Rejuvenation of the mid-faceAuthor: M. Sean Freeman, MD, FACS

Introduction

Rejuvenation of the mid-face is more commonly asked for now than in the past. This is in part due to younger patients seeking facial rejuvenation and in part due to increased awareness among consumers that targeted rejuvenation is possible. Patients in general are searching for techniques that can provide renewal with as little downtime as possible. Patients are more conscious of the length of time that they will need to take off work to recuperate and are seeking procedures were the healing period is minimized. Along this same vein, patients are similarly interested in procedures that provide natural looking results with minimal visible incisions. Fortunately for the interested patient and the trained facial plastic surgeon there are good techniques available that can accomplish these goals in the midface.The intent of this chapter is to provide the author's bias as it relates to rejuvenation of the midface and to briefly review other treatment options. Having expertise and the availability of an endoscope is an aid in performing the midface lifts described below. As the surgeon gains experience with these techniques or in the hands of an experienced surgeon in mid-face surgery, it is not an instrument that I find absolutely necessary in order to accomplish these procedures. There are other approaches to the mid-face other than the techniques that the author has a preference for, which have need of mentioning. The first is the endoscopic subperiosteal midface lift as popularized by Ramirez and others 1, 2. This approach is an interesting procedure from a theoretical viewpoint but in the author's point of view has limited applications 3. The reason for this can be found by reviewing the anatomy of the fold. From a review of mid-face anatomy we find that there are fascio-fiber connections between the dermis and the underlying superficial muscles of facial expression, which allows these muscles to animate the nasolabial fold. Over time the effects of gravity and repeated animation result in the malar fat pad rotating in a medial - inferior direction that results in a deepening of the nasolabial fold. Therefore by repositioning the muscles of facial expression along with the malar wad together by a subperiosteal approach little to no improvement in the fold can be anticipated since there is no relative change in the position of the malar wad with respect to the underlying facial muscles. This is what is needed to expect a positive effect on the depth of the nasolabial fold.

Another major strike against this approach, other than the fact that it doesn’t work well, is the prolonged healing that is necessitated with the use of this procedure. Interested readers are referred to the bibliography for further reading. Another approach that has recently gained popularity in the lay press is the technique that has been called a “lunchtime” lift 4. This technique attempts to lift the ptotic malar wad without much more than a temporal incision and craftily placed transcutaneous mid-face sutures rescued from the mid-face and secured to the deep temporal fascia via a bluntly advanced trocar. This approach would seem to excellently fit the requirements of limited healing and invisible incisions. The results obtained may be another consideration. There is no attempt to release the zygomatic cutaneous ligaments; this step in the authors experience is necessary to get significant long-term elevation of the malar wad. The other concern with this approach relates to the suture placement necessitated by the technique. By approaching the depressed malar wad with sutures placed thru the skin it would be difficult to position said sutures deep enough within the malar wad to obtain elevation without risking dimpling of the skin. Indeed this is one of the more difficult tasks when suture fixating this wad from underneath, as will be described later. Perhaps this approach will prove itself to be useful enough over time to be considered as an alternative. Elevating the malar wad from a deeper approach has been labeled by the author as the “SMAS division mid-face lift”; this procedure is a modification of the technique originally described by the author as the “endoscopic malar pad lift” 5,6. The endoscopic malar pad lift was modified to allow lifting of the mid-face with a less visible incision. The SMAS division mid-face lift circumvents many of the disadvantages of the subperiosteal mid-face lift and in general is more effective. This technique can also be used in conjunction with a subperiosteal brow lift and/or a facelift. Finally there is an approach to the midface that is designed mainly for improving tear trough deformity but is also beneficial in helping the mid-face. This technique was initially described in the literature by the author and has been coined a “SOOF lift blepharoplasty” 7,8. There have been many techniques described in the literature to improve tear trough deformity, also known as naso-jugular deformities 9,10. As is typically the case when there exists several different techniques to improve the same problem, none of these approaches has stood the test of time and become the favored. The SOOF lift blepharoplasty has been used by the author since December of 1998 and has proven to be safe, reliable and yield good to excellent results.

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This approach to the lower lid has become the main approach for lower lid rejuvenation in my practice and aids in mid-face rejuvenation.The discussion that follows concentrates on surgical approaches to mid-face rejuvenation. I would be remiss in not mentioning that there are certainly other techniques available to aid in mid-face rejuvenation that are relatively simply, fairly effective and accomplish the goal of speedy healing. I am referring to fillers that can be injected or surgically implanted to the nasolabial fold. This is an approach to the problem of deepening of the nasolabial fold that is often used by the author but is in general applied to patients with mild signs of mid-face aging. The interested reader is referred to the many available articles that review the fillers available and the appropriate associated techniques11, 12. Certainly the use of fillers is the most common approach to selective management of early mid-face aging.The surgical approaches described below assume the patient has adequate supporting skeletal structures. Should a patient present with a complaint of aging of the mid-face and the facial plastic surgeon notes that the patient has mid-face atrophy and/or deficient development of the malar eminence, then the treatment should be directed to malar, sub-malar or combined augmentation (fig. 1). A well-trained and experienced facial plastic surgeon should have no trouble discerning which patients fit into this category.

Advantages/Disadvantages

SMAS Division Mid-face LiftThe main benefit of this approach is its proficiency in decreasing the depth of the nasolabial fold while at the same time restoring a youthful mid-face contour. The technique used is also very adaptable in that it can be performed as a sole procedure or easily incorporated into an endoscopic brow lift or a routine facelift. When this lift is performed by itself, the incision is located in the temporal hair and extended minimally into the preauricular skin. When this procedure is done with an endoscopic brow lift, the lateral brow lift incision is extended minimally into the preauricular area. The reason for extending the incision minimally into the preauricular area is that the surgeon will find that he or she will be dealing with a standing cone due to the tissue excess that is generated following mid-face elevation. In addition, a SMAS division mid-face lift is routinely performed during a face-lift, with or without a brow lift. The efficacy of this approach as it relates to the nasolabial fold can be understood if we look at the regional anatomy involved in the dynamics of midface laxity. The gradual deepening of the nasolabial fold occurs over

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time by the combination of repeated pulling on the dermis by the fascio-fiber connections between the dermis and the underlying muscles of facial expression and by the inferior to medial rotation of the malar wad 5,13 (fig 2). The net effect of releasing and elevating the malar wad is to reposition this wad of fibro-fatty tissue along a posterior to superior vector in addition to providing a pull on the epidermis lateral to the fold. The outcome is an improvement in the depth of the nasolabial fold as well as the contour of the malar area. The main disadvantage of this approach is that it takes a surgeon with an adequate working knowledge of the special anatomy in this area of the face to accomplish the procedure safely. An endoscope allows the surgeon to more easily identify the correct plane of dissection and its use is encouraged with the beginning surgeon. Swelling typically lasts to the point were it is a concern for the patient for approximately 7-10 days. In addition, surplus lower lid skin can result which will at times oblige removal using a pinch technique or improvement via resurfacing.As with any endoscopic procedure, adequate didactic and cadaver training are required. There is risk of injury to the buccal branch of the facial nerve, which lies below the zygomaticus major muscle. In addition, suture fixation must be done properly to obtain a satisfactory result and to avoid indention of the epidermis.

SOOF Lift BlepharoplastyThe main advantage of this approach is that it allows the physician to safely improve a nasojugal deformity in a predictable fashion. In addition the physician carries out a lower lid blepharoplasty via a transconjunctival approach. Should the facial plastic surgeon follow the authors’ advice and remove orbital fat from only the lateral fat compartment, then their patients will retain orbital volume and not develop enophthalmos from over aggressive orbital fat removal. Finally by lifting the SOOF, there is improvement in midface laxity.

The main disadvantage is that the patient can expect swelling of the infraorbital area to last slightly longer than the swelling from a routine transconjunctival blepharoplasty.

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Indications/Contraindications

SMAS Division Mid-face LiftThe SMAS division mid-face lift is in general applicable to any patient who desires improvement in significant mid-face aging. The procedure can be used either by itself or in conjunction with a subperiosteal endoscopic brow lift. Patients’ intent on a face-lift should have a SMAS division mid-face lift incorporated into their procedure. The SMAS division mid-face lift is contraindicated in patients who are noted on exam to have little to no malar fat pad. In the authors experience these patients are ectomorphic to the point that they have little mid-face fat ptosis for the simple reason that they have a paucity of fat in general. Most of these patients do well with traditional SMAS plication techniques or mid-face fillers. Patients who have had previous aesthetic surgery in the mid-face can safely have this procedure.

SOOF Lift BlepharoplastyPerhaps it is more appropriate to discuss which patients do not fall into the category as being candidates for this approach. Although it has been my experience that the majority of patients benefit from this technique, there are categories of patients that would benefit from a different procedure.Occasionally a patient will present in there twenties to thirties with early onset of pseudo-herniation of the lower lids. This small group of patients typically does well with conventional transconjunctival lower lid blepharoplasty with aggressive fat excision from each orbital compartment (fig 3). Rarely there is the patient who presents later in life for surgical correction but who developed pseudo-herniation their twenties to thirties; they do not seek a surgical correction until later on when they also have skin laxity and a nasojugal deformity. In this group of patients an aggressive transconjunctival lower lid blepharoplasty is recommended with fat excision from each orbital compartment along with and a SOOF lift and concomitant CO2 resurfacing. There is another group of patients that have little to no pseudo-herniation, but mainly complain of wrinkling of the lower lid skin. In this group of

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patients CO2 resurfacing or aggressive chemical peeling is the recommended approach (fig 4). There is a smaller subset of this group that has persistent redundancy of the orbicularis oculi muscle that will require pinch excision, typically as a secondary procedure after laser resurfacing (fig 5). Lastly, there are patients that have significant laxity of the lower lid skin and muscle, festooning, a degree of pseudo-herniation and typically laxity of the lower lid. This small group of patients requires a transcutaneous skin flap past the area of the festooning along with a separate muscle flap, sparing the pretarsal component. A lateral canthoplasty is then added with suturing of the muscle flap to the periosteum of the lateral orbital rim utilizing a lateral superior vector and finally removal of excess skin. The fat pads in this group are usually trimmed and the SOOF lifted (fig 6). This technique has been described in the literature as an extended blepharoplasty 14.The rest of the patients are a candidate for the SOOF lift blepharoplasty. The average patient presents in there forties to fifties with a depression along the medial portion of the lower lid in association with the normal aging process (fig 7). Most will have a degree of skin laxity and occasionally orbicularis oculi hypertrophy. The SOOF lift blepharoplasty with minimal fat excision has become the dominant approach for rejuvenation of the lower lid in the authors practice and can be safely performed in conjunction with laser resurfacing, facelift surgery and/or endoscopic forehead or mid-face surgery.

Procedure

SMAS Division Mid-face LiftWhen performed as a sole procedure an incision is made posterior to the temporal hairline immediately above the anterior superior attachment of the auricle (fig 8). Dissection is carried down past the superficial temporal fascia to the deep temporal fascia. To protect hair follicles, dissection is carried out on top of the deep temporal fascia towards the malar eminence; once the surgeon is beyond the hair, the dissection is in a subcutaneous plane over the zygomatic arch. Following this plane will protect the frontal branch of the facial nerve which at this level is beneath the SMAS and superficial to the periosteum of the arch. Dissection is continued in this plane up to the malar eminence. At this level the SMAS is split and the surgeon identifies the attachment of the zygomaticus major and minor to the malar eminence (fig 9). The endoscope is a useful aid in identifying the zygomaticus muscle. Recall the

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spatial anatomy in this area, the orbicularis oculi overlies the zygomaticus major muscle and the buccal branch of the facial nerve will be coming in underneath the zygomaticus major muscle, typically in the mid-part of the muscle (Fig 10). The SMAS invests the superficial muscles of facial expression but also invests the malar wad so in essence it is at this point that the facial plastic surgeon is splitting the SMAS. The attachment of the zygomaticus muscle is dissected to the point that one can insert a finger superficial to the muscle and its investing fascia. Confirmation can be obtained that one is indeed looking at the zygomaticus by observing contraction of the muscle when the patient smiles.Using a combination of finger dissection and endoscopic controlled blunt dissection a pocket is created between the underlying zygomaticus muscle and its investing SMAS fascia and the overlying SMAS fascia, fat and skin. The direction of the dissection is parallel to the zygomaticus or toward the commissura labiorum. The depth of the dissection proceeds from deep on top of the SMAS investment of the zygomaticus muscle to superficial and the dissection ends at the level of the nasolabial fold.At this point the fibro-fatty malar pad is identified just medial to the dissection pocket. The surgeon must then release the zygomatic-cutaneous ligament just superior and lateral to the malar wad. The author feels that this step is crucial to obtaining significant long lasting mid-face rejuvenation (fig 11). A 3-0 permanent braided suture is used to secure the malar wad in a superior-lateral direction using a figure of 8 stitch. The suture is secured to the deep temporal fascia. The placement of this suture is key to successful surgery and the beginning surgeon may have to place this suture several times before obtaining the desired result. A suture secured in a superficial plane may produce an indention of the epidermis whereas a suture fixated at the level of or thru some of the fibers of the zygomaticus may actually deepen the fold while at the same time elevating the commissura of the lips. It is not infrequent to have to repeatedly suture fixate the malar wad before an adequate lift is obtained. With experience this lift becomes routine and the fixation step becomes less problematic.When this procedure is done with an endoscopic browplasty, the fixation suture is also secured to the deep temporal fascia. The dissection is the same as that described above. The only point to be made is that the endoscopic dissection of the forehead should precede the mid-face dissection. Mid-face dissection and suture fixation should go before lateral suspension of the forehead.

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SOOF Lift BlepharoplastyThe first step is to make a routine incision for a transconjunctival blepharoplasty. It is important to make this incision approximately three to four millimeters below the caudal margin of the tarsal thickening. Making this incision too close to the sulcus could increase the possibility of a contraction scar from the incision to the arcus marginalis. The conjunctival flap is then raised leaving the fibers of the orbital septum posterior so as to keep the nasal, medial, and lateral orbital fat pockets contained (fig 12). At this point the surgeon needs to decide if the patient requires excision of fat. Excising fat in the average patient should be avoided in the nasal and mid fat pockets. Over zealous excision of orbital fat tends to make a patient’s lower lids appear artificially concave 15,16. There are exceptions, patients that presents with familial pseudo-herniation in their twenties to thirties and have significant positive vector have an excess of orbital fat and do better with aggressive excision of fat from each compartment.When the orbital septum is left intact it can be cauterized with a bipolar to contain the fat in the nasal and medial compartments. Bipolar cauterization of the orbital septum stimulates thickening and strengthening of the septum by inducing a layer of scar tissue formation 17. The lateral fat pocket seems to fall into a separate category. Failure to excise fat from this pocket in the average patient will result in fullness of the lateral lower lid post operatively in a significant percentage of patients (personal experience). Therefore, fat is routinely removed from the lateral pocket. The reason for this is that the orbital septum over this area of the lid is more tenuous and should there be any excess pressure on the septum post operatively, it is here that it will fail. Think of this area of the septum as a pressure relief valve, excess pressure (fat) that is detected following bipolar cauterization of the mid and nasal areas of the septum is released by judicious removal of fat from the lateral compartment. This concept works since there are in reality not three fat compartments to the lower lid; all of the fat within the orbital cone commingles posterior to the orbital septum 18. Therefore removing a small amount of fat from the lateral compartment in reality redistributes pressure throughout the orbit behind the orbital septum.The next step is to make an incision just above the arcus marginalis down to the periosteum along the medial half of the infra-orbital rim. The incision is made down to the periosteum but not through this layer. Dissection is then

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carried out on top of the periosteum past the inferior margin of the tear trough deformity (Fig. 13). Following the initial development of the dissection plane with a small scissors a good portion of this dissection is performed bluntly using Q-tips. The SOOF is then identified. Typically, the SOOF will be found on the inside portion of the elevated flap or wrapping around the levator anguli oris. A horizontal mattress suspension suture from the SOOF to the arcus marginalis of the infra-orbital rim is performed along the width of the deformity (Fig. 14 a-d). The author prefers a 4-0 braided suture for this step. Enough tension must be applied to raise the SOOF to the level of the rim. Attention must be paid to the vector applied at the level of the rim to prevent inadvertent tearing of the periosteum.Once the SOOF has been successfully repositioned, a buried single absorbable suture is used to repair the conjunctival incision. This stitch should be placed lateral to the cornea. Any bothersome bleeding encountered during the surgery should be controlled with a bipolar cautery, preferably a bipolar that is insulated. Using a unipolar cautery may inadvertently injure the inferior orbital nerve, the overlying skin, or the orbit.

Discussion

There have been many papers written concerning the correct way to approach rejuvenation of the midface. The techniques presented within this article address the midface from different directions and depths. The deepest approach of the three is the subperiosteal lift, which is not covered in detail. The reason for this is that the author feels that subperiosteal midface-lifts should in general be replaced by SMAS division mid-face lifts due to the contention that the latter procedure to improves the nasolabial fold more completely and has a lower morbidity. There are, however, some patients who remain candidates for this approach. I would consider this approach as an option for a cosmetic patient who was a heavy smoker, had a severe redundancy of their lower eyelid skin and complained of a down turned corner of the mouth; as long as they understood that their nasolabial fold would not be significantly improved over time.The SMAS division mid-face lift is an approach that certainly improves the depth of the nasolabial fold while restoring a youthful cheek contour. The percentage of patients that present with a complaint solely of mid-face laxity is low. Most patients have other concerns in addition to their midface. However the number of patients presenting with concerns specific to the mid-face seems to be increasing. This may have something to do with

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increased patient awareness that mid-face rejuvenation is a possibility or may more simply be due to aging baby boomers. Regardless of the experience of the individual facial plastic surgeon in regards to this specific request, it is important for any facial aesthetic surgical expert to be familiar with the anatomy in this area and become comfortable with mid-face rejuvenation techniques. The reason for this is that it is the authors’ belief that most patients undergoing a facelift should also have a SMAS division mid-face lift (fig 15).The versatility of the SMAS division mid-face lift has been an advantage and will allow the physician to offer rejuvenation of the mid-face solely or in conjunction with a brow lift (fig 16). When done alone, swelling lateral to the orbit can be occasionally a concern for two – four weeks. However most patients are satisfied with the improvement after seven to fourteen days. The amount of swelling has been relatively well accepted.There haven’t been any cases of post operative facial nerve paralysis noted in the over three hundred cases of mid-face rejuvenation performed over the past five years including all patients who have had mid-face rejuvenation using a SMAS division approach. As was reported in an earlier publication there were initially two cases of mild mid-face dyskinesis, both of which cleared in less than six week6. These cases were felt to be due to excessive pressure exerted on the zygomaticus muscle and/or to violation of the SMAS sheath of the muscle during the initial dissection. The addition of the SOOF lift blepharoplasty to the authors’ surgical armamentarium has improved the results in the midface. This technique certainly would not replace a SMAS division mid-face lift for primary mid-face rejuvenation. However, since developing this technique and gaining experience, more patients have been identified who benefit from both approaches. Indeed, even when this technique is performed by itself, a modest improvement in the midface can be anticipated (Fig 17).Utilization of the transconjunctival approach to accomplish a SOOF lift blepharoplasty minimizes the risk of scleral show and virtually eliminates the risk of ectropion. A transconjunctival approach allows the facial plastic surgeon to adequately address the weakening of the orbital septum that occurs over time resulting in pseudoherniation of orbital fat. In the majority of patients that do not have early onset of pseudoherniation associated with a positive vector and a definite family history, using the approach advocated by the author of judicious removal of orbital fat from the lateral compartment only while tightening the orbital septum using a bipolar cautery, will allow resolution of a patients pseudoherniation without giving the patients a hollow/sunken appearance. Unfortunately, sole dependence on

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classical transconjunctival blepharoplasty with aggressive fat removal from all three areas of the lower lid often leaves patients with a somewhat hollowed-out appearance and surgical enophthalmos. Adding a SOOF lift to these patients simply improves the result even more by addressing the associated nasojugal deformity and improving the transition from the lower lid to the mid-face. Surgeons who adopt this approach to the lower lid will need to be comfortable with addressing the overlying skin and muscle of the lower lid as a separate distinct entity requiring management. Many patients will require no additional treatment other than the SOOF lift blepharoplasty. Other patients will desire improvement in even mild lower lid and cheek rhytids. This problem can be adequately overcome in the average patient by performing simultaneous laser resurfacing of the lower lids or aggressive chemical peeling. Patients that have persistent lower lid rhytids due to the orbicularis oculi muscle should be corrected using a pinch excision. This is a safer way of managing this problem than utilizing a skin muscle flap. Done correctly the risk of postoperative drooping of the lower lid should be minimal. The only downside to using this approach is that the incision is not hidden quite as well. The authors’ personal experience has been that this is rarely a cause of concern for the patient. For those patients that feel their incision is too visible, light CO2 resurfacing has sufficed to mitigate their concerns. Perhaps the main question that remains unanswered in reference to the SOOF lift blepharoplasy technique as originally published by the author relates to cauterizing the orbital septum and expecting this approach alone to contain the nasal and medial fat pockets. The concept of cauterization of the orbital septum is not new having initially been reported by Cook 17. The approach advocated in that article was to cauterize the orbital septum in basically all patients without fat removal. Unfortunately, over time there was recurrence of patients pseudo-herniation in a percentage of patients and the technique was not universally accepted. I believe the reason the approach advocated by Cook was not more widely employed whereas the SOOF lift blepharoplasty appears to be more predictable is tri-fold. First, there is the issue of patient selection. As discussed, in the case of pseudo-herniation noted in patients twenties to thirties there exists a relative overabundance of orbital fat and excision is warranted. Indeed failure to excise fat will result in a recurrence of pseudo-herniation, so treatment of patients in this category with techniques that ignored fat excision resulted in patient failures. Second, for patients with middle age or late onset of pseudo-herniation treated with bipolar cauterization of the orbital septum utilizing the SOOF lift

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blepharoplasty technique, it is recommended that a small amount of fat be removed from the lateral fat pocket. This step was omitted in previous approaches. Removing orbital fat from the lateral pocket may relieve some pressure on the orbital septum since, as was discussed earlier, all three fat pockets are connected. Finally, by lifting the SOOF pad and filling in the nasojugal depression, a small degree of fullness in the medial and nasal compartments may be less noticeable since there is no longer a depression to accentuate the fullness.

CONCLUSION

There are several techniques available to the facial plastic surgeon to affect a positive change in reference to the midface. Using an endoscope to assist in these procedures is advantageous. The author has found that the subperiosteal lift is not as good at improving the aging midface as procedures that attempt to lift the malar wad and or the SOOF pad. The SOOF lift blepharoplasty is the newest procedure to be added to the facial plastic surgeons armamentarium and has been useful in improving this challenging area.

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