| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Plastic Surgery > RHYTIDECTOMY
Facelift, Mid Face
Article Last Updated: Oct 3, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Keith M Robertson, MD, LRCSI, LRCPI, FACS, Consulting Staff, Chesapeake Plastic Surgery Associates, Suburban Hospital, Esthetique Internationale; Consulting Staff, Department of Plastic Surgery, Greater Baltimore Medical Center
Keith M Robertson is a member of the following medical societies: American College of Surgeons
Coauthor(s):
Oscar Ramirez, MD, Clinical Assistant Professor, Department of Plastic Surgery, Johns Hopkins University, University of Maryland
Editors: David W Furnas, MD, Clinical Professor Emeritus, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California at Irvine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery
Author and Editor Disclosure
Synonyms and related keywords:
mid face lift, cervicofacial rhytidectomy, malar fat, midface retrusion, subperiosteal facelift, face lift, suborbicularis oculi fat, SOOF
The mid face can be defined as the area lying between the bicanthal and oral commisural planes. The mid face is one of the first areas that ages. In individuals in their early 30s, some descent of the malar fat can be observed. This may lead to the formation of dark circles beneath the eyes and deepening of the nasolabial and nasojugal (tear trough) creases. This occurs earlier in people with poor bony support and those with midface retrusion. The area is not addressed by the standard cervicofacial rhytidectomy.
During the past 15 years, several techniques have been described to specifically address this area. Presently, restoration of cheek contour and volume can be achieved by performing a separate subperiosteal vertically oriented lift with independent suspension of the various cheek structures. This may be supplemented with a cheek implant if deemed necessary. Most importantly, this can be performed with small and hidden incisions (scarless approach).
History of the Procedure
Early in the authors' practice, an extended open subperiosteal facelift was performed, and the intermediate temporal fascia (Image 1) was used to anchor the mid face. To better elevate the cheek, the suspension point was changed to the suborbicularis oculi fat (SOOF). These techniques usually were performed through a full blepharoplasty incision, but this resulted in an unacceptable level of eyelid retraction. The access incision then was modified to a crow's foot incision, spreading the orbicularis oculi at the site of the incision without disrupting the muscle. The orbital septum was not violated. The infraorbital fat only was resected in patients with obvious proptosis (5% of patients). With these modifications, no permanent ectropion or eyelid malposition was observed. The authors now have eliminated the need to perform any periocular incision. The periosteum is raised over the entire anterior malar area and the anterior two thirds of the zygomatic arch. Tunnels are made over the zygomatic arch, and independent suture suspension of the SOOF, inferior malar soft tissues, and Bichat fat pad is performed.
Etiology
As individuals age, the bony skeleton and soft tissues of the face lose volume and shrink, producing a slightly wider orbital aperture and less anterior projection. This decreases the overall projection of the cheek and diminishes bony support for the overlying soft tissue structures. The preseptal part of the orbicularis oculi muscle loses some of its tone and allows subsequent herniation of the intraocular fat.
Ptosis of the cheek fat exposes the edge of the inferior orbital rim. If this cheek fat separates from the SOOF, a faint diagonal groove can be seen in the infraorbital area parallel to the nasolabial crease. As the cheek fat descends, it is limited in its inferomedial path by the nasolabial fold. The anterior portion of the Bichat fat pad descends over the upper mandible, accentuating the degree of the jowl.
This procedure is indicated for beautification and for correction of aging in the mid face. It has minor involvement in patients with asymmetry of the mid face. In all patients, the SOOF is suspended to the temporalis fascia proper (TFP). The suspension of the inferior malar soft tissues to the temporal fascia has some imbrication effect, tending to increase the anteroposterior dimension of the cheek. If this is not desirable, then this lower malar soft tissue suture is not placed.
The Bichat fat pad is a relatively mobile structure. It is a vascularized fat pad, which may be moved to the area of perceived deficit. For example, patients with a wide bigonial distance and a smaller bizygomatic distance may benefit aesthetically from lateral placement of the fat pad. Those with a malar deficit, which is more anterior, may benefit from anterior placement of the fat pad, whereas the patient with an obese or full face and a wide bizygomatic distance may benefit from removal of the fat pad. The fat pad may be placed over a cheek implant, thus disguising the edge of the implant and decreasing its palpability. Its suspension or removal significantly improves the upper extension of jowling. Autologous fat grafting is frequently used as an adjunct.
The best plane for dissection is the subperiosteal plane. This plane is relatively bloodless and straightforward to dissect. Chance of injury to the facial nerve is minimal. Implants may be placed safely using this plane.
The buccal fat pad is a distinct body of fat contained within its own capsule. It has branches extending to the buccal, pterygoid, and deep temporal areas. The pad weighs approximately 9 g in adults. It receives its main blood supply from the maxillary artery. Part of this fat pad extends inferior to the parotid duct. The authors' anatomic studies have demonstrated that the parotid duct travels in the capsule of the buccal space. It is separated from the buccal fat pad by this fascia and by the thin capsule of the buccal fat pad (Hester, 1996).
The SOOF is a fibrous portion of fat located at the inferolateral quadrant of the inferior orbit. This is not a distinct fat pad but rather an area where the fat is septate and thick. As individuals age, the lateral canthus descends so that it comes to lie at a level inferior to that of the medial canthus. This produces a negative slant to the eye, giving a sad appearance to the face. This also leads to less lateral support for the orbicularis oculi muscle, thus the muscle tends to fall inferiorly and medially, lending less support to the orbital septum. A subsequent weakening of the septum occurs, as does loss of tone in the orbicularis oculi muscle. This leads to partial prolapse of the posteriorly located fat.
The motor nerve supply to the orbicularis muscle is mainly through the zygomatic branches of the facial nerve. Transection of the orbicularis muscle during standard blepharoplasty leads to denervation of the pretarsal portion of this muscle, which may be permanent, especially in elderly patients.
The path of dissection taken to raise the periosteum of the zygomatic arch starts over the TFP. Traveling inferiorly, the intermediate temporal fascia is crossed, with the yellow-colored intermediate temporal fat pad beneath. This plane is continued until 2-3 mm superior to the zygomatic arch. At this point, the intermediate temporal fascia is pierced, raising the intermediate temporal fascia and immediately the periosteum of the zygomatic arch. These act as a cushion for the frontal branch of the facial nerve.
Beneath the superficial musculoaponeurotic system (SMAS) lies the parotid gland. In the same plane as the parotid gland, the facial nerve travels toward the temple just beneath the temporoparietal (superficial temporal) fascia. In the zygomatic arch and temporal region, a small fat pad is present beneath the superficial temporal fascia. This is termed the superficial temporal fat pad. In the same plane as the masseter muscle lie the zygomatic arch and the intermediate temporal fat pad.
At the zygomatic arch, what was the masseter fascia below becomes the periosteum of the zygomatic arch and above it the intermediate temporal fascia. In other words, these 3 structures are in the same surgical plane. Beneath the intermediate temporal fat pad lies the deep temporal fascia, and beneath it lies the deep temporal fat pad. Therefore, beneath each temporal fascia lies its corresponding temporal fat pad.
The frontal nerve crosses the zygomatic arch in its middle third at a point approximately halfway between the lateral canthus and the tragus. Dissecting the anterior and posterior thirds of the arch before dissecting the middle third is safest. The temporal region contains 3 veins that communicate between the superficial and deep systems, numbered temporal veins 1, 2, and 3 from superior to inferior. Temporal vein 1 is located near the region of the zygomaticofrontal suture, temporal vein 2 is situated inferior and posterior to the lateral canthus, and temporal vein 3 is located around the middle of the zygomatic arch. The zygomaticotemporal nerve may be seen to either side of vein 2.
Patients with previous zygomaticomaxillary fractures present a relative contraindication. The authors have performed a midface lift on a few such patients. Raising the mid face in a subperiosteal plane is challenging, and contouring alloplastic implants to this irregular and scarred surface is difficult.
Preoperative Details
- Analyze the mid face for asymmetries. Note the position of the lateral canthi, the amount of anterior and lateral projection to the cheek, the depth of both nasolabial creases, and the volume of both Bichat fat pads.
- Determine whether the patient requires placement of alloplastic implants in addition to a midface lift. Also determine whether most of the deficit lies laterally, medially, or in the submalar region. The fat pads then can be used to help augment the deficient area and improve asymmetry.
- A photograph of the patient at a younger age is useful so the age-related changes can be demonstrated to the patient (eg, ptosis of the lateral canthus, cheek fat pad, deepening of the nasolabial fold, formation of the jowl, atrophy of facial fat). Generally speaking, the younger patient is more accepting of a higher lateral canthus and psychologically can accept a more radical change than an older patient.
- Preoperative photographs are taken.
- The patient is started on cephalexin 1 day prior to surgery and is administered clonidine on the morning of surgery to counter the effects of epinephrine and any tendency to hypertension.
- Preoperatively, mark the patient's zygomaxillary point. This is a new anthropometric and aesthetic point and is defined as the point where a vertical line through the lateral orbital rim intersects the Frankfort horizontal. This is usually the region of greatest projection in a patient seen in a three-quarter view.
- Mark the nasolabial creases, note asymmetry, and mark the position of the Bichat fat pad.
Intraoperative Details
- Prepare the patient's face. Prepare the mouth with povidone-iodine solution (Betadine) and inject the midface area with lidocaine 0.5% with epinephrine 1:200,000.
- Make a 12-mm temporal incision 2 cm behind the temporal hairline. The central aspect of the incision lies perpendicular to a line through the nasal ala and lateral canthus.
- Identify and incise the superficial temporal fascia. This is retracted by the assistant, and deep to this is an "angel hair pasta" plane (subgaleal fascia). This area can be spread easily with the scissors, and deep to this lies the TFP. A No. 4 periosteal elevator can be used to expose the TFP circumferentially.
- Insert a plastic port protector into the incision. If the need for a large vertical lift has been determined preoperatively, then the dissection also is carried superiorly toward the temporal line of fusion.
- Enter the subperiosteal plane at the temporal line of fusion with a No. 8 periosteal elevator. Then carry the dissection toward the mid line of the skull.
- Next, continue the dissection toward the zygomaticofrontal suture and down toward the arch. After several centimeters of dissection, with the TFP lying beneath the dissector, a color change is noted as the dissector passes over the intermediate temporal fascia with its underlying intermediate temporal fat pad.
- Approaching the zygomaticofrontal suture, use a zero elevator. This has a rounded tip and does not damage the veins and nerves found in this area. Perform gentle dissection in this area to isolate temporal vein 1. This vein often is divided. Traveling inferiorly along the lateral orbital rim, vein 2 (sentinel vein) is encountered. This is a large vein and should be preserved. Inferior to this, the zygomaticotemporal nerve may be found.
- Once the anterior one third of the zygomatic arch has been dissected, attention then is turned to the posterior one third. This also is dissected through the temporal incision using a No. 9 elevator and traveling over the intermediate temporal fascia to just above the zygomatic arch.
- Lastly, dissect the middle one third in the same plane. Approximately 2-3 mm above the zygomatic arch, incise the intermediate temporal fascia using this periosteal elevator. Raise this intermediate temporal fascia and some of the intermediate temporal fat pad superiorly.
- Dissection continues in the plane of the intermediate temporal fat pad to the zygomatic arch. Then, raise the periosteum of the zygomatic arch upward. This provides a cushion to the frontal nerve consisting of the intermediate temporal fascia and a portion of the intermediate temporal fat. Several windows can be made in this plane through the zygomatic arch periosteum and into the masseter muscle lying below.
- Dissect tunnels between the zygomaticotemporal nerve and temporal vein 3. Vein 3 is found at approximately the junction of the middle and posterior thirds of the zygomatic arch.
- At this point, the dissection of this area is halted. Place epinephrine-soaked pledgets in this region through the temporal incision and turn attention to the gingivobuccal sulcus.
- Again prepare the mouth with povidone-iodine solution and make an inverted "V" incision over the first premolar tooth.
- Incise the underlying muscle and use a No. 9 periosteal elevator to elevate the periosteum sharply and in a single plane.
- Continue this dissection almost to the pyriform aperture and superiorly up to the inferior orbital rim. This dissection can be performed without the aid of the endoscope up to malar bone.
- To dissect the zygomatic arch, using an endoscope and one of a series of narrow curved periosteal elevators (Ramirez Minus Series) is necessary. Using these periosteal elevators, elevating the periosteum of the entire length of the zygomatic arch without a periocular incision is possible.
- Continue the dissection slightly inferiorly to raise the masseter fascia from the masseter muscle for approximately 2-3 cm. This is performed to allow for a vertical translation of the superficial soft tissues.
- Redraping or removal of the orbital fat is performed at this time if indicated. This also is performed through the gingivobuccal incision. Use a No. 4 periosteal elevator to dissect the periosteum up and over the inferior orbital rim.
- At this point, the intraorbital fat can be identified, and the middle and lateral compartments carefully are freed with a spreading motion using endoscopic scissors. Light pressure on the globe permits prolapse of these fat pads. They then may be sutured over the rim to the malar periosteum/SOOF using 4-0 polydioxanone (PDS) suture.
- Place a suture in the SOOF through the gingivobuccal sulcus. Because it is thin at this point, and the suture may cause a dimple, it is important to avoid grasping too superiorly in the SOOF. The authors prefer to place the suture at or slightly inferior to the zygomaxillary point and use 3-0 PDS suture. Feed the free ends of this over the zygomatic arch and exit the temporal incision.
- The next structure to be suspended is the inferior malar soft tissue. This is a flimsy structure, which is grasped in a tangential weaving motion with 4-0 PDS. Of importance, do not include the multiple small branches of the long buccal nerve. Trauma to these branches may result in some paracommissural numbness. Both free ends of this suture also are passed over the zygomatic arch and exit the temporal incision. This suture lies superior and medial to the SOOF suspension suture.
- If a deficit is noted in the region of the malar bone or the submalar area, then the buccal fat pad may be released and repositioned to these areas. If additional augmentation is not required in the malar or submalar areas, the fat pad may be released or resected as necessary.
- The fat pads may be reached through the same intraoral incision by dissecting between the periosteum and buccinator muscle. Gentle teasing of the buccal fat pad can be performed using two smooth-tipped bayonet forceps. The fat pad can be teased gently from the overlying fascia. Importantly, do not tear the connective tissue covering of the fat pad while performing this maneuver. This connective tissue carries the blood supply to the fat pad and gives it structural integrity to support the sutures placed in it.
- Once the fat pad has been released, it herniates. If it is to be removed, it may be clamped and amputated using cautery. If it is to be suspended, then a 4-0 PDS suture is woven through the connective tissue overlying the fat pad and the fat itself.
- Placement of the free ends of this suture depends on the aesthetic goal. If more lateral fullness is required, pass the suture over the zygomatic arch medial and superior to both other sutures. If more anterior fullness is desired, the suture holding the fat pads may be knotted around the suture holding the SOOF.
- Retract the temporal incision inferiorly and suture the 3 sutures to the TFP in a position inferior and anterior to the incision.
- Place the SOOF suspension suture most laterally and place the buccal fat pad suture most medial and superior. Place the suture that suspends the inferior malar soft tissues between these two.
- When performing the procedure on the second side, tension can be adjusted as the sutures are being tied to achieve symmetry with the first side.
- Butterfly drains connected to Vacutainer tubes are placed on either side through a separate puncture incision. Direct the free end of the drain over the zygomatic arch and into the mid face. Then suspend the superficial temporal fascia superomedially to the TFP.
- The scalp is retracted in a superomedial direction by an assistant while the anterior edge of the superficial temporal fascia is sutured. Place two sutures of 4-0 PDS. Close the skin with interrupted 4-0 gut sutures. Prior to closing the mouth incision, irrigate the cavity with saline and then with antibiotic-containing solution.
- The V-shaped incisions are advanced superiorly and closed in a "Y" configuration. The authors use 4-0 chromic horizontal mattress sutures. This has the effect of everting the wound edges, creating a valve system and decreasing the probability of saliva entering within the wound.
Fat grafting is often used to augment facial volume or to correct asymmetry.
Postoperative Details
- Iced saline sponges are applied to the area 20 minutes on and 20 minutes off for the first 24 hours.
- Advance the drain at 24 hours and remove it at 48 hours.
- Continue perioperative antibiotics for 5 days.
- Ask the patient to avoid swishing liquids and brushing the upper teeth, since this may cause particles and saliva to enter the gingivobuccal incision.
- Instruct patients to clean the incision with povidone-iodine solution swabs twice daily for 1 week.
- Ask patients to keep their heads elevated at all times and to avoid chewing for the first week. Liquid and soft foods are given during this time.
This is a safe procedure with few complications. No permanent instances of frontal nerve palsy have occurred. One episode of temporary inferior orbital paraesthesia occurred due to irritation caused by a small hematoma adjacent to the nerve. Infection is rare and tends to occur in patients in whom an implant has been placed. Beaded nylon implants (Porex) are placed in the subperiosteal plane. While these implants are more technically difficult to place, they do not have problems with local tissue reactions and capsule formation. In addition, when these implants become infected, they can be salvaged by opening the gingivobuccal sulcus and irrigating the cavity with antibiotics. Unlike silastic implants, no bony erosion is associated.
The authors have performed the endoscopic midface lift since 1993. This operation can produce reliable and reproducible results and can improve the tear trough, refine the projection of the cheek, elevate the jowls, and lift both the corner of the mouth and the lateral canthus of the eye. Asymmetry of the cheek mound also can be addressed by placing a larger volume of Bichat fat pad to the smaller cheek. Fine-tuning of this area and of the nasolabial crease also can be accomplished using fat-grafting techniques. For additional relevant images see the authors' Web site Scarless Facelift or the authors' other eMedicine article Facelift, Subperiosteal.
While this procedure is very appealing to the patient (addressing the cheek mound through 2 small nonvisible scars), it may not be as appealing to the surgeon because of the steep learning curve. Once mastered, the technique is safe and reliable. It is technically more challenging than the endoscopic forehead lift. Although it involves dissection millimeters away from the frontal branch of the facial nerve, it is much safer than the intermediate plane techniques.
| Media file 1:
Midface facelift. The dissection over the zygomatic arch (ZA) is challenging due to the proximity of the frontal branch of the facial nerve (FN). Dissection starts over the temporal fascia proper (TFP) and proceeds inferiorly and anteriorly over the intermediate temporal fascia. Just before reaching the zygomatic arch the fascia is incised and the intermediate temporal fat pad (IFP) is divided. The IFP is raised in continuity with the periosteum overlying the ZA. The masseter muscle (MM) is divided in line with its fibers.
Just above the plane of dissection lies the FN and the superficial temporal fascia (STF).
Directly beneath the plane of dissection lies the TFP and its underlying temporalis muscle. The deep temporal fascia (DTF) overlies the deep temporal fat pad (DFP).
The large arrow represents the direction of dissection. The parotid gland is indicated by PG. |
 |  View Full Size Image | |
Media type: Image
|
| Media file 2:
Midface facelift. The main soft tissue components of the mid face are suspended to the fascia of the temporalis muscle (T). The suborbicularis oculi fat (SOOF) (S) is attached most laterally and most inferiorly. The buccal fat pad of Bichet (B) is suspended most medially and most superiorly. The inferior malar periosteum (I) is suspended between them.
The intraorbital fat pads (O) are frequently released and sutured to the SOOF. The tissues superficial to the plane of dissection are translated superomedially (in the direction of the arrow), then sutured to the fascia of the temporal muscle in this new position. |
 | View Full Size Image | |
Media type: Image
|
| Media file 3:
Midface facelift. Before: anteroposterior view.
Patient has a heavy appearance of the upper eyelids and brow with slight downturning of the lateral canthi. There is descent of the suborbicularis oculi fat and early nasolabial folds. The corners of the mouth have started to turn downwards. Early jowling is present. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 4:
Midface facelift. After: anteroposterior view.
The periocular area appears refreshed. No upper blepharoplasty was performed. The cheek mound sits at a higher level. There is some softening of the nasolabial folds and slight elevation of the corners of the mouth. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 5:
Midface facelift. Before: lateral view. Note the hooding of the lateral orbit and the position of the jowl. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 6:
Midface facelift. After: lateral view. Both the lateral brow and the jowl have been lifted. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 7:
Midface facelift. Before: anteroposterior view. This person has slight brow ptosis with a heavy appearing upper lid and infraorbital hollowing and visible infraorbital rims. The upper lid crease is not readily seen. The left corner of the mouth is drooping. The face has a heavy and square appearance. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 8:
Midface facelift. After: anteroposterior view. Patient had an endoscopic forehead and midface lift. Now the brows are at a higher level. She has crisp upper eyelid creases. The infraorbital rims are not clearly seen. The left corner of the mouth has been elevated. The heavy appearance of the lower face has been eliminated. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 9:
Midface facelift. Before: three-quarters view. Early nasolabial folds and marionette lines are present. The cheek has lost some of its youthful fullness. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 10:
Midface facelift. After: three-quarters view. There is no hooding of the lateral brow. The orbit is not visible beneath the soft tissues of the cheek. The authors have repositioned the buccal fat pad from the jowl to the cheek area. Jowling is improved and cheek volume is augmented. |
 | View Full Size Image | |
Media type: Photo
|
- Fuente del Campo A. Centrofacial lifting. Perspect Plast Surg. 1993;7:87-99.
- Hester TR, Codner MA, McCord CD. The "centrofacial approach" for correction of facial aging using the transblepharoplasty subperiosteal cheek lift. Aesthet Surg Q. 1996;16:51-58.
- Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation. Plast Reconstr Surg. Aug 1991;88(2):227-36; discussion 237-8. [Medline].
- Ramirez OM. Endoscopic full facelift. Aesthetic Plast Surg. Fall 1994;18(4):363-71. [Medline].
- Ramirez OM. Buccal fat pad pedicle flap for midface augmentation. Ann Plast Surg. Aug 1999;43(2):109-18. [Medline].
- Ramirez OM, Santamarina R. Spatial orientation of motor innervation to the lower orbicularis oculi muscle. Aesthetic Plast Surg. 2000;20:107-113.
- Tessier P. [Subperiosteal face-lift]. Ann Chir Plast Esthet. 1989;34(3):193-7. [Medline].
- Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg. Jun 1986;44(6):435-40. [Medline].
Facelift, Mid Face excerpt Article Last Updated: Oct 3, 2006
|
