Current techniques in midface lifting

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PERCUTANEOUS MALAR FAT PAD ELEVATION

A simple method of malar fat pad elevation through direct percutaneous suspension previously has been described and recently modified by the senior author. This procedure is indicated in patients with concerns for aging limited mainly to the midface. Appropriate candidates are often younger and do not demonstrate excessive skin laxity.

By way of a 2- to 3- cm incision in the temporal hairline, dissection is performed to the deep temporal fascia. Elevation of the temporoparietal fascia is

ENDOSCOPIC MIDFACE REJUVENATION

This procedure often can be combined with an endoscopic brow elevation. It is of particular benefit in younger patients with brow ptosis who lack significant jowling. With the different endoscopic approaches, it is crucial to appreciate the differential vectors of pull required on the multiple components of the midface. A vertical direction of pull is needed on the deeper midfacial tissues, while the superficial midfacial tissues require a more superolateral pull extending perpendicular to the

TRANSCUTANEOUS MIDFACE LIFT

To obtain a proper midface lift by way of a blepharoplasty approach, a composite subcutaneous and subperiosteal dissection needs to be performed through a lower eyelid subciliary incision. A canthoplasty or canthopexy is performed in all patients undergoing this procedure.Apreseptal dissection is performed, and the periosteum of the inferior orbital rim is opened widely from the medial to the lateral canthus. Subperiosteal dissection is performed down to the origin of the zygomaticus muscles.

VOLUMETRIC RESCULPTURE BY MALAR IMBRICATION

Recently, malar imbrication as compared with malar elevation has been proposed as a more natural and more effective technique for the rejuvenation of the midface.8 This technique avoids dissection in the plane of the seventh cranial nerve. In addition, there is no need to free or release the tissues around the zygomatic arch. It is described as an additive procedure in which existing malar tissues are left in place and augmented from below and underneath as submalar and transitional tissues are

TRANSCONJUNCTIVAL SOOF LIFT WITH OR WITHOUT SPACER PLACEMENT

For the treatment of lower eyelid retraction or for the patient with a round eye, the transconjunctival SOOF lift with a canthoplasty may be used. Additionally, a spacer may be used for the augmentation of the weakened or deficient supporting element of the lower eyelid. This procedure also has been used with some success for the treatment of the tear trough deformity.

After performing an inferior forniceal incision along with a lateral canthotomy and lysis of the inferior limb of the canthal

ASSOCIATED PROCEDURES

In the past, many techniques have been used to improve the malar fat pad and nasolabial fold positioning. In cases of early aging, some surgeons believe that in addition to performing midfacial elevation, volumetric tissue loss needs to be addressed to restructure the facial contour.2 Studies using autogenous fat have shown encouraging results. Lipostructure has been described as a natural method of filling and supporting the face using intricate layering of infiltrated autologous tissue. This

COMPLICATIONS OF MIDFACE ELEVATION

Complications of midface elevation are determined by the particular approach chosen. The most common postoperative finding is that of prolonged edema, especially with the subperiosteal dissections. Lasting up to 3 months, this edema is caused by the dissection and repositioning of the midface soft tissues. Because of limited skin elevation, the incidence of skin slough and major hematomas are less with the described techniques compared with the more conventional midface lift procedures. The

SUMMARY

Midface elevation is an evolving procedure. The current trends toward less manipulation of the midface soft tissues with less visible incisions and use of endoscopic and percutaneous techniques have allowed for the rejuvenation of the facial features of younger patients. The creation of a natural, unoperated, and youthful appearance to the midface are readily accomplished with these newer procedures. For patients with significant facial skin excess, the endoscopic and percutaneous or

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