Midface Lift
Edwin F. Williams
INTRODUCTION
Prior to the early 1990s, the majority of surgical and nonsurgical techniques exclusively addressed the brows, eyes, neck, and jawlines. The midface region was essentially ignored until Hamra and colleagues, who first noted that the “windswept” appearance of patients whose lower face was treated while the midface was ignored, first discussed the anatomic and aesthetic importance of this area. The midface region is bordered superiorly by the inferior orbital rim, medially by the medial canthus, laterally by the lateral canthus, and inferiorly by the lateral oral commissure. Changes related to aging of this region lead to overlying ptosis of soft tissue as well as volumetric changes in the adipose and soft tissues.
During the mid to late 1990s, several techniques were developed to provide rejuvenation and lifting of the midface. Many of these procedures described the elevation of a skin-muscle flap through the lower eyelid, while additional publications described endoscopic techniques using a lateral orbital incision, a transtemporal approach, and even procedures that gained access through the gingivobuccal sulcus of the oral cavity. As time went by and experience was gained, many of the complications that arose from some of the more aggressive approaches became more apparent.
By the early 2000s, emphasis in the midfacial area had shifted to the treatment of volumetric loss in addition to the descent of the midface soft tissues. It was at this time that soft tissue fillers were developed and approved by the FDA. The reemergence and improvement in autologous adipose tissue grafting also provided a truly compatible biologic adjunct in the volumetric rejuvenation of the midface.
The midface lift has been well described by various authors. My approach of choice includes a subperiosteal midface lift that is used in conjunction with endoscopic brow lifting. For more than 15 years, this approach has proven to be safe and effective for our patient population. The following sections will attempt to describe the subtleties and nuances of my preferred approach in the rejuvenation of the midface.
HISTORY
I take a complete medical history on all surgical patients, which includes any current comorbidities, past medical history, past surgical history, medications particularly anticoagulants and alternative medicines, allergies, substance use, family history, and social history. Questions are asked concerning the use of tobacco, diabetes, connective tissue disorders, and bleeding disorders as such elements can compromise wound healing and overall surgical outcomes. Additional attention is given to the midface region regarding previous appearance, previous interventions, and current desired outcomes. Evaluation of the patient’s current expectations during history taking is important as it helps to reveal appropriate or unrealistic social ramifications for and from the surgery.
PHYSICAL EXAMINATION
The physical examination requires a complete inspection of the midface region. I typically describe the midface as previously outlined, but controversy exists with regard to the superior limits of the midfacial unit. One could submit that the midface is contiguous with the lower eyelid. Better stated, the inferior boundary of the lower eyelid is typically defined by a shadow that is cast as the lower lid transitions to the midface. The dimension of this interface changes with age. The lower eyelid begins as a shorter and fuller region that subsequently elongates over time with the deflation and descent of the midface. As a result, the lower eyelid appears to lengthen while the shadowed soft tissue interface descends inferiorly into the midface region. It is important to note that the shadowing that develops along the orbital rim is created by the aforementioned soft tissue interface and the presence of the orbital retaining ligament attachment to the overlying skin. The zygomaticocutaneous ligament also extends from the orbital rim laterally and inferiorly toward the zygomatic arch to create an oblique soft tissue shadow often described in its upper limit as a malar mound or festoon. This shadow begins to show its presence in most patients by the late 1930s and becomes more prominent in the decades of the 1940s and 1950s. In addition to ptosis of the midface, I attempt to assess the degree of loss of global facial volume as well (Fig. 12.1).
INDICATIONS
My indications for the midface lift may be different from other surgeons and I will attempt to detail my rationale from this point forward. I have chosen to perform a subperiosteal midface lift in all patients who are undergoing an endoscopic-assisted brow lift. My rationale is that the brow and temporal area are contiguous with the midface. It is difficult to compartmentalize anatomy in a rejuvenation process, especially when one is elevating the brow and temple. Furthermore, I usually dissect to the zygomatic arch in an endoscopically assisted brow lift. Carrying this dissection into the midface, in a subperiosteal plane, does not present significant efforts or risks that are not counterbalanced by the favorable rejuvenation of the midface. However, I do not find the approach to the midface, through the lower eyelid, to be a favorable endeavor and so I almost never perform an isolated midface lift. It is difficult for me to justify elevation of the midface into the temporal region without addressing the soft tissue of the temple and eyebrow as there is potential for:
Undertreating the temporal area
Producing disharmony and bunching of soft tissues at the junction of the midface and temporal area with an effective midface lift
 FIGURE 12.1 Aging is a panfacial process with the loss of facial volume and skeletal support in addition to the soft tissue laxity. This is well observed in the midfacial region with deflation and soft tissue ptosis. |
In my hands, the indications for a subperiosteal midface lift include the following:
Essentially all patients undergoing a subperiosteal endoscopically assisted brow lift procedure.
The very rare situation where there is significant midfacial aging with good position and very little aging and ptosis of the brow and temporal area. In these patients, a transtemporal approach can be performed as an isolated procedure.
I do not perform a midface lift through either a transconjunctival incision or a lower lid incision as I find the risk-benefit ratio to be unfavorable.
CONTRAINDICATIONS
Contraindications are essentially anecdotal and are based upon unfavorable or limited results. These include the following:
The patient who has a very round face or the patient who is obese. Given the difficulty in achieving a rejuvenated appearance to the midface in this small population, I feel that the results are very limited and that the risk-benefit ratio is unfavorable.
The patient with moderate to significant isolated brow ptosis. This is a very small patient population. Most patients who are evaluated for brow rejuvenation also display significant ptosis and settling of the midface. The additional time, effort, and marginal additional risk to rejuvenate the midface are well worth the investment. For this reason, well over 95% of patients undergoing forehead rejuvenation will receive a subperiosteal midface lift.
The patient who has had a previous midface lift. This patient population has a higher incidence of neurapraxia for reasons that are currently unknown. Again, such circumstances are anecdotal, but it would be difficult to justify the additional risk in this small patient population.
PREOPERATIVE PLANNING
Preoperative planning for the subperiosteal midface lift using a transtemporal incision is essentially identical to patients undergoing an endoscopic brow lift. I prefer to use five incisions. One incision located in the midline just posterior to the hairline. There are two incisions (about 2 cm long) located in the paramedian position (approximately at the lateral canthus) just posterior to the hairline, and two additional, longer (3 cm) incisions located more temporally, camouflaged by the hairline. I believe that it is imperative to have adequate visual and functional access to the midface. Incisional lines are marked with a surgical pen and the hair is separated and tied using a one-half inch brown paper tape.
SURGICAL TECHNIQUE
I prefer to have the patient under general endotracheal anesthesia in the supine position. The table is turned 90 degrees in a counterclockwise fashion, fully elevated and placed at a 30-degree incline. This allows the surgeon to sit while operating and to visualize the dissection to the zygomatic arch with a retractor and a headlight in a stable operative field. Even a small amount of movement by the patient in an inclined setting will cause the patient to slide down the table making it more difficult for the surgeon to extend the patient’s head, which allows a direct line of vision through the incision down to the zygomatic arch. I originally used the endoscopic instrumentation when performing this procedure but now reserve such techniques for teaching purposes only. I do not perform an incision in the gingivobuccal sulcus. I use local anesthetic consisting of 0.5% lidocaine, 0.5% Marcaine, and 100:100,000 epinephrine placed along the orbital rims and along the incision line. The remainder of the operative field is not anesthetized.
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