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Midface-Lifting: Evolution, Indications, and Technique

Nadine Hachach-Haram, BSc Hons, MBBS, MRCS1 W. Niall A. Kirkpatrick, BDS, MBBS, MD, FRCS, FRCS(Plast)1
Address for correspondence Nadine Hachach-Haram, BSc Hons, MBBS, Flat E, 15 Lancaster Gate, London, W2 3LH, United Kingdom (e-mail: Nadine.haram@gmail.com).
1 Craniofacial Unit, Chelsea & Westminster Hospital, London, United

Kingdom Facial Plast Surg 2013;29:289 294.

Abstract
Keywords

Anatomy of Midfacial Aging

Historically, the face has been somewhat arbitrarily divided in to three zonesupper, middle, and lowerwith the midfacial component represented as the middle third. This middle third skeleton is formed by the maxilla in the medial and middle third and the body and arch of the zygoma in the lateral third.1,2 The midface, however, is a triangular area below the eyelid bounded medially by the nasofacial angle, laterally by the pretragal skin, inferiorly by the nasolabial fold and corner of the mouth, and superiorly by the lower eyelid and tear trough and the lateral canthus at the superolateral aspect. It is derived from the union of three main components: the nasolabial segment, the malar segment, and the lidcheek segment.2 Key elements of midfacial aging are gradual ptosis of the cheek skin below the infraorbital rim creating infraorbital hollowness, descent of the malar fat pad with loss of malar prominence, deepening of the tear trough, and associated exaggeration of the nasolabial fold.37 When assessing the aging face, it is important to consider the skeletal architecture, the soft tissue layers including the anterior fat pads, the osseocutaneous ligament anchors, and nally the overlying skin.

of these structures determines the vector of the midface and also the skeletal support available for the soft tissues of the midface. It is important to recognize that the anterior maxilla is signi cantly concave. Decreased malar projection and increased orbital aperture seen in aging have been attributed to skeletal resorption both at the periorbital level and maxillary level. This can have signi cant consequences on the projection and prominence of the maxilla and on the location of facial ligament attachments and the mechanical advantage on their associated soft tissues.8,9 Possibly due to the fact that it is of dental origin, the maxilla undergoes the most signi cant skeletal resorption in aging, with up to 10-degree loss in the maxillary angle, contributing to the typical aging cheek stigmata associated with the loss of maxillary projection and resulting in the development of a lidcheek continuum deformity and a prominent nasolabial fold.2

Soft Tissue
Soft tissue layers of the midface include the periosteum and deep fascia, the osseocutaneous ligaments and loose areolar tissue, the musculoaponeurotic layer followed by the subcutaneous and skin layer. Importantly, there is much less ligamentous support for the midface along the infraorbital margins than the signi cant ligaments along the zygoma and zygomatic arch for the lateral cheek element. Aging of the soft tissues of the midface is multifactorial and is attributed to a combination of increased laxity of the

Skeletal Architecture in the Aging Face

The inferior orbital rim is composed of the zygoma, the lacrimal bone, and the anterior maxilla, and the projection

Issue Theme Periocular Aesthetic Rejuvenation; Guest Editor, Naresh Joshi, FRCOphth

Copyright 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0033-1349366. ISSN 0736-6825.

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midface SMAS malar fat pad facelifts

The youthful face is often dened by malar and lateral cheek fullness with associated submalar concavity, giving a smooth contour between the different subunits coupled with an aesthetically pleasing convex lower eyelid cheek continuum. This article reviews the key anatomical concepts of midfacial aging, the evolution of midface-lifting techniques, and indications and contraindications for their use.

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orbicularis oculi muscle and of the orbital septum, horizontal laxity of the tarsal plate component of the lower lid, laxity of the zygomaticus muscles and elevators of the upper lip with subsequent deepening of the nasolabial fold, and fat atrophy. Most signi cantly, attenuation of the osseocutaneous ligaments, including the orbitomalar and orbicularis retaining ligament (ORL), with descent and inferior migration of the soft tissues, including the malar and other fat pads, into the anterior maxillary hollow inferomedial, results in an apparent volume loss in the anterior cheek with visual lengthening of the lower eyelids and gives the face a more squared, vertical appearance.2,913 In youth the upper anterior cheek skin is rmly supported by the orbitomalar septum that allows little or no downward migration.8 Facial septa extending from the Super cial Muscular Aponeurotic System (SMAS) through the malar fat pad to the overlying dermis further support the malar fat pad.12 Repeated movements of animation, as well as repeated zygomaticus and levator muscle contraction and shortening, result in pressures within the overlying cheek and prominence of the nasolabial fold.12 Over time, the supporting fat pad facial septa stretch and weaken resulting in downward migration of the malar fat pad and the appearance of infraorbital attening or hollowing and permanent prominence of the nasolabial fold.12 The fat pads, which include suborbicularis oculi fat (SOOF), temporal fat, malar fat pad, and the buccal fat pad, form an important part of the facial architecture. They are partitioned into discrete compartments. Variance in aging suggests that aging of these fat pads is not entirely con uent but is characterized by how these compartments independently change with age.1215 Disruption of the lower eyelid cheek complex, due to inferior migration of the malar fat pad and the SOOF, results in a double-contour deformity of the midface.15,16 The midface receives its sensory innervation from the zygomaticofacial, infraorbital, and posterior maxillary nerves and its motor innervation from the facial nerve. These nerves are at risk of injury during midfacial dissection. Finally, skin changes and collagen degradation add to the aging process by affecting the facial surface and skin thinning and may also be a component that needs to be addressed.

Hachach-Haram, Kirkpatrick
Mendelson and colleagues described the use of an extended SMAS dissection and periosteal xation that re ned the process of elevating the ptotic malar fat pad, resulting in effacement of the nasolabial fold.8,11 Ramirez et al, Ortiz-Monasterio, and Tapia et al, concerned with the risk of neuropraxia, independently demonstrated that careful subperiosteal dissection using multiple subperiosteal pockets minimized these risks.7 Furthermore, by dissecting beneath both layers of the temporal fascia, midfacial rejuvenation was achievable.7,1719 In 1992 Hamra and Choucair1 described the composite rhytidectomy, incorporating a lower blepharoplasty approach with undermining of the orbicularis oculi muscle, along with facelift dissection, creating a composite ap of orbicularis oculi, malar fat, and SMAS allowing for correction of three midfacial components.20 Hamra later added zygorbicular dissection to the composite rhytidectomy to eliminate the occasional prolonged edema and occasional temporary dystonia previously observed.21 Thus, one could accomplish repositioning of all the layers of the face while maintaining their anatomical integrity and furthermore, by repositioning the malar fat over the orbital rim, achieve a more youthful contour of the lower lid cheek continuum.1 Hamra further modi ed the composite facelift in 2004 by addressing the ORL. By dividing the ORL, the orbital septum could be advanced slightly inferiorly and sutured to the preperiosteal tissues of the anterior aspect of the inferior orbital rim. The septo-orbital fat complex is redraped, without resecting any fat. An orbicularis oculi muscle ap is elevated and fashioned into a triangular muscle ap and tunneled under a skin bridge and sutured to the thick condensation of deep temporal fascia as it blends with the superolateral orbital rim.20,21 For additional support to the lateral canthal tissues in the early healing phase, a transcanthal canthopexy is performed.20,21 A variety of midface-lifting techniques are available, and the speci c choice depends on the patients indications and the surgeons ability to generate movement of the tissues to achieve the desired rejuvenation. The extent of submuscular dissection can be extensive, down to the nasolabial fold, or more limited. It is only necessary to dissect as far as is required to elevate the tissues comfortably. Subperiosteal dissection can be performed via lower eyelid incisions, limited temporal incisions often in combination with intraoral sulcus incisions, and the coronal mask-lift approach. The decision as to which approach to use largely depends on the need to control the lateral canthus and brow complex. Some patients will also require release of the parotid-masseteric ligaments as these can restrict midfacial elevation. Subperiosteal dissection along the zygomatic arch with inferior dissection on the superior surface of the masseter muscle allows release of these ligaments. Both subciliary and transconjunctival lower eyelid incisions can be used to elevate the midface in the subperiosteal plane alone. The subciliary approach is required to elevate the midface in the submuscular plane, allowing fashioning of the orbicularis ap as described by Hamra.7,20 This approach also

History and Technique of the Midface-Lift

Over the past 15 years, there has been increasing interest in the midface-lift as a sophisticated component of facial rejuvenation, with the development of techniques other than the traditional pre- and postauricular approaches.11 Newer approaches are based on the principle of lifting in a more vertical or superolateral vector.11 Tessier7 advanced the subperiosteal approach for middle third facial rejuvenation and also highlighted the use of the coronal approach to achieve adequate lifting of the temporal and lateral canthal areas. In the 1980s, Santana described the importance of subperiosteal dissection to allow traction of the deeper structures to improve the nasolabial fold and recommended resection of Bichats fat pad (buccal fat) to produce a more prominent malar appearance.7
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Midface-Lifting: Evolution, Indications, and Technique

allows separate subperiosteal dissection and elevation in a biplanar technique. Superior xation can be achieved by a variety of techniques including deep suture xation to bone-drilled holes along the inferior and lateral orbital rim and to the deep temporal fascia superiorly depending on the surgical approach. Fixation of the orbicularis ap is to the condensation of temporalis fascia at the superolateral orbital rim as described by Hamra.7,20 In 2005, Berkowitz et al described the use of the Endotine device (Coapt Systems, Palo Alto, CA) for midface-lifting. Endotine devices are biodegradable polylactide polymer devices that provide simultaneous elevation and xation of tissue.11 These devices are the senior authors preferred method of xation of the subperiosteal dissection as they provide a wide platform of purchase on these tissues, allowing controlled and reliable xation. These devices can be anchored either to the deep temporal fascia superiorly with sutures or with screw xation to the inferolateral orbital rim and can be augmented with suture xation to the inferior orbital rim where indicated. Lateral canthal support is an important component of midface-lifting. Most commonly this can be provided by transcanthal canthopexy as described by Hamra,7,20 but when rmer xation is required, we recommend boneanchored canthoplasty.

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Patient Evaluation
Preoperative assessment should include a history of eye health, previous blepharoplasty surgery, and physical evaluation of lid tone and laxity, the lidcheek junction, and the midface. As previously stated, canthal support procedures are an important consideration for patients undergoing midfacelifting. Previous blepharoplasty surgery may have removed orbital fat from the lower eyelid, making it more challenging to restore the concave lidcheek disjunction to a convex lid cheek continuum.1 Examination of the midface should not be considered in isolation but as part of the assessment of the patients entire face and careful consideration of the patients own goals and expectations. For some patients, midface-lifting can be a useful procedure alone, but for many it may be part of several procedures to harmoniously rejuvenate a face. A major consideration in the midface is the orbital vector (i.e., the relationship between the inferior orbital margin and the anterior corneal surface). The orbital vector is positive if the inferior orbital margin is anterior to the corneal surface, neutral if in-line, and negative if behind the cornea. The patient with negative vector has poor support for the lower eyelids, which slope backward and develop deep nasojugal grooves earlier. These patients are at greater risk for developing inferior lower eyelid malposition following both lower eyelid and midface surgery due to the limited skeletal and osteocutaneous support available. In this group of patients, consideration may need to be given to the advantages of converting a negative vector to a positive vector orbit with

Fig. 1 (A D ) Insertion of orbital rim implants signi cantly alters the lid cheek dynamics and changes a negative vector orbit to a positive vector orbit.
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appropriate implants or grafts to the inferior orbital rim and zygoma, thus providing adequate support to the eyelid and midface structures (Fig. 1A to D). It is important to assess the degree of skin aging and soft tissue ptosis and therefore the need to independently control the various soft tissue layers. In younger patients, where there is less soft tissue aging and midfacial ptosis, there is no need to control the overlying skin envelope. In such patients the subperiosteal mask-lift described by Tessier and Krastinova13,22 allows the midfacial tissues to be elevated subperiosteally out of the anterior maxillary concavity and to reemphasize the malar prominence (Fig. 2).9,22 This technique also has the advantage of powerful correction of the lateral canthal and brow position. In older patients with signi cant ptosis and a double contour deformity of the midface, a stepped subciliary approach allows separate control of the skin and subcutaneous tissues, allowing a smooth restoration of the lidcheek continuum. In the older patient it is necessary to assess the volume of ptotic tissue hidden in the anterior maxillary concavity by intraoral palpation. In some patients these deeper ptotic fat pads require elevation out of the anterior maxillary concavity onto the zygomatic prominence in a subperiosteal dissection and resuspension in addition to support of the malar fat pad by the orbicularis ap described by Hamra1,7,20 (Fig. 3A to D).

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Fig. 2 Patient pre- and post mask-lift and bone-drilled lateral canthoplasty with midface and forehead Endotines (Coapt Systems, Palo Alto, CA).

Fig. 4 Pre and post midface-lift, lateral SMASectomy, and endoscopic browlift resulting in a harmonious facial rejuvenation.

Fig. 5 Pre and post upper blepharoplasty, midface-lift, and SMAS ap producing a harmonious and more youthful appearance.

3 months, with an appearance temporarily characterized by an overelevated lateral canthus, chemosis, lateral canthal swelling and bunching of the tissues, lateral extension of the lower lid incision, and sensory paresthesia or anesthesia. There are risks of asymmetry and lower eyelid inferior malposition.

Other Indications for Midface-Lifting

Fig. 3 (A D ) Patient pre and post biplanar midface-lift in submuscular and subperiosteal planes.

Midface-lifting is less effective in patients with aging inferior to the oral commissure and along the inferior mandibular border. Conversely, SMAS vector facelifts are signi cantly rejuvenating in these areas, the neck and the lateral cheek element. Such patients therefore bene t from several procedures in addition to midface-lifting to produce a harmonious rejuvenation (Figs. 4 and 5). Patients must also be aware that midface-lifting has a lengthy postoperative downtime, which can last up to
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Other than rejuvenation of the aging face, midface-lifting may also be indicated for the management of other conditions. Perhaps the most common indication is the management of postblepharoplasty syndrome. In these patients the inferior eyelid malposition secondary to overresection of anterior lamella tissues may be improved by effectively recruiting cheek skin into the lower eyelid as a consequence of elevating the midface. Care needs to be taken in some patients to avoid a sharp demarcation between the thicker skin of the cheek and thinner eyelid skin. Where there is signi cant inferior retraction, the advanced cheek tissues require rm anchoring support and may require elevation and xation in both the subperiosteal and submuscular planes. With such an approach large anterior lamella losses can be addressed (Fig. 6).

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Fig. 6 Pre and post bilateral midfacial tissue expansion and subperiosteal midface-lift incorporating bilateral heteropalpebral aps to address the complications of previous blepharoplasty surgery.

Premature aging of the midface can be observed following midfacial trauma particularly when patients present with midfacial descent either because of the stripping of midfacial tissues from the skeleton as a direct result of the trauma itself or, more commonly, as a result of access to repair fractures and failure to resuspend the midfacial tissues at the end of surgery. In such patients subperiosteal midfacial dissection can be performed followed by resuspension and xation of the tissues to their correct position. In our experience midface-lifting can also be useful in treating congenital deformities such as Treacher Collins syndrome. The fundamental shortage of all midfacial soft tissues needs to be addressed prior to skeletal augmentation. This can be done with the use of midfacial tissue expanders placed subperiosteally. Following tissue expansion the midfacial skeleton can be augmented and the expanded soft tissues elevated and xed higher onto the augmented skeleton (Fig. 7A to D).

Fig. 7 (A D ) Pre and post bilateral midfacial tissue expansion, insertion of midfacial implants, biplanar midfacial elevation, rhinoplasty, and sliding advancement genioplasty in a patient with Treacher Collins syndrome.

Discussion
The smooth, convex, youthful lidcheek continuum is the most rejuvenating component in restoration of the midface. Conventional SMAS procedures certainly rejuvenate the middle third of the face by elevating tissues over the malar eminence with slight effacement of the nasolabial fold. The points of xation for the most vertically elevated SMAS ap lie lateral to the orbit along the line of the zygoma and zygomatic arch. These techniques can address the jowls and produce an excellent jawline, as well as correct laxity in the neck and the lateral cheek. However, these procedures do not address the volume changes below the eyes and the problem of malar and anterior fat repositioning in its entirety. Consequently, they do not rejuvenate the true midface and their results on the midface are unpredictable. Enhancement of malar volume may therefore be achieved without adequately restoring the lower lidcheek continuum. SMAS procedures may well produce acceptable results with a high satisfaction rate in younger patients, but in older patients or those with more complex problems, SMAS procedures alone will gener-

ally fall short of ideal. Moreover, SMAS lifts can exacerbate the problem of the concavity and hollow appearance of the lower lid, giving the typical lateral sweep facelift appearance. In contrast, reelevating the midface using the orbicularis oculi ap as the primary vehicle, with or without subperiosteal dissection and resuspension, can restore the more youthful convexity of the lower lidcheek continuum usually best seen in the photographic three-quarters views. Recent development of volume-enhancing nonsurgical techniques, such as autologous fat transfer, has led some surgeons to opt for simpler techniques with minimal postoperative edema. Filling of the midfacial contour defects allows for a quick return to normal life. However, the fundamental problem of midfacial descent is not addressed and may even be made worse by weighting the tissues further. Irregularity of the tissues may also become apparent once the postsurgical edema resolves, and often these results are not forgiving. These patients may subsequently bene t from corrective midface surgery (Fig. 8A to D). Although midface-lifting techniques are more complex to perform and require careful patient assessment and choice of procedure, they can better address the aging of the anterior cheek than conventional facelifting techniques. Performed either in isolation or in conjunction with other facelift or periorbital procedures, they produce harmonious and natural
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3 Hester TR Jr. Evolution of lower lid support following lower lid/

4 5

7 8

9 10 11

12

13 14

Fig. 8 (A D ) Pre- and postremoval of irregular fat grafts in the lower eyelids and biplanar midface-lift with bone-anchored canthoplasty.

15

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rejuvenation for patients. Furthermore, they can be used as powerful reconstructive tools for patients with soft tissue midfacial de ciencies.

17

18 19

References
1 Choucair RJ, Hamra ST. Extended super cial musculaponeurotic 20 21 22

system dissection and composite rhytidectomy. Clin Plast Surg 2008;35:607622, vii 2 Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg 2012;36:753760

midface rejuvenation: the pretarsal orbicularis lateral canthopexy. Clin Plast Surg 2001;28:639652 Saltz R, Ohana B. Thirteen years of experience with the endoscopic midface lift. Aesthet Surg J 2012;32:927936 Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg 1995;22:295311 Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg 1993;91(3):462474; discussion 475476 Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in aesthetic plastic surgery. Plast Reconstr Surg 2006;117:18091827 Mendelson BC, Hartley W, Scott M, McNab A, Granzow JW. Agerelated changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg 2007;31:419423 Nahai F. The Art of Aesthetic Surgery: Principles and Techniques. MO: Quality Medical Publishing; 2005 Yousif NJ, Mendelson BC. Anatomy of the midface. Clin Plast Surg 1995;22:227240 Berkowitz RL, Jacobs DI, Gorman PJ. Brow xation with the Endotine Forehead device in endoscopic brow lift. Plast Reconstr Surg 2005;116:17611767, discussion 17681770 Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg 1993;91:463474, discussion 475476 Krastinova-Lolov D. [Subperiosteal face-lift]. Ann Chir Plast Esthet 1989;34:199211 McCollough EG, Scurry WC Jr, Shirazi MA. The midface-lift as a misnomer for correctly identifying procedures designed to lift and rejuvenate the cheeks and malar regions of the face. Arch Facial Plast Surg 2009;11:257262 Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;119:22192227, discussion 22282231 Ransom ER, Stong BC, Jacono AA. Persistent improvement in lower eyelid-cheek contour after a transtemporal midface lift. Aesthetic Plast Surg 2012;36:12771282 Ramirez OM. Full face rejuvenation in three dimensions: a facelifting for the new millennium. Aesthetic Plast Surg 2001;25: 152164 Ortiz Monasterio F. Aesthetic surgery of the facial skeleton: the forehead. Clin Plast Surg 1991;18:1927 Tapia A, Mejina D, Ferreira B. Treatment of double bags during rhytidectomy. Plast Reconstr Surg 2002;109:21292134, discussion 2135 Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 1992; 90:113 Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg 1998;102:16461657 Tessier P. [Subperiosteal face-lift]. Ann Chir Plast Esthet 1989;34: 193197

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