Midface Lift : Panel Discussion

Greg Keller, MDa,*, Vito C. Quatela, MDb,*,Marcelo B. Antunes, MDc,*, Jonathan M. Sykes, MDd,*,Christina K. Magill, MDe,*, Rahul Seth, MDf,*

Midface Lift Panel Discussion

Greg Keller, MD with Rahul Seth, MD, Vito C. Quatela, MD with Marcelo B. Antunes, MD, and JonathanM. Skyes, MD with Christina K. Magill, MD address questions for discussion and debate:

1. What is the most efficient dissection plane to perform midface lift?

2. What is the best incision/approach (preauricular, transtemporal, transoral)? Why?

3. What specific technique do you use? Why?

4. What is the best method/substance for adding volume to midface lifting?

5. In approaching the midface, how do you see the relationship of blepharoplasty versus fillers versusmidface lifting?

6. Analysis: How has your procedure or approach evolved over the past 5 years?What have you learned,first-person experience, in doing this procedure?

KEYWORDS

� Midface lift � Panel discussion � Techniques

Dr Quatela and Dr Antunes provide 2 videos demonstrating the plane of dissection in midface lift(videos 1 and 2) alongwith 2 videos demonstrating placement of suspension sutures (videos 3 and 4)

What is the most efficient dissection plane to perform midface lift?

KELLER AND SETH

The midface lift can be performed in manydissection planes and efficient is a word thathas many meanings.1–12 So, it depends onwhat the surgeon wishes to do, how much effortthat he/she wishes to expend, what his/her tech-nical capabilities are, what the patient’s signs ofaging are, and what sort of result the patientexpects.

There are 4 fat pads involved in midface liftingthat can be repositioned:

a Keller Facial Plastic Surgery, David Geffen School ofMedicCA,USA; b Quatela Center for Plastic Surgery, 973 East Aventer for Facial Plastic Surgery, Austin, TX, USA; d Facial Plasti2521 Stockton Boulevard, Suite 7200, Sacramento, CA 958Surgery, Department of Otolaryngology - Head and NeckBoulevard, Suite 7200, Sacramento, CA 95817, USA; f DepDivision of Facial Plastic and Reconstructive Surgery, Univer* Corresponding authors.E-mail addresses: faclft@aol.com (Keller); vquatela@quaedu (Sykes); christine.k.magill@gmail.com (Magill); rahul

Facial Plast Surg Clin N Am 22 (2014) 119–137http://dx.doi.org/10.1016/j.fsc.2013.09.0051064-7406/14/$ – see front matter � 2014 Elsevier Inc. All

1. Supraperiosteal fat pad, which contributes tothe malar crescent and is bound to the perios-teum and bone

2. Nasolabial or malar fat pad, which is held up bytrue ligaments to the malar eminence

3. Buccal fat pad, which is held up by falseligaments

4. Orbital fat, which can bulge anteriorly throughthe weakened orbital septum and over theorbital rim to the level of the fallen orbicularisretaining ligaments

ine, University of California, Los Angeles, Santa Barbara,ue, Suite 100, Rochester NY 14607, USA; c Antunes Cen-c Surgery, University of California-Davis Medical Center,17, USA; e Division of Facial Plastic and ReconstructiveSurgery, University of California-Davis, 2521 Stocktonartment of Otolaryngology- Head and Neck Surgery,sity of California, San Francisco, San Francisco, CA, USA

tela.com (Quatela); jonathan.sykes@ucdmc.ucdavis..seth@ucsf.edu (Seth)

rights reserved. facialplastic.theclinics.com

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Descent of these fat pads can be related togravitational descent, stretching of the ligamen-tous attachments of these fat pads, and volumeloss due to posterior retraction of the malar bone.In addition, the superficial fascia/superficial

musculoaponeurotic system (SMAS), deep fascia,and subcutaneous tissue fuse together and attachto bone at several locations in the midface. Theseoccur at the orbit, the malar eminence, the massa-teric tendon/malar interface, nasal bone, zygo-matic arch, frontal/zygomatic suture lines, etc).There are also ligamentous attachments of theSMAS that progress from bone to the skin ofthe midface (the malar ligaments, the orbicularisretaining ligament. Sagging of the skin and subcu-taneous structures is related to the aging changesin these attachments. Another attachment relatedto malar edema is the “malar septum” extendingfrom the arcus marginalis to the midface skin.In addition, volume loss occurs in the face. This

is present to a greater degree in the older patient.The skin of the midface is also not immune fromthe aging process. Both intrinsic and extrinsiccauses of skin aging affect the midface.To obtain a “best” natural appearance, defi-

ciencies of aging related to these pathologiesneed to be addressed or camouflaged. Agingproblems can be multiple and may vary individu-ally or by age group. For instance, a 50 to 60-year-old woman will not have as much volumeloss as a 75-year-old woman. Often a “smiletest” is helpful to assess volume depletion of themidface. If the patient smiles and the fat pad as-cends (meloplication) to fill out the cheek, it is likelythat a surgical approach to lift the malar fat padwill work. If the fat pad does not add enoughvolume with the act of smiling, volume augmenta-tion with filler or implants may be required.At UCLA, we objectively evaluate our surgical

approach based on the patient’s pathology. Wehave looked at several indicators that help usto do this: the presence of an ogee curve; thedistance from eyelashes to the optical bottom ofthe eyelid; orbital fat protrusion and degree of orbitalfat “fall”; anterior projection of the malar eminence,and the presence of a negative or positive vector.While there are other subjective considerations,these indicators are useful in planning an approach.While we favor certain planes and approaches, wemay use any or all of the planes that we list below.For the younger patient, or the surgeon with

limited technical capabilities, an “efficient ap-proach” from a surgeon’s perspective, may be toperform a subcutaneous face lift (with or withoutSMAS plication, such as a MACS or S-lift) and/orinject fat into the cheek to try to camouflage ab-normalities. If there is a limited increase in distance

from the lashes to the apparent optical bottom ofthe eyelid, a decent ogee curve, and good anteriorprojection (all contributing to a “positive vector”),this may produce a happy patient and surgeon(and a short procedure). However, in many in-dividuals, as the edema resolves and the fatdisappears, the patient’s preoperative and postoper-ative photos may not appear much different, exceptthat the jowls and neck are resolved. If the onlyapproach is to camouflage with filler in the settingof significant fallen fat pads, the patient may lookartificially bloated (“puffer fish” abnormality) or thecheekmay be filled, but the fallen malar padmay stillprotrude over the nasolabial fold (“rock in the sock”abnormality). In either case, the patient may exhibitan “artificial” appearance.While many American authors are given credit for

sub-SMAS or deep plane procedures, internationalsurgeons are actually responsible for these moresophisticated approaches to the midface. TorgSkoog evolved the deep plane approach to the mid-face and Tessier, with his fellow, Mitz, explored andevolved the subperiosteal and “low” sub-SMAS pro-cedures.BosseandPapillondefined themalar retain-ing ligaments and sub-SMAS procedures to themidface that describe the facial nerve course. Theprocedures of Bosse and Papillon are, essentially,the “high SMAS” procedures that are used today. Ihad the privilege of meeting Bosse at an endoscopicmeetinganddiscussing the implicationsof thesepro-cedures on the muscles of facial expression, whichare significant and beyond the scope of this discus-sion. Reading of these authors is essential, shouldthe surgeon wish to perform deeper procedures.The “low SMAS” procedure involves a limited

SMAS dissection plane below the zygomatic arch.Used alone, this approach, by itself, produces littleeffect on themidface unless it is carried over thema-lar eminence. It is often used with liporeinjection ofthe midface. The part of this procedure that is signif-icant for the midface is that, with relaxation and fatreabsorption, a Nike “swoop” line can be producedas, over time, the midface sags over the tightenedSMAS. A solution to this problem can be to partiallysupport the midface with a percutaneous “melopli-cation” procedure of the fat pad or a subperiostealelevation. For the surgeon with sufficient skill andthe patient with a lesser degree of malar sag andshorter eyelid length, this can produce a nice result.Another set of approach planes to the midface

are the deep plane, suprafibromuscular, and“high SMAS” lifts. I group these together, as allof them release the malar ligaments and attach-ments. A Nike “swoop” line from midface re-laxation is usually avoided, but the concavity ofthe ogee curve can be accentuated. All of theseapproaches, by freeing up the ligamentous

Fig. 1. Keller. Note the diminished distance from eyelash to bottom of the eyelid in this patient with a deep planeface lift and subperiosteal midface lift. (Courtesy of G. Keller, MD, Santa Barbara CA. � Gregory Keller.)

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attachments of the midface, allow the malar fatpad to ascend, though this effect may be for alimited time. Combining these approaches withother midface lifting or augmentation techniquescan produce a longer lasting result.

Another plane of dissection is the preperiostealplane of dissection over the malar eminence.This plane of dissection extends under the subor-bicularis oculi fat (SOOF) and over the deep fasciaof the malar eminence. It is most commonly usedfrom a blepharoplasty approach for orbital fatrepositioning. The preperiosteal plane is also a“finger dissection” plane from a lateral and tem-poral face lift approach over the malar eminenceand is used by some surgeons to elevate the malararea during a face lift.

The final plane of approach, and the one thatwe most often utilize, is the subperiosteal plane.This is the only plane that elevates the malar fatpad, the preperiosteal fat pad, and the SOOF. In

addition, the orbicularis muscle, the periosteumand overlying structures adherent to it, and thelip elevators can also be repositioned, if desired.A more extensive description of the techniquefollows. While a procedure involving a subperios-teal approach is not efficient from the surgeon’sstandpoint as it lengthens the procedure time, itis the most efficient approach to reposition fatpads, ligament, and muscle. Tessier describedthis procedure through a coronal approach andcalled it a “mask” lift, as it took the “mask” ofthe fallen face, and restored a youthful appear-ance (Fig. 1). When I viewed the results of thisprocedure, I was impressed that the pictures ofTessier, Psillakis and others using this approachwere better than any others that I had seen.This procedure was invasive, and we began, in1989 (procedure patented in 1991), to use anendoscope to reduce the edema associatedwith it.

QUATELA AND ANTUNES

The most efficient plane to elevate the midfaceis the subperiosteal plane. This plane can beelevated quickly with minimal bleeding. It is alsoa safe plane to avoid injury to nerves and the facial

mimetic musculature. The only nerves that are atrisk are the frontal branch of the facial nerve andthe maxillary division of the trigeminal nerve. Thefrontal branch can be avoided if the dissection is

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performed in the appropriate plane, elevating theperiosteum without disruption. The maxillary nervecan be protected by palpation of the foramen and

Fig. 2. Sykes and Magill. The tissue layers of the face asuperficial musculoaponeurotic system (SMAS) (investingand parotidomasseteric fascia (deep fascia). The image othe level of the zygomatic arch. The frontal branch of tand is reflected laterally with the overlying subcutaneousis beneath the temporoparietal fascia and splits into a supthe deep temporal fascia inserts onto the margin of the zyfascia inserts on the medial surface of the zygomatic archdeep temporal fascia. Beneath deep temporal fascia lies t

holding pressure at that point while the subperios-teal dissector elevates the midface above andbelow the exit of this nerve.

SYKES AND MAGILL

In general, the more superficial the dissectionplane, the more efficient and secure the lift. Effi-ciency results from performing only the neededamount of dissection in order to achieve thedesired result. In the forehead/brow, for example,the subcutaneous/suprafrontalis muscle dissec-tion plane is more efficient than either the sub-galeal or subperiosteal plane. The justificationfor performing further dissection, using a moredistant incision, and developing a thicker flap isto hide the incision and preserve a vascular sup-ply to the flap.In the midface, the flap needs to be thick enough

to camouflage suture irregularities (eg, dimpling),while allowing efficient undermining and elevation

of the soft tissue envelope. The possible dissec-tion planes for midface lifting include1,2:

1. Immediate subcutaneous plane2. Sub-SMAS plane (superficial to the zygomatic

musculature)3. Preperiosteal plane4. Subperiosteal plane (Fig. 2)

The subcutaneous plane has the greatestchance for contour irregularities, while the subper-iosteal plane is the most inefficient, requiring thegreatest release of soft tissues. The subcutaneousplane is the most efficient plane for elevation of themidface, but flap fixation can lead to contour irreg-ularities of the facial skin.

re shown on the left: skin, subcutaneous issue, thefascia), the sub-SMAS plane (loose areolar tissue),

n the right demonstrates the fascial relationships athe facial nerve travels in the temporoparietal fasciatissue and skin. The deep layer of the temporal fasciaerficial layer and a deep layer. The superficial layer ofgomatic arch and the deep layer of the deep temporal. A fat pad is enveloped between the 2 layers of thehe deep temporal fat pad the temporalis muscle.

What is the best incision/approach (preauricular, transtemporal,transoral)? Why?

KELLER AND SETH

Generally, I prefer a temporal approach posteriorto the hairline for lifting the midface. If the temporalincision is placed superior enough (close to thetemporal line), an almost vertical direction of pullcan be maintained. I will, on occasion, use anextended subciliary eyelid incision, in the face of

severe temporal fascia scarring from previous pro-cedures, though I can usually avoid this incision.An extended subciliary incision can produce aneyelid scar that needs to be covered with makeup,and can be associated with eyelid retraction andscleral show.

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For positioning of an endotine in the properposition or for placing a malar implant, the intraoralincision is valuable. This incision gives the bestaccess to the lower malar areas and the mas-sateric tendon.

I will often use a transconjunctival incision toretroposition fat over the orbital rim, if orbital fatprotrusion is a problem. Often, the orbital fathas protruded through a weakened septum,the globe has recessed, the SOOF fat has

fallen, the orbicularis muscle has descended,and the malar fat pad has descended. Overall,this combination of aging effects produces theappearance of a “pot belly over fallen jeans.”This set of anatomic problems can occur evenin the younger individual. While all ethnicgroups exhibit this “pot belly over fallen jeans”phenomena, many people of Middle Easternand Asian descent manifest it at a relativelyyoung age.

QUATELA AND ANTUNES

Over the course of the years, I have used transoral,transorbital, and transtemporal approaches toachieve midface elevation. In my opinion, thebest incision/approach is the transtemporal.

The transtemporal approach, as the nameillustrates, achieves midface elevation through asmall temporal incision. The dissection startsseparating the deep temporal fascia from thedeep layer of the superficial fascia and from thereto the subperiosteal plane. The forehead andthe zygomatic arch are elevated subperiosteally,and this way, as previously mentioned, the frontalbranch is protected. The dissection proceedsinferiorly, elevating the soft tissues of the midfacefrom the maxilla. This approach has several ad-vantages over the preauricular and transorbitalapproaches due to its vector of pull, increasedlower lid support, and avoidance of lower lidmalposition. In addition, this approach allows fora temporal lift simultaneously, which will elevatethe lateral brow and avoid bunching of tissues inthe temple. This way, the midface, lower lid, tem-ples, and lateral brow are rejuvenated as a group,creating a more harmonious appearance. Initially,I combined this with a transoral approach to com-plete the dissection, but with more experience,I found this practice to be unnecessary, as I couldget complete release of the midface from thetemporal incision.

The preauricular approach can achieve midfaceelevation through a deep plane rhytidectomy dis-section. In this approach, the SMAS layer is en-tered anterior to the frontal branch of the facial

nerve and the dissection proceeds medially deepto the malar fat pad and superficial to the zygoma-ticus major muscle. After the zygomaticocutaneusligaments are released, the malar fat pad can beelevated. The major advantage of the transtempo-ral approach over the preauricular approach is thevector of pull. The deep plane rhytidectomy has amore lateral vector, which is not optimal.

The transorbital approach also involves subper-iosteal elevation of the midface soft tissue and itsfixation to the deep temporalis fascia posterior tothe orbital rim at a point just above the lateralcanthus. Theundermined skin-muscle flap elevatedwith the subciliary approach is then redrapedand itsexcess removed. Following fixation and conserva-tive excision of the lower lid skin, there is the needto create lower lid support, and this could beachieved with cathoplasty or a canthopexy, whichcan create several issues. Advocates for this tech-nique claim that has the advantage of its dissectionto avoid risk to branches of the facial nerve andcreate a vertical vector of pull. I don’t think the fron-tal branch is under high risk with the transtemporalapproach, since in over 1000 cases I only had onecase of permanent paresis that occurred during acomplex revision procedure. Moreover, this tech-nique carries a higher risk of lower lid malpositionand creates bunching of soft tissue and skin in thelateral orbital rim, sometimes creating an unnaturalappearance. The transtemporal approach, on theother hand, will increase lower lid support and theconcurrent temporal lift will avoid this lateralbunching.

SYKES AND MAGILL

The incision(s), approach, and fixation used to liftthe midface are integrally related (ie, the incisionused will affect the dissection plane and themethod of flap fixation). There are several possibleways to approach the midface, including3:

1. Lateral temporal incision and approach

2. Transblepharoplasty approach with a transcon-junctival or transcutaneous incision

3. Preauricular incision with a subcutaneousapproach transitioning to a sub-SMAS plane

The advantages of a lateral temporal ap-proach are the lateral vector of lift and the

Fig. 3. Sykes and Magill. Intraoperative images of atransblepharoplasty approach to the midface. Trans-cutaneous incisions and lower blepharoplasties havebeen performed in the upper image. In the lowerimage, a left-sided midface lift has been performed.The left lid is tighter after fixation sutures.

Fig. 4. Sykes and Magill. Landmarks for transition tothe deep plane. The lateral mark demonstrates theapproach to the midface in the subcutaneous plane.Note the more medial line drawn from the angle ofthe mandible to the right lateral canthus. The moremedial line demarcates the transition to a deep planeof dissection. The deep plane of dissection is deep tothe SMAS and superficial to the zygomaticus majorand minor muscles, which have been marked out.

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well-camouflaged incision. The transblepharo-plasty approach provides good access to themidface, and a vertical vector of lift (Fig. 3). Thelevel of the inferior orbital rim is the superior limitof the lifting vector with the transblepharoplastyapproach.I prefer the preauricular incision with a subcu-

taneous preauricular dissection plane transitioningto a sub-SMAS plane at a line which joins themandibular angle with the lateral canthus (Fig. 4).

The reason for not initially dissecting in the sub-SMAS plane is that the superficial and deep fasciaare fused in the immediate preauricular region. Themidface flap is then fixated to the deep temporalfascia.

What specific technique do you use? Why?

KELLER AND SETH

I use almost every technique for addressing themidface that there is, depending on the pathologypresent. My favorite technique is the subperiostealmidface lift.For the younger individual, filler substances are

often the entry into cosmetic enhancement of theaging midface. Usually, these patients present intheir 30s or 40s. There is not a great deal of pathol-ogy in these early midface patients, and they can

be filled conservatively, without producing the“bloated” look of a puffer fish.As gravitational descent becomes more

apparent, I most often use a subperiosteal midfacelift with endotine fixation. Most of the patients inmy practice exhibit gravitational descent as theirprimary problem as they approach and pass50 years of age, particularly around and after thetime of menopause. At this point, there is not

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usually a great deal of volume loss, and a naturalfacial rejuvenation can be obtained with surgery.

Througha temporal hairline incision, I dissect alongthe superficial layer of deep temporal fascia, pushingthe temporoparietal fat pad and the innominatefascia superficially. I progress toward the zygomati-cofrontal suture line until reaching the sentinel vein,which I cauterize with a bipolar if it is in the way ofmy dissection. I enter a subperiosteal plane at thelateral orbital rim and then dissect inferiorly over themalar eminence with a finger on the infraorbital nerveto protect it. Effort is alsomade tomaintain the zygo-maticofacial and zygomaticotemporal nerves. Thedissection extends no further lateral than the medialthird of the zygomatic arch, to avoid the temporalbranchof the facial nerve. Imayormaynot useanen-doscope, and the use of one is not mandatory.

At this point, I make a buccal gingival incision andcarry the subperiosteal dissection upward to join thesuperior dissection. I also take down the fascialconfluence of themalar periosteumand deep fasciaof the massateric ligament, so that the periosteumcan be freed and retracted upward. This is a similar

approach to that of placing a malar/submalarimplant. An endotine is placed through the gingivo-buccal incisions and pulled superolaterally towardthe temporal dissection. The endotine prongs enterthe fascia and buccal fat pad, elevating thesestructures. The endotine is secured to the superficiallayer of the deep temporal fascia.

The endotine fixation has a number of ad-vantages. It elevates all of the major cheek fatpads, increases cheek projection, and restoresthe ogee curve. By using this fixation, it is notnecessary to elevate the periosteum past themedial one-third over the zygomatic arch. Thisavoids exposure to the temporal branch of thefacial nerve.

Another procedure that I use is to “meloplicate”the cheek fat pad. This technique uses a Gore-Texsuture to suspend the malar fat pad to the tem-poral fascia, and is described in our previous pub-lications. It can be performed by a percutaneoustechnique. I reserve this procedure for patientswho wish to undergo a less extensive or less costlyprocedure.

QUATELA AND ANTUNES

Dr Quatela and Dr Antunes provide 2 videos demonstrating the plane of dissection in midface lift(videos 1 and 2) alongwith 2 videos demonstrating placement of suspension sutures (videos 3 and 4)

My preferred technique is the transtemporal sub-periosteal approach for all the reasons describedabove (optimal vector of pull, increased supportof the lower eyelid, and concurrent elevation ofthe temple). Every time I perform a subperiostealmidface elevation, I perform brow repositioningand a lower blepharoplasty at the same time.

In further detail, I start by marking the temporalincision approximately 1 cm behind the hairlineat the superior aspect of the temporalis muscle,and this incision continues for 3 cm inferolaterally.I have the patient contract his/her temporalismuscle to see where the temporal line is, and Imake sure that the starting point is 1.5 to 2 cminferior to the superior temporal line, otherwisethe suspension sutures into the deep temporalfascia will be difficult to place. When making theincision, I bevel the scalpel parallel to the hairfollicles, preserving them to achieve maximalscar camouflage, as transecting the hair folliclesresults in a few millimeters of permanent alopecia.The medial incisions for brow suspension begin afew millimeters behind the hairline centered overthe lateral canthus and extend posteriorly for 2 cm.

The temporal incision is carried down throughthe superficial temporal fascia to the deep tem-poral fascia. A dissector is used to elevate thesuperficial temporal fascia and overlying tissue

off the deep temporal fascia to the temporal line.The dissection continues superiorly in a subper-iosteal plane and ends at the level of the occiput.This ensures that the elevated forehead and lateraltemporal tissues will redrape and not bunch ante-riorly once suspended. Inferior to the incision,dissection on top of the deep temporal fascia isperformed blindly for 2 to 3 cm. Anteriorly, thiselevation requires lysis of the fascia at thetemporal line, and subperiosteal dissection iscontinued to the supraorbital rim. The arcus mar-ginalis often can be released from lateral to within1 cm to the notch of the supraorbital neurovas-cular bundle. Bimanual dissection often is helpful,and the hand placed on the surface of the skinhelps prevent injury to the orbit with inferiordissection. Laterally, the conjoint tendon is dis-sected bluntly. If this fascial condensation is notreleased adequately, elevation of the lateral browwill be incomplete during suspension.

With inferior temporal dissection, I take extracare in the region of Pitanguy’s line. In this areathere are multiple bridging veins that penetratethe plane of dissection perpendicularly in the re-gion of the frontal branch of the facial nerve areencountered during this dissection (Fig. 5). I amalso very careful in the temporal region, becauseforceful dissection may result in penetration

Fig. 5. Quatela and Antunes. Endoscopic view of thezygomaticofacial vein (sentinel vein), which estimatesthe course of the frontal branch of the facial nerve.

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through the deep temporal fascia, which wouldexpose the infratemporal fat pad, and evenminimaltrauma can result in reduction of its volume withtemporal wasting postoperatively. With further infe-rior dissection, I encounter the zygomatic arch. Atthe level of the deep temporal fascia split, the inter-mediate temporal fat is encountered, being safe todissect within this fat pad. However, I prefer toelevate the intermediate fat pad up and dissecton top of the deep temporal fascia. I believe thatelevating all these tissues helps provide an addi-tional cuff of tissue to insulate the frontal branchfrom thermal or mechanical trauma.I preserve an area of 1 cm lateral to the lateral

canthus to prevent permanent canthal distortionpostoperatively. Even though initially the eye maylook pulled, the preservation of the canthal inser-tion ensures that the eye will return to normal aftera few weeks. Over the zygomatic arch, the perios-teum over the entire superior aspect is exposed,and it is incised at the anterior aspect of the arch.The zygomaticofacial foramen often is encounteredand the neurovascular structures kept intact, asthis is an important landmark for later suspensionof the midface. Subperiosteal dissection continuesposteriorly at the superior edge of the zygomaticarch to within 1 cm of the external auditory canal.Once the edge is exposed, the periosteum overthe zygomatic arch is released. This subperiostealdissection is continued medially over the infraorbi-tal rim to the nose in a blind fashion. Bimanualdissection is required with the dissector passedbetween the index finger that protects the globeand the thumb positioned over the infraorbitalnerve. The periosteal dissector is then passed sub-periosteally starting at the body of the zygomadirected toward the pyriform aperture, inferior tothe infraorbital nerve. This accomplishes dissectionover the face of the maxilla and with a superiorsweeping motion releases all tissue inferior the

infraorbital nerve. I avoid violating the buccal mu-cosa. Some surgeons perform an incision there,but I find it unnecessary. The only time I make anincision is when there is excessive bleeding in themidface and that incision allows for drainage. Sub-sequentially, the tendinous attachments at thelateral aspect of the maxilla are lysed with thedown-biting dissector, and the masseteric tendonjust inferior to the inferior aspect of the zygomaticarch is cut with a downward motion. The flap isdissected inferiorly below the masseteric aponeu-rosis just on top of the belly of the masseter toapproximately 1 cm superior to the gonial angle.The medial subperiosteal midface dissectionpocket and lateral submasseteric aponeurosispocket are connected with a sweeping fingerdissection from the medial to lateral pocketbreaking the last few fascial attachments at thelateral aspect of the maxilla. This dissection ac-complishes a complete release of the midface aswell as the tissues laterally to the external auditorycanal and inferiorly to the level of the gonial angle.This ensures free mobility of the midface, malar fatpad, and SOOF (see Videos 1 and 2 for the de-monstration of the plane of dissection online at).I suspend the midface and temples with 5

sutures. The first one is from the released perios-teum just lateral to the zygomaticofacial foramento the deep temporal fascia at a vector superiorand slightly lateral. The second suspension sutureis placed posterior and superior to Pitanguy’s linein the flap and back to the deep temporal fascia.These 2 sutures will create the midface suspen-sion. In addition, I place 3 suspension sutures atthe anterior skin edge through the superficial tem-poral fascia, suspending it to the deep temporalfascia posterosuperiorly in the region of the tem-poral line. These 3 sutures are the reason theplacement of the lateral incision is so important,because placement of the incision too high willprevent the ability to suspend the excess skin ofthe temporal region that bunches after elevationof the midface (see Videos 3 and 4 for the place-ment of suspension sutures, online at). With themidface lift, even if a full endoscopic foreheadlift is not performed, a lateral temporal lift withrelease of the arcus marginalis and conjointtendon is done and prevents bunching of skin inthe lateral temporal region. After the midfaceand temples are suspended, the forehead eleva-tion is performed. Two removable screws areplaced into the holes drilled through the medialincisions, the forehead is then retracted posteriorlyuntil its leading edge rests against the screw, and astaple is placed just behind the screw. This mostanterior staple sits behind the screws and pre-vents the forehead flap from gravitating inferiorly.

Fig. 6. Quatela and Antunes. Before and after frontal (A) and three-quarter (B) views following an endoscopicmidface lift. Note the correction of the double contour deformity of the lower eyelid with padding of the inferiororbital rim, elevation of the midfacial fat pads, and improvement in the jowling.

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The lateral temporal incisions are closed withsutures. Fig. 6 illustrates the result after amidface lift.

SYKES AND MAGILL

Fig. 8. Sykes and Magill. Right face of a cadaverfollowing the dissection of a subcutaneous and sub-SMAS flap. The deep plane can be seen in focus,and the subcutaneous dissection proximally is out offocus. It is important to lyse all zygomaticocutaneousand mandibulocutaneous ligaments.

In most individuals, I use the preauricular ap-proach to the midface. The preauricular ap-proach offers good camouflage for incisions, awide lateral vector arch for lift, and reliable fixa-tion. The preauricular incision is made with astandard retrotragal (or tragal top) incision infemales, and a pretragal incision in males. Theincision is carried to a level just inferior to thetragus (if midface lifting is performed alone) andis carried around the ear lobule if lower face liftingis also being performed. Sharp dissection is usedin the preauricular subcutaneous plane. At a linejoining the mandibular angle and the lateralcanthus, the sub-SMAS plane is entered. Afterthe plane is entered with sharp dissection, bluntdissection can be accomplished to extend thedeep sub-SMAS plane (Fig. 7).4,5 The mandibulo-cutaneous and zygomaticocutaneous ligamentsare then lysed to mobilize the midfacial flap(Fig. 8).In the temporal region, a pretrichial or side-

burn splitting incision is used to expose thedeep temporal fascia. Back dissection deep tothe temporoparietal fascia exposes the densedeep temporal fascia (Fig. 9). This is a rigidstructure that is immobile and provides a good

Fig. 7. Sykes and Magill. A cadaveric dissection ofthe left face demonstrating the transition fromthe subcutaneous to the deep plane. A flap hasbeen developed in the subcutaneous plane. Scissorsheld at a 90� angle to the tissues are used to enterthe deep plane. This transition is made distal to aline drawn from the angle of the mandible to thelateral canthus.

foundation for fixation of the facial flap. Afterfull mobility of the facial flap and exposure ofthe deep temporal fascia, fixation sutures maybe placed. These are accomplished from theedge of the SMAS in a running locking fashionto the deep temporal fascia. Additional individualsutures from the malar fat pad to the deep tem-poral fascia are also performed. Suture fixation isaccomplished with 2–0 monofilament absorb-able sutures.

Fig. 9. Sykes and Magill. Right facial dissectiondemonstrating the deep temporal fascia on the leftside of the image with the temporoparietal fasciaelevated with the skin flap. The zygomatic arch hasbeen marked out and the dissection plane belowthis is in the subcutaneous plane. The traversing linemarked out delineates the expected course of thefrontal branch of the facial nerve.

Midface Lift 129

What is the best method/substance for adding volume to midface lifting?

KELLER AND SETH

For the congenitally narrow face in the patientthat does not wish major bony distraction sur-gery, the best solution is probably a malar/submalar implant. That being said, I almostnever use malar implants as a solution for facialaging.

If I see a patient who is not ready for a surgicalprocedure, I regard liporeinjection as an excellentvolumizer. However, there are several problemswith fat injections that have caused me to backaway from the technique, in recent years (I’veperformed liporeinjection since 1982). One isthat the procedure, as a “non-surgical” procedurehas a very rare incidence of blindness. While Iwould not let that stop me from personally havingliporeinjection, I find that many patients, onceinformed of this risk, opt out of liporeinjection.While many patients might accept the risk ofblindness with a surgical procedure such asblepharoplasty, these same patients associatefillers with no risks of significance and are notwilling to accept a risk of blindness for a less in-vasive procedure.

Currently, my “go to” filler for the midface is acombination of platelet rich plasma (PRP) andhyaluronic acid (HA). I first inject the HA to theareas of concern, and then inject the PRP, whichis activated with calcium chloride or gluconate.The HA acts as a scaffold for the PRP. Theamount of HA injected is not enough to providea meaningful fill without the PRP. I use a bluntneedle for the injection, and there is rarely anybruising.

Sclafani has provided evidence-based researchthat the PRP activates a cellular process with 5effects:

1. PRP activates unipotent stem cells.2. PRP promotes angiogenesis, which improves

the color and texture of the skin.3. PRP promotes activation of fibroblasts, which

secrete collagen and thicken the skin.4. PRP promotes activation of adipocytes within

the skin, which encourages volume filling andrepair.

5. PRP provides a fill which lasts approximately18 months.

Our experience has been that patients without agreat deal of sagging do quite well with this proce-dure, which we most often use as a prelude to amidface lift.

In the office, and for the patient wishing a “quicksolution,” commercially available fillers suffice.These include HAs, sculptra, and Radiesse. Theseare covered more completely by other authors.

Another surgical method of providing volume tothe midface (in addition to midface lifting andmeloplication) is orbital fat transposition. Doubt-less, this technique is covered by another authorof this journal. It is worth mentioning, however,that with the arcus marginalis release and thetransposition of fat over the malar eminence, theorbicularis re-establishes itself at a more superiorlevel and some of the orbicularis “sag” is reduced.As a result, the eyelash-to-bottom-of-eyelid dis-tance becomes shorter.

QUATELA AND ANTUNES

The most popular way of adding volume to themidface is by autologous fat transfer or syntheticfillers. My personal preference is to volumize themidface with fat grafting; however, this involves aprocedure in the operating room. If the patienthas reservations regarding going to the operatingroom or cannot afford any downtime, I offer syn-thetic fillers. Also, I often use fillers in additionthe midface lift in the postoperative period whenpatients have severe loss of facial volume. Invery few occasions, in patients that require a largevolume replacement, I place a submalar implantand add more volume with fillers and fat asneeded.

Fat has been described as the being the idealfiller because it is biocompatible, lacks toxicity,

has a low cost, a very low incidence of complica-tions, and is a renewable resource.1 Autologousfat transfer for facial rejuvenation is not a newidea. Since its first successful report, over a cen-tury ago,2 multiple studies reported variable re-sults with fat transfer. There has been greatdisparity on the reported results in regard to graftsurvival and long-term outcomes, with volumeretention ranging from 10% to 90%.3–6 It is impor-tant to observe that the vast majority of these datacomes from subjective analysis of patients’ photo-graphs. Very few studies actually report objectivemeasurements of volume retention using mag-netic resonance imaging and three-dimensionalphotography7,8 with long-term success rates inthose studies ranging from 30% to 45% of the

Keller et al130

initial injected volume. My impression is thatpatients usually retain about 60% of the injectedvolume at 1 year after injection. In my experience,patients retain that volume even after many yearsproviding they do not have significant weightloss. The physiology of adipocytes explains whysome fat graft volume loss happens due totenuous blood supply at the recipient site, and untilangiogenesis is complete, the cells are nourishedby diffusion.9 This led to the conclusion that thelarger the graft, the greater would be the degreeof resorption. Additionally, inflammatory infiltratesthat surrounded the fat grafts would contribute tocell loss and subsequently volume loss. Thishighlights the importance of atraumatic tissuehandling during harvest and injection and empha-sizes the importance of fat processing to eliminatefatty acids, blood products, and cellular debristhat would exacerbate the local inflammatoryresponse. My preference is to use a syringe-assisted liposuction is the least traumatic way toobtain the grafts; however, there is a great dealof controversy in methods used to prepare andinject the fat. These include the mixture of insulin,growth factors and b-blocker washes amongothers.10–13 I do not use these products, and justprepare the fat by removing all the oil from thesyringe, washing it, and subsequently centrifugingit to further remove the oil and blood. Thisstep cannot be overemphasized for the reasonsmentioned above. Injection is usually performedwith blunt cannulas into the soft tissues. Severalpassages are made with the cannulas to disperse

the fat within the tissue, enhancing the surfacearea between the cells and surrounding tissues.Because my preferred technique of midface liftinginvolves subperiosteal elevation, I do not performfat transfer at the same time of surgery.Of the commercially available ones, poly-L-lactic

acid (PLLA) is the best for volumizing the malarregions. This product provides the most clinicallynoticeable volume, with the least amount ofproduct used. Administration involves a depotinjection of product on the malar eminence andin the regions of greatest volume loss followedby deep subcutaneous fanning with cross-hatching, creating a layering effect of product.This technique helps to evenly distribute the fillerthroughout the cheek region. Filling the submalarregion can significantly improve the drawn ap-pearance associated with hollowness in this re-gion, which is often seen with significant weightloss. Patient counseling is especially importantwhen using PLLA due to its delayed effect. More-over, most patients usually require more than 1treatment, with 3 treatments spaced 6 weeks be-tween injections constituting the most commonclinical scenario. In some cases, several additionaltreatments may be necessary over a 4- to 6-monthperiod to obtain optimal volume. Collagen produc-tion usually starts in 6 to 8 weeks14 following injec-tion, and continue to form for up to 9 to 12 monthsafter the last treatment.15 The volumetric benefitslasts about 2 to 3 years.16 Meanwhile, PLLA parti-cles start to be reabsorbed around 6 months anddisappear by 9 months.17

SYKES AND MAGILL

Although permanent alloplast implants are usedby many surgeons, I prefer autologous fat toaugment the soft tissues of the midface and pro-vide volume to this area. Alloplasts provide per-manent augmentation, but the issues related tothis surgery can create long-lasting soft tissuecomplications. Fat augmentation has the disad-vantage of being impermanent in its effect. How-ever, fat can be placed in more areas and ismore titratable. In order to be effective, allo-plasts are typically placed over bone and require

bony fixation. Fat can be placed in variouslayers of the face and has the advantage ofcreating radial, three-dimensional soft tissueaugmentation.6

When placing fat in addition to static lifting, Iprefer to inject the fat after the lifting procedureis completed and the incisions are closed. Byperforming the fat augmentation as a final step, Ibelieve I have the most control over volumeaugmentation and a better appreciation for theareas that need to be filled.

In approaching the midface, how do you see the relationship ofblepharoplasty versus fillers versus midface lifting?

KELLER AND SETH

All of these procedures have their place. Orbital fattransposition blepharoplasty, as mentioned above,can be useful in the younger individual and, in

Middle Eastern and Asian patients to elevate theorbicularis muscle (via an arcus marginalis release)and to fill a portion of the midface with orbital fat.

Midface Lift 131

Fillers are usually used, in my practice, for theyounger patient or the patient reluctant to committo surgery or transcutaneous meloplication. Thefillers are usually performed in the office witheither local or topical anesthesia.

If a smile test is positive, and the patient is willingto undergo a minor procedure under local anes-thesia, I will perform a transcutaneousmeloplication.If the patient is willing to undergo an IV anesthesia,then a subperiosteal midface lift is preferred. Attimes, the midface correction may obviate the

Fig. 10. Quatela and Antunes. Photos of patient with seveto a midface lift. The patient initially underwent a midfaSubsequently this patient underwent autologous fat tran

need for a lower blepharoplasty fat correction. Liftingthe malar fat pad and SOOF may lift the “fallenjeans” over the “pot belly” of fallen fat.

Malar bags, due to orbicularis retaining ligamentrelaxation, preperiosteal fat, edema, and excesseyelid skin remain a challenge. My best resultsinvolve combining blepharoplasty with a temporalsubperiosteal midface lift.

If a patient has a genetically narrow midface,then I might recommend malar or submalarimplants.

QUATELA AND ANTUNES

The midface lift, blepharoplasty and fillers areintimately related when it comes to midfacial reju-venation. I consider these 3 modalities as part of aspectrum to create a youthful midface. One of themost important goals in approaching the midfaceis the effacement of the lower lid-cheek junctionand restoration of the contour of the cheek andmalar eminence. Sometimes, these goals can beachieved with fillers or fat transfer alone or incombination with blepharoplasty and sometimesa midface lift is required to achieve those goals.It is important that the understands the agingprocess and how it affects these structures sohe/she can better counsel the patient on whichwould be the best approach. Aging changes in 1anatomical region will have an impact the neigh-boring areas; the midface ages together with thelower lid in the same manner that the brow ageswith the upper eyelids.

In patients with loss of facial volume andminimalsoft tissue ptosis, synthetic fillers or autologous fattransfer can improve the lid-cheek junction andcreate a rounder and smoother cheek. I usuallyuse a combination of HA and PLLA for the teartrough and malar eminence, respectively. The HAis placed deeply, at the level of the orbital rim whilethe PLLA is placed as described above. If thepatient is willing to go the operating room, I preferfat transfer, which I perform in isolation or in com-bination with other procedures. However, I rarelyperform fat transfer for the midface and infraorbitalrim at the same time I do a subperiosteal midfacelift. If decision is made on a lift, my preference is toallow the soft tissues to settle after the lift anddecide on the need of volume augmentation at alater time. I have been surprised that more oftenthan not, soft tissue reposition alone will abbre-viate the need for volume replacement.

re midfacial ptosis and loss of facial volume submittedce lift (A) before and (B) after 1 year postoperatively.sfer (C).

Keller et al132

In some patients with mild to moderate midfacialsoft tissue ptosis and exposure of the orbital rim,I often perform either a midface lift or a lowerblepharoplasty. I have a discussion about thedifference in downtime and recovery period forboth procedures and educate the patient onwhat each procedure can achieve. If decision ismade to proceed with a lower blepharoplastyalone, I usually perform a fat transposition to padthe orbital rim, especially if the patient has anegative vector. This procedure alone will fill thelid-cheek junction but will not address the cheekor suffice in patients with more midfacial softtissue ptosis.In patients with significant exposure of the infe-

rior orbital rim and midfacial soft tissues ptosis,my preference is to perform a midface lift. It is

important to realize that the patients who willbenefit more from the midface lift are also thesame ones who are in most need of volumeaugmentation. This is explained to the patientpreoperatively and I add volume as describedabove. Moreover, I perform a lower blepharo-plasty in every midface lift without exceptions.The extent of the lower blepharoplasty is usuallya simple skin excision with or without transcon-junctival fat removal. The skin excision can bemore aggressive than usual due to the fact thatmidface suspension will increase the tension inthe lower lid and decrease the risk of lid retrac-tion.18 Fig. 10 illustrates this point demonstratinga patient with severe midfacial ptosis and loss offacial volume who underwent a midface lift and asubsequent session of autologous fat transfer.

SYKES AND MAGILL

I rarely perform midface lifting through a blepha-roplasty approach. It is safer to remove lowereyelid skin when midface lifting is performed inconjunction with lower blepharoplasty. The mid-face lift creates a foundation for the lower eyelidand a supportive sling to the lid. Volume augmen-tation of the midface, whether with “off-the-shelf”fillers or autologous fat, also supports the lowereyelid and increases safety for lower eyelid skinexcision.

The decision to perform surgical lifting andlower blepharoplasty versus soft tissue filling isbased on the individual diagnosis of the patientand on the patient’s preference for surgical versusnoninvasive enhancement. Clearly, aesthetic sur-geons have realized that filling the lower eyelid-cheek junction is as important as lifting of thesoft tissue structures.7 Often, a combination ofthese techniques is required to maximize facialappearance and rejuvenate the midface.

Analysis: over the past 5 years, how has your technique evolved or what isthe most important thing you have learned doing midface lifts?

KELLER AND SETH

The best available procedure for restoring themidface remains the subperiosteal midface lift,as first described by Tessier (mask lift). Psillakisnoted that the procedure avoided injuries to thetemporal branch of the facial nerve if the subper-iosteal dissection extended no further laterallythan the medial one-third of the zygomatic arch.Fixation of the malar fat pad was not as easywith this limited dissection until the endotine fixa-tion device avoided the problems of “cheesewiring” that occurred with sutures. In the late1980s and early 90s, we used a “loop” fixationof Gore-Tex delivered transcutaneous with thesubperiosteal dissection. This has remained a“backup” fixation to this day.For the patient that does not wish to commit to a

surgical solution to the midface, other proceduresare available, but do not address many of thestructural ramifications of aging. The subperiostealmidface lift reliably addresses many of these, and

restores the structures of the face to their naturalposition.As an aside, our approach to the aging face is a

restorative one. While there are many articles thatdefine the “ideal” dimensions of the face, we donot necessarily try to duplicate these dimensionsand proportions in our aging face corrections.Changing an aging face patient’s facial dimen-sions from their previous youthful features hasdifferent ramifications than changing dimensionsin younger patients. Most aging face patientsthat I see in my practice prefer a “natural”look that restores their own youthful beauty.That being said, no rule is without an exception(Figs. 11–13).A midface lift (sometimes called an “endo-

scopic face lift”) may be performed as a soleprocedure in the younger patient, or as a revisionin a patient who has had a face lift withoutcorrection of midface ptosis. However, I most

Fig. 11. Keller. Preoperative (red arrows) and postoperative (blue arrows) height of the lower lid, as measuredfrom the lid margin to the lid-cheek junction. There is a significant reduction in the height of the lower lidfollowing a midface lift. (Courtesy of G. Keller, MD, Santa Barbara CA. � Gregory Keller.)

Fig. 12. Keller. Preoperative (red arrows) and postoperative (blue arrows) midface contour as seen from thethree-quarters oblique view. Note the restoration of the ogee curve following midface lift. (Courtesy of G. Keller,MD, Santa Barbara CA. � Gregory Keller.)

Midface Lift 133

Fig. 13. Keller. Preoperative (red arrows) and postoperative (blue arrows) midface projection measurementdemonstrating a modest but noticeable increase following a midface lift. (Courtesy of G. Keller, MD, Santa Bar-bara CA. � Gregory Keller.)

Keller et al134

often perform a midface lift in association witha face lift procedure that addresses the facialligament sagging, first described by Skoog,Bosse, and Papillon and subsequently byFurnas. As noted above, the midface lift pro-cedure often is a part of the overall aging facecorrection.For the younger patient, or the patient that does

not wish to invest the financial resources or

wishes to avoid surgery, fillers, the percutaneousmidface lift, and more limited facial proceduresmay represent a reasonable “compromise” solu-tion to the midface. Because of the rare instanceof blindness, many of these patients, when in-formed of this complication, decide against lipor-einjection. For many of these, an HA combinedwith PRP injection has offered an acceptablealternative.

QUATELA AND ANTUNES

In my opinion, perhaps the biggest advancementin the rejuvenation of the midface over the lastdecade was our better understanding of theaging changes that occur in the area. In additionto the changes in the skin envelope, significantchanges occur in the soft tissues and underlyingcraniofacial skeleton. This concept has rein-forced my feelings that not only the ptoticmidface should be repositioned but also volu-metrically augmented to achieve a more naturalresult.Over the past 5 years, I have not changed my

surgical technique significantly. I perform lessorbicularis myotomies to elevate the brow further,

because this leads to prolonged supraorbital andupper eyelid edema. When I suspend the midface,there is no tension on the sutures, since the eleva-tion is a result of an adequate release of the softtissue envelope. My suspension is also lessaggressive, which avoids lateral canthal distortion.I also routinely preserve the sentinel vein and theother bridging veins, as this will decrease theskin and subcutaneous engorgement on thetemple and forehead in the postoperative period.All this minor adjustments that I learn over thelast 20 years of midface lifting made big improve-ments in achieving a natural and long-lastingoutcome.

Midface Lift 135

SYKES AND MAGILL

Patient satisfaction from midface rejuvenationis based on a combination of factors. These in-clude careful patient selection, individualizeddiagnosis, and meticulous execution. I am se-lective in which patients I offer midface liftingto. Specifically, many patients are less-than-ideal candidates for midface lifting secondaryto the fact that their expectations include resolu-tion of fine midfacial skin rhytids and near-totaleffacement of the melolabial folds. These im-provements are typically not achievable. Ad-ditionally, I realize that three-dimensionalvolume enhancement of the face is as important

Fig. 14. Sykes and Magill. Preoperative photos are shownthe bottom row. The patient has undergone bilateral uppelift, a midface lift, and neck lift. Combined procedures we

as surgical lifting. The dominant focus on vol-ume restoration of the face in order to achievea more youthful appearance has augmented,and in some cases replaced, midface lifting. Inorder to achieve ideal midfacial rejuvenation,a combination of these techniques is usuallynecessary (Fig. 14).

SUPPLEMENTARY DATA

Supplementary data related to this article can befound online at http://dx.doi.org/10.1016/j.fsc.2013.09.005.

on the top row, followed by postoperative photos inr and lower blepharoplasties, a lateral temporal browre used to give the patient an optimal cosmetic result.

Keller et al136

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