The midface sling: a new technique to rejuvenate the midface

In the early 1990s, the midface became the focus of facial rejuvenation, and various techniques effected elevation by plicating, or on, the midface. Recent analyses of facial aging demonstrate that selective ptosis of the midfacial tissues lateral to the nasolabial fold results in an infraorbital hollow and deepening of the nasolabial fold. Therefore, the authors propose that the midface, from the lower portion of the cheek mass, will result in superior midface positioning. Since 1996, the authors have elevated the midface in select patients by placing a sling of prosthetic (Gore-Tex) or autogenous (tendon or fascia) material through the cheek mass. The sling is secured medially to the infraorbital rim using a nonabsorbable periosteal suture or a mechanical anchor. As variable tension is applied laterally toward the superficial temporal fascia, the sling functions as a fulcrum to return the cheek mass to a more youthful anatomical position. Elevating the cheek mass in this fashion fills the infraorbital hollow and results in amelioration of deep nasolabial folds and jowling. With a mean follow-up of 18 months, 50 patients treated with the midface sling report satisfaction with the procedure. There have been no instances of nerve damage, infection, or hematoma in the midface. None of the slings have required removal and ectropion has not occurred. Because of postoperative asymmetry in one patient, additional elevation of the ipsilateral cheek mass was performed by increasing the tension on the lateral cheek portion of the midface sling. Mathematical models demonstrate the biomechanical superiority of lift through the use of multiple vectors as compared with linear pull techniques. In this fashion, the midface sling supports the cheek mass, providing rapid, simple, and secure elevation. Because of the limited subcutaneous dissection, there is a reduced risk of facial nerve damage and cutaneous vascular compromise. Unlike with other techniques, the lateral portion of the sling may be easily identified through a small incision in the temporal scalp, facilitating subsequent postoperative adjustment of the midface suspension. Furthermore, because the entire cheek mass is permanently supported with an inelastic sling, the results may last longer than those with techniques that rely on sutures to plicate or lift portions of the superficial musculoaponeurotic system.     

Transblepharoplasty endoscopic subperiosteal midface lift

The use of endoscopy in the transblepharoplasty midface lift is essential for preventing the complications of facial nerve injury and bleeding. Complete observation allows precise dissection and release of all structures in the composite flap. This technique fully preserves the zygo-orbicular nerve plexus and prevents denervation of the orbicularis oculi and zygomaticus muscles. Blind dissection has a significant probability of denervation of the entire zygo-orbital muscle complex, and avulsion of the zygomaticofacial vessels, with associated postoperative bleeding complications. The modification involving suturing of the "vest" of the combined lateral orbital periosteal and superficial layers of the deep temporal fascia over the elevated "pants" of the orbicularis periosteal flap provides very secure fixation for suspension of the lower eyelid and midface. The use of slowly absorbable polydioxanone sutures for this technique prevents the problems caused by permanent sutures beneath the very thin skin of the lateral canthal area. Careful trimming of the prominent roll of the orbicularis muscle that often develops with suspension eliminates the uneven contour and yields a smooth lower lid appearance. The details and modifications described should decrease the complications and morbidity that can occur with this procedure and provide for a more precise and reliable procedure for rejuvenation of the lower eyelid and midface.     

The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation.

The subperiosteal face lift described by Psillakis has been criticized for not showing a more dramatic improvement over conventional brow/face lift procedures. His approach also has a significantly high incidence of nerve injury. This study reports our anatomic findings and surgical modifications, which have permitted a significant improvement in the safety of execution and clinical results using the subperiosteal face lift concept. Pertinent points of applied local anatomy and dissection techniques are as follows: First, we use extensive interconnected subperiosteal dissection that includes the entire zygomatic arch. This allows better repositioning of the deep soft tissues of the entire upper face, most of the midface, and indirectly, key structures of the lower face. Second, the upward pull of the muscles of the cheek and mouth will produce an elevation of the corner of the mouth, affecting positively the smiling mechanism, the oral frowning, and the jowls. Third, the dissection deep to both layers of the temporal fascia decreases the risk of injury to the frontalis nerve. Fourth, the temporal fascia is used as a lifter and anchoring element of the entire cheek-perioral soft tissues as opposed to the periorbital fibrofatty tissues. This will decrease the risk of injuring the frontal and zygomatic branches of the facial nerve. These modifications have been used in 28 patients. Our rate of patient satisfaction has been high, and no complications with regard to nerve injury have been observed. This compares favorably with our initial 60 patients, in whom the Psillakis or Tessier approach was used. In these patients, there was an 11 and 20 percent rate of nerve injury, respectively.     

Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad

The anatomy of the temporal region, with reference to the frontal branch of the facial nerve, was examined in 12 fresh cadaver dissections. In all dissections, the frontal branch traveled in a constant plane along the undersurface of the temporoparietal fascia and was quite superficial as it crossed the zygomatic arch. The deep temporal fascia and superficial temporal fat pad are anatomically important structures which adjoin the periosteum of the zygomatic arch and lie deep to the frontal nerve. Based on these relationships, a safe method of dissection within the temporal region is formulated.     

Meloplication of the malar fat pads by percutaneous cable-suture technique for midface rejuvenation: outcome study (392 cases, 6 years' experience)

The aging anterior midface is restored by reversing the contour undulations produced by sagging of the malar fat pad complex toward the nasolabial line. The convex irregularities include the exposed bulges of the post-septal fat, the unveiled malar bag, and the prominent nasolabial fold. The depressed irregularities are represented by the cresent-shaped hollow at the lid-cheek junction, the accentuated nasojugal groove, and the deepening nasolabial line. Repositioning of the ptotic malar fat pad, among other elements of meloplasty, represents a key procedure. In this study, the malar fat pad has been defined as a fan-shaped structure by external anatomic landmarks that correlate closely to the findings in cadaveric dissections and clinical cases, confirmed by the findings of spiral computed tomographic scanning. A simple but powerful adjustable and long-lasting percutaneous suture elevation technique was developed over the past 6 years by the senior author (G.H.S.) to reposition the fat pad in a superolateral direction. Through a dot incision within the nasolabial line, a permanent CV-3 Gore-Tex (or 4-0 clear Prolene) suspension suture, looped through a Gore-Tex anchor graft, suspends the malar fat pad in a direction perpendicular to the nasolabial line. A second suspension system is identically passed through another lower dot incision to broaden the repositioning vectors on the malar fat pad. Tension on each of the paired suture ends elevates the malar fat pad by 1 to 3 mm as measured from the nasolabial dot incisions. The sutures are fixed to the deep temporal fascia through a Gore-Tex tab, effectively stabilizing the soft-tissue repositioning. This maneuver may be performed in younger patients who present with an isolated malar fat pad ptosis without excess facial skin. The procedure may also be incorporated into open rhytidectomies to address this recalcitrant area along with superficial musculoaponeurotic system tightening. A total of 392 patients since 1995 underwent suture elevation of the malar fat pads. An outcome study indicated that the usage of two permanent sutures with Gore-Tex anchor grafts since 1998 resulted in improvement in midface rejuvenation of over 82 percent. Early and late complication rates were small and temporary. Patient acceptance was excellent, indicative of the benefits of anatomic repositioning of the malar fat pad complex.     

Endoscopically assisted malarplasty: one incision and two dissection planes

Asian society is uniquely concerned about the distinctive facial features associated with malar prominence. Various methods of reduction malarplasty have been developed and are currently being applied. In this study, a new approach to malarplasty was experimentally assessed between December of 1999 and August of 2001. After having received careful observations of their facial features and full counseling sessions, 32 patients were selected. These patients had three distinctive characteristics: (1) severe zygomatic arch prominence and normal zygomatic body prominence, (2) desire for only a reduction of the lateral prominence, and (3) desire for a less invasive surgery. Through a short incision in the temporal area, the authors performed the dissection as two different planes. Endoscopic dissection between the superficial layer of deep temporal fascia and the temporoparietal fascia to the zygomatic body and blunt dissection under the deep layer of the deep temporal fascia to the zygomatic arch were performed. Complete osteotomy of the zygomatic arch and an incomplete osteotomy of the zygomatic body were then performed with a reciprocating saw. Finally, the zygomatic arch for the zygoma infraction was pressed manually. The major advantages of this procedure are its simplicity and the short operation and recovery time, with little bleeding and edema.     

Rejuvenation of the midface by elevating the malar fat pad: review of technique,cases, and complications

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.     

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

The transmalar subperiosteal midface lift is a simple, direct-approach procedure to be performed with a meloplasty. The entry into the midface is at the site of maximum suture tension, which allows for more elevation. The skin is elevated enough to expose the entry site, which is on the zygoma just cephalad to the origins of the zygomaticus muscles. Through a small hole at that site, a periosteal elevator is used for the midface dissection. This is a blind dissection, and the technique is described. The advantages of the technique are that there is (1) no lower-lid incision or risk of an ectropion, (2) a resultant tightening and elevation of the lower lid, (3) more elevation and durability because the zygomaticus muscle origins are elevated with the periosteum and are sutured to the very substantial deep temporal fascia, (4) a simple and fast procedure, and (5) no telltale sign of a face lift. Both the superficial musculoaponeurotic system (SMAS) and the skin are substantially elevated with the transmalar subperiosteal midface lift to the extent that they should be only minimally dissected. In the author's opinion, the extended dissection of the skin and/or the SMAS does not increase the amount of tissue lift and probably reduces it in most cases, considering that the goal is a natural look and not one that appears pulled or stretched. The skin is elevated only for exposure, and the SMAS is elevated only enough to create a preauricular SMAS-platysma flap to tighten the neck. With two fewer layers of dissection, there is significantly less postoperative swelling and recovery time. The article presents the technique, the results on 272 patients over a period of 5 years, and a discussion. No patients described have had secondary procedures such as lasers, so the transmalar subperiosteal midface lift can be evaluated on its own merit.     

Circumauricular incision (water-drop shape) for mid- to lower face lift

The conventional method of mid- to lower face rhytidectomy that involves removing a strip of occipital scalp always creates a conspicuous transverse scar crossing the postauricular skin, which may leave a stair-step deformity at the occipital hairline. The author has designed a new face lift method using a circumauricular incision, shaped like a water droplet, that curves around the auricle. In this new method, the upper part of the "O" shape is modified to the tip of a water droplet. The dissection of the cheek and neck is performed as in the conventional method with light-retractor assistance. The temporal region above the deep temporal fascia is managed under endoscopic control. This dissection can extend to the forehead region lateral to the supraoptic nerve and around the lateral orbital rim to release the arcus marginalis. A mesentery of superficial temporal fascia is created cephalic to the zygomatic arch. The postauricular dissection is performed beneath the galea in the upper part and beneath the occipital scalp and neck skin in the lower area. The lifting vector is upward and backward for the anterior skin flap and upward for the posterior skin flap. The excess skin is trimmed around the ear. The wound at the upper pole of the incision is closed in a V-to-Y advancement fashion. The dog-ear is left above the normal hairline, and there is little or no hairy scalp to be removed. The skin pleating in the postauricular region will settle down spontaneously after several months. The dog-ear in the scalp will become smaller and flat as well. The scar around the ear is quite inconspicuous and well covered under the upper pole of the auricle. From the author's experience, the new "water drop" circumauricular incision is a good alternative for the mid- to lower face lift. It can also be used in conjunction with endoforehead lift for full-face rejuvenation.     

The evolution of the midface lift in aesthetic plastic surgery

The midface lift has recently gained significant popularity with many surgeons. It allows the surgeon an opportunity to achieve greater facial harmony with facial rejuvenation procedures by correcting midfacial atrophy, addressing the tear trough deformity, and correcting the perceived malposition of the malar fat pad. This article examines the history of midfacial procedures. Surgical attempts at improving the aging face have evolved from minimal excisions and skin closure to aggressive dissections at multiple planes. The midface target area is peripheral to classic approaches, and its correction has required further anterior dissection from a distance or direct access centrally. Ultimately, conquering the stigmata of midface aging is entirely related to vectors and volume.     

Surgical anatomy and blood supply of the fascial layers of the temporal region

In 15 fresh cadavers (30 sides), we studied the two layers of fascia in the temporal region, with particular regard to their blood supply and to their usefulness--together or separately--as microvascular free-tissue autografts. The superficial temporal fascia (temporoparietal fascia, epicranial aponeurosis) lies immediately deep to the hair follicles. It is part of the subcutaneous musculoaponeurotic system and is continuous in all directions with other structures belonging to that layer--including the galea above and the SMAS layer of the face below. The deep temporal fascia (temporalis fascia, investing fascia of temporalis) is separated from the superficial fascia by an avascular plane of loose areolar tissue. It completely invests the superficial aspect of the temporalis muscle down to (but not beyond) the zygomatic arch. It is firmly attached to periosteum all around the margin of the muscles. Below it is attached to the upper border of the zygomatic arch. We found the deep temporal fascia to be supplied solely by the middle temporal artery, a constant branch of the superficial temporal. The middle temporal artery arises 1 to 3 cm below the upper border of the zygomatic arch, runs always superficial to the arch, and enters the deep temporal fascia immediately above that layer's attachment to the zygomatic arch. If the middle temporal vessels are protected, the two layers of temporal fascia can be raised together as a fully vascularized tissue island. This island can be fashioned as a bilobed or a double-layered flap, depending on the manner of dissection. The potential surgical usefulness of these findings is discussed.     

Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication

The rejuvenation technique of malar imbrication, which avoids dissection in the plane of the seventh cranial nerve, is presented to address the author's altered priorities in midfacial rejuvenation. These priorities target volumetric over tension-based goals in a manner that is simpler, safer, and more sculpturally effective than existing techniques. Volumetric manipulations in the subperiosteal and subcutaneous planes also bring substantial rejuvenation to the periorbital and perioral regions, without lip or lower lid incisions. Fourteen of the 172 patients (8 percent) who underwent consecutive procedures for primary facial rejuvenation suffered temporary upper lip paresis. Other complications were infrequent and limited. One patient underwent reoperation for asymmetry. Increased postoperative swelling and recovery are a necessary consequence of the subperiosteal component, just as increased operative time attends the wide undermining of the subcutaneous component. Despite these liabilities, the author recommends adding volumetric resculpture to the existing conventional tools of soft-tissue displacement under tension and topical resurfacing in pursuit of safer, more effective, and more natural rejuvenation of the aging face.     

Repositioning the orbicularis oculi muscle in the composite rhytidectomy.

While blepharoplasties are routinely done with face lift procedures, the improvement is accomplished by removing excess orbital fat with eyelid skin and muscle along the incisional line. The orbicularis oculi muscle remains intact as its inferior border, which has become ptotic and redundant with aging, and actually remains in the same position following a conventional lower lid blepharoplasty and rhytidectomy. However, by elevating the orbicularis oculi with the cheek fat and platysma in a composite face lift flap, and by excising the redundant inferior border of the orbicularis muscle, a total rejuvenation of the malar area is accomplished. The descent of the orbicularis oculi muscle is in an inferolateral vector, whereas the vector of facial aging is inferomedial. Thus, repositioning the orbicularis oculi is in a superomedial vector and is obligatory in a composite rhytidectomy.     

The use of a temporal osteoperiosteal flap for the reconstruction of malar hypoplasia in Treacher Collins syndrome

The clinical use of a temporal periosteal bone flap for the reconstruction of a malar bone in a patient with the Treacher Collins syndrome is presented. The temporal muscle functions as an axial carrier of the periosteum that induces osteogenesis in young children, whereas the bone segments may serve as a nucleus for further bone formation from the periosteum. Correction of the eyelid coloboma was obtained by the rotation and advancement of a temporopalpebral flap.     

Harvesting fat from the infratemporal fossa

As part of forehead rejuvenation and surgical treatment of migraine headaches, the mass of the corrugator supercilii, the procerus, and the depressor supercilii muscles is replaced with fat for optimal aesthetic contouring of this region and to help prevent recurrence of the glabellar lines. The authors propose a new fat graft donor site that is convenient and safe and that adds only minutes to the total operating time. This fat is located between the deep layer of deep temporal fascia and the temporalis muscle as it approaches the zygomatic arch. The temporal musculofascial anatomy as it relates to the available fat donor sites is described. This source has been used on 74 occasions at 128 sites, from July 1, 2002, to December 31, 2002, with no complications attributable to the technique.     

Multiplane face lift with the subperiosteal dissection for orientals

A subperiosteal face lift rejuvenates the midface and periorbital region by restoring facial muscle tone. Since 1993, the authors have performed this procedure on Oriental patients who have their own distinct facial contours: the brachycephalic cranium and a prominent zygoma and mandibular angle. Although it was thought that these protuberances might disturb the subperiosteal procedure, especially in the anterior midface, the procedure could be performed easily by adopting the ancillary upper buccovestibular and subciliary incisions; the authors found that the protuberances actually act as fulcrums to keep up the lifting vectors reliably. For older patients, the procedure was combined with a deep subcutaneous dissection. A simple lift of the periosteum would not improve a severe nasolabial fold deformity and prominent wrinkles adequately because of "lag-lifting" of the superficial layer. It was concluded that the multiplane face lift, consisting of the subperiosteal and the deep subcutaneous approaches, achieves a natural-appearing rejuvenation of the Oriental aging face.     

Surgical treatment of thyrotoxic exophthalmos

Conservative treatment of thyrotoxic exophthalmos has not given satisfactory results. Our observations, modifications of the standard surgical technique, and the results of orbital decompression for this condition are presented. Through a transverse incision close to the lower eyelid margin, the floor and the lateral orbital wall are explored. The posterior part of the orbital floor and the zygomatic part of the lateral orbital wall, as well as the periorbital fat, are removed. Through an incision made over the medial margin of the orbit, the medial orbital wall is explored and its ethmoidal part is removed. By the same approach, further retrobulbar fat is removed. Through an upper eyelid incision, fat is removed from the eyelid region and the levator aponeurosis is divided. This produces satisfactory symmetrical decompression of the orbit with good correction of exophthalmos and a significant decrease in the signs and symptoms of this condition.     

Depth of the facial nerve in face lift dissections

Facial nerve depth was measured in 12 cadaver face halves after bilateral face lift dissections. The main nerve trunk emerged anterior to the midearlobe and was 20.1 +/- 3.1 mm deep. Nerve exit from the parotid edge also was deep, averaging 9.1 +/- 2.8 mm for temporal, 9.2 +/- 2.2 mm for zygomatic, 9.6 +/- 2.0 mm for buccal, and 10.6 +/- 2.7 mm for mandibular branches. Distal to the parotid gland, danger areas where nerve branches became superficial were distal temporal, lower buccal, and upper mandibular branches over the masseter muscle and marginal mandibular as it crossed the facial artery. Some protection in these danger areas was provided by fascia, especially superficial temporal and masseteric, while platysma provided some protection for the mandibular branch. Fascial and muscle protection was less in thin cadavers. Face lift dissection can be rapid in areas where facial nerve branches are deep or absent, such as postauricular, inferior to the zygomatic prominence, and near the earlobe.