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How to improve the midface during rytidectomy

How to improve the midface during

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Page 1: How to improve the midface during

How to improve the midface during

rytidectomy

Page 2: How to improve the midface during

M. Sean Freeman MD, FACSCharlotte, NC

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The lower lid and mid-face are both important in obtaining the inverse triangle of a youthful face

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Midface Rejuvenation• Adequate skeletal and soft tissue envelope must be present

at the level of the malar eminence and infraorbital rim for a youthful look– Cause of hollow look under eye, migration of SOOF

– Answer “SOOF lift blepharoplasty”– Cause of soft tissue inadequacy of the rest of midface

– Ptosis of malar pad– Shallow malar eminence– Mid-face fat atrophy– Combination of the above

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SOOF lift blepharoplasty15 year retrospective

• Highlights of procedure– Transconjunctival approach with incision through the

capsulopalpebral fascia– Tighten the orbital septum over the nasal and mid fat pockets and

remove fat from the lateral fat pocket only– We do not grow fat as we age!!!

– Extraperiosteal dissection inferior to the arcus marginalis– SOOF released and elevated to arcus marginalis

– Closure of capsulopalpebral fascia and conjunctival mucosa– Light CO2 laser of lower lid skin

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Previous subciliary approach with aggressive fat removal

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SOOF lift blepharoplasty15 year retrospective

• I’ve performed over 750 of these procedures• Operative failures since 2001

– One patient– Recurrence of pseudoherniation of orbital fat due to misdiagnosis

– Patient had congenital pseudoherniation which requires more aggressive fat removal

– No patients with scleral show or frank ectropion– No loss of eradication of nasojugal depression to date

• Operative failures prior to 2001– Trichiasis(~5)

– Lack of reconstituting the capsulopalpebral fascia/inferior tarsal muscle

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SOOF lift blepharoplasty15 year retrospective

• Why does this procedure work so well with so few risks?????– Restoring the lower eyelid anatomy to it’s youthful position

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Midface Rejuvenation• Adequate skeletal and soft tissue envelope must be present

at the level of the malar eminence and infraorbital rim for a youthful look– Cause of hollow look under eye, migration of SOOF

– Answer “SOOF lift blepharoplasty”– Inadequate 3D volume at the malar eminence

– Shallow malar eminence / Midface fat atrophy– Answer; Malar augmentation

– Main risks/infection, poor implant placement– Alternative; Fat injections

– Main risks/inability to quantify, clumping, poor longevity– Ptosis of malar pad

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Inadequate 3D volume at the malar eminence

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Midface fat atrophy

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Midface Rejuvenation• Adequate skeletal and soft tissue envelope must be present

at the level of the malar eminence and infraorbital rim for a youthful look– Cause of hollow look under eye, migration of SOOF

– Answer “SOOF lift blepharoplasty”– Inadequate 3D volume at the malar eminence

– Mid-face fat atrophy– Shallow malar eminence

– Ptosis of malar pad– Midface lift/ “Malar pad lift”

– Main risks/ infection, tethering of lift (release during surgery-McGregor’s patch)

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Midface Rejuvenation•Importance of SMAS in relation to aging

–Fascio-fiber connections between the superficial muscles of facial expression, the SMAS and the dermis at the level of the nasolabial fold trap the migration of the malar fat pad over time thus deepening this fold

–Over time, midface fibro-fatty tissue is displaced above the level of the SMAS and then trapped by the SMAS connections at the nasolabial fold

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Midface rejuvenation

Subperiosteal approach for the midface The periosteum does not relax with time Pulling up on the periosteum in the midface

lifts the superficial muscles of facial expression which will result in pulling in of the fascio-fiber connections between these muscles and the nasolabial fold

Net effect on the depth of the fold is negligible

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What is the best plane in the midface? Between the investing SMAS of the superficial

muscles of facial expression and the overlying malar fat pad

Allows repositioning of the malar fat pad Allows release of the zygomatic cutaneous ligament

Midface rejuvenation

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Midface RejuvenationManagement of regional fat ptosis• Know how to deal with inferior

migration of the SOOF. Learn how to do a “SOOF lift blepharoplasty”!

• Learn how to deal with inferior to medial migration of the malar wad via a malar pad lift.

Management of inadequate 3D volume of the cheek• Should this be due to

inadequate bone structure consider a cheek implant

• Should this be due to midface fat atrophy consider cheek implants or fillers such as fat injections