings
Agarwal CA, Mendenhall SD III, Foreman KB, et al. The course of the frontal branch of the
facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg 125:532-
537, 2010.
Aufricht G. Surgery for excess skin of the face. In Transactions of the Second International
Congress of Plastic and Reconstructive Surgery. Edinburgh: E & S Livingston, 1960.
Baker DC. Short-scar face lift: evolution and applications. In Tonnard PL, Verpaele AM, eds.
Short-Scar Face Lift: Operative Strategies and Techniques. St Louis: Quality Medical Pub-
lishing, 2007.
Baker DC. SMASectomy/SMAS plication. Presented at the Expanding Horizons Symposium:
New Paradigms in Aesthetic Plastic Surgery, cosponsored by the American Society of
Plastic Surgeons and the American Society for Aesthetic Plastic Surgery, Las Vegas, Jan
2010.
Connell BF. Operative strategies: male face lift. Aesthet Surg J 22:385-396, 2002.
Duffy MJ, Friedland JA. The superficial-plane rhytidectomy revisited. Plast Reconstr Surg
93:1392-1403; discussion 1404-1405, 1994.
Feldman JJ. Neck Lift. St Louis: Quality Medical Publishing, 2006.
Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 86:53, 1990.
Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair.
Plast Reconstr Surg 102:1658-1666, 1998.
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Part VII  Midfacial Rejuvenation

Hester TR, Szczerba S. Midface rejuvenation. In Nahai F, ed. The Art of Aesthetic Surgery:
Principles & Techniques. St Louis: Quality Medical Publishing, 2005.
Hoefflin SM. The extended supraplatysmal plane (ESP) face lift. Plast Reconstr Surg 101:494-
503, 1997.
Hoefflin SM. The ligamentous facial fence: the cause of nasolabial folds and jowling. Plast
Reconstr Surg 101:1148, 1998.
Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year
quest. Reviewing 910 patients. Plast Reconstr Surg 113:381-387; discussion 388-390,
2004.
Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg 124:2118-2126,
2009.
Little JW. Subcutaneous plication: XJ lift (with structural fat). Presented at the Expanding
Horizons Symposium: New Paradigms in Aesthetic Plastic Surgery, cosponsored by the
American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Sur-
gery, Las Vegas, Jan 2010.
Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar
imbrication. Plast Reconstr Surg 105:267-285; discussion 286-289, 2000.
Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation.
Plast Reconstr Surg 105:252-266; discussion 286-289, 2000.
Mitz V, Peyronie M. Superficial musculo-aponeurotic system (SMAS) in the parotid and cheek
area. Plast Reconstr Surg 58:80-88, 1976.
Nahai F. Clinical decision-making in face lift and neck lift. In Nahai F, ed. The Art of Aes-
thetic Surgery: Principles & Techniques. St Louis: Quality Medical Publishing, 2005.
Robbins LB, Brothers DB, Marshall DM. Anterior SMAS plication for the treatment of promi-
nent nasomandibular folds and restoration of normal cheek contour. Plast Reconstr Surg
96:1279-1287; discussion 1288, 1995.
Rubin LR, Simpson RL. The new deep plane face lift dissections versus the old superficial
techniques: A comparison of neurologic complications. Plast Reconstr Surg 97:1461-
1465, 1996.
Skoog T. Plastic Surgery: New Methods and Refinements. Philadelphia: WB Saunders, 1974.
Tipton JB. Should the subcutaneous tissue be plicated in a face lift? Plast Reconstr Surg 54:1-
5, 1974.
Tonnard PL, Verpaele AM. The MACS-lift short-scar face lift: technical and strategic con-
siderations. In Tonnard PL, Verpaele AM, eds. Short-Scar Face Lift: Operative Strategies
and Techniques. St Louis: Quality Medical Publishing, 2007.
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Midface Recontouring

T. RODERICK HESTER, JR.,
J. NICOLAS MCLEAN
CHAPTER 37

S
urgical rejuvenation of the aging face has become one of the most frequently
performed surgical procedures in the United States. Loss of volume and gravi-
tational descent combine to create an appearance of facial aging that is evident in
all facial features. The youthful eyelid’s almond-shaped horizontal palpebral fissure,
with its slight upward slant from the medial to lateral commissure, changes and elon-
gates with aging, creating a rounder shape with increasing scleral show. As the malar
fat pad descends, cheek prominence is lost, and malar bags may occur. The nasolabial
fold deepens, and the tear trough deformity may appear. In summary, the vertically
short youthful orbit elongates with aging.
Correction of aging changes in the lower lid and midface is essential for producing a
balanced, natural-appearing result after surgical facial rejuvenation. Options for
achieving these rejuvenative goals include endoscopic procedures through a tempo-
ral approach with suspension sutures to reposition midfacial tissue, open face-lift
procedures with superficial musculoaponeurotic system (SMAS) plication, and di-
rect repositioning of the malar fat pad.
Our preferred technique for correction of aging in the critical zone encompassing
the lower lid and midface is based on three basic principles:
1. Direct vertical elevation and fixation of midfacial descended soft tissue
2. Orbicularis oculi superolateral redraping with suturing to the periosteum of
the lateral orbital rim and temporalis fascia
3. Volume replacement and fat repositioning
Our approach to lower lid and midface rejuvenation includes the following:
 A lateral lower lid incision with minimal myotomy to allow for endoscope-
assisted subperiosteal dissection
 Release of malar soft tissues
 Orbicularis oculi muscle redraping
Evolution of Technique
The senior author (T.R.H.) has been using the trans–lower lid blepharoplasty, sub-
periosteal midface dissection for rejuvenation of the lower lid and midface since
1994. Our approach to transorbital midface rejuvenation has been influenced sig-
nificantly by the work of others. The subperiosteal approach in facial rejuvenation
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Part VII  Midfacial Rejuvenation

was first described by Tessier. Psillakis and Ramirez expanded and further described
the use of subperiosteal dissection and release of the midface. Hamra emphasized
the importance of vertical elongation of the aged orbit, and both Ramirez and Hamra
emphasized the importance of vertical elevation of midfacial soft tissue as more ap-
propriate for correction of midfacial aging. McCord, Codner, and Jelks et al have
significantly influenced our own technique for rejuvenation of the lower lid compo-
nent while minimizing the risk of complications.
The senior author’s experience with transorbital midfacial rejuvenation has been
previously documented. Since the original description more than 16 years ago, it has
evolved from an “open” lower lid approach to an endoscopically assisted approach
that avoids dissection and trauma in the plane between the orbicularis oculi and or-
bital septum, reducing the chance for postoperative lower lid malposition.
Indications and Contraindications
Any patient with aging of the lower lid and midface is a candidate for this proce-
dure. In our experience, the direct vertical elevation of the midface and redraping of
the orbicularis that occur with this technique result in a more pleasing and natural
appearance than could be obtained with traditional lateral-vector techniques. The
senior author now uses this procedure in all face lifts, thereby eliminating the need for
extensive lateral to central deep-plane or sub-SMAS dissection. We have found, how-
ever, that patients with more severe degrees of facial volume loss, especially when
this is accompanied by malar bony retrusion, will have less than ideal outcomes un-
less the volume deficiency is addressed. In these patients, autologous fat grafting
and/or appropriate facial implants will significantly improve results.
The midface lift is not used to improve the aging changes inferior to the oral com-
missure and along the inferior mandibular border. In this situation, a traditional face
lift with a more lateral-vector preauricular and postauricular approach is used to
better correct aging in these areas, including the lower neck.
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Chapter 37  Midface Recontouring

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Part VII  Midfacial Rejuvenation
Pertinent Anatomy
Familiarity with the anatomy of the face, specifically the lower lid and midface, is
essential for a successful outcome with this procedure. The following anatomic prin-
ciples apply.
In this difficult zone of the face, it is important to understand the anatomic changes
associated with aging and have a clear vision of what needs to be accomplished for
correction. Surgically, the midfacial area moves as a unit, behaving as a composite
structure because of the firm attachments of the suborbicularis oculi fat and malar fat
to the orbicularis muscle. The orbicularis–facial fat complex is invested with the
SMAS, which emanates from bony periosteal attachments at the inferior orbital rim
and zygoma. It penetrates through the orbicularis fibers outward and extending to
the malar subcutaneous fat, where it permeates and divides the anterior fat. This sys-
tem of cheek attachments allows full cheek movement and repositioning by upward
tension and supraplacement of the orbicularis arc of muscle.
The malar fat pad is superficial to the SMAS. The deep suborbicularis oculi fat
(SOOF) lies beneath the SMAS and orbicularis oculi. This anatomic relationship al-
lows the SMAS, orbicularis, and periosteum to be used as a “musculoligamentous
carrier” to reposition midfacial fat superiorly, rather than depending on sutures in
the structurally weakest component of cheek soft tissue—the fat.
As aging occurs, the more lax lower lid skin, muscle, and fat descend over the rela-
tively fixed orbitomalar ligament, creating a malar bag. Likewise, with descent of
cheek soft tissue over the relatively fixed nasolabial retaining ligaments, the fold
may deepen.
Suborbicularis oculi fat (SOOF)
Orbitomalar ligament
Orbital fat
Zygomaticus major muscle
Malar fat pad
Zygomaticocutaneous ligament
Infraorbital nerve
Lid-cheek junction
Orbital septum
Orbitomalar ligament
Orbital fat
Lid-cheek junction
Orbital septum
YOUTHFUL ANATOMY
AGING ANATOMY WITH MIDFACE DESCENDED

 A major component of lower lid and midfacial aging is laxity of the orbicu-
laris muscle. The orbicularis derives innervation from the zygomatic branch
of the facial nerve laterally and the buccal branch medially. It appears from
our studies that the pretarsal orbicularis, the critical segment responsible for
the blink reflex, derives its innervation nasally via the buccal branch. The re-
maining body of the orbicularis is responsible for tight closure of the lids and
serves to protect the globe from trauma.
 The lower lid is highly intolerant of misguided surgical trauma. Traditionally,
lower lid rejuvenation is performed using open preseptal dissection. In our
technique, the septum remains attached to the orbicularis when the muscle is
redraped superolaterally, eliminating the need for excision or other manipula-
tion of the septum and decreasing the possibility of traumatically induced scar-
ring and lid retraction.
 Because dissection and release of midfacial soft tissue are done in the subperi -
osteal plane with the use an endoscope, anatomic concerns related to sensory
or motor nerve damage are minimized. All motor branches of the facial nerve
are above the plane of dissection and “out of harm’s way,” and there is no de -
ner vation of the orbicularis muscle.
1141
Chapter 37  Midface Recontouring
Zygomatic branch
Buccal branch

1142
Part VII  Midfacial Rejuvenation
Zygomaticotemporal nerve
Zygomaticofacial nerve
Supraorbital nerve
Supratrochlear nerve
Infratrochlear nerve
Infraorbital nerve (V2)
 The infraorbital nerve (V2; the maxillary division of the trigeminal nerve) is
the most important sensory nerve encountered during subperiosteal cheek dis-
section. It emerges through a foramen in the malar bone approximately 2 cm
below the infraorbital rim and 2 cm lateral to the nasomaxillary fissure. This
nerve provides sensation to the body of the cheek, lateral nasal skin, and lateral
upper lid. Surgical trauma can result in significant, prolonged paresthesia over
these areas.
 The zygomaticofacial nerve emerges through a small foramen in the zygoma
approximately 4 cm below the lateral canthus and provides additional sensa-
tion to the lateral malar skin and cheek. This nerve is usually small and is of-
ten divided during the dissection. In our experience, division of the zygomati-
cofacial nerve is of little consequence, occasionally resulting in a minor
temporary paresthesia (see Chapter 40 for a detailed discussion of facial
anatomy).
Preoperative Assessment
Preoperative assessment should include a detailed history of any medical problems,
but focused to general eye health, dry eyes, personal or family history of glaucoma,
LASIK procedures, and a physical evaluation of lid tone. As a safety measure, we
wait at least 6 months before performing any eyelid procedure in a patient who has
recently had LASIK surgery. We have a low threshold for requesting an ophthal-
mology evaluation when there is any question.

As is true for all areas of the face, the cause of periorbital aging is multifactorial and
necessitates a comprehensive approach if correction is to be optimal. A full evalua-
tion of the face is performed, including the entire periorbital area and the lower face.
Particular attention is paid to the lower lid, the lid-cheek junction, and the midface.
Aging of the lower lid and midface is characterized by both descent and, in patients
who are not obese, some degree of soft tissue deflation. Such changes are looked for
and noted.
Important anatomic components of lower lid and midface aging include the fol-
lowing:
 Laxity and descent of the orbicularis muscle
 Laxity of the orbital septum and pseudoherniation of the orbital fat
 Eyelid tone and laxity
 Descent of the lid-cheek junction
 Horizontal laxity of the tarsal plate component of the lower lid
 Descent of the cheek fat pad with laxity of the orbitomalar ligament
 Laxity of the zygomaticus muscles and other elevators of the upper lip
 Loss of soft tissues volume
 Bone deficiency
 In some cases, some degree of deepening of the nasolabial fold
1143
Chapter 37  Midface Recontouring
Orbital morphology was determined before surgery by using the Hertel exophthal-
mometer. This instrument measures the distance in millimeters from the anterior-
most point of the lateral orbital rim and the anterior border of the globe.
Lateral orbital rim to anterior
border of globe (12-22 mm)
Anterior border
of globe
Anterior border
of lateral orbital rim

Loss of soft tissue volume exaggerates the effects of soft tissue descent. In fact, some
surgeons think that volume loss is the most important component of facial aging.
There is certainly thinning of the tear trough, with deepening of the nasojugal groove.
As the midface descends and deflates, there is concomitant lengthening and thinning
of the upper lip and subtle descent of the lateral oral commissure. Finally, actinic skin
changes with accompanying collagen degradation result in surface aging, with skin
thinning and increasing numbers of both static and expression-induced wrinkles.
Patient Education
Patients should be informed of potential morbidity after lower lid rejuvenation com-
bined with midfacial rejuvenation. Potential morbidities include the following:
 Swelling: Periorbital swelling is most significant in the first 3 to 4 days after
surgery. Head elevation, ice, and occasionally a diuretic are the most effective
treatments. More chronic, lesser degrees of swelling in the lateral orbital area
can require 3 to 5 weeks to totally resolve. Total surgical maturation can re-
quire several months.
 Incisions: The lateral extensions of the upper and lower lid incisions will be
obvious for the first 3 to 4 weeks. These gradually fade into lateral orbital
creases, but in a few patients these may require revision (laser, dermabrasion,
or surgical).
 Nerve injury: Sensory paresthesia related to surgical manipulation of the in-
fraorbital nerve occurs in a few patients and is usually minimal and short lived.
There is near-zero chance of motor nerve injury when the procedure is done
properly using the subperiosteal plane of dissection.
1144
Part VII  Midfacial Rejuvenation
Laxity of orbital septum
Laxity and descent of
orbicularis muscle
Descent of lid-cheek junction
Descent of cheek fat pad with
laxity of orbitomalar ligament
Laxity of zygomaticus muscles
and other elevators of upper lip
Deepening of nasolabial fold

 Lower lid malposition: When the technique is performed properly, the chance
that significant ectropion will occur is extremely low. However, older patients
with horizontal lower lid laxity of 6 mm or greater with an exophthalmome-
ter measurement of 18 mm or less should have appropriate horizontal lid short-
ening and canthal support to prevent lesser degrees of lower lid malposition.
Operative Technique
Markings and Incisions
1145
Chapter 37  Midface Recontouring
The proposed incision in the upper eyelid is marked according to the patient’s mor-
phologic and aging changes. A subciliary lower lid incision is marked on the lower
eyelid with a short lateral extension within the preexisting skin line (if present).
Patient Positioning and Anesthesia
The operation is performed with the patient supine and the head slightly elevated.
The corneas are protected with either ointment or plastic protectors, according to
individual preferences. We usually perform this operation with the patient under gen-
eral anesthesia, because it is combined with other aesthetic procedures.
Upper Lid Blepharoplasty: Exposure of the Lateral
Orbital Rim and Temporal Fascia
If required, an upper blepharoplasty using an open-sky technique is performed to
remove skin and muscle of the upper eyelid and to expose the lateral orbital rim and
temporal fascia. Laterally, the orbital rim is identified; here it is very important to
leave the periosteum intact, because it will serve as the point of midface fixation.
Lateral to the orbital rim, the temporal fascia is exposed sufficiently to allow even-
tual midface fixation. Selectively, if needed, conservative fat excision from the upper
eyelid is performed.

1146
Part VII  Midfacial Rejuvenation
Extent of subperiosteal
dissection and release
Orbicularis-septal
interface not disrupted
Through the lateral myotomy on the orbicularis oculi, subperiosteal dissection and
release of midfacial soft tissue are accomplished with a periosteal elevator under di-
rect vision with endoscopic assistance. This dissection totally spares the pretarsal and
preseptal portions of the orbicularis oculi muscle as well as the entire orbital sep-
tum, significantly reducing surgical trauma within the middle lamella of the lower
lid. Dissection continues medially along the orbital rim, above the infraorbital nerve
to the nasomaxillary suture line, and below the infraorbital nerve; the dissection also
extends to the nasolabial fold medially, the lower edge of the malar bone inferiorly,
and to the junction of the anterior and medial third of the zygomatic arch posteri-
orly. The extent of this dissection results in release of the soft tissues of the cheek,
allowing subsequent elevation and fixation. The dissection includes a release of the
tendinous origins of the levator labii superioris and zygomaticus major and minor, the
suborbicularis fat pad, the lower third of the orbicularis oculi muscle, the cheek fat
pad, and finally, overlying skin, which can be vertically elevated as a unit. Because
the dissection is subperiosteal, branches of the seventh nerve to the involved muscles
are not at significant risk.
Midface Dissection
A subciliary lower lid skin-only incision is made extending 10 to 12 mm lateral to
the lateral canthus. This incision will be parallel and located approximately 5 to
7 mm inferior to the lateral extension of the upper blepharoplasty incision. Through
the lateral extension of the incision, a small myotomy large enough to pass an en-
doscope is performed in the orbicularis muscle to allow a preperiosteal dissection of
the inferolateral orbital rim, connecting superiorly with the dissection previously
performed through the upper lid. The pretarsal orbicularis is not divided.

Septal
tightening
reduces
postseptal fat
1147
Chapter 37  Midface Recontouring
A skin flap is elevated along the lateral third of the subciliary incision, exposing the
underlying full-thickness cheek flap to allow fixation. A suture is placed through the
already elevated cheek flap and then passed under the skin bridge between the up-
per and lower lid incisions. Initial fixation is performed to the temporal fascia above
the arch and just behind the lateral orbital rim. A very important second suture brings
together the medial edge of the elevated flap to the periosteum on the inner surface
of the lateral orbital rim. This step provides additional fixation for strength and pulls
the lid against the globe.
Key suspension
suture number 1
(inside of orbital rim)
Suture number 2
(primary fixation to
temporal fascia)
Running suture number 3
(secondary fixation
to periosteum and
temporal fascia)
Full-thickness cheek flap
Vertical midface elevation
Elevation and Fixation
As the orbicularis muscle flap is redraped and tightened, the septum is also tight-
ened, resulting in reduction of herniated postseptal fat, eliminating the need for fat
excision in most cases. Retention of this lateral segment allows anatomic repair of
the lower lid and provides a “passive tightening” of the lateral canthal tendon and
Preoperative
Postoperative

1148
Part VII  Midfacial Rejuvenation
eliminates the necessity canthopexy. In an occasional patient, the nasal fat pad may
be particularly prominent and may not be adequately reduced with septal tighten-
ing alone. In this rare situation, reduction of the offending pad is performed several
months postoperatively using a simple transconjunctival approach.
Excision of Lower Lid Skin
Full-thickness
lateral tarsal
wedge excised
for horizontal
lid laxity
4-6 mm
1-3 mm
0-1 mm
A guide for skin excision is as follows:
 From the medial canthus to the pupil, 0 to 1 mm
 From the pupil to the lateral canthus, 1 to 3 mm
 Lateral to the lateral canthus, 4 to 6 mm
Overresection of lower lid skin will cause lower lid malposition, and overresection
on the nasal side of the pupil is the most problematic.
Lower lid skin is excised conservatively. Uncorrected lower lid laxity can lead to post-
operative malposition and lid retraction. In both primary and secondary patients,
no matter how secure the midface fixation and canthal support, a deficiency of skin
in the lower lid will invariably result in postoperative lower lid malposition.

1149
Chapter 37  Midface Recontouring
In all patients, orbital morphology is evaluated
preoperatively; lower lid laxity is assessed intra-
operatively and corrected if indicated. Lower lid
laxity can be assessed using the snap-back test
or the more accurate distraction test. The upper
border of the lower lid is grasped as it crosses
the base of the limbus. If the lower lid can be
pulled 6 mm or more away from the globe, sig-
nificant laxity is present and a horizontal lid
shortening should be performed.
Fat injected into
tear trough and
nasojugal groove
Freshly aspirated fat is harvested and 1 to 2 cc is injected into the medial tear trough
through a 21-gauge blunt needle. If indicated, additional amounts of fat (5 to 8 cc)
are injected into deficient zones of the cheek and lower face.
When indicated, a 2 to 4 mm full-thickness wedge of the ciliary margin and the tarsal
plate is excised.
Volume Replacement
5
Inferior orbital rim
Lower lid
10

1150
Part VII  Midfacial Rejuvenation
Nasojugal groove
Tear trough
Autologous fat graft
along orbital rim,
tear trough, and
nasojugal groove
Prominent
nasolabial
fold
Microsuction of fat from
medial edge of prominent
nasolabial fold
Early on we began using autologous fat injection to better cover the inferior orbital
rim and add indicated volume to the tear trough and nasojugal groove.
Conversely, we found it helpful in patients with deep nasolabial folds to reduce vol-
ume in the medial edge of the fold by suctioning with a small 1 or 2 mm cannula.

1151
Chapter 37  Midface Recontouring
Brow Repositioning and Neck Lifting as a Component
of Midface Rejuvenation
Lower lid and midface rejuvenation is usually done as an important component of
comprehensive facial rejuvenation. In essentially all cases, some degree of brow repo-
sitioning is necessary. Our preferred technique is an endoscopically assisted subperi -
osteal approach that includes resection of the corrugator and procerus muscles. If
the central brow is not an issue, a limited lateral approach is used. The purpose of
the brow manipulation is to correct brow ptosis when present, and, just as impor-
tant, to smooth and redrape lateral orbital soft tissue excess that occurs with the
powerful vertical vector cheek lift. (See Chapter 24 for detailed information on en-
doscopic brow lift.)
A lower face and neck lift is also performed in patients with significant aging at and
below the oral commissure and in the neck. Preauricular and postauricular incisions
are used. Sufficient subcutaneous dissection is done to allow lateral plication of the
lower SMAS and platysma. As indicated, treatment of the midline of the neck is per-
formed through a submental incision.
Rejuvenation of the midface as we have described eliminates the need for extensive
lateral to medial sub-SMAS dissection in the cheek and lower face.
Endoscopic incisions
No temporal incision
Preauricular incision
Hairline extension
Postauricular incision
Because the lateral brow is elevated with endoscopic assistance, it is not necessary
to extend the preauricular incision into the temporal scalp. Thus elevation of the side-
burns or a potentially visible scar in the hair line is avoided.

1152
Part VII  Midfacial Rejuvenation
Upper brow vectors
(vertical/medial)
Midface vectors
(vertical)
Neck/lower face vectors
(posterolateral)
The vectors used for comprehensive facial rejuvenation are depicted.
Skin Resurfacing
When indicated, skin rejuvenation with an erbium laser or a peel is performed at
this stage. If concomitant aesthetic facial procedures are planned, the peel or laser
should be the final step after completion of those procedures. Concomitant skin re-
juvenation with this procedure is safe, because the dissection of the midface is done
in the subperiosteal plane, and the blood supply to the skin is not significantly af-
fected. When the procedure is combined with a face and neck lift, there is limited
subcutaneous dissection of preauricular skin, and resurfacing should be superficial
to the affected zones.
Postoperative Care
The postoperative course for patients undergoing this technique is comparable to
other comprehensive rejuvenation operations. Periorbital swelling can be troubling
early, and care must be exercised to protect the globe with drops and ointment. By
2 weeks postoperatively, all sutures and fixation devices are removed. By the third
to fourth week, most patients can manage with appropriate cosmetic coverage tech-
niques; 2 to 3 months is required for more complete healing, and in general, revi-
sions are not done for 6 months.

Problems and Complications
The senior author has more than 20 years of experience with the transorbital ap-
proach to lower lid and midface rejuvenation in more than 1500 patients. As indi-
cated earlier, the original technique was through an “open” lower lid, incorporat-
ing a subciliary incision with a traditional skin-muscle flap dissected to the orbital
rim. An overview of this experience was published in 2000. Although overall results
were excellent, a small but troubling number of patients had postoperative lower lid
malposition, possibly related to the extensive lower lid dissection required. Some pa-
tients developed minor degrees of webbing or blunting of the lateral canthal angle
secondary to canthoplasty. To minimize these problems, two important modifications
of the technique were incorporated in 1999. Open dissection of a skin-muscle flap in
the lower lid was abandoned in favor of a “closed” endoscopically assisted approach
that avoids dissection in the body of the lower lid. This modification of technique sig-
nificantly decreased the rate of postoperative lower lid malposition. In addition, can-
thoplasty involving a transcanthal incision has been eliminated. In 2005 new steps
were added to further improve the results, virtually eliminating the incidence of se-
vere lower lid malposition. These new steps included the intraoperative correction
of significant horizontal lower lid laxity and decreasing operative septal trauma.
The importance of “deflation” as a significant component of facial aging, in many
cases, has stimulated us to be more aggressive with volume replacement when indi-
cated. The use of autologous fat grafting is certainly an attractive option in these
cases. However, not all plastic surgeons are enthused about the success rates for fat
grafting. In our experience, fat grafting has been useful, but success appears to be
very technique dependent. It is important that aspiration be as atraumatic as possi-
ble and that injections be done with small-gauge, blunt needles, with small amounts
injected in multiple passes. We have also used solid silicone cheek and orbital rim
implants, especially in patients with severe degrees of maxillary retrusion.
Outcomes
The very low incidence of this troublesome morbidity is probably related to the de-
creased trauma to the lid and lateral canthus inherent in the technique. We found
that in most cases the tightening of the pretarsal orbicularis muscle that occurs with
these modifications provided excellent lower lid support and eliminated the need for
a formal canthoplasty. Because the muscle was not dissected off the septum, orbi -
cularis redraping passively tightened the septum, thus reducing postseptal fat herni-
ation without the necessity of direct septal manipulation.
1153
Chapter 37  Midface Recontouring

A 2009 article by the senior author highlighted very important steps to decrease
complications in lower lid and midface rejuvenation, with the finding that patients
with horizontal lid laxity of 6 mm or greater with an exophthalmometer measure-
ment of 18 mm or less were at increased risk of lower lid malposition. When sig-
nificant horizontal lower lid laxity is present, a lateral lower lid wedge excision is
used as described earlier. This maneuver spares the angle and markedly decreases
the incidence of healing deformity of the lateral canthal angle. Our experience sug-
gested that patients with enophthalmic orbits combined with horizontal lower lid
laxity are also at increased risk.
It should be emphasized that the passive septal tightening that occurs is very effec-
tive in correcting postseptal fat prolapse without the trauma inherent in open lower
lid procedures.
Results
1154
Part VII  Midfacial Rejuvenation
This 54-year-old woman is shown before and 1 year after closed endoscopically as-
sisted midface lift and brow lift with appropriate skin excision in the upper and lower
lids. She also had fat injection along the orbital rim and erbium laser skin resurfac-
ing for acne scarring. The split-view clearly confirms the elevation of the lid-cheek
junction, softening of the nasolabial fold, and decreased corrugator and transverse
forehead wrinkles without overskeletonization of the upper and lower lids.

1155
Chapter 37  Midface Recontouring
Desiring midface rejuvenation and a more uplifted appearance, this 57-year-old
woman underwent an endoscopically assisted midface and brow lift, neck lift, and
a TCA peel. She was very pleased with the results, which provided elevation of the
lid-cheek junction and oral commissure and rejuvenation of her jowls and neck. She
is shown 18 months after treatment. The oblique views and split-view dramatically
demonstrate the midface elevation that has been achieved.

1156
Part VII  Midfacial Rejuvenation
This woman is shown before and 1 year after a closed endoscopically assisted mid-
face lift and brow lift with appropriate skin excision in the upper and lower lids.
Clinical Caveats
 Trauma can be limited by eliminating preseptal dissection in the body of the lower
lid and endoscopically assisted subperiosteal dissection of midfacial soft tissue.
 Elevation and fixation of the midface should be vertical rather than lateral.
 The technique involves vigorous vertical elevation and redraping of the orbicularis
oculi.
 Patients with horizontal lid laxity of 6 mm or greater with an exophthalmometer
measurement of 18 mm or less are at increased risk of lower lid malposition.
 Horizontal lower lid laxity is corrected intraoperatively when present.
 Volume should be replaced when indicated.
 Skin rejuvenation should be performed when indicated.

Annotated Bibliography
Finger ER. A 5-year study of the transmalar subperiosteal midface lift with minimal skin and
superficial musculoaponeurotic system dissection: a durable, natural-appearing lift with
less surgery and recovery time. Plast Reconstr Surg 107:1273-1283; discussion 1284,
2001.
The author describes the transmalar subperiosteal midface lift technique as well as its
advantages. The results in 272 patients over a 5-year period are presented.
Hester TR. Evolution of lower lid support following lower/midface rejuvenation: the pre-
tarsal orbicularis lateral canthopexy. Clin Plast Surg 28:639-652, 2001.
An 18-month experience with an endoscopically assisted closed technique of modified
transblepharoplasty lower lid and midface rejuvenation is presented.
Hester TR, Codner MA, McCord CD, et al. Evolution of technique of the direct transbleph -
aroplasty approach for the correction of lower lid and midfacial aging: maximizing results
and minimizing complications in a 5-year experience. Plast Reconstr Surg 105:393-406;
discussion 407-408, 2000.
The purpose of this article is twofold: to provide a comprehensive retrospective evalu-
ation of the value and promise of the technique, and to present a comprehensive dis-
cussion of the pitfalls and complications that have been associated with use of this tech-
nique. In addition, technical modifications that may lower the rate of morbidity
associated with the use of the procedure are described. The authors’ experience with
transblepharoplasty midface and lower lid rejuvenation confirms that the key to pre-
venting complications lies in the surgeon’s ability to manage the lower lid skin/muscle
excess that is returned to the orbit after vertical elevation of the midface.
McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconstr
Surg 102:2471-2479, 1998.
The authors discuss the surgical technique of redraping of the inferior arc of the orbi -
cularis oculi muscle, used primarily to produce lower lid and midfacial smoothing in
patients undergoing aesthetic surgery. They also describe the technique modifications
necessary for treating patients with prominent eyes and distensible lower lids as well as
adjunctive procedures.
Psillakis JM, Rumley TO, Carmagos A. Subperiosteal approach as an improved concept for
correction of the aging face. Plast Reconstr Surg 82:383-394, 1988.
A harmonious facial appearance is determined by a balanced relationship among all tis-
sues of the face. With advancing age, balance is lost among the bone, muscle, fat, and
skin as progressive changes occur in their volume, shape, position, and consistency. The
authors present the subperiosteal rhytidectomy technique to achieve natural results of
the upper and central face, eyebrows, periorbital, external canthus, cheeks, and na-
solabial folds. They also include patient results and discuss complications.
1157
Chapter 37  Midface Recontouring

Sullivan SA, Dailey RA. Endoscopic subperiosteal midface lift: surgical technique with indi-
cations and outcomes. Ophthal Plast Reconstr Surg 18:319-330; discussion 329-330,
2002.
The authors review the indications for and the surgical technique of the endoscopic sub-
periosteal midface lift. They also present clinical outcomes in 22 consecutive patients.
They found this technique to be an effective method for elevating the midface and achiev-
ing a more youthful appearance.
Suggested Readings
Codner MA, McCord CD, Hester TR. The lateral canthoplasty. Oper Tech Plast Surg 5:90-
98, 1998.
Coleman SR. Facial recontouring with liposculpture. Clin Plast Surg 24:347-367, 1997.
Hamra ST. Periorbital rejuvenation in composite rhytidectomy. Oper Tech Plast Reconstr
Surg 5:155-162, 1998.
Hester TR. Subperiosteal malar cheek lift with lower lid blepharoplasty. In McCord CD, ed.
Eyelid Surgery. Philadelphia: Lippincott-Raven, 1995.
Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial
aging using the transblepharoplasty subperiosteal cheek lift. Aesthetic Surg Q 16:51-58,
1996.
Hester TR, Codner MA, McCord CD, et al. Transorbital lower lid and midface rejuvenation.
Oper Tech Plast Reconstr Surg 5:163, 1998.
Hester TR Jr, Douglas T, Szczerba S. Decreasing complications in lower lid and midface re-
juvenation: the importance of orbital morphology, horizontal lower lid laxity, history
of previous surgery, and minimizing trauma to the orbital septum: a critical review of
269 consecutive cases. Plast Reconstr Surg 123:1037-1049, 2009.
Hester TR, Grover S. Avoiding complications in transblepharoplasty lower lid and midface
rejuvenation. Aesthetic Surg Q 20:61, 2000.
Hirmand H, Codner MA, McCord CD, Hester TR Jr, Nahai F. Prominent eye: operative man-
agement in lower lid and midfacial rejuvenation and the morphologic classification sys-
tem. Plast Reconstr Surg 110:620-628, 2002.
Jelks GW, Glat PM, Jelks EB. The inferior retinacular lateral canthoplasty. Plast Reconstr
Surg 100:1262-1270; discussion 1271-1275, 1997.
Lambros V. Fat injection for the aging face. Oper Tech Plast Surg 5:129-137, 1998.
Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional
stereolithography, with reference to the pathogenesis of midfacial aging, scleral show,
and the lateral suborbital through deformity. Plast Reconstr Surg 106:479-488; discussion
489-490, 2000.
Ramirez OH. The subperiosteal approach for the correction of the deep nasolabial fold and
the central third of the face. Clin Plast Surg 22:341-356, 1995.
Seify H, Jones G, Bostwick J, Hester TR. Endoscopic-assisted face lift: review of 200 cases.
Ann Plast Surg 52:234-239, 2004.
Tessier P. [Subperiosteal facelift] Ann Chir Plast Esthet 34:193-197, 1989.
1158
Part VII  Midfacial Rejuvenation

Endoscopic Rejuvenation
of the Midface

RENATO SALTZ, CARLOS CASAGRANDE,
ANDERSON SACILOTO,
GABRIELE CÁCERES MIOTTO
CHAPTER 38

1160
Part VII  Midfacial Rejuvenation
A
better understanding of the pathophysiology of midface aging and the intrin-
sic anatomic structures involved in this process has allowed plastic surgeons
to develop safe techniques for midface rejuvenation, and significant progress has been
made in recent years. Many different approaches have been introduced for the treat-
ment of the aging midface, including these areas:
 Lower eyelid
 Face lift
 Open temporal incision
 Use of barbed sutures
 Endoscopic temporal and oral incisions
The endoscopic temporal approach for the treatment of the midface has obvious ad-
vantages. It provides a safe plane of dissection along the deep temporal fascia and
along the subperiosteal plane of the midface or the forehead. It can easily be com-
bined with an endoscopic brow lift when necessary. It provides excellent visualiza-
tion of the midface anatomy and permits easy fixation, regardless of the method cho-
sen. Because of the extensive dissection and creation of an excellent optical cavity in
the midface pocket, one can often eliminate the need for an intraoral incision, thus de-
creasing the possible risk of infection. Furthermore, endoscopic midface suspension
has, in our hands, been shown to be a safe, reproducible technique with good long-
term results. Patients appear to be more satisfied because the scars are smaller, there
is less bruising, and recovery is faster. Endoscopic magnification provides better vi-
sualization of the complex midface anatomy, resulting in reduced morbidity.
Pertinent Anatomy
Success with any operation for facial rejuvenation requires a basic understanding of
the aesthetic subunits and anatomic structures of the face and how they are affected
by the aging process; these should be studied and respected to obtain a harmonious
result. It is important to know which structures need to be altered and then to match
the correct treatment with the most appropriate technique.
Midface aging is characterized by four anatomic changes:
1. Descent of the malar fat pad
2. Descent of the lid-cheek junction
3. Increase in prominence of the nasolabial folds
4. Loss of cheek projection

The changes associated with midface aging occur as a result of ptosis of the malar
fat pads, with an inferior medial sliding of this tissue. Concomitantly, cutaneous and
ligamentous laxity results in the descent of the facial muscles: the zygomaticus mi-
nor and major and the levator of the upper lip. Together these changes accentuate
the nasolabial groove and contribute to flattening of the malar area.
1161
Chapter 38  Endoscopic Rejuvenation of the Midface
An excess of tissue known as the malar bag or festoon may also develop. This is a
thick fat layer located between the skin and the superficial musculoaponeurotic sys-
tem (SMAS). Other changes include maxillary reabsorption and ptosis of the cor-
ners of the mouth, resulting in what patients refer to as a “sadistic smile.” This ag-
ing process also creates an artificial increase in the vertical length of the lower eyelid.
Orbicularis
retaining
ligament
Zygomatico-
cutaneous
ligament
Tear trough
Descent of
lid skin below
orbital rim
Malar fat pad
Nasolabial fold

The musculature of the face is also subject to the aging process. The arcus margin-
alis of the lower eyelid divides the orbital region and the midface. It is formed by the
orbital septum and a thin fascia of the deep portion of the orbicularis oculi inserted
at the inferior orbital rim.
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Part VII  Midfacial Rejuvenation
With aging, this structure becomes loose and weak and slides downward, further
emphasizing the changes of the aging face.
The muscles of the orbitofrontal area have a fundamental importance in determining
brow position. The frontal muscle terminates abruptly along the superior temporal
line (the crest of the temporal bone); it is an extension of the galea aponeurotica, be-
ginning at the level of hairline implantation and extending through the supraorbital
skin. Its function is to elevate the brows. The brow is suspended by the frontal mus-
cle only in its medial two thirds. Because of that anatomic aspect, the descent of the
tail of the brow is usually more evident than in the head and body. Clinically, the de-
scent of the brow tissues in the temporal region contributes to the tired or sad facial
appearance often associated with aging. The temporal area and lateral periorbital
Orbital rim
Orbital septum
Orbicularis oculi
muscle
Arcus marginalis

area can also be considered to be a continuation of the middle third of the face and
equally responsible for the anatomic manifestations of the aging face.
FACIAL ANALYSIS
Zones of the Brow and Midface
Careful patient evaluation is fundamental to achieving a good surgical result. Facial
aging is nothing more than the clinical manifestation of the physiologic alterations
of facial anatomy. The midface has a direct anatomic relationship with the temporal
and periorbital areas. Our facial analysis consists of a detailed evaluation of the dif-
ferent facial zones and their structural changes from aging.
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Chapter 38  Endoscopic Rejuvenation of the Midface
To facilitate understanding of the endoscopic anatomy of the brow and midface, we
have divided the upper face and midface into surgical zones. Success with any oper-
ation for facial rejuvenation requires a basic understanding of these aesthetic zones
and the anatomic structures that are affected by the aging process.
Zone One
Zone 1 comprises the temporal region, extending medially to the temporal crest, in-
feriorly to the supraorbital rim, and downward along the lateral orbital rim and the
superior border of the zygomatic arch. The floor of zone 1 is the temporalis muscle
and the deep temporal fascia, and the roof is the superficial temporal fascia and all
of the other structures superficial to it. Dissection at this level is suprafascial—on
top of the deep temporal fascia and below the temporal parietal fascia.
Zone 1
Zone 3
Zone 2

Zone Two
Zone 2 is limited laterally by the two temporal crests, inferiorly by the supraorbital
rims and nose, and superiorly to the level of the incisions. Dissection in zone 2 is
subperiosteal, keeping the galea and the skin above intact. During midface surgery,
the surgeon must connect zones 1 and 2 by releasing the areolar tissue at the level
of the temporal crest.
Zone Three
Zone 3 comprises the lateral and inferior orbital rim, malar bone, and the premax-
illa. Dissection is subperiosteal, under the malar fat pad. The infraorbital rim is of-
ten visualized in the medialmost aspect of the dissected pocket.
Zone 3 also incorporates the inferior eyelid, which we do not consider to be part of
the midface.
Transitions
Understanding the transition between zones 1 and 3 and their anatomic structures
is critical for safe and precise dissection in the midface. The transition between zones
1 and 3 is outlined by the sentinel veins, the medial temporal zygomatic nerve, the
lateral temporal zygomatic nerve, and the lateral temporal zygomatic veins and ar-
tery. It is essential to preserve these cutaneous nerves and avoid numbness over this
area of dissection.
Indications and Contraindications
Clinical indications for midfacial lifting include the following:
 Accentuation of the nasolabial grooves
 Ptosis of the corners of the mouth
 Ptosis of the lateral corner of the eyelids
 Sliding of the malar bags
 Deepening of the orbital rims
 Loss of the projection (flattening) of the malar area
 Accentuated nasojugal grooves
 Ptosis of the tail of the brows
 Dynamic periorbital wrinkles
Contraindications for endoscopic treatment of the midface include the following:
 Prominent malar bone that compensates for midface ptosis
 Lack of adequate soft tissue volume to restore midface contour
 Need for full facial rejuvenation; this category of patients can undergo mid-
face rejuvenation without the need for a separate endoscopic procedure
 Other medical contraindications
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Part VII  Midfacial Rejuvenation

Preoperative Assessment
Preoperative evaluation includes questions about anamnesis, current pathologies,
and medications—specifically ones that change platelet adhesion, such as aspirin,
ginkgo biloba, and antiinflammatory drugs. The requested preoperative exams in-
clude the following:
 Complete blood cell count
 Coagulation function assay
 Glycemia testing
 Creatinine levels and clearance
 Electrocardiogram
 Chest radiographs
Planning
Pertinent Instruments
The following instruments are of particu-
lar importance for endoscopic midfacial re-
juvenation:
 Subperiosteal hockey-stick elevators
 Fixation devices
– Casagrande needle
– Endotine device
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Chapter 38  Endoscopic Rejuvenation of the Midface
Casagrande needle
Endotine device
Basic surgical instrumentation for facial endoscopic surgery
Hockey-stick elevators

Operative Technique
Markings
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Part VII  Midfacial Rejuvenation
Anterior
temporal line
Supraorbital
nerve
Zon
on
Z
e 1
e 1
Zone 3
Zon
Zo e 2
Point A
or
Inferio
l rim
orbita
Anterior
poral line
temp
aorbital
Supra
nerve
Facial nerve
Zygomatic
Zygomatic
arch
3
3 c
3 c
3 c
3 m
abial
Nasol
fold
The midface is a small area of the face, but it represents a very important aesthetic
unit. Anatomically, it is delimited superiorly by the inferior eyelid, medially by the
nasofacial angle, laterally by the pretragal area and sideburn, and inferiorly by the
nasolabial groove. The three zones of dissection should be outlined at this point. En-
doscopic midface rejuvenation can be combined with an endoscopic brow lift (zones
1, 2, and 3) or performed as an isolated procedure (zones 1 and 3). The scalp and
temporal areas are prepared and marked.

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Chapter 38  Endoscopic Rejuvenation of the Midface
Back table
Mayo stand
Videoendoscopic
equipment
(including monitor)
The deep branch of the supraorbital nerve is an important landmark. Its trajectory
should be outlined during marking to avoid incisions in this area, which can cause
paresthesia in the anterior scalp.
The following landmarks are marked for endoscopic treatment of the midface:
 The inferior orbital rim and zygomatic arch
 The nasolabial folds
 Point A at 3 cm lateral to the lateral orbital rim at the level of the superior zy-
gomatic arch
 A line communicating the distal third of the nasolabial fold to define the area
of subperiosteal dissection of the midface, which is anatomically defined su-
periorly by the lower eyelid, medially by the nasofacial angle, laterally by the
pretragal area and sideburn, and inferiorly by the nasolabial fold
 The anterior temporal line (a periosteal fold that separates the frontal from
the temporal area)
 A line from the inferior earlobe to the lateral corner of the lateral brow to out-
line the trajectory of the temporal branch of the facial nerve
 A line from the superior zygomatic arch at the lateral corner of the eye to out-
line the transition from the temporal area to the midface (zones 1 to 3)
 A line that crosses the frontal area until 2 cm above the superior orbital edge
divides the frontal area in two areas
Operating Room Setup and Patient Positioning
The surgical suite must be well organized to
perform an endoscopic procedure. A complete
surgical plan is essential to define the patient’s
positioning. The imaging equipment should
be at the foot of the surgical table to permit
better visualization. The surgeon and the as-
sistant should be at the head of the table.
The endotracheal tube should be tied to a
tooth using dental floss and wrapped with
sterile plastic so that it is visible through the
entire surgical case. The microcamera cable
should be long enough to permit adequate
movement and should be covered with a ster-
ilized plastic sleeve. The fiber of the cold light
and the optical should be disinfected in 2%
glutaraldehyde solution.

The patient’s head should be placed on a soft head support that facilitates the bi-
lateral mobilization. The endotracheal tube, when used, should be fastened appro-
priately to avoid accidents during some mobilization. The positioning of the team
and the patient is very important to facilitate the procedure.
Patient Preparation
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Part VII  Midfacial Rejuvenation
The patient’s hair is tied back without shaving to allow spaces for marking the in-
cisions in the temporal and paramedian scalp sites.
Infiltration
This procedure is done with the patient under local anesthesia and sedation. Tumes-
cent infiltration with a local anesthetic to the temporal, forehead, and midface
areas allows creation of an excellent optical cavity by providing vasoconstriction and
easy dissection. General anesthesia can be used with the endotracheal tube secured to
the upper teeth with dental floss. The tube is wrapped with a sterile plastic sleeve
and is incorporated into the sterile field. It should be visible and readily accessible
at all times and if necessary adjusted without breaking sterile technique. The eyes
should be protected with ointment and shields.
We infiltrate lidocaine 2% without epinephrine for nerve blockade (supraorbital,
supratrochlear, and infraorbital). An anesthetic solution contains 20 ml of 2%
lidocaine without epinephrine, 20 ml of 0.5% bupivacaine without epinephrine,
1 ml epinephrine, and 160 ml of cold isotonic saline solution for a total volume of
200 ml.

Zone 1
Zone 3
Zone 2
Incision
2 cm
Incisions
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Chapter 38  Endoscopic Rejuvenation of the Midface
A temporal incision (red dashed lines) gives access to the temporal area and the mid-
face. It is positioned 2 cm posterior to the hairline in a coronal direction, corre-
sponding to a line from the lateral wing of the nose, passing through the lateral tail
of the brow, and reaching the scalp.
Dissection
Dissection through the temporal incisions is carried down to the deep temporal fas-
cia. Identifying the temporal muscle under the deep temporal fascia is useful to se-
cure the right plane of dissection, which should be above the deep temporal fascia.

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Part VII  Midfacial Rejuvenation
Plane of dissection
Temporalis muscle
Temporoparietal fascia
Fat
Skin
Deep temporal fascia
Area of
dissection
Blunt dissection continues inferiorly down to a point
of resistance at the level of the supraorbital rim. At this
point, the endoscope is introduced in the cavity to al-
low better visualization, safer dissection, and adequate
hemostasis. Medially the dissection continues through
the areolar tissue connecting the deep temporal fascia
with the subperiosteal plane (zones 1 and 2).
The plane of dissection in this anatomic zone
is under skin, fat, and the temporoparietal
fascia. The temporal branch of the facial
nerve is superficial to this plane of dissection.
It is protected by the intermediate fascia
(loose areolar tissue), the superficial tempo-
ral fat pad, and the temporoparietal fascia.
The nerve is in the “roof” of the dissection.
Dissection continues along the areolar plane
until it reaches the supraorbital rim and su-
perior border of the zygomatic arch.