The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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VII Midfacial Rejuvenation
40.2 Temporal Approach
The temporal approach entails an incision in the temporal area
and endoscopic dissection into the midface. Elevation and fixation
of the midface are accomplished through long suspension sutures
or fixation devices, such as the Endotine devices (MicroAire
Surgical Instruments, LLC, Charlottesville, VA).
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 junc-
tion. However, it produces only 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 combined with blepharoplasty
and a lower facelift in individuals with panfacial aging.
40.3 Transpalpebral Approach
This approach affords not only a diagonal vector but also the only
true vertical vector for elevation of the midface, combined with
lower lid rejuvenation. The major concern about this approach
involves lower lid retraction. The approach can be modified to
minimize the risk.
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 techniques and a
diagonal vector on the orbicularis oculi muscle to add extra support
to the lower lid in addition to the aesthetic improvement (Fig. 40.2).
If fat manipulation is not planned, a very limited incision is
made laterally in the orbicularis, and midface mobilization is
accomplished with an endoscope, a headlight, or a small lighted
Aufricht retractor. This alternative approach, in which the orbi-
cularis 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 (Fig. 40.3).
40.3.1 Clinical Cases
Two cases of this approach are shown in Fig. 40.4 and Fig. 40.5.
40.4 Facelift Incisions
Through the standard facelift incision or the modified prehair-
line incision, the superficial musculoaponeurotic system (SMAS)
is easily accessed and can be manipulated to elevate the midface.
Surgical Options
• The high-SMAS technique
• The extended minimal-access cranial suspension (MACS) lift
• SMASectomy and SMAS plication
40.4.1 The High-SMAS Technique
The incision in the SMAS at or above the level of the zygomatic
arch, combined with adequate mobilization of the SMAS, facili-
tates effective elevation of the midface and malar fat pad with
blending of the lid–cheek junction in a diagonal direction. :hen
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 (Fig. 40.6).
40.4.2 The Extended MACS Lift
The third and highest of the purse-string sutures described with
the extended MACS lift effectively and diagonally elevates the
midface with some blending of the lid-cheek junction (Fig. 40.7).
Tonnard and Verpaele combine this procedure with a skin–pinch
blepharoplasty to rejuvenate the aging lower lid.
Fig. 40.2 Elevation of the mid face through upward traction and
fixation of the orbicularis flap.
Fig. 40.3 Vertical and diagonal vectors of midface elevation through
the transpalpebral approach.

40 Clinical Decision Making in the Midface
475
Fig. 40.4 (a) This 51-year-old woman underwent an endoscopically assisted brow lift, upper lid blepharoplasty, and lower lid blepharoplasty, together
with transpalpebral midface lift with orbicularis redraping and canthopexy. She also had a short-scar facelift. (b) The postoperative view at 1 year
shows blending of the lid–cheek junction and elevation of her midface as a result of the transpalpebral procedure. The lower face improvement is the
result of the short-scar facelift.
Fig. 40.5 (a) This 59-year-old woman underwent a secondary short-scar facelift and secondary upper- and lower-lid blepharoplasty, with transpalpe-
bral endoscopic midface lift and orbicularis redraping with canthopexy. (b) Her result is shown 1 year postoperatively with elevation of the midface
and blending of the lid–cheek junction.

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40.4.3 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 rejuvenate the lower
eyelid fully, the surgeon must perform a blepharoplasty to deal
with the eyelid, skin, and orbicularis muscle (Fig. 40.8).
40.5 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 exten-
sive skin, muscle, or fat manipulation, the temporal and facelift
approaches are suitable options. Fat grafts or fillers offer a less
invasive option for these patients.
Fig. 40.6 (a) Superficial musculoaponeurotic system (SMAS) mobilization for complete cheek and eyelid rejuvenation. (b) SMAS mobilization for
jowls and neck only.
Fig. 40.7 Malar fat pad suspension using the extended minimal-access cranial suspension (MACS) lift.
Fig. 40.8: Midface elevation by superficial aponeurotic system (SMAS)
excision and closure or plication.
a
b

40 Clinical Decision Making in the Midface
477
Although the transpalpebral approach affords a more direct
midface lift with unlimited 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 ade-
quately 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 (Table 40.1).
Suggested Reading
[1] Codner MA, McCord CD, Hester TR. The lateral canthoplasty. Oper Tech Plast
Reconstr Surg 1998;5(2):90–98
>2@ Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg
1997;24(2):347–367
>3@ 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
2001;107(5):1273–1283, discussion 1284
>4@ Hamra ST. Periorbital rejuvenation in composite rhytidectomy. Oper Tech Plast
Reconstr Surg 1998;5(2):155–162
>5@ Hester TR Jr. Evolution of lower lid support following lower lid/midface
rejuvenation: the pretarsal orbicularis lateral canthopexy. Clin Plast Surg
2001;28(4):639–652
>6@ Hester TR. Subperiosteal malar cheek lift with lower lid blepharoplasty. In Mc-
Cord CD, ed. Eyelid Surgery. Philadelphia, PA: Lippincott-Raven; 1995
[7] Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of
facial aging using the transblepharoplasty subperiosteal cheek lift. Aesthetic Surg
Q 1996;16(1):51–58
[8] Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos A. Evolution of
technique of the direct transblepharoplasty approach for the correction of lower
lid and midfacial aging: maximizing results and minimizing complications
in a 5-year experience. Plast Reconstr Surg 2000;105(1):393–406, discussion
407–408
[9] Hester TR, Codner MA, McCord CD, Nahai F. Transorbital lower-lid and midface
rejuvenation. Oper Tech Plast Reconstr Surg 1998;5(2):163–185
>10@ Hester TR, Grover S. Avoiding complications of transblepharoplasty lower-lid and
midface rejuvenation. Aesthet Surg J 2000;20(1):61–67
[11] Hirmand H, Codner MA, McCord CD, Hester TR -r, 1ahai F. Prominent eye: operative
management in lower lid and midfacial rejuvenation and the morphologic classi-
fication system. Plast Reconstr Surg 2002;110(2):620–628, discussion 629–634
>12@ -elks G:, Glat PM, -elks EB, Longaker MT. The inferior retinacular lateral cantho-
plasty: a new technique. Plast Reconstr Surg 1997;100(5):1262–1270, discussion
1271–1275
>13@ Lambros V. Fat injection for the aging midface. Oper Tech Plast Reconstr Surg
1998;5(2):129–137
>14@ McCord CD -r, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast
Reconstr Surg 1998;102(7):2471–2479
>15@ Psillakis -M, Rumley TO, Camargos A. Subperiosteal approach as an improved
concept for correction of the aging face. Plast Reconstr Surg 1988;82(3):383–394
>16@ Ramirez OM. The subperiosteal approach for the correction of the deep nasolabi-
al fold and the central third of the face. Clin Plast Surg 1995;22(2):341–356
[17] Saltz R, Ohana B. Thirteen years of experience with the endoscopic midface lift.
Aesthet Surg J 2012;32(8):927–936
[18] Sullivan SA, Dailey RA. Endoscopic subperiosteal midface lift: surgical technique
with indications and outcomes. Ophthal Plast Reconstr Surg 2002;18(5):319–330,
discussion 329–330
[19] Tessier P. Subperiosteal face-lift >in French@. Ann Chir Plast Esthet
1989;34(3):193–197
Table 40.1 Choosing the best option for midface rejuvenation
Vectors
Rejuvenation/lift
Vertical
Diagonal
Eyelids
Midface
Lower
face
Jawline
Transpalpebral
+ + + +
+ + + +
+ + + +
+ + + +
—
—
Transtemporal
+
+ + + +
+ +
+ + +
+
—
Facelift
approach
+
+ + + +
+ +
+ + + +
+ + +
+ + +

478
VII Midfacial Rejuvenation
41 Midface Recontouring
Patrick Tonnard, Alexis Verpaele, and Adriana Cely
Abstract
Midface recontouring can be seen as the correction of centrofa-
cial deflation as part of the facial aging process or as a minimally
invasive method to correct facial deformities in facial bone
hypoplasias. A better understanding of the aging process of the
face shows that a combination of processes occurs rather than
just sagginess of the skin. There are changes in skin texture and
pigmentation, and volume is lost in certain areas of the face.
The deflation process is most important in the centrofacial area,
which consists of the periorbital and perioral areas.
Fat grafting has become an integral and indispensable part of
the modern facial rejuvenation process. If the treatment goal is a
total and natural facial rejuvenation, the therapeutic plan must be
a combination of different modalities individually adapted to each
patient’s needs. In this chapter, main techniques for centrofacial
rejuvenation are reviewed as augmentation blepharoplasty, correc-
tion of nasolabial fold, lip enhancement, lip lift, perioral sharp-nee-
dle intradermal fat injection (S1IF), lip resurfacing, and nanofat
treatment, showing results and outcomes with different cases.
The main purpose of microfat grafting in facial contouring is
aesthetic correction of the facial proportions while avoiding inva-
sive orthognathic surgery in patients with mild maxillary or man-
dibular hypoplasia where occlusion problems of the teeth occur
infrequently and can usually be corrected through orthodontic
treatment. This technique has become a valuable alternative
to performing more complicated advancement osteotomies in
patients solely for aesthetic reasons. The low morbidity and rapid
recovery associated with facial microfat grafting make it a power-
ful tool in the armamentarium of the modern aesthetic surgeon.
Keywords
facial aging, midface rejuvenation, facial contouring, centrofacial
rejuvenation, augmentation blepharoplasty, fat grafting, lip lift,
nanofat, lipofilling, prophyloplast
41.1 Introduction
The different mechanisms involved in facial aging are expressed to
varying degrees and in different combinations in each individual.
Furthermore, because the distinct fat compartments in the face can
change at different rates with age, the whole face does not age as a
compound mass. Skin texture and pigmentation also change with
aging. Aging skin loses elasticity, resulting in sagging of certain facial
features, especially around the mouth and the neck. Contraction of
certain muscles will produce permanent wrinkles³for example,
in the frontal area and the glabella, or the muscular bands of the
anterior neck. Finally, volume loss or deflation results in an implo-
sion-like appearance with aging (Fig. 41.1). Sagging of facial skin can
be corrected with a surgical facelift procedure. Surgeons can treat
the eyelids, the eyebrows, the lips, and the neck; perform subman-
dibular gland resection; or remove the adipose corpus of Bichat.
The difficulty is not in mastering all the surgical techniques but
rather in choosing the right combination of procedures and in
understanding the correct indications for the different techniques.
The texture and quality of the skin can be altered by skin care
products with alpha-hydroxy acids or retinoic acid, light therapy
such as intense pulsed light (IPL), or, more drastically, with resur-
facing techniques such as dermabrasion, a chemical peel, or carbon
Fig. 41.1 Aging is a combination of different mechanisms: sagging, wrinkling, contraction, volume loss, and loss of animation. Understanding the
importance of each of these factors will influence the therapeutic plan. IPL, intense pulsed light; SMASectomy, resection of the superficial musculoapo-
neurotic system. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New

41 Midface Recontouring
479
dioxide (CO2) or erbium laser resurfacing. Muscle hypertrophy
or hypertonia can be treated with surgical myotomies, selective
neurotomies, or less invasive temporary chemical denervation with
botulinum toxin. Volume depletion can be corrected with volumet-
ric surgical techniques or by adding volume with a heterologous
filler or autologous fat.
Every patient must be carefully analyzed, and a personal treat-
ment plan must be developed in consultation with the patient. The
surgeon is personally responsible for choosing and combining the
different treatment modalities according to the patient’s wishes,
the surgeon’s personal experience, and technical training. For the
past 20 years, we have always tried to use a combination of mini-
mally invasive surgical techniques. The magic word in this context
is ´synergy.µ The combination of fat grafting and surgical facelift
is an example of synergy. Performing facial fat grafting alone can
produce certain results, whereas surgical facelift procedures have
certain other effects. However, the combination of these two can
achieve results that cannot be obtained by either option alone.
41.2 Facial Aging
Loss of fat tissue is an important cause of physical aging in the
face. On the basis of analyzing more youthful pictures of patients
seeking consultation for facial rejuvenation surgery, we have
found that most volume loss appears to take place in the centro-
facial and temporal regions, areas where the most muscle³and
hence motion activity³is present. This observation led us to
propose the ´hinge hypothesisµ of fat disappearance with age,
which rests on the fact that fat cells are known to atrophy under
higher pressure (Fig. 41.2). This can be seen clinically in skin
overlying tissue expanders, where subcutaneous fat atrophy
is observed in the expanded flap, as well as in the skin under
an abdominal belt. In regions where repetitive motions occur
over an extended period of time, such as in the periorbital and
perioral areas, it seems plausible that fat cells will get atrophic
with time. This might provide a purely mechanical explanation
for the fat atrophy seen in the centrofacial and temporal regions,
even in patients who have gained weight while aging. The only
peripheral facial area where significant volume atrophy can be
observed is the temporal area, overlying the temporal muscle.
Understanding the importance of facial fat grafting in facial reju-
venation depends on understanding the difference between facial
sagging and facial deflation. Facial sagging occurs at the periphery of
the face (for example, lateral to the lateral canthus and oral commis-
sure) and continues into the neck (Fig. 41.3a). Facial deflation takes
place in the central part of the face, such as the periorbital region,
Fig. 41.2 Deep facial grooves are mainly present in areas of repeated facial animation, such as occurs with crow’s feet, orbitomalar grooves, nasola-
bial folds, or a marionette groove. With time these folds become permanent as a consequence of atrophy of the underlying fat tissue. (Reproduced
from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New

480
VII Midfacial Rejuvenation
including the glabella and the eyelids, the malar area, and the perioral
region (Fig. 41.3b). This is exactly the region where most mimic mus-
culature is present and most movement occurs in the face. Superficial
changes in skin surface quality are independent from both sagging
and deflation and take place on the whole facial skin (Fig. 41.3c).
For facial rejuvenation, volume distribution in the face plays
a very important role in this process. The typical changes in the
transition from a younger to an older face make up the evolution
from an inverted triangle with high cheekbones, a full midface, and
a well-defined sharp jawline to an upright triangular shape with
flat cheekbones, an empty midface, and an undefined heavy jaw-
line. Little made this analysis previously in his description of ´the
inverted cone of youth.”
The 62-year-old-woman shown in Fig. 41.4a requested facial reju-
venation and correction of a secondary nasal deformity. Compared
with the photograph taken of her at age 26 (Fig. 41.4b), the malar area
and the lips are deflated. The treatment plan consisted of an extended
minimal-access cranial suspension (MACS) lift, short-scar temporal
lift, secondary rhinoplasty, and microfat grafting of the upper eyelids,
malar area, and lips. The result 18 months after surgery is seen in Fig.
41.4c. Except for correcting the sagging of the neck, jowls, and tail
of the eyebrow, the reconstruction of the facial architecture can be
compared with the photograph showing the patient at 26 years of
age; the facial ogee curve and periorbital and perioral volume have
been restored. This natural rejuvenation result could not have been
obtained without restoration of centrofacial volume.
41.2.1 Centrofacial Rejuvenation
The current perspective is that centrofacial aging is more the result
of deflation than of sagging. Lambros showed in his tridimensional,
long-term facial aging study that centrofacial landmarks such
as nevi and folds are not displaced downward during aging. This
means that lifting the soft tissues in the central part of the face, as
Fig. 41.4 (a) Patient aged 62 with lifting and volume repletion. (b) Patient at age 26, showing facial architecture of youth. (c) Restoration by microfat
grafting of the periorbital area, the midface, and the lips. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New York,
N<: Thieme Medical Publishers; 2018.)
Fig. 41.3 Different modalities of aging. (a) Sagging, especially in the lower third of the face and neck. (b) Deflation problem. (c) Structural changes in
skin quality. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New

41 Midface Recontouring
481
is done in traditional facelift, may not be logical. He concluded that
facial deflation, which is present in almost every aging face, mimics
descent. Our experience is similar, especially regarding the midface
and eyelids. Difficult and invasive midfacelift techniques have
been replaced by filling techniques with far better results, without
the risks of disastrous complications and with less morbidity and
a shorter recovery. In our MACS lift experience, placement of the
third suture loop to lift the midface has been almost completely
replaced by lipofilling of the malar area. The logic behind this is that
an empty space does not need to be lifted but rather to be filled.
That facial deflation mimics descent and most facial landmarks
stay exactly in the same position is particularly true for the
midface. The only facial feature that lengthens (descends) is the
vertical height of the upper lip (Fig. 41.5). The concept of cen-
trofacial rejuvenation is based on the premise that deflation is a
major causal factor. The center of the face involves three zones:
the periorbital area, the midface, and the perioral area.
Traditionally, periorbital aging was treated with a combination
of resection and lifting procedures. Current concepts reveal that
periorbital aging is more the result of deflation than of sagging.
Fig. 41.5 Visual illusion of sagging in aging faces while all the anatomic landmarks (eyebrows, orbitomalar groove, nasal tip, and mental crease)
remain in the same position. The only feature that truly lengthens is the upper lip. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New

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VII Midfacial Rejuvenation
Fagien described volume-preserving blepharoplasty as the first
step toward a more natural eyelid rejuvenation. Several surgeons
(Benslimane, Little, Marten, Roberts, and Trepsat) have taken a
further step by adding volume around the orbit. This has led to
the concept of augmentation blepharoplasty.
Perioral aging involves different aging mechanisms such as volume
loss, sagging of the upper lip, and textural changes in the skin. The
logical treatment involves a combination of different techniques that
will work synergistically toward a comprehensive rejuvenation.
41.3 Microfat Grafting
Microfat grafting is now used in 95 of all facial rejuvenation
treatments. :e realized that a reduction in grafted particle size
may resolve many of the problems that arise with conventional
fat grafting techniques. According to exceeding 2 mm in diameter will have a central necrosis zone.
Geometry teaches that the ratio of the surface area of a spherical
particle to its volume is inversely proportional to its radius (Fig.
41.6). Thus, given a certain volume of fat particles, reducing the
particles to half their size will double the total contact surface
area. Because a fat particle is dependent on the diffusion of nutri-
ents during its initial embedding phase before revascularization,
the likelihood of particle survival is increased.
Benefits of smaller fat graft particles are better survival, less need
for overcorrection, reduced downtime, and less risk of visible and
palpable lumps, especially under the thin lower eyelid skin. At present
we harvest all fat with small (2- to 3-mm-diameter) cannulas with
multiple sharpened 1-mm-diameter holes. :ith the sharp holes, the
fat is literally grated out of the subcutaneous tissue. These cannulas
are known as grater-type cannulas (Fig. 41.7). :ith this method of
harvesting, which results in smaller fat particles, we have begun to
use smaller-diameter injection cannulas. Today we exclusively inject
microfat through 0.7- to 0.9-mm-diameter blunt-tipped cannulas.
:e usually select the infraumbilical region, the inner thighs, or
the knee areas as donor sites, because these areas are easily acces-
sible with the patient in the supine position. The donor areas are
infiltrated with a tumescent .lein solution containing 0.8 lidocaine
and 1:1,000,000 epinephrine. In the acceptor areas the anesthetic
solution is the same as that used for MACS lift procedures: a diluted
0.3 lidocaine solution is used along with 1:650,000 epinephrine,
2 mL of 8.4 sodium bicarbonate (when under local), and 0.15
Fig. 41.6 The principle on which microfat grafting relies: Reducing the diameter of a sphere proportionally increases its contact surface. (Reproduced
from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Fig. 41.7 Sharp “grater” or “Tonnard” cannula. The harvesting cannula
consists of a sharp, multiport cannula that is 2.4 mm in diameter, with
holes 1 mm in diameter. (Courtesy Tulip Medical Products, San Diego, CA.)

41 Midface Recontouring
483
ropivacaine (a long-acting local anesthetic with very low cardiotox-
icity). After harvesting, the fat is rinsed with either normal saline or
lactated Ringer’s solution through a nylon tissue cloth with a pore
size of 400 pm, which is mounted on a sterile canister. :hen the oil
and debris are washed away, the fat is transferred to 10-mL Luer lock
syringes with a spatula or by direct aspiration. Then 1-mL syringes
are filled from the 10-mL syringes with the help of a female-to-
female Luer lock adapter. :e prefer the filtering and rinsing method
rather than centrifugation, because this produces a very liquid graft,
which can easily be injected through 0.7-mm cannulas with min-
imal plunger pressure. For microfat injection a skin puncture hole
is created with an 18-gauge intravenous needle. The multistroke
delivery of the fat graft is key. On average, 30 to 50 passes are made
to inject a volume of 1 mL of fat. A meticulous injection technique is
very important. By moving the injection cannula swiftly backward
and forward, only minute amounts of graft are deposited with each
pass. For facial microfat grafting, midface recontouring is achieved
by putting the fat in the main areas hit by deflation or with bone
hypoplasia (Fig. 41.8), considering the correct plane and the advised
quantities (Table 41.1), which are discussed later in this chapter.
41.4 Periorbital Rejuvenation
For the upper eyelid, analysis of photographs of people aged
80 years or older reveals that almost all of them have hollow
eyelids (Fig. 41.9). Even in the presence of a bulging medial fat
pad, a hollowing in the apex of the eyelid can be observed, often
referred to as the A-frame deformity. As aging continues, the
eyelids continue to deflate and an apparent skin excess develops.
Because skin growth likely is not occurring in that region, the
skin excess can be seen as an optical illusion provoked by both
the deflation phenomenon and the descent of the tail of the eye-
brow. The descent of the tail of the eyebrow is known as temporal
hooding and is explained by the lack of muscular suspension from
the frontal muscle in its lateral part. :e believe that periorbital
aging is essentially a deflation phenomenon; this concept has led
to a paradigm shift from resection toward filling in periorbital
rejuvenation. The logical way to rejuvenate the upper periorbital
region is thus to suspend the tail of the eyebrow by a temporal
lift, together with filling the hollowness below the supraorbital
rim and conservative resection of skin excess if necessary.
In the lower eyelid, the aging eyelid deformity is accentuated by
the deflation of the midface or malar area below the orbit. Most
of this deflation takes place in the anterior malar area medial to
the lateral canthus. This is logical in view of the hinge hypothesis
(Fig. 41.2), which states that most deflation takes place in a region
overlying a gap between mimic muscles. A logical correction of the
Fig. 41.8 Areas where a fat grafting procedure in the face is usually
indicated.
Fig. 41.9 (a-d) Hollow eyelids in older adults. (Reproduced from
Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New
Table 41.1 Usual and advised quantities of fat for each face region and
level of injection
Grafted area
Level of injection
Volume (mL)
Infra brow
Deep
0.8–2.0
Malar
Deep
3.0–15.0
Nasolabial fold
Deep and superficial
and intradermal
1.0–3.0
Perioral
Superficial and
intradermal
1.0–4.0
Marionette grooves
Deep and superficial
1.5–3.0

484
VII Midfacial Rejuvenation
lower eyelid aging deformity is to add volume to the deflated malar
area, especially in its anterior part medial to the lateral canthus. This
can be combined with a resection or transposition of the bulging fat
from the lower eyelid compartments over the inferior orbital rim.
In 2003, on the basis of studies by Trepsat, Lambros, Little,
Roberts, and Benslimane, we began using fat grafts to address
periorbital aging, gradually incorporating the correction of volume
loss into standard orbital rejuvenation procedures. Since 2008 we
have been using this revised approach, which now incorporates
fine-particle fat grafting (microfat grafting) in 95 of cases, and we
call it augmentation blepharoplasty. The term augmentation bleph-
aroplasty refers to the two components of the surgical procedure:
the addition of volume and the resection of skin. Unlike classic
resection blepharoplasty techniques, our approach is based on
maximal preservation of all existing volume, along with correction
of volume loss in the eyelids and the periorbital region by means of
microfat grafting and conservative trimming of excess skin.
Deflation is an integral part of the aging process. Consequently,
volume restoration is necessary in almost every aged eyelid situa-
tion. This is the true expression of a paradigm shift. Once one learns
to analyze the aging eyelid properly, a deflation can be discovered
in nearly all situations. An isolated skin redundancy can be found
in a small subpopulation of young people who have a familial eyelid
laxity. In those cases, a pure skin resection may still be indicated
(Fig. 41.10). :hen deflation has not yet occurred as a consequence
of the aging process, such as in very young patients (younger than 35
years), a conservative skin excision may be sufficient. Once deflation
begins, a classic resection blepharoplasty will result in more tarsal
show, but an aged, deflated eyelid will remain (Fig. 41.11).
Because of the different mechanisms that influence facial aging
(such as sagging, deflation, wrinkling, contraction, and loss of ani-
mation) and because facial aging is not the same in every patient,
we routinely ask all facial rejuvenation patients to bring pictures
taken at a younger age (20–30 years), and these are analyzed
during the preoperative consultation to determinate the main
areas to be treated so as to restore a youthful appearance.
41.4.1 Upper Eyelid Rejuvenation
Critical analysis of pictures of patients at a younger age reveals
that there is nearly always a certain degree of volume loss in
the upper eyelid, especially in the medial part. This was earlier
described as the A-frame deformity. Classic resection blepha-
roplasty removes the apparent excess of upper eyelid skin and
orbicularis muscle with or without emptying of the medial and
lateral fat compartments. This approach will rarely restore the
features of youth if volume loss is not addressed.
Surgical Technique
The area to be augmented is marked in green preoperatively with
the patient in the upright position (Fig. 41.12). This area typically
comprises the medial one-half to two-thirds of the infrabrow
region and often incorporates the lower third of the medial part
Fig. 41.10 Traditional resection blepharoplasty will suffice for patients whose upper eyelids are still full. In this case only a conservative excision of skin
has been performed. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Fig. 41.11 Classic resection blepharoplasty performed in the presence of deflation will fail to rejuvenate the eyelids. It results in increased tarsal
show, but it does not correct the hollowing of the infrabrow region. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation.
New

41 Midface Recontouring
485
of the eyebrow. Eyelid fat grafting is a confusing and anatomically
incorrect term; the fat is injected not into the eyelid proper but
rather into the infrabrow region extending under the upper orbital
rim. The extent of this area depends on the hollowness of the upper
eyelid in comparison with how it appeared when the patient was
younger.
The area marked is infiltrated in a deep layer beneath the muscle
with a lidocaine and epinephrine solution (0.3 lidocaine and
1:600,000 epinephrine) together with subdermal infiltration of
the marked upper eyelid skin excess. Starting with the micro fat
grafting, an 18-gauge needle is used to make a puncture hole in the
lateral part of the eyebrow. The 0.7-mm microcannula is inserted,
and the fat is deposited with the typical multistroke Coleman
technique in a layer deep to the orbicularis muscle in contact with
the superior orbital rim (Fig. 41.13). An important factor is that
the fat is deposited not into the eyelid but rather directly onto the
periosteum of the inferior and anterior surface of the supraorbital
rim (Fig. 41.14). This is actually more under the eyebrow skin than
under the eyelid skin. Grafting the upper eyelid skin could lead to
undesirable fullness and even ptosis of the upper eyelid.
An amount of 0.5 to 2.5 mL is injected depending on the
patient’s needs. Most frequently the fat injection is accompanied
by a resection of apparent skin excess in the upper eyelid. This can
be done before or after eyelid fat grafting. Orbicularis muscle is
not resected, so as to preserve as much volume as possible.
41.4.2 Lower Eyelid and Malar
Rejuvenation
Most patients experience a loss of volume in the malar area,
especially in the anterior part, even those who have gained some
weight in recent decades. The malar area typically supports the
lower eyelid; therefore, volume loss in this area will accentuate
the appearance of the ´bagsµ in the lower eyelid. In traditional
lower eyelid blepharoplasty, fat is removed from the medial,
median, and lateral compartments, with or without suspension
of the orbicularis muscle and trimming of the lower eyelid skin.
Although the bulging of the lower eyelid is temporarily corrected,
the blending of the eyelid–cheek junction is seldom improved,
especially as further deflation of the malar area takes place with
aging. These shortcomings thus decrease the rejuvenative value
of standard resection blepharoplasty techniques.
The decision to combine fat grafting of the malar area with
fat manipulation through lower eyelid surgery is based on the
extent of fat herniation in the lower eyelids. In patients who
do not have fat herniation and whose eyelid–cheek junction is
slightly marked (mostly in the medial part, nasojugal groove, or
tear trough), isolated fat grafting of the tear trough together with
the malar area is proposed. :hen obvious fat herniation exists,
transconjunctival trimming of excess orbital fat is performed. Fat
transposition over the inferior orbital rim through a subciliary
lower eyelid incision combined with fat grafting of the malar area
can also be used for augmentation of the malar area. However,
Fig. 41.12 Areas of microfat grafting of the infrabrow area and the tear
trough and malar area are marked in green. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Thieme Medical Publishers; 2018.)
Fig. 41.13 Infrabrow fat grafting with approach from the lateral part of
the eyebrow.

486
VII Midfacial Rejuvenation
this increases the risk for temporary scleral show by denervating
the orbicularis oculi muscle and lower eyelid retraction by mid-
lamellar cicatrization. Incision in the muscle is avoided whenever
possible.
Surgical Technique
The malar recipient area is marked preoperatively with the
patient standing or sitting. The marked areas are infiltrated with
the previously mentioned solutions in the deep layer on top of
the zygomatic bone. For patients who will have lower eyelid
surgery, infiltration is performed in the classic way.
Malar area fat grafting is performed through two 18-gauge needle
punctures (lateral and inferior; Fig. 41.15). A perpendicular approach
is made to the tear trough and malar area from the inferior puncture
to crisscross the grafted area and to prevent a sausagelike deposit of
the grafted fat. The index finger of the surgeon’s nondominant hand
is used for tactile control over the position of the cannula tip. This is
especially important when grafting from the inferior puncture over
the inferior orbital rim. If necessary, the malar augmentation can
Fig. 41.15 Malar fat grafting. (a) Inferior access to perpendicular approach to fat grafting of the tear trough and malar area. (b) Lateral access to
address malar body.
Fig. 41.14 Fat grafting to fill the hollowness below the supraorbital rim of the upper eyelid. The area that is augmented comprises the medial one
half to two thirds of the upper eyelid and the lower third of the medial part of the eyebrow. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New

41 Midface Recontouring
487
blend out into the lower eyelid up to the level of the inferior border
of the lower tarsus. However, the level of injection is always beneath
the orbicularis muscle. The lateral part of the malar area must not
be overfilled. Most of the volume will go in the anterior part of the
malar area, medial to the level of the lateral canthus, where most
volume loss has taken place (Fig. 41.16, Fig. 41.17).
The amount of fat injected varies depending on the volume
loss in the midface and the desired amount of anterior projection.
This amount is determined during the preoperative assessment
and marked in the patient notes. On average 4 to 10 mL of fat per
side is injected, but some cases may require as much as 25 mL per
side. However, we do not overcorrect the periorbital fat grafting,
because very little or no fat resorption occurs in this immobile
area. :hen skin excess exists, a conservative skin excision is
performed (pinch blepharoplasty). After transconjunctival fat
resection, good alternatives to skin trimming are croton oil peel-
ing or erbium-doped yttrium aluminum garnet (Er:improve the eyelid skin quality and tighten the skin.
41.4.3 Nanofat Treatment for Dark Circles
:ith the nanofat grafting technique, we inject regenerative cells
and elements by processing adipose tissue with a very simple
mechanical manipulation. The mechanical emulsification destroys
the mature adipocytes but leaves the complex mixture of peri-
vascular smaller cellular components intact and in their native
paracrine environment. :e could perceive changes in quality,
pigmentation, and texture of the facial skin of many patients
months after they had nanofat transferred into certain regions of
the face. Dark circles under the eyes are caused by a combination
of translucency of the skin because of thin dermis and a degree of
Fig. 41.17 Placement of microfat grafts in the malar area of the lower eyelid, extending over the infraorbital rim. Most of the grafted volume is in the
malar area, blending into the lower eyelid. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Medical Publishers; 2018.)
Fig. 41.16 Marking and guideline for volume distribution of malar
augmentation. Because most of the deflation is anterior, two-thirds
of the volume will go to the area medial to the lateral canthus.
The area lateral to the lateral canthus will take approximately
one-third of the volume. (Reproduced from Tonnard P, Verpaele A,
Bensimon R. Centrofacial Rejuvenation. New Publishers; 2018.)

488
VII Midfacial Rejuvenation
melanin pigment deposits. Both components appear to improve
after nanofat grafting. 1anofat is injected in a superficial intra-
dermal plane in the area to be treated. The 33-year-old woman
in Fig. 41.18 presented with baggy eyelids with dark pigmented
circles since childhood. Treatment involved a lower fat redraping
blepharoplasty through a subciliary incision and nanofat injection
(1.6 mL per side) of the lower eyelid and the pigmented nasojugal
groove. She had inflammation in the nanofat-treated skin in the
early postoperative follow-up, complete disappearance of the dark
skin pigmentation by 7 months postoperative, and stable results at
5 years postoperative.
The appearance of the lower eyelids immediately after nanofat
injection can be quite concerning and has the aspect of a giant
xanthelasma (Fig. 41.19a). However, because nanofat contains no
viable adipocytes, this appearance is simply the result of the oily
fraction of the disrupted cells and disappears within a few hours
after injection. By postoperative day 7 it appears as a slightly
erythematous inflammation (Fig. 41.19b); this inflammation can
persist for several weeks.
41.4.4 Postoperative Care
1o obvious increase of bruising or swelling is seen compared
with a classic blepharoplasty. Oral antibiotics are prescribed for
3 days (amoxicillin 500 mg three times daily). Smoking is strictly
prohibited from 3 weeks before until 3 weeks after surgery. The
patient must avoid losing body weight during the first 4 months
after microfat grafting, because any catabolic state will counter-
act the take of the fat graft. Patients are seen for follow-up after
6 days for suture removal and then after 6 weeks, 3 months, 6
months, and 1 year. At the 3-month follow-up, the take of the fat
graft is assessed. Approximately 15 of patients need a touchup
microfat grafting refill, depending on the surgeon’s clinical judg-
ment and the patient’s desires. All touchup procedures are done
on an outpatient basis with a local anesthetic.
41.4.5 Results and Outcomes
The 40-year-old woman in Fig. 41.20 presented with bulging of
the lower eyelid orbital fat and a marked tear trough and orbi-
tomalar groove. Treatment consisted of a transconjunctival fat
resection in three compartments and microfat grafting with 2.5
mL in the tear trough and 3 mL in the malar area. The result is
shown at 7 months postoperatively. The eyelid–cheek junction
is blended, the malar contour is improved, and correction of the
negative vector is evident in the lateral view.
The 55-year-old woman in Fig. 41.21 presented for upper and
lower blepharoplasty. She had low-lying eyebrows, deflated upper
eyelids (especially in the medial portion), and a descent of the tail
of the eyebrow resulting in temporal hooding. Her lower eyelids
showed marked bulging of retroseptal fat, resulting in a very marked
eyelid–cheek junction and atrophy of the anterior malar area.
An augmentation blepharoplasty was performed under local
anesthesia. Simple skin excision (no muscle or fat resection) was
performed in the upper eyelid, with 1.5 mL of microfat grafted
in the medial part of the upper eyelid. Internal browpexy was
performed to lift the tail of the eyebrow. In the lower eyelid, a fat
Fig. 41.18 This 33-year-old woman presented with baggy eyelids with dark pigmented circles. Nanofat grafting of the lower eyelids was performed.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New (b) At 4 months postoperative. (c) At 7 months postoperative. (d) At 5 years postoperative.
Fig. 41.19 Nanofat injection: (a) intraoperative view; (b) 7 days
postoperative. (Reproduced with permission from Tonnard P, Verpaele
A, Peeters G, et al. Nanofat grafting: basic research and clinical
applications. Plast Reconstr Surg. 2013; 132:1017-1026.)

41 Midface Recontouring
489
Fig. 41.21 Augmentation blepharoplasty, simple skin excision, internal browpexy, and fat redraping in a 55-year-old woman. (Left) Preoperative.
(Center) 2 months postoperative. (Right) 9 months postoperative. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation.
New Fig. 41.20 Transconjunctival fat resection and nanofat injection in a 40-year-old woman. (Left) Preoperative. (Right) 7 months postoperative.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New

490
VII Midfacial Rejuvenation
redraping procedure was performed without resection of fat, and
4 mL of microfat was grafted into the anterior malar area. Skin
was excised conservatively after orbicularis muscle suspension.
An elevated position of the eyebrow tail and a smooth eyelid–
cheek junction were obvious after 2 months preoperatively. 1ine
months after the augmentation blepharoplasty, the stability of
the result was evident.
41.5 Perioral Rejuvenation
The mouth and the perioral area are, like the periocular area, a
source of the emotional expression and sensuality of the face.
1evertheless, this area’s aging is often overlooked, resulting in
a disappointing result of a comprehensive facial rejuvenation.
Nearly every facial rejuvenation treatment should involve some
modality of perioral rejuvenation.
Aging changes around the mouth are multifactorial, and
contrary to common belief, they are not limited to deflation
alone. Therefore, only revolumizing the vermilion may result
in disappointing or even unnatural results. Redefining the lip
contours should also be a consideration rather than blowing up
the vermilion with volume. This, combined with resurfacing or
lip lift, delivers a more comprehensive restoration of the youthful
appearance of the lips and perioral area.
Aging of the perioral region involves the accentuation of the
nasolabial crease and fold; changes in skin texture with the appear-
ance of perioral rhytids (´barcodeµ); atrophy of the vermilion
volume; loss of definition of the vermilion border, white roll, and
philtrum; and increase in vertical height of the upper lip between
alar base and vermiliocutaneous border (Fig. 41.22, Fig. 41.23).
Remarkably, this lengthening of the upper lip is the only region in
the central part of the face where ´saggingµ is obvious, observed in
long-term photographic studies of facial aging. The treatment plan
is multimodal by combining fat grafting, resurfacing techniques,
and surgical lip lift. The combination of these techniques is another
example of synergy in the rejuvenation of the perioral area.
41.5.1 Perioral Rejuvenation Techniques
Correction of the Nasolabial Folds
The nasolabial fold has historically been corrected with a multi-
tude of techniques, which is most often a sign that none of them
is perfect. In particular, the ´liftingµ techniques, for which the
nasolabial fold was seen as a component of the descent of the
midface, were prone to relapse. Some techniques even described
very extensive undermining from the facelift incision progressing
under the nasolabial fold or even more medially, but they could
not guarantee long-lasting results. If the nasolabial fold is con-
sidered as an atrophying area, because of repetitive movements
over the years, the logical treatment is filling. In theory, another
option would be to stop the movement in this area with toxins.
This can be observed in the case of facial paralysis, in which the
affected hemiface nasolabial groove is completely eradicated.
However, clinically this is impossible, because all mimic activity
of the face would be disturbed. Therefore, correction of the naso-
labial fold is better achieved by microfat grafting.
The deep filling of the crease is accomplished with classic 0.7-
to 0.9-mm fine blunt cannulas via a puncture with an 18-gauge
intravenous needle. A crisscrossing approach is used, starting
perpendicularly to the crease in the deep plane, to build up a
foundation. This is important to prevent a sausagelike deformity,
as seen in parallel lipofilling techniques. Most volume goes into
the canine fossa, with a triangular blending extension toward the
corner of the mouth (Fig. 41.24). 1ext, a second, more superfi-
cial layer is deposited parallel into the fold. Finally, a subdermal
subcision maneuver is executed with an 18-gauge needle, used
as an internal knife. This procedure cuts all the ligament attach-
ments from the skin to the deeper structures (Fig. 41.25). A small
volume of microfat (0.3–0.5 mL) is then injected into the created
cavity, not so much as a filler but rather as a spacer to prevent
reattachment of the skin to the deep tissues.
The average injected volumes are 1 to 3 mL of microfat per
side. Undercorrection is preferable to overcorrection in this area.
Effective, natural, and long-term correction is expected with
this technique. Marionette grooves can be addressed with this
technique from the same access or from a chin approach in an
intermedium plane (Fig. 41.26).
Fig. 41.22 Mouth and perioral area in the same woman between
(a) age 24 years and (b) age 54 years. With aging, a deflation of the
vermilion, decreased turgor and an inversion of the vermilion mucosa,
a lengthening of the vertical skin segment between the alar base and
vermiliocutaneous border, and vertical rhytids appear gradually in the
upper lip skin and later in the lower lip skin. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Thieme Medical Publishers; 2018.)
Fig. 41.23 Mouth and perioral area of the same woman between
(a) age 50 years and (b) age 65 years. The most obvious change is in
the perioral skin surface with the appearance of vertical rhytids and
an accentuation of the nasolabial folds. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Thieme Medical Publishers; 2018.)

41 Midface Recontouring
491
Fig. 41.24 Correction of nasolabial folds. Deep microfat grafting filling of the crease with 0.7-mm fine blunt cannula.
Fig. 41.25 Nasolabial fold fat grafting with the anatomic location of the associated fat grafting planes: (a) deep plane perpendicular to the fold
(SMAS: superficial musculoaponeurotic system); (b) the superficial plane parallel to the fold; (c) surgical subcision and subsequent placement of a
small amount of fat graft in the cavity created. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Medical Publishers; 2018.)

492
VII Midfacial Rejuvenation
Lip Rejuvenation and Enhancement
Adding volume to the lips and vermilion can be very rejuvenating
and feminizing. Lip augmentation is not only restricted to rejuvena-
tion procedures but also is used for younger patients who wish to
enhance the shape and volume of their native thin lips. Volumizing
the lips can certainly enhance the sensuality of the mouth. However,
when this is exaggerated, it likely will result in a sausagelike or
ducklike deformity of the upper and/or lower lip. Eversion of the
vermilion border is better achieved by adding a lip lift.
Ideal lip aesthetic proportions may cause some confusion, in most
people the lower lip is somewhat larger than the upper lip in the
frontal view. The proportions of upper to lower lip dimensions must
be respected (Fig. 41.27; Table 41.2). In the frontal view the lower lip
should be approximately 60 higher than the upper lip (approximat-
ing the golden proportion of 1:1.618). In the profile view, in contrast,
the upper lip should project slightly (1–2 mm) further anterior than
the lower lip. Often patients ask for an isolated upper lip augmenta-
tion. In most cases this disturbs the natural proportions of the upper
to lower lips. Failure to respect these observations may result in an
unnatural appearance. The surgeon should explain to these patients
that the lower lip needs to be enhanced in proportion to the upper lip.
In the young lip, the vermiliocutaneous border, or white roll, is
well defined and pouted, with a distinct Cupid’s bow in the frontal
view. The contour from the nasal base to the vermilion border
should be slightly concave. The philtral columns are prominent
and well-defined. The oral commissures should be horizontal or
curve slightly upward. The mucosa is soft with a distinct turgor.
The skin surface is smooth, equally toned, and without rhytids.
Aging disturbs these parameters to a certain degree. The vermilio-
cutaneous border loses its definition and flattens out. The definition of
the Cupid’s bow fades in the frontal view. The projection of the upper
lip decreases and becomes level with or even posterior to the lower
lip. The contour from the nasal base to the vermilion border becomes
straight to convex because of lengthening of the lip and subsequent
inversion of the vermilion. The philtral columns lose prominence and
definition. The oral commissures tend to turn downward. The ver-
milion mucosal surface becomes dryer and atrophic and loses turgor.
The skin surface becomes rough, pigmentary irregularities occur, and
vertical rhytids appear (the ´barcodeµ appearance).
Fig. 41.26 Marionette grooves can be corrected by fat grafting with
the same access of the nasolabial folds or from a chin approach.
Fig. 41.27 Comparison of female youthful (left) and aged (right) lips.
In the frontal view, deflation of lip volume, change in skin texture, and
diminished definition of the white roll and philtrum occur. In profile
view, loss of projection of both the upper and lower lips, a change
in upper lip shape from concave to convex, and a lengthening of the
vertical height of the upper lip skin segment is apparent with aging.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New Table 41.2 Comparison of lip characteristics in the youthful and aged
female lip
Youthful Female Lip
Aged Female Lip
Upper to lower lip
height ratio
1:1.618
Mostly unaltered
Projection of upper lip
Upper lip 1–2 mm
anterior to lower lip
Upper lip equally
projected or posterior
to lower lip
Vermiliocutaneous
border
Well defined, pouted
Ill-defined, loss of
pouting
Cupid’s bow
Distinct
Faded
Nasal base to vermilion
Concave
Straight or convex
Philtral columns
Distinct
Faded
Mucosa
Soft, good turgor
Dry, loss of turgor
Skin surface
Smooth, equal tone
Rough, pigmented:
rhytids
Oral commissures
Horizontal or curved
upward
Curved downward

41 Midface Recontouring
493
Ideally, harmonic lip enhancement treats all of these aesthetic
features. A combination of several treatment modalities will work
synergistically toward a natural enhanced appearance. The tools
are volume enhancement, lip lift, and resurfacing.
Lip Microfat Grafting
Because of the high mobility of both lips, this is the area with
the highest fat graft resorption of the whole face. :e estimate
the average resorption of lip microfat grafting to be 40–50. The
patient must be counseled about this likelihood and allowed
to choose between overcorrection with a prolonged downtime
(months) or else one or two touchup procedures under local
anesthesia 4 to 6 months apart. :e believe that the latter option
is better, and most of our patients make this choice.
All patients are prescribed acyclovir 800 mg daily for 5 days for
herpes simplex prophylaxis.
Lip enhancement indications can be divided into two catego-
ries: lip volume and lip definition. For lip volume enhancement,
most of the fat will be delivered into the orbicularis oris muscle.
For enhancing the lip definition and shape, the injection should
be made more superficially into the white roll with S1IF. This
technique is explained in more detail in Chapter 46 of this book.
The perioral area can easily be numbed by a double nerve block
of both infraorbital and mental nerves. The microfat is injected with
a 0.7- or 0.9-mm blunt microfat cannula via two punctures made
with an 18-gauge needle in both oral commissures. The fat is deliv-
ered in all layers, with most of the volume in the orbicularis muscle
(Fig. 41.28). Bidigital palpation is used to check the homogeneous
distribution of the injected fat. Minor irregularities can be corrected
by gentle bidigital massage. The punctures are not closed. Average
volumes are 0.5 to 2.0 mL per hemilip. Thus, the total volume for
a complete mouth rarely exceeds 8 mL. The average volume for a
standard vermilion lip augmentation is between 5 and 6 mL.
The white roll can be enhanced with a 21-gauge sharp-needle
injection or a blunt 0.7-mm cannula inserted immediately sub-
dermally, threading the roll and injecting upon withdrawal. On
the average a volume of 1 mL is injected in the white roll of both
the upper and lower lip. The philtral columns can be enhanced
by S1IF with the same needle. An average volume of 0.25 mL per
column is used (Fig. 41.29).
Lip Lift
The upper lip is the only feature in the central part of the face
that actually descends with age, resulting in an increase of the
vertical height of the lip (nasal base–vermilion border). This is
very commonly overlooked, but careful analysis of the aging face
reveals that most of these patients demonstrate a ptosis of the
upper lip (Fig. 41.30). This is another good reason for comparing
the patient’s present face with pictures taken at a more youthful
age. A lip lift is a very simple and rewarding surgical procedure
Fig. 41.28 Parasagittal section of the lips, before and after enhancement with microfat, illustrating the location of sharp-needle intradermal fat
grafting (SNIF) and deep intramuscular lipofilling. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Thieme Medical Publishers; 2018.)

494
VII Midfacial Rejuvenation
with a very feminizing and rejuvenating effect. It effectively
everts the vermilion border and restores the concave shape of
the lip segment between the nasal base and vermilion border.
Because of its simplicity and its very limited morbidity and com-
plication rate, this is one of the few procedures that we suggest
to our patients even if they do not request it. Most people are
aware of this aged feature of their mouth.
The combination of lip lift with microfat grafting of the vermil-
ion works synergistically: the fat grafting results in an increased
anterior projection, whereas the lip lift creates an eversion of the
vermilion (Fig. 41.31). Any attempt to evert the lip by filling alone
will result in an unnatural sausagelike or ´fish-mouthµ deformity.
A lip lift consists of resecting a segment of subnasal skin at the
base of the nose. Many pattern shapes have been described, the most
popular ones being gullwing or bullhorn shapes. :e find the most
effective pattern more approaches the shape of a mustache. This
pattern extends well laterally into the alar crease, with the purpose
of creating a concentric lift of the lateral portions of the upper lip.
The upper excision line follows the alar base, and then turns inside
the nostril sill to hide the scar effectively inside the nostril. It crosses
the midline exactly at the columellar base (Fig. 41.32). The lower
excision line is then tailored to the desired lip shape. Most commonly
the lower line is almost straight. This causes a maximal lifting effect at
both apices of the Cupid’s bow. If more lifting is desired in the lateral
aspect of the lip, the lower excision can be curved slightly downward,
or in some cases the excision can be extended into the nasolabial fold.
On the average a 3- to 6-mm-wide segment is excised. Only skin is
excised, and only 1 to 2 mm of undermining is performed at the caudal
Fig. 41.29 Superficial sharp-needle intradermal fat grafting (SNIF)
with a 21-gauge needle for definition of (a) the vermilion border (white
roll) and (b) philtral columns. The superior and inferior labial arteries
are a safe distance from the location of the SNIF.
Fig. 41.31 Patient consulted for a secondary rhinoplasty and perioral
rejuvenation. She presented with a long, masculine, unattractive
upper lip. The secondary open rhinoplasty was combined with a lip lift,
including resection of 3 mm of skin at the nostril base. The anterior lip
projection was enhanced by 3 mL of intramuscular microfat grafting.
Shortening of the vertical height of the upper lip and attractive ever-
sion of the vermilion border are evident. (Reproduced from Tonnard
P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New Thieme Medical Publishers; 2018.)
Fig. 41.30 Patient is shown (a) at age 20 years and (b) at 48 years. Nearly
all anatomic landmarks (eyebrow, pupil, orbitomalar groove, nasal tip,
nasal base, labiomental crease) stay exactly in the same position. The only
feature that truly lengthens in the central part of the face is the upper
lip. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New a
b

41 Midface Recontouring
495
skin edge to promote skin edge eversion. After thorough hemostasis
the skin is closed in two layers with 5–0 polydioxanone subcutaneous
sutures and an intradermal 4–0 monofilament polyglactin suture. The
knots of the skin suture are hidden in the nostril base. If the lengths of
the skin segments exhibit a significant incongruence, the skin closure
can better be performed with a running 5–0 monofilament nylon
horizontal mattress suture for more effective adjustment (Fig. 41.33).
These sutures are removed at postoperative day 6.
Because the excision is at the interface of two adjacent aesthetic
units, the final scar is inconspicuous even in younger patients.
However, the surgeon must respect the inward curving of the
excision line into the nostril sill to prevent a disturbing scar at the
nostril base.
The different excision patterns are demonstrated in Fig. 41.34.
:e believe that only pattern A delivers a satisfactory result.
Perioral Sharp-Needle Intradermal Fat Injection
The sharp-needle intradermal fat injection method was pub-
lished by =eltzer, Tonnard, and Verpaele under the acronym SNIF.
This procedure involves the injection of microfat intradermally
through a sharp needle into facial rhytids with the intent of
achieving a permanent correction without the perils of a syn-
thetic permanent filler. It can be used liberally in combination
with any facial cosmetic procedure and is used for static perioral
wrinkles (nasolabial and barcode) and enhancing the lip definition
and shape of the white roll and philtral columns. Injection needs
to be performed meticulously, and the receptor area should be
infiltrated with a local solution containing epinephrine. Before
injection the facial rhytids are marked with a fine permanent
marker while the patient stands and makes exaggerated facial
expressions. Injection is done with a 23-gauge needle and should
be made in a superficial dermal plane, never in the subcutaneous
plane (Fig. 41.35). The S1IF endpoint is slight overcorrection
with blanching of the skin that will disappear in few minutes.
Fig. 41.32 Lip lift markings. The upper incision starts along the alar
groove, curves along the alar base into the nostril sill, and crosses the
columellar base. The lower incision curves out in the lateral portion
around the alar groove; the medial section is straight.
Fig. 41.33 Lip lift technique. (a) Skin resection. On average a 3- to 6-mm-wide segment is excised, preserving perioral muscle fibers intact. (b) Skin is
closed in two layers with 5–0 polydioxanone subcutaneous sutures and running 5–0 monofilament nylon horizontal mattress suture. (c) After white
roll and upper lip microfat grafting.

496
VII Midfacial Rejuvenation
The 56-year-old woman in Fig. 41.36 had a MACS lift combined
with pure S1IF on her fine perioral rhytids (nasolabial and barcode).
A total volume of 4.6 mL was used. The result was powerful and
stable. As in any microfat grafting procedure, after S1IF a variable
resorption of the injected fat occurs, which stabilizes after 4 months.
Perioral Nanofat Treatment
Nanofat is applied as an adjunct to perioral rejuvenation for
enhancing the quality of the lip skin and vermilion. 1anofat has
no filling capacity and must be considered an in vivo tissue regen-
eration cellular therapy. Therefore it can be applied in conjunction
with other modes of perioral rejuvenation such as S1IF, microfat,
resurfacing, and lip lifting. 1anofat is applied in the skin by fan-
shaped superficial injection with a 27-gauge needle or with the
needling device that reaches the dermis with 20 needles 1.5-mm
long. The 60-year-old woman in Fig. 41.37 sought correction of
upper lip aging. Treatment consisted of S1IF injection into indi-
vidual vertical rhytids (red circles) and the vermilion border and
nanofat injection of the whole upper lip skin. The improvement of
skin quality can be observed on the left side of the image (green
circles). A volume of 4 mL of nanofat was used for the whole upper
lip. The result is shown 6 months postoperatively.
The 71-year-old woman in Fig. 41.38 sought correction of aging
in the perioral area and lip vermilion. Treatment included a com-
bination of fat injection techniques: S1IF with a 23-gauge needle
into the individual rhytids of the upper lip and nasolabial fold (1.5
mL), S1IF with a 21-gauge needle into the philtral columns and
the white roll (2.7 mL), and nanofat injection of the whole upper
lip surface and dry lip vermilion. A total of 4.5 mL of nanofat was
Fig. 41.34 Correct and incorrect excision patterns for lip lift. (a) Correct pattern of lip lift. This creates an adequate lift of the lateral lip and an accen-
tuation of the Cupid’s bow. (b) Gullwing or bullhorn excision pattern. This creates insufficient lifting of the Cupid’s bow. (c) Straight incision crossing
the nostril sill. This pattern results in a visible scar. (d) Correct pattern shape, but made too narrow with no effect on the lateral lip. This may result in
an unnatural “puppetlike” pouting of the central lip and overaccentuation of the Cupid’s bow. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New Fig. 41.35 Sharp-needle intradermal fat (SNIF) injection of the
nasolabial fold in a superficial dermal plane with a slight overcorrection
with blanching of the skin.

41 Midface Recontouring
497
injected into the skin, and 2 mL was injected into the vermilion.
The result is shown 2 years postoperatively.
Lip Resurfacing
An effective resurfacing technique is necessary to correct the
surface changes of the aging lip. Historically we started with
mechanical dermabrasion and later introduced the CO2 laser.
Because of prolonged erythema and a high incidence of depig-
mentation, we replaced the CO2 laser with the purely ablative
´coldµ Er:croton oil peeling, which is a very inexpensive but very effective
method for deep peeling.
Preoperatively, the patient is prescribed a 0.1 tretinoin
ointment for 4 to 6 weeks. This renders the stratum corneum
more compact, thickens the stratum granulosum, and decreases
melanin density. In the dermis, it stimulates the formation of
new collagen. If the patient has a high risk for postinflammatory
hyperpigmentation, a 4 hydroquinone ointment can be added.
For herpes simplex prevention, a minimum of 800 mg of acyclovir
is administered daily starting 2 days preoperatively and continu-
ing until complete reepithelialization occurs.
Routine safety precautions are necessary for Er:facing: metal eye shields and dental protection with a moist gauze
for the patient, safety goggles for the surgeon and assistant, and
smoke evacuation.
For resurfacing of the whole lip, a spot size of 5 mm is used at
1000 m-, which results in a fluence of 6.25 -/cm2, at a frequency of
10 to 12 Hz. The surface is painted in three to four layers with a
50 overlap between the patterns, crisscrossed to each other until
an even surface is obtained. The endpoint is the visual elimination
of rhytids, before the appearance of the typical pattern of the
reticular dermis. In most cases bleeding of the papillary dermis
doesn’t occur because of vasoconstriction. If bleeding does occur,
the laser energy is absorbed by the blood and efficient wrinkle
reduction is no longer possible.
If a patient has only a few isolated rhytids and the skin quality
between them is good, a ´spot paintingµ or ´microlaser resurfac-
ingµ of the rhytid can be considered (Fig. 41.39). :e then use a
2-mm spot at 200 m-. This significantly shortens the recovery
time and reduces the morbidity of the procedure.
Fig. 41.36 Minimal-access cranial suspension (MACS) lift combined with perioral sharp-needle intradermal fat (SNIF) injection in a 56-year-old
woman. (a) Preoperative. (b) At 1 year postoperatively. (c) At 24 months postoperatively. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New Fig. 41.37 Correction of upper lip aging in a 60-year-old woman,
(a) preoperatively and (b) 6 months postoperatively. Red circles show
the effect of the sharp-needle intradermal fat grafting (SNIF) injection
directly into the rhytids. Green circles show the effect of nanofat injec-
tion on the skin quality. (Reproduced with permission from Tonnard
P, Verpaele A, Peeters G, et al. Nanofat grafting: basic research and
clinical applications. Plast Reconstr Surg. 2013; 132:1017-1026.)
Fig. 41.38 Correction of lip perioral aging in a 71-year-old woman,
(a) preoperatively and (b) 2 years postoperatively. (Reproduced from
Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New
a
a
b
b

498
VII Midfacial Rejuvenation
:e use an open dressing technique with a nonantibiotic oint-
ment, consisting of equal parts of petroleum jelly and paraffin.
The addition of liquid paraffin to the petroleum jelly makes it
less viscous and easier to apply over the wound. The patient is
instructed to continuously keep the wound moist and well cov-
ered with ointment.
41.5.2 Results and Outcomes
The patients shown in Fig. 41.40 and Fig. 41.41 give a good over-
view of all of the perioral aesthetic features that were discussed
in this chapter. The selected rejuvenation technique is based on
analysis of images of the patient in a more youthful stage of their
Fig. 41.39 Upper lip rhytids, (a) before and (b) 6 months after microlaser resurfacing. (Reproduced from Tonnard P, Verpaele A, Bensimon R.
Centrofacial Rejuvenation. New Fig. 41.40 This 73-year-old woman had a minimal access cranial suspension (MACS) lift with perioral rejuvenation that included microfat grafting
of the nasolabial folds and marionette grooves, sharp needle intradermal fat grafting (SNIF) of the vertical lip rhytids, and erbium-doped yttrium
aluminum garnet (Er:Thieme Medical Publishers; 2018.) (a) Preoperative view. (b) One year after her procedure, she has notable shortening of the vertical height of the
upper lip and eversion of the vermilion, together with complete eradication of the vertical upper lip rhytids.
Fig. 41.41 This 54-year-old woman had facial and perioral aging. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation.
New deflation of the upper and lower lips, and an accentuation of the nasolabial and marionette grooves are evident in comparison with (b) her image
from 30 years earlier. (c) The result 7 months after a combination of minimal access cranial suspension (MACS) lift and liplift with sharp-needle
intradermal fat grafting (SNIF) in the white roll and philtral columns and microfat grafting in the nasolabial folds and marionette groove.

41 Midface Recontouring
499
lives (between age 20 and 30 years). The treatment is always per-
sonalized to the individual morphology and needs. The endpoint
should be a natural perioral area that approximates the aspect of
the individual’s youthful mouth.
41.6 Facial Contouring
The appearance of the face is mainly based on two structures:
the bony framework of the skull and the soft-tissue cover. Some
patients have congenital hypoplasia by either osseous underde-
velopment (for example, maxillary and mandibular hypoplasia,
cranial clefts, and syndromes such as Treacher Collins syndrome)
or atrophies of the soft tissues as seen in Parry–Romberg
syndrome), and some have a combination of osseous atrophy
with deflation in the midface that cause a visible facial volume
deficit. Hypoplasia of bony structures has been treated through
orthognathic surgery. However, the rate of complications is high
due to the invasiveness of the procedure, and patients inevitably
face a long recovery period. In patients with mild maxillary or
mandibular hypoplasia, occlusion problems of the teeth occur
infrequently and can usually be corrected in childhood or later,
during adult life, through orthodontic treatment. Therefore, the
main purpose of this patients is a purely aesthetic correction
of the facial proportions. In this group of patients we consider
the use of facial fat grafting to address volume deficiency. Facial
microfat grafting is a safe and effective alternative to more com-
plicated and potentially dangerous advancement osteotomies
performed in patients for purely aesthetic reasons in the absence
of any functional problems.
The impression of facial beauty relies largely on symmetry
and balanced proportions. Although the eyes and the lips are
typically the most striking facial elements, the appearance of the
middle and lower thirds of the face and their relationship to each
other play a pivotal role in creating harmony. This is particularly
true when the face is viewed laterally; that is, in profile, when
disproportions in the relationship between the maxilla and the
mandible become more evident. The most common procedures
to address facial hypoplasia are the Le Fort I osteotomy for
maxillary hypoplasia and the bilateral sagittal split osteotomy
(BSSO) with or without genioplasty for mandibular hypoplasia.
The most commonly performed genioplastic procedure is chin
augmentation, which can be achieved through sliding genio-
plasty or implant placement, and the risk for mental nerve
injury in genioplasty alone has been described to be as high as
10 and up to 29 in genioplasty combined with BSSO. In case
of insertion of a chin implant to augment soft tissue volume
without having to perform an osteotomy, complication rates are
lower because of a decreased chance for nerve injury, but one
major issue related to silicone chin implants is bony resorption.
This loss of bone tissue may lead to exposure of the roots of the
incisors with an overall tooth complication rate of 3, including
infection and extrusion.
:ith these complications in mind, most patients are requesting
aesthetic corrections that carry a lower risk of potentially per-
manent damage. Soft tissue augmentation by microfat grafting
to address bony hypoplasia has become an effective method to
achieve good aesthetic facial correction, leading to high patient
satisfaction. It is obvious that severe maxillary or mandibular
hypoplasia with pronounced malocclusions, especially Type 3,
requires orthognathic correction. Dental malocclusion can be
treated through orthodontic splinting.
The procedure is performed most of the time under local anes-
thesia, and the microfat grafting is done as previously explained in
this chapter. For maxillary hypoplasia, the malar region and the lip
are treated. For malar augmentation, fat deposition is carried out
as deep as possible on the malar bone. To augment the anterior
projection of the upper lip, the whole thickness of the upper lip
is injected 3-dimensionally from one nasolabial fold to the other,
from the nasal base to the vermilion border, and from the oral
mucosa to the lip skin. In patients with mandibular hypoplasia,
the treatment areas include the mandibular ramus and the chin as
well as the lower part of the lower lip. Chin augmentation is made
with 0.7-mm canulae approaching lateral in a deep plane with
multistroke technique (Fig. 41.42). In mandibular augmentation,
the microfat grafts are deposited along the mandibular bone in
the chin area, blending into the lower lip (Fig. 41.43, Fig. 41.44).
Injected volumes of microfat range from 8 to 25 mL (mean,
13 mL) per side for the malar areas, from 8 to 17 mL (mean, 12
mL) for the upper lip, and from 12 to 27 mL (mean, 15 mL) for
the chin area. :hen we start, the only complication is visible fat
lobules under the lower eyelid skin, which is resolved by using
1-mm multiholed cannulae and avoiding excessively superficial
fat deposition under the lower eyelid skin. Fat resorption is seen
in all patients and ranges clinically from “15 in the immobile
malar area and chin region to “50 in the mobile lip area. The
low morbidity and swift recovery associated with facial microfat
grafting make it a valuable new tool in the armamentarium of the
facial aesthetic surgeon.
Fig. 41.42 Chin augmentation. Lateral approach to fat grafting in a
deep plane of the chin.

500
VII Midfacial Rejuvenation
41.6.1 Problems and Complications
Periorbital Fat Grafting
Fat grafting in the upper and lower orbital region has not been
without complications, especially in the earlier phase, when the
procedure was introduced. Between 2003 and 2008 we gradually
started introducing fat grafting in our blepharoplasty practice.
After 2008 we applied microfat grafting as a routine addition to
virtually all blepharoplasties. Most complications were seen in
the early phase of our use of the technique and can be attributed
to technical errors or misconceptions.
Typical beginner mistakes are grafting too much volume, graft-
ing too close to the skin and too close to the eyelid margin, and,
most significant, grafting with too large fat particles, producing
visible or palpable lumps under the skin (Fig. 41.45).
The classic 2-mm Coleman injection cannulas are too big to
be used under the delicate, fine eyelid skin. :e adapted the style
of harvesting and injection cannulas to the specific needs of the
periorbital region. For harvesting the fat, we started using the typ-
ical ´graterµ multihole sharpened cannulas with 1-mm-diameter
holes on the tip.
Another mistake is failure to blend the fat into the shape of
the surrounding structures. Depositing the fat as a lump into the
Fig. 41.43 This 41-year-old woman presented with moderate midfacial retrusion. An upper and lower blepharoplasty combined with lipofilling
of the midface were proposed. 8 mL of microfat was grafted into each malar region, 2.5 mL in the nasolabial folds, and the 10 mL in the upper lip
region. In the upper lip, fat was distributed in the whole thickness of the lip to augment the anterior projection of the lip region. (Reproduced with
permission from Lindenblatt N, et al. The role of microfat grafting in facial contouring. Aesthet Surg J. 2015; 35(7): 763-771.) (a–c) Preoperative. (d–f)
Photographs 3 years after the procedure demonstrate the improvement of the anterior projection of the midface and the change of the proportion
of the upper to lower lip projection because of the microfat grafting and show durable results.

41 Midface Recontouring
501
Fig. 41.44 18-year-old woman consulted for facial contouring. (Reproduced with permission from Lindenblatt N, et al. The role of microfat grafting in
facial contouring. Aesthet Surg J. 2015; 35(7): 763-771.) (a,d,g) She presented with rhinokyphosis and hypoplasia of the chin with stable occlusion after
orthodontic treatment. Chin augmentation was done with microfat grafting. Nine months later the patient underwent for a second procedure in which 5
mL of microfat were placed. (b,e,h) The posttreatment result 11 months after the second infiltration shows the rhinoplasty result, which is a significant
improvement in chin projection. (c,f,i) The photographs taken 5 years posttreatment prove the stability of the microfat grafting.

502
VII Midfacial Rejuvenation
infrabrow sulcus without fading it out into the lateral eyebrow
region can lead to unsatisfactory show of the fat graft (Fig. 41.46).
Secondary blending can be performed in touchup procedures.
:e have had no major complications. Complications in the early
´premicrofatµ phase (before 2008, n 138) included underfilling
(21), overfilling (9), graft visibility and lumps (8), asymmetry (4),
scleral show (2), and hematoma (1). In the late ´microfatµ series
(after 2008, n 362) we have not had any expanding hematomas, but
bruising was seen in varying degrees in all patients. Prolonged edema
(more than 1 month postoperatively) of the malar area occurred in
7 of patients. Postoperative scleral show occurred in 1, associated
with orbital fat redraping (skin–muscle flap). There were no reports
of sensory or motor nerve lesions, infections, asymmetries, or over-
filling. One patient in this series who gained 12 kg of weight over the
course of a year after smoking cessation for her facelift surgery ended
up with an overprojection of both malar areas. This was solved by
performing a microliposuction under local anesthesia.
Perioral Fat Grafting
The main problems can be categorized as follows:
• Underfilling (easy to correct)
• Overfilling (very difficult to correct and less acceptable to the
patients)
• Malpositioning of fat (prevented by meticulous preoperative
planning, marking, and technique)
Lip Lift
The main problems are caused by an incorrectly designed
excision pattern and sloppy suturing technique (Fig. 41.47).
The scar should not visibly cross the nostril sill. Inadequate
lateral excision results in an unnatural pouting of the central
Fig. 41.45 Beginners’ mistakes include overgrafting and malpositioning. (Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New Assuming an important resorption would take place, 3 mL of fat was administered, resulting in a permanent overcorrection, for which revision
surgery was needed. (c,d) Two months later, 2 mL of fat graft was excised. (e) The living adipose tissue under the orbicularis muscle.
Fig. 41.46 Micro fat grafting of the infrabrow sulcus failed to blend into
the lateral brow. This is most visible in a forced eyebrow elevation. It can
be prevented by blending the fat graft laterally into the eyebrow region.
(Reproduced from Tonnard P, Verpaele A, Bensimon R. Centrofacial
Rejuvenation. New

41 Midface Recontouring
503
lip. Overresection of lip skin can lead to impossibility of mouth
closure and is virtually irreparable.
Lip Resurfacing
The main problems are undercorrection, scarring, hypopigmen-
tation, and hyperpigmentation.
• Undercorrection results from resurfacing too superficially and
is easily solved by a cautious touchup procedure. :e never
promise our patients complete wrinkle removal but rather a
significant wrinkle reduction.
• Overcorrection may lead to scarring and can be caused by
resurfacing too deeply or by concomitant bacterial or viral
infection. Herpes simplex prophylaxis is routinely adminis-
tered, and meticulous wound care and close follow-up for 3
months postoperatively are important for infection preven-
tion. Any induration may lead to a hypertrophic scar and is
immediately treated with an intralesional injection of 50/50
triamcinolone and 5-fluorouracil.
41.7 Concluding Thoughts
Around the turn of the millennium, the awareness that physical
aging of the face is a multifactorial process was growing. Aging
is now understood to consist of facial sagging and skin laxity,
changes in skin texture and pigmentation, changes in volume in
certain areas of the face, and contraction of certain facial mus-
cles producing permanent folds and rhytids. This understanding
has caused a true paradigm shift in how surgeons analyze and
treat the aging face. The deflation process is most important
in the centrofacial area, which consists of the periorbital and
perioral areas and can be addressed very well by combining dif-
ferent kinds of fat applications such as lipofilling with microfat
grafting technique, explained in this chapter, to add volume in
the infrabrow and malar area, and fill folds in nasolabial and
marionette grooves; S1IF for superficial rhytids; and nanofat
grafting to improve skin quality. All these procedures become an
essential tool for rejuvenation of the face additional to surgical
techniques such as lip lift and MACS lift. Furthermore, lipofilling
is being used as a valid procedure to correct facial proportions,
avoiding invasive orthognathic surgery in patients with mild
maxillary or mandibular hypoplasia, becoming a valuable alter-
native to more complicated surgeries. The low morbidity and
rapid recovery make facial microfat grafting a welcome tool in
the armamentarium of the modern aesthetic surgeon.
Clinical Caveats
• The surgeon should think in terms of definition and shape and
not so much in terms of volume.
• Patients must be educated; most patients need to be
informed of the different components of aging, and pictures
of their youthful appearance are a great tool to help them
understand the mechanisms of deflation and lengthening of
the upper lip.
• There is a relationship between graft particle diameter and
the diameter of the holes in the harvesting cannula. “Fine-
particle fat” can be obtained by harvesting fat with small-hole
cannulas.
• Small fat particles can be grafted with small-diameter can-
nulas (0.7–0.9 mm). This is indicated if grafting will be done
underneath thin fine skin, such as grafting eyelids, preventing
complications such as visible and palpable fat grafts under
the skin.
• Small fat particle grafting will also reduce postoperative
morbidity and downtime as a result of the reduced resorption
of the fat particles.
• Augmentation blepharoplasty combines the restoration
of lost periorbital volume with judicious and conservative
excision of lax skin, with or without a lifting of the tail of the
eyebrow.
• Periorbital microfat grafting is a valuable and safe alternative
to complicated, difficult, and potentially dangerous midface
and eyelid rejuvenation techniques.
• In particular when grafting the lips, less overcorrection is
needed if small fat particles are used because of diminished
resorption and thus better take of the fat.
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42 Endoscopic Rejuvenation of the Midface
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42 Endoscopic Rejuvenation of the Midface
Renato Saltz, Gabriele Miotto, and Carlos Casagrande
Abstract
Over the years, many different approaches have been described
for the treatment of the aging midface, including access through
the lower eyelid, face lift, open temporal, endoscopic temporal,
and intraoral. The use of endoscopic surgical techniques for
midface lift rejuvenation has advantages. It allows for smaller
and hidden incision placement and precise dissection under
magnification. Critical anatomy can be clearly identified and
preserved. It provides a safe plane of dissection along the deep
temporal fascia in the upper lateral face, along the orbital rim
periosteum in the periocular area, and along the periosteum in
the midface and lid–cheek junction. The extend of the dissection
can be tailored to specific patient needs, and the type of fixation
can be modified accordingly. Creating an optical cavity in the
midface allows for excellent visualization and easy fixation.
Endoscopic midface lifts can be easily combined with brow lifts
or associated with neck lifts for a global facial rejuvenation. In
our hands, endoscopic midface suspension has been a safe and
reproducible technique with stable long-term results.
Keywords
facial rejuvenation, midface lift, endoscopic midface lift, endo-
scopic facial rejuvenation, cheek lift
42.1 Indications and
Contraindications
The most common clinical indications for endoscopic midface
lifting are the following:
• Ptosis of the malar fat pad
• Loss of the projection of the malar area
• Accentuation of the nasolabial fold
• Ptosis of the corner of the mouth
• Ptosis of the lateral corner of the eyelid
• Deep orbitomalar groove
• Accentuated nasojugal groove
Contraindications for endoscopic treatment of the midface:
• Lack of soft tissue volume in the midface
• Prominent malar bones or adequate midface volume
• Medical contraindications
42.2 Pertinent Anatomy
Success with facial rejuvenation surgery requires a basic under-
standing 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 deformity with the most appropriate tech-
nique for correction of it.
Midface aging is characterized by four anatomic changes:
1. Descent of the malar fat pad
2. Increase in markedness 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 due to defla-
tion and descent, with an inferior medial sliding of tissues due
to cutaneous and ligamentous laxity. Malar bags or festoon may
also develop in the malar area. Other changes include maxillary
reabsorption, ptosis of the corners of the mouth, and descent
of the perioral tissues (Fig. 42.1). The aging process also creates
an increase in the vertical length of the lower eyelid and a more
demarcated lid–cheek junction. The arcus marginalis of the lower
eyelid divides the orbital region from the midface. Aging makes
this transition more demarcated: the orbitomalar groove. 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. Release
of this ligament improves the lid–cheek junction grooving and
makes the midface blend better into the lower lid.
The muscles of the orbitofrontal area have a fundamental
importance in determining brow position. The frontal muscle is
the anterior belly of the occipitofrontal muscle, a paired muscle
that covers the forehead and actively lifts the brows. It begins at
the level of the hairline extending through the supraorbital skin.
Its function is to elevate the brows. It extends laterally toward
the superior temporal line (temporal crest) and varies in width;
it is an extension of the galea aponeurotica in the midline of the
scalp. The brow is strongly suspended by the frontal muscle in
its medial two-thirds. Because the lateral third is usually thinner
and weaker, the descent of the tail of the brow is usually more
evident than in the head and body. Clinically, the descent of the
brow in the temporal region contributes to the hooded and tired
facial appearance often associated with aging. :e consider the
temporal area and lateral periorbital area a continuation of the
middle third of the face, and these areas are routinely addressed
during endoscopic midface rejuvenation, since it is unlikely that
there will be no upper face aging when there is midface aging.

506
VII Midfacial Rejuvenation
42.3 Preoperative Assessment
Preoperative evaluation includes a complete evaluation of the
face, skin quality, history of previous procedures and current
skin care routine, complete medical history, and medications³
especially the ones that change platelet adhesion, such as
aspirin, ginkgo biloba, and anti-inflammatory drugs. Patients are
scheduled for a formal preoperative visit with the surgeon, the
nursing team, and the anesthesiologist 1 to 2 weeks before the
procedure to review all the details of the surgical procedure, pro-
vide prescriptions, plan for medication discontinuation, perform
the venous thromboembolism (VTE) risk assessment, evaluate
the need for preoperative testing, and address special equipment
needs and any other preoperative requirements. If needed by
history and physical exam, the requested preoperative exams
include the following:
• Complete blood cell count
• Coagulation function assay
• Glycemia testing
• Electrocardiogram
• Chest radiographs
42.4 Preoperative Planning
and Markings
42.4.1 Zones of the Brow and Midface
Facial aging is a clinical manifestation of the changes in volume
and position of the facial anatomy. The midface has a direct
anatomic relationship with the temporal and periorbital areas,
and we divided the upper face and midface into three surgical
zones to facilitate understanding of the endoscopic anatomy and
surgical technique (Fig. 42.2).
Zone 1
=one 1 comprises the temporal region, starting 2 cm behind the
hairline, extending medially to the temporal crest, inferiorly to
the supraorbital and lateral orbital rim, laterally to the inferior
temporal septum, and inferolaterally to the superiomedial
zygoma. The floor of zone 1 is the deep temporal fascia, and the
roof is the superficial temporal fascia above the temporal muscle
and the periosteum at the level of the orbital rim and zygoma.
Fig. 42.1 Anatomic aging changes in the midface and periocular area. (a) Malar fat pad compartment descent and deflation; (b) ligament, muscle,
and skin laxity.
b
a

42 Endoscopic Rejuvenation of the Midface
507
Zone 2
=one 2 extends laterally to the temporal crest, inferiorly to the
supraorbital rim and radix, and superiorly to the level of the
incisions. Dissection in zone 2 is subperiosteal, keeping the galea
and the skin above intact. During a midface surgery, the surgeon
must connect zones 1 and 2 by releasing the temporal crest and
the lateral orbital adhesions.
Zone 3
=one 3 starts at the lateral and inferior orbital rim, zygoma, and
premaxilla. Dissection is subperiosteal, under the malar fat pad.
The infraorbital rim is often visualized in its lateral half. =one 3
also incorporates the inferior eyelid, but we do not consider it to
be part of the midface approach.
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 vein, the zygomaticotemporal nerve, and the zygoma-
ticotemporal vein and artery. The preservation of these cutaneous
nerves avoids numbness over this area of dissection.
The midface is limited superiorly by the lid–cheek junction,
medially by the nasofacial angle, laterally by the pretragal area
and sideburn, and inferiorly by the nasolabial groove. The three
zones of dissection are routinely marked on the skin before the
procedure starts. The scalp and temporal areas are marked, and
the hair can be styled to accommodate the incision sites, either by
combing or by using hair bands.
The deep branch of the supraorbital nerve is an important
landmark. Its trajectory should be outlined to avoid incisions and
fixation points in its trajectory, which can cause pain and pares-
thesias. Fig. 42.3 shows the following landmarks:
• 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 border of the zygomatic arch
• A line between the distal end of the nasolabial fold and point
A, to define the area of subperiosteal dissection and elevation
of the midface
• The anterior temporal line
• A line outlining the trajectory of the temporal branch of the
facial nerve
• A line that outlines the orbital rim
42.5 Operative Technique
42.5.1 Pertinent Instruments
The following instruments are of particular importance for
endoscopic midfacial rejuvenation (Fig. 42.4):
• Subperiosteal hockey-stick elevators
• Fixation devices
Fig. 42.2 Anatomic zones of the upper and midface that are addressed
during a midface lift.
Fig. 42.3 Preoperative markings of the upper and midface used as
landmarks for dissection during the endoscopic midface lift.

508
VII Midfacial Rejuvenation
̑ Casagrande’s needle and 3–0 nylon or polydioxanone
sutures (PDS)
̑ Endotine Midface (MicroAire Surgical Instruments, LLC,
Charlottesville, VA)
42.5.2 Operating Room Setup and
Patient Positioning
The surgical suite must be well organized to perform an endo-
scopic procedure, including correct patient positioning. The
imaging equipment should be at the foot of the surgical table to
permit better visualization; the surgeon and the assistant should
be at the head of the table (Fig. 42.5). The endotracheal tube
should be tied to a tooth using dental floss or wire and wrapped
with sterile drapes. The patient’s head should be placed on a
soft head support that facilitates bilateral head mobilization.
The patient’s hair is prepped and tied back without shaving. The
eyes should be protected with ointment and corneal shields.
The endoscope cord should be long enough to permit adequate
movement and should be covered with a sterile plastic sleeve.
42.5.3 ,nÀOWrDWiRn
The endoscopic midface lift can be done under local anesthesia
and sedation or general anesthesia. Tumescent infiltration with
a local anesthetic to the temporal, forehead, and midface areas
creates an excellent field for dissection.
:e perform nerve blocks with lidocaine 2 with epinephrine
(supraorbital, supratrochlear, zygomaticofacial, and infraorbital).
An anesthetic solution containing 20 mL of 2 lidocaine, 20 mL of
0.5 bupivacaine, 1 mL epinephrine, and 160 mL of normal saline
is used to inject the dissection areas.
42.5.4 Incisions
A temporal incision gives access to the temporal area, the lateral
frontal area, and the midface. It is positioned 2 cm posterior
to the hairline in a coronal direction, corresponding to a line
from the alar base of the nose, passing through the lateral tail
of the brow, and reaching the scalp. Three other access points
can be created with incisions placed just behind the hairline in
a longitudinal fashion when the complete forehead needs to be
undermined for a complete endobrow lift (Fig. 42.6).
Fig. 42.4 Instruments and fixation tools used for endoscopic midface lift. (a) Complete set. (b) Hockey stick elevators. (c) Casagrande’s needle.
Fig. 42.5 (a) Operating room setup and (b) surgical instrumentation for the endoscopic midface lift.

42 Endoscopic Rejuvenation of the Midface
509
42.5.5 Dissection
Dissection through the temporal incision is carried down on top
of the deep temporal fascia. Identifying the temporal muscle
under the deep temporal fascia is useful to secure the right plane
of dissection (Fig. 42.7). Blunt dissection continues inferiorly
down to a point of resistance at the level of the supraorbital rim.
At this point, the endoscope is introduced into the cavity to allow
better visualization, safer dissection, and adequate hemostasis.
Medially the dissection continues through the areolar tissue up
to the fusion line (temporal crest), where the deep temporal fascia
fuses with the subperiosteal plane (zones 1 and 2). The fusion line
is released, and dissection continues in the subperiosteal plane
with the release of the lateral supraorbital rim periosteum for
temporal elevation. This dissection extends to the frontal area in
case of a combined endobrow.
In zone 1, the temporal branch of the facial nerve is superficial
to the plane of dissection. It is above the intermediate fat pad
and superficial temporal fascia. The nerve is in the ´roofµ of the
dissection. The temporal dissection continues on top of the deep
temporal fascia until it reaches the supraorbital rim and superio-
medial border of the zygoma, where zone 3 begins.
The sentinel vein is identified at this point, preserved when
possible or cauterized under direct vision (Fig. 42.8). The assistant
should aspirate or irrigate the dissection site when necessary to
optimize the quality of the optical field.
Creation of a limited area of dissection in the transition between
zones 1 and 3 will prevent harm to the frontal branch of the facial
nerve by avoiding the two lateral thirds of the zygomatic arch,
where the nerve transits from deep to superficial (Fig. 42.9).
If the brow is also being elevated (zone 2), the supraorbital dis-
section continues medially until the corrugator muscle is seen. The
corrugators are completely avulsed with an endoscopic grasper;
the branches of the supraorbital and supratrochlear nerves are
preserved (Fig. 42.10). The assistant keeps finger pressure over
the glabella to assist in the removal of the corrugator fibers and to
minimize trauma to the underlying skin and the development of
possible future indentations in this area.
If the brow is not being treated, only zones 1 and 3 are dissected.
After the fusion line is released, the subperiosteal dissection is
carried down into the lateral orbital rim. Careful attention to this
narrow and delicate area is needed to maximize endoscopic vision
and minimize trauma to the neurovascular structures present in
this transition zone.
The endoscopic temporal subperiosteal approach for release of
the orbitomalar ligament does not interfere with the lower eyelid
Fig. 42.6 Access incisions for the endoscopic midface lift. For access
to zones 1 and 3, the temporal incision is usually the only one needed.
For complete access to the forehead such as for a complete endoscopic
browlift, three other frontal incisions are also needed. (Adapted
with permission from Saltz R. Endoscopic temporal-incision only
midface lift is enhanced by Endotine technique. Aesthet Surg J.
2005; 25:80-83.)
Fig. 42.7 Temporal incision and exposure of the temporal muscle
below the deep temporal fascia, confirming the correct dissection
plane.
Fig. 42.8 (a) Intraoperative endoscopic view of the sentinel vein
piercing through the deep temporal fascia and (b) being cauterized.
a
b

510
VII Midfacial Rejuvenation
structures and thereby avoids the risk of ectropion and scleral
show that can sometimes be seen with the subperiosteal approach
through the inferior eyelid. Once the lateral orbit rim periosteum is
elevated, the endoscope is advanced and subperiosteal undermining
of the inferior orbital rim is performed with a hockey-stick elevator
to allow improvement of the orbitomalar groove. The subperiosteal
dissection of zone 3 continues inferiorly. It is sometimes necessary
to release some of the attachment fibers of the masseter muscle
from the zygomatic bone for midface access. These fibers should
be carefully avulsed or transected with the endoscopic scissors.
Dissection in this very narrow tunnel allows better visualization
of the midface cavity, more secure fixations, and decreased inci-
dence of relapse after midface lifting with the potential for better
long-term results (Fig. 42.11). However, a wide midface dissection
can also cause pronounced and prolonged edema. The buccal fat
pad can also be suspended during the endoscopic midface lift. It
is located inferiorly and deeper to the malar fat pad, medial to the
masseter muscle and superficial to the buccinator muscle.
:hen needed, the inferior eyelid fat pads are treated separately
through a transconjunctival approach. If there is skin excess, it is
usually treated by very conservative skin-only removal or by laser
therapy.
42.5.6 Fixation
Long-lasting results of an endoscopic midface lift depend on
adequate dissection, periosteal release, and appropriate fixation.
Two different techniques of fixation are used by the authors: the
direct needle fixation technique with Casagrande’s needle and
the fixation with Endotine.
Direct Needle Fixation
This technique uses a straight, thin needle with an eye in its
sharp tip, based on a modified Reverdin needle that has been
developed by one of the authors (Casagrande’s needle; Fig. 42.12).
Under endoscopic visualization, the needle is introduced
through the skin at premarked points of traction for optimal tissue
Fig. 42.9 Dissection of zone 1 and partial dissection of zone 2 for
release of the lateral orbital adhesions and elevation of the lateral brow.
Fig. 42.10 Intraoperative endoscopic view of the transition between
zones 1 and 2.
Fig. 42.11 The extent of dissection of zones 1 and 3 for midface
elevation, and pertinent anatomy. DTF: deep temporal fascia; TPF :
temporoparietal fascia.

42 Endoscopic Rejuvenation of the Midface
511
elevation. The endoscopic visualization allows direct observation
of the needle penetrating the optical cavity. The needle is brought
out through the temporal incision, and a braided nonabsorbable
suture is introduced through the needle tip. The needle tip suture
grasps the soft tissues as a loop and is brought out again through
the temporal incision. Both sutures are removed from the needle’s
eye. Traction is confirmed by pulling the suture and noticing ele-
vation of the tissues before suture fixation to the deep temporal
fascia. The midface loops are placed first, and two or three or
more points of fixation can be used. Usually the first point is at
the level of the malar fat pad, the second to the sub–orbicularis
oculi fat (SOOF) pad, and a third one at the infraorbital area when
necessary.
In the frontal region, the lateral fixation points are placed in
a line of traction that elevates the lateral corner of the eye, the
lateral brow, and the temporal skin below the hairline. The fixa-
tion should be placed as close as possible to the hairline to avoid
visible indentation on the temporal skin. This fixation technique
permits precise repositioning and fixation of soft tissues. Care is
taken to achieve maximum symmetry between sides at the end
of the fixation.
The subperiosteal dissection provides an adequate blood
supply to the skin flaps and allows the simultaneous use of skin
resurfacing modalities, such as lasers and chemical peels. The lim-
itations of this technique are that it (1) relies on suture suspension
only and appropriate healing, (2) may result in minor asymmetry
because of different vectors for fixation and different traction
forces between sides, and (3) involves a long learning curve and
dexterity with the use of the endoscope (Fig. 42.13).
Fixation Using Endotine
The Endotine Midface device (Fig. 42.4c) is the senior author’s
preferred method of suspension and fixation for midface lifts.
The Endotine Midface device is an absorbable device with five
prongs or tines that will engage the soft tissues and suspend them
in position. A sleeve protects the device during insertion, and
deployment is achieved with a simple trigger release to attach
tines to soft tissue. Digital pressure engages the tines. Once the
soft tissue is engaged, the insertion sleeve is removed through
the temporal incision. Tension is applied to the anchoring end of
the device to achieve the desired elevation. The end of the device
is then sutured to the temporal fascia and the excess is trimmed
(Fig. 42.14).
This is an easy step-by-step midface suspension–fixation that
provides adjustability for elevation and projection, and maintains
mechanical fixation until healing is completed. The five tines pro-
vide multiple points of contact for secure soft tissue fixation. The
elevation forces are evenly distributed over a wide area, prevent-
ing potential skin irregularities. Insertion and deployment are
accomplished through the temporal incision. Implant palpability
is minimal, and reabsorption starts at 6 months. The Endotine
Midface fixation technique offers the following advantages:
• No intraoral incision
• No sutures
• Simple deployment with multipoint fixation
• Absorbable device
• Fast and simple adjustability for control of the elevation and
volume of the midface
Fig. 42.12 (a) Casagrande’s needle and (b,c) the Endotine Ribbon
device. (Reproduced with permission from Casagrande C, Pintarelli
G, Barazetti DO. Tratamento cir~rgico total da face. In: Casagrande C.
ed. Plástica da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica,
Convencional e Procedimentos Não Invasivos. Smo Paulo, Brazil: Dilivros;
2018:223–238.)
Fig. 42.13 Fixation with Casagrande’s needle. (Reproduced
with permission from Casagrande C, Pintarelli G, Barazetti DO.
Tratamento cir~rgico total da face. In: Casagrande C. ed. Plástica
da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica,
Convencional e Procedimentos Não Invasivos. Smo Paulo, Brazil: Dilivros;
2018:223–238.)
a
c
b

512
VII Midfacial Rejuvenation
42.5.7 Closure
The scalp is closed in the temporal area with several sutures
between the scalp and the deep temporal fascia to seal the dead
space. The incision is closed with interrupted nylon sutures,
the hair and scalp are shampooed and rinsed, and the patient is
extubated and taken to the recovery room.
42.6 Postoperative Care
In the recovery room the position of the patient’s head is main-
tained elevated to 30ƒ to avoid airway obstruction and excessive
facial edema. The patient’s blood pressure must be carefully
monitored to avoid bleeding and hematomas, usually maintaining
it below 120/80 mm Hg. Crushed ice bags can be used over the
eyes, forehead, and midface. The patient is allowed to shower on
the first postoperative day. Oral analgesia is given, and antibiotics
are used for up to 24 hours. Lymphatic drainage massage, starting
at 48 to 72 hours postoperatively, can help with initial swelling
improvement in the initial postop period, improve discomfort,
and improve appearance in the early postoperative period.
42.7 Outcomes
Endoscopic midface lifts are safe procedures but require specific
equipment and training and have a long learning curve. They are
Fig. 42.14 Endotine Midface device fixation. (a) Deployment system protects the device during insertion. Trigger release to attach tines to soft
tissue. Digital pressure engages the tines. (b) Insertion sleeve is removed. (c) Tension is applied to the device for elevation. Device is sutured to the
temporal fascia. (Adapted with permission from Saltz R. Endoscopic temporal-incision only midface lift is enhanced by Endotine technique. Aesthet
Surg J. 2005; 25:80-83.)

42 Endoscopic Rejuvenation of the Midface
513
routinely combined with brow lifts and neck lifts in our clinical
practice for global facial rejuvenation with reproducible results.
Swelling may be present for 3 to 4 weeks and numbness for 6 to
8 weeks.
Temporary supraorbital and supratrochlear nerve paresthesias
are caused by pocket dissection and stretching of the nerves. They
are common for 2 to 3 weeks, are manifested frequently as numb-
ness or forehead and scalp itching, and recover spontaneously,
usually at 8 weeks.
Temporary paralyses of the frontal branches of the facial nerve
can also happen but are rare.
42.8 Results
Three case studies are shown in Fig. 42.15, Fig. 42.16, and Fig.
42.17.
42.9 Concluding Thoughts
Endoscopic midface suspension has been a safe and reproducible
technique with stable long-term results. Proper elevation of
the flaps and precise dissection in the subperiosteal plane at
the level of the lateral orbital rim are the key to facilitating safe
undermining and fixation of the midface.
Fig. 42.15 (a,c,e) Preoperative images of a patient in her 40s with brow ptosis, midface descent, upper and lower lid skin excess, and neck
laxity. (b,d,f) Postoperative images after endoscopic brow and midface lift (treatment of zones 1, 2, and 3) associated with upper and lower lid
blepharoplasty and limited neck lift with superficial musculoaponeurotic system (SMAS) plication. (Reproduced with permission from Casagrande C,
Pintarelli G, Barazetti DO. Tratamento cir~rgico total da face. In: Casagrande C. ed. Plástica da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica,
Covencional e Procediments Não Invasivos. Smo Paulo – SP: Dilivros; 2018: 223-238.)

514
VII Midfacial Rejuvenation
Clinical Caveats
• The endoscopic midface lift should be precise to preserve
the neurovascular structures of the face to avoid permanent
facial paresthesias.
• The sentinel veins can be preserved or cauterized for better
dissection exposure and easier instrument manipulation in the
transition zone between the temporal region and the midface.
• Subperiosteal elevation of the lateral orbital rim is a key to
facilitating safe undermining and fixation of the midface.
• Proper visualization and dissection of the midface may require
release of masseter attachments from the malar bone.
• Fixation with needle is safe and inexpensive and can be
tailored for different elevation needs. Fixation with Endotine
Midface is quick, safe, reliable, and less likely to produce
asymmetry than suture fixation.
• It is important to preserve the integrity of the inferior orbital
nerve so as to prevent midface paresthesias.
• Patients should be informed that swelling may be present for
3 to 4 weeks and numbness for 6 to 8 weeks.
• Endoscopic midface lifting does not treat jowling and aging
of the neck—it does not replace a face lift.
Fig. 42.16 (a,c,e) Preoperative images of a patient in her 50s with brow ptosis, midface descent, upper and lower lid skin excess, and neck laxity.
(b,d,f) Postoperative images after endoscopic brow and midface lift (treatment of zones 1, 2, and 3) associated with upper and lower lid blepha-
roplasty and neck lift with superficial musculoaponeurotic system (SMAS) plication. (Reproduced with permission from Casagrande C, Pintarelli G,
Barazetti DO. Tratamento cir~rgico total da face. In: Casagrande C. ed. Plástica da Face. Rejuvenescimento Facial. Cirurgia Videoendoscópica, Covencional
e Procediments Não Invasivos. Smo Paulo – SP: Dilivros; 2018: 223-238.)

42 Endoscopic Rejuvenation of the Midface
515
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1997;5:167
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Part VIII
Surgical Rejuvenation
of the Face and Neck
VIII

(Trang không có chữ)

519
43 Clinical Anatomy of the Face and Neck:
Visualizing the Face
Joel E. Pessa and Foad Nahai
Abstract
:e present a fresh approach to facial anatomy for the aesthetic
surgeon. Aesthetic surgery challenges the clinician to under-
stand basic anatomy: how it is arranged during youth and how
it changes with age. The ability to visualize the face as a logical,
three-dimensional construct enables the aesthetic surgeon to
meet these challenges. The authors include some novel ana-
tomic findings gleaned from thousands of hours of anatomic
work performed during the past 5 years, many of which are as
yet unreported. By improving the clinician’s understanding of
facial anatomy, this chapter will help in avoiding some common
iatrogenic injuries and achieving safe, effective, and predictable
surgical results.
Keywords
facial anatomy, face, fascia, anatomic spaces, lymphatic supply,
wrinkles, rhytides, fat, fat compartments
43.1 How the Face Is Designed
Although facial anatomy exhibits tremendous variability between
individuals, we see a common pattern or design, much like a
building or a mall. The ground floor (the deep fascia) rests atop
a foundation (the facial skeleton). Escalators (retaining ligaments)
travel from the ground floor to the roof (skin and dermis). The
escalators act like walls and form rooms on the ground floor
(the deep fat compartments) and on the first floor (VXSHUfiFLDO fDW
compartments). On the way up, the visitor may get off on the first
floor (motor nerves) or travel directly from the ground floor (deep
fascia) to the roof (skin) (perforating blood vessels, sensory nerves).
Traffic (lymphatic vessels, veins) usually descends directly from
the roof (skin) to the ground floor (deep fascia). Only on the floor
does one encounter special rooms (anatomic spaces). One likewise
encounters some business-use-only escalators (facial muscles; lip
elevators) traveling from the foundation (bone) to the roof (skin),
or traveling along the first floor (VXSHUfiFLDO fDVFLD RUELFXODULV DQG
platysma). The roof may develop cracks (wrinkles, creases) over
exposed pipe (lymphatic vessels). Although tremendous variabil-
ity exists, it does so within this common design (Fig. 43.1).
43.2 Learning Anatomy:
An Approach
One can learn facial anatomy in a variety of ways. The great
atlases such as Grant’s, Gray’s, and Sabotta’s provide a wealth
of information and detail. Earlier textbooks, notably those
of McClellan and Bell, supplemented their dissections with
exquisite drawings and lithography. A determined study of these
texts more than satisfies the needs of the basic anatomist. The
aesthetic surgeon, however, faces several unique challenges that
suggest a slightly different approach.
The aesthetic surgeon not only needs to understand basic
structure but must know how structures are arranged in youth
and how they change with age. 1o two faces are exactly alike:
therefore, variability in size, shape, and structural relationships
to one another is the rule. Anatomic variability further extends
to discrete structures: for example, a bifid zygomaticus major
muscle. The surgeon must also be able to anticipate the location
of structures to avoid injury, even when intraoperative edema
distorts the basic framework of the face.
:e therefore propose a slightly different approach to learning
facial anatomy. Our approach is not the only way, maybe not even
the best way, but it does address the distinct challenges faced by
the aesthetic surgeon while simultaneously providing flexibility
to incorporate new observations and findings. :e simply build
a mental image³a three-dimensional construct³of how facial
anatomy is arranged and why. Each section begins with a rep-
resentative dissection or illustration. The sections are brief and
follow one another, so that by the end the reader has assembled
a working roadmap of the human face. Supplemental images are
included to provide greater detail for the interested reader.
43.3 Wrinkles, Crow’s Feet,
and Laugh Lines
Terminology
Crease: indentation that occurs at the boundary between
some superficial fat compartments, perpendicular to muscular
action. Defined lymphatics travel beneath creases.
Rhytid (wrinkle): an indentation into dermis that may occur
(1) related to muscular activity or (2) in a more random fashion
with age. Large wrinkles (crow’s feet) are related to lymphatic
vessels.
Facial communication involves interpreting expression, much
of which is dictated by dynamic creases and wrinkles. Facial
animation, such as contraction of the zygomaticus major muscle,
accentuates the nasolabial crease. Although current literature
tends to draw a distinction between static (e.g., nasojugal or
lid/crease junction) and dynamic (nasolabial) creases, anatomic
dissection suggests a remarkable similarity in their constant
relationship to a major underlying lymphatic vessel.
The nasojugal crease defines the lid–cheek junction (Fig.
43.2a). A plexus of lymphatic vessels travels from medial to
43 Clinical Anatomy of the Face and Neck: Visualizing the Face

520
VIII Surgical Rejuvenation of the Face and Neck
lateral, parallel to the so-called ´V-deformityµ (both superficial
and deep!). This lymphatic plexus lies directly deep to the
crease. One can always identify this structure in vitro and in vivo.
Recurrent lower lid edema has been problematic for the plastic
surgeon. Furnas used the term malar festoons to describe what he
thought were redundant furrows of skin and muscle. In the mid-
1800s, Sichel, an ophthalmologist, used the term blepharochalasis
to describe a phenomenon he thought to be related to recurrent
lower lid edema. Over 150 years later, our dissections substantiate
Sichel’s hypothesis: lower lid edema always occurs superior to the
lid–cheek crease defined by a subdermal lymphatic plexus.
:ork over the past 5 years suggests that the cutaneous
boundaries between some fat compartments are determined by
underlying lymphatic plexuses. This is true for the nasolabial
crease (Fig. 43.2b). In vitro one can inject just deep to the dermis
with filler to show the course of the nasolabial crease lymphatic.
To date, a growing number of cutaneous creases and rhytides are
known to be associated with a major subdermal lymphatic plexus.
Fig. 43.1 The design of (a) the face is similar to that of (b) a building or mall. The ground floor (deep fascia) lies atop the foundation (facial skeleton).
Escalators travel from the ground floor (deep fascia) to the first floor (superficial fascia or SMAS) and then to the roof (skin). Escalators (retaining
ligaments) divide the ground floor rooms (deep fat compartments) and the first floor rooms (superficial fat compartments). Special rooms (anatomic
spaces) occur only on the ground floor. Traffic may travel from ground floor to first floor (nerves), from ground floor to roof (blood vessels), and from
roof to ground floor (lymphatic vessels).
Fig. 43.2 (a) Static rhytides such as the nasojugal crease occur directly over major lymphatic vessels. Direct cannulation of the nasojugal lymphatic
system and injection with fluorescent tracers identifies continuity from medial to lateral across the entire crease. Crow’s feet overlie smaller
lymphatic vessels that join nasojugal crease lymphatics at the lateral canthus. Nasojugal lymphatics drain the periorbital contents and some of the
sclera, especially medially. No artery lies directly beneath the nasojugal crease: this cutaneous boundary is determined solely by lymphatic pathways.
(b) Dynamic rhytides and the cutaneous boundaries between some adjacent fat compartments lie directly over major lymphatic vessels. Dynamic
wrinkles form perpendicular to the direction of muscular activity (e.g., the nasolabial crease forms perpendicular to contraction of the zygomaticus
major muscle) and directly over a major lymphatic vessel and/or plexus. Repetitive muscular contraction over a relatively fixed site (i.e., the lymphatic
vessels and perilymphatic fat) is a possible etiological factor in dynamic rhytid formation. Other dynamic creases, including corrugator creases and
the transverse nasal crease (perpendicular to the procerus muscle), likewise occur over definite, identifiable superficial lymphatic systems. When
we perceive expression displayed by rhytides—crow’s feet and corrugator and nasolabial creases—we are observing lymphatic territories and their
distribution on the human face.

521
43 Clinical Anatomy of the Face and Neck: Visualizing the Face
43.4 Anatomical Correlation of
the Boundaries between
Topographic Planes
Terminology
Facet: A landmark created where two planes of tissue, not bound-
aries between fat compartments, meet each other. Examples:
vermilion cutaneous junction, lower lid rim between conjunctiva
and skin. DeÀned by: lymphatic vessels traveling beneath dermis.
Transitions in facial planes, or facets, may occur at the boundar-
ies between adjacent superficial fat compartments. Transitions
between facets also occur at the vermilion–cutaneous junction
of the upper lip and along the philtral columns (Fig. 43.3).
Histologic evaluation and even electron microscopy have pre-
viously failed to identify any distinct anatomy associated with
these particular areas. However, as Fig. 43.3a illustrates, a major
lymphatic vessel with accompanying perilymphatic fat is always
situated directly beneath the vermilion–cutaneous junction. This
particular lymphatic vessel had a lumen that could be cannu-
lated with a 25-gauge needle. The lymphatic vessel travels in
the superficial fat, enabling it to be easily differentiated from the
labial artery traveling in the muscular layer.
Lymphatic mapping with near-infrared imaging (1IR) docu-
ments proximity of a lymphatic vessel to the vermilion cutaneous
junction (Fig. 43.3b). Subcutaneously injected fluorescent tracer
does not invade the lumen of the lymphatic vessel. However, wide-
spread diffusion of dye is noted within the perilymphatic fat. This
imaging technique is tremendously more precise than mapping
with visible dyes and carries a profound message for the aesthetic
surgeon. What we observe with our vision (under ambient light)
GXULQJ URXWLQH IDFLDO LQMHFWLRQV VLJQLÀFDQWO\ XQGHUHVWLPDWHV
WKH H[WHQW RI GL̵XVLRQ WKDW DFWXDOO\ RFFXUV. Suami discusses the
role of indocyanine green lymphography, a technique of unques-
tionable value for future work.
This anatomy suggests a possible explanation for long-term
distortion of the upper lip that is occasionally associated with
aggressive lip augmentation techniques. The nasolabial crease,
vermilion cutaneous junction, and philtral columns are defined
by underlying lymphatic vessels that drain the upper lip. Probably
nothing untoward occurs if one inadvertently occludes one
lymphatic. However, if one obstructs the philtral column and
the vermilion cutaneous junction and the nasolabial lymphatics
(by direct intraluminal injection or by increased pressure within
the perilymphatic fat), the redundancy in this design is over-
come. Lymphatic obstruction leads to cytokine production and
inflammation, which in turn leads to scarring and adipose depo-
sition. The end result is distorted anatomy and loss of definition.
Lymphatic obstruction is the major cause of chronic lip distortion
seen after upper lip augmentation.
43.5 Building a Roadmap:
Types of Adipose Tissue
Terminology
SuSerÀFiDO IDW above superficial musculoaponeurotic system
(SMAS).
Fig. 43.3 (a) Topographical planes change acutely between some anatomic tissues and/or structures, examples being Cupid’s bow and the vermilion
cutaneous junction. The philtral column is another boundary between anatomic facets or planes. Previously these were thought to be regions with
no anatomic distinction. Recent work has provided overwhelming support that the vermilion–cutaneous junction lies directly over, and is defined by,
a large underlying lymphatic vessel with its accompanying perilymphatic fat. This anatomy applies equally to the philtral columns, thought previously
to be related solely to interblending of the orbicularis oris muscle. With modern-day cadaver preparation, the major lymphatic of the white roll can
be identified without magnification. Note that the dissected lymphatic is superÀcial to the orbicularis oris muscle. The superior labial artery has an
intramuscular location. (b) Dynamic near infrared imaging (NIR) identifies the lymphatic anatomy of Cupid’s bow. Random subcutaneous injection of
infrared fluorochrome travels around the lymphatic vessel beneath the white roll. Dye does not flow into the lymphatic unless injected directly into
the lumen. However, NIR imaging shows that dye diffuses widely along the entire upper lip throughout the perilymphatic fat. This occurs clinically when
the clinician injects the vermilion cutaneous junction and notes flow along the entire course of the upper lip. This imaging technique is tremendously
more precise than mapping with visible dyes and carries a profound message for the aesthetic surgeon. What we observe with our vision (under
ambient light) during routine facial injections significantly underestimates the extent of diffusion that actually occurs.

522
VIII Surgical Rejuvenation of the Face and Neck
Deep fat: beneath SMAS.
Fat compartments: discrete regions determined by the system
of retaining ligaments.
Sub–orbicularis oculi fat (SOOF): fat between the orbicularis
retaining ligament (ORL) and zygomaticocutaneous ligament
below the lower eyelid.
Retro–orbicularis oculi fat (ROOF): fat deep to the upper lid
ORL.
Our first impression of the human face is largely determined by
adipose tissue draped about the skeletal framework. Anatomists
such as Hunter and Bell referred to this as subcutaneous fat.
Bichat identified and named the buccal fat pad, a type of fat
thought to facilitate muscular gliding. Later anatomists more
precisely defined the subcutaneous layer as consisting of superfi-
cial and deep layers (Fig. 43.4a). Adipose tissue plays a variety of
roles, including metabolic and structural support. To date, types
of adipose tissue are classified based on location and/or morpho-
logical appearance. Metabolic studies are in their infancy.
Fig. 43.4b shows adipose tissue within the orbit as well as the
cerebrospinal fluid (CSF) circulation of the optic nerve’s dural
sheath. CSF channels are not lymphatic vessels (they do not dis-
play lymphatic biomarkers). This system is the extracranial analog
of the intracranial glymphatic system (CSF circulation) identified
by Iliff in murine cortex. It is critical for the aesthetic surgeon to
recognize that these novel CSF transport vessels on nerves com-
municate with and drain directly into the intraorbital lymphatic
system.
Intraorbital lymphatics drain to the lower lid along the orbi-
cularis retaining ligament (ORL) via perforating vessels and along
veins and ligamentous support (e.g., the canthi). The nasojugal
crease lymphatic is in communication with the intraorbital system,
suggesting a potential retrograde path by which extraorbital
injections may travel retrograde into the orbit.
The aesthetic surgeon is most familiar with manipulation of the
superficial and deep layers of fat. The morphological differenti-
ation between these two layers has been recognized at least as
early as Bell and Hunter. The divisionary structure is, of course,
the superficial fascia.
43.6 The Many Faces of
SuSerÀFiDO )DVFiD
Terminology
SuSerÀFiDO IDVFiD Synonym: superficial musculoaponeurotic
system (SMAS). Name based on location: cervical fascia, tempo-
roparietal fascia, SMAS, Scarpa’s fascia.
The superficial fascia is the dividing boundary between super-
ficial and deep facial adipose tissue. Recognized throughout
history in a variety of forms, it was probably first noted by Sir
Charles Bell, in the late 1790s. Bell was aware that the cervical
fascia continues onto the face. Antonio Scarpa identified the
superficial fascia of the trunk and thorax. Skoog mentioned this
layer in the description of his face lift technique; Tessier presented
his work in 1974. However, the definitive work was performed by
Mitz and Peyronie, two of Tessier’s trainees, who coined the term
VXSHUfiFLDO PXVFXORDSRQHXURWLF V\VWHP (SMAS; Fig. 43.5).
Fig. 43.4 (a) There are several types of adipose tissue based on
morphology and location, including superficial and deep layers.
Anatomists have historically characterized adipose tissue based on
either its location or its gross structural appearance. The two layers
of fat are well known: superficial and deep. More recent work on the
molecular basis suggests several additional layers may exist. Fat always
surrounds muscles, thereby reducing friction and enhancing glide.
The levator anguli oris muscle shown here literally pierces several
fat compartments on its way to insert at the modiolus. Fat within
anatomic spaces, such as the buccal fat shown here, provides archi-
tectural support (here, for the inner cheek) and facilitates muscular
movement (here, gliding of the underlying buccinator muscle). The
clinician knows from experience that the thickness of the superficial
layer varies, the most demonstrable variations occurring near muscular
insertions and around the oral and orbital apertures. This observation
suggests adipose tissue provides “stiffness” and structural support:
regions with the greatest mobility usually have the thinnest layer of
superficial adipose tissue. Abbreviations: ROOF, retro–orbicularis oculi
fat; SOOF, sub–orbicularis oculi fat. (b) While the aesthetic surgeon
focuses on structural support offered by adipose tissue, it is important
to remember that it also plays a metabolic role. Here it surrounds the
intraorbital optic nerve. Cerebrospinal fluid (CSF) transport channels
in the dura, like the (true) lymphatics into which they drain (to
decompress the nerve), are always invested by a delicate layer of fat.
The association of adipose tissue with the lymphatic vascular system is
poorly understood: lymphatic damage leads to adipose hypertrophy,
as seen in several disease and posttraumatic conditions.
a
b