eMedicine Specialties > Plastic Surgery > Rhytidectomy

Facelift, Mid Face

Author: Keith M Robertson, MD, LRCSI, LRCPI, FACS, Consulting Staff, Chesapeake Plastic Surgery Associates, Suburban Hospital, Esthetique Internationale; Consulting Staff, Department of Plastic Surgery, Greater Baltimore Medical Center
Coauthor(s): Oscar Ramirez, MD, Clinical Assistant Professor, Department of Plastic Surgery, Johns Hopkins University, University of Maryland
Contributor Information and Disclosures

Updated: Oct 3, 2006

Introduction

The mid face can be defined as the area lying between the bicanthal and oral commisural planes. The mid face is one of the first areas that ages. In individuals in their early 30s, some descent of the malar fat can be observed. This may lead to the formation of dark circles beneath the eyes and deepening of the nasolabial and nasojugal (tear trough) creases. This occurs earlier in people with poor bony support and those with midface retrusion. The area is not addressed by the standard cervicofacial rhytidectomy.

During the past 15 years, several techniques have been described to specifically address this area. Presently, restoration of cheek contour and volume can be achieved by performing a separate subperiosteal vertically oriented lift with independent suspension of the various cheek structures. This may be supplemented with a cheek implant if deemed necessary. Most importantly, this can be performed with small and hidden incisions (scarless approach).

History of the Procedure

Early in the authors' practice, an extended open subperiosteal facelift was performed, and the intermediate temporal fascia (Image 1) 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.

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.

Etiology

As individuals age, the bony skeleton and soft tissues of the face lose volume and shrink, 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 part of the orbicularis oculi muscle loses some of its tone and allows subsequent herniation of the intraocular fat.

Ptosis of the cheek fat exposes the edge of the inferior orbital rim. If this cheek fat separates from the SOOF, a faint diagonal groove can be seen in the infraorbital area parallel to the nasolabial crease. As the cheek fat descends, it is limited in its inferomedial path by the nasolabial fold. The anterior portion of the Bichat fat pad descends over the upper mandible, accentuating the degree of the jowl.

Indications

This procedure is indicated for beautification and for correction of aging in the mid face. It has minor involvement in patients with asymmetry of the mid face. In all patients, the SOOF is suspended to the temporalis fascia proper (TFP). The suspension of the inferior malar soft tissues to the temporal fascia has some imbrication effect, tending to increase the anteroposterior dimension of the cheek. If this is not desirable, then this lower malar soft tissue suture is not placed.

The Bichat fat pad is a relatively mobile structure. It is a vascularized fat pad, which may be moved to the area of perceived deficit. For example, patients with a wide bigonial distance and a smaller bizygomatic distance may benefit aesthetically from lateral placement of the fat pad. Those with a malar deficit, which is more anterior, may benefit from anterior placement of the fat pad, whereas the patient with an obese or full face and a wide bizygomatic distance may benefit from removal of the fat pad. The fat pad may be placed over a cheek implant, thus disguising the edge of the implant and decreasing its palpability. Its suspension or removal significantly improves the upper extension of jowling. Autologous fat grafting is frequently used as an adjunct.

Relevant Anatomy

The best plane for dissection is the subperiosteal plane. This plane is relatively bloodless and straightforward to dissect. Chance of injury to the facial nerve is minimal. Implants may be placed safely using this plane.

The buccal fat pad is a distinct body of fat contained within its own capsule. It has branches extending to the buccal, pterygoid, and deep temporal areas. The pad weighs approximately 9 g in adults. It receives its main blood supply from the maxillary artery. Part of this fat pad extends inferior to the parotid duct. The authors' anatomic studies have demonstrated that the parotid duct travels in the capsule of the buccal space. It is separated from the buccal fat pad by this fascia and by the thin capsule of the buccal fat pad (Hester, 1996).

The SOOF is a fibrous portion of fat located at the inferolateral quadrant of the inferior orbit. This is not a distinct fat pad but rather an area where the fat is septate and thick. As individuals age, the lateral canthus descends so that it comes to lie at a level inferior to that of the medial canthus. This produces a negative slant to the eye, giving a sad appearance to the face. This also leads to less lateral support for the orbicularis oculi muscle, thus the muscle tends to fall inferiorly and medially, lending less support to the orbital septum. A subsequent weakening of the septum occurs, as does loss of tone in the orbicularis oculi muscle. This leads to partial prolapse of the posteriorly located fat.

The motor nerve supply to the orbicularis muscle is mainly through the zygomatic branches of the facial nerve. Transection of the orbicularis muscle during standard blepharoplasty leads to denervation of the pretarsal portion of this muscle, which may be permanent, especially in elderly patients.

The path of dissection taken to raise the periosteum of the zygomatic arch starts over the TFP. Traveling inferiorly, the intermediate temporal fascia is crossed, with the yellow-colored intermediate temporal fat pad beneath. This plane is continued until 2-3 mm superior to the zygomatic arch. At this point, the intermediate temporal fascia is pierced, raising the intermediate temporal fascia and immediately the periosteum of the zygomatic arch. These act as a cushion for the frontal branch of the facial nerve.

Beneath the superficial musculoaponeurotic system (SMAS) lies the parotid gland. In the same plane as the parotid gland, the facial nerve travels toward the temple just beneath the temporoparietal (superficial temporal) fascia. In the zygomatic arch and temporal region, a small fat pad is present beneath the superficial temporal fascia. This is termed the superficial temporal fat pad. In the same plane as the masseter muscle lie the zygomatic arch and the intermediate temporal fat pad.

At the zygomatic arch, what was the masseter fascia below becomes the periosteum of the zygomatic arch and above it the intermediate temporal fascia. In other words, these 3 structures are in the same surgical plane. Beneath the intermediate temporal fat pad lies the deep temporal fascia, and beneath it lies the deep temporal fat pad. Therefore, beneath each temporal fascia lies its corresponding temporal fat pad.

The frontal nerve crosses the zygomatic arch in its middle third at a point approximately halfway between the lateral canthus and the tragus. Dissecting the anterior and posterior thirds of the arch before dissecting the middle third is safest. The temporal region contains 3 veins that communicate between the superficial and deep systems, numbered temporal veins 1, 2, and 3 from superior to inferior. Temporal vein 1 is located near the region of the zygomaticofrontal suture, temporal vein 2 is situated inferior and posterior to the lateral canthus, and temporal vein 3 is located around the middle of the zygomatic arch. The zygomaticotemporal nerve may be seen to either side of vein 2.

Contraindications

Patients with previous zygomaticomaxillary fractures present a relative contraindication. The authors have performed a midface lift on a few such patients. Raising the mid face in a subperiosteal plane is challenging, and contouring alloplastic implants to this irregular and scarred surface is difficult.

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