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Mid Face Facelift

The mid face is the area lying between the bicanthal and oral commissure. The mid face is one of the first facial areas to show signs of aging. As individuals age, the bony skeleton and soft tissues of the face lose volume, producing a slightly wider orbital aperture and less anterior projection. This decreases the overall projection of the cheek and diminishes bony support for the overlying soft tissue structures. The preseptal orbicularis oculi muscle loses tone, resulting in herniation of the intraorbital fat.

Ptosis of midfacial adiposity exposes the inferior orbital rim. Further descent of cheek fat and separation from the suborbicularis oculi fat (SOOF) can be heralded by a faint diagonal groove in the infraorbital area parallel to the nasolabial crease. Furthermore, descent of the Bichat fat pad over the upper mandible can increase lower facial jowling.

Individuals in their early 30s may have descent of the malar fat pad; this may lead to the formation of infraorbital dark circles and deepening of the nasolabial and nasojugal (tear trough) creases. These changes occur earlier in the presence of poor bony support and midface retrusion.

During the past 15 years, several techniques have been described to specifically address the mid face, since this area is not addressed with standard cervicofacial rhytidectomy. Presently, restoration of cheek contour and volume can be achieved by performing a subperiosteal, vertically oriented lift with independent suspension of the various cheek structures. The lift can be performed with small and hidden incisions and supplemented with a cheek implant if deemed necessary.

History of the procedure

Early in the authors’ practice, an extended open subperiosteal facelift was performed, and the intermediate temporal fascia (see image below) was used to anchor the mid face. To better elevate the cheek, the suspension point was changed to the suborbicularis oculi fat (SOOF). These techniques usually were performed through a full blepharoplasty incision, but this resulted in an unacceptable level of eyelid retraction.

Midface facelift. The dissection over the zygomatic arch (ZA) is challenging due to the proximity of the frontal branch of the facial nerve (FN). Dissection starts over the temporal fascia proper (TFP) and proceeds inferiorly and anteriorly over the intermediate temporal fascia. Just before reaching the zygomatic arch, the fascia is incised and the intermediate temporal fat pad (IFP) is divided. The IFP is raised in continuity with the periosteum overlying the ZA. The masseter muscle (MM) is divided in line with its fibers.Just above the plane of dissection lie the FN and the superficial temporal fascia (STF). Directly beneath the plane of dissection lie the TFP and its underlying temporalis muscle. The deep temporal fascia (DTF) overlies the deep temporal fat pad (DFP). The large arrow represents the direction of dissection. The parotid gland is indicated by PG.

The access incision then was modified to a crow’s foot incision, spreading the orbicularis oculi at the site of the incision without disrupting the muscle. The orbital septum was not violated. The infraorbital fat only was resected in patients with obvious proptosis (5% of patients). With these modifications, no permanent ectropion or eyelid malposition was observed.The authors now have eliminated the need to perform any periocular incision. The periosteum is raised over the entire anterior malar area and the anterior two thirds of the zygomatic arch. Tunnels are made over the zygomatic arch, and independent suture suspension of the SOOF, inferior malar soft tissues, and Bichat fat pad is performed.

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