eMedicine Specialties > Plastic Surgery > Rhytidectomy

Facelift, Mid Face: Treatment

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

Treatment

Preoperative Details

• Analyze the mid face for asymmetries. Note the position of the lateral canthi, the amount of anterior and lateral projection to the cheek, the depth of both nasolabial creases, and the volume of both Bichat fat pads.
• Determine whether the patient requires placement of alloplastic implants in addition to a midface lift. Also determine whether most of the deficit lies laterally, medially, or in the submalar region. The fat pads then can be used to help augment the deficient area and improve asymmetry.
• A photograph of the patient at a younger age is useful so the age-related changes can be demonstrated to the patient (eg, ptosis of the lateral canthus, cheek fat pad, deepening of the nasolabial fold, formation of the jowl, atrophy of facial fat). Generally speaking, the younger patient is more accepting of a higher lateral canthus and psychologically can accept a more radical change than an older patient.
• Preoperative photographs are taken.
• The patient is started on cephalexin 1 day prior to surgery and is administered clonidine on the morning of surgery to counter the effects of epinephrine and any tendency to hypertension.
• Preoperatively, mark the patient's zygomaxillary point. This is a new anthropometric and aesthetic point and is defined as the point where a vertical line through the lateral orbital rim intersects the Frankfort horizontal. This is usually the region of greatest projection in a patient seen in a three-quarter view.
• Mark the nasolabial creases, note asymmetry, and mark the position of the Bichat fat pad.

Intraoperative Details

• Prepare the patient's face. Prepare the mouth with povidone-iodine solution (Betadine) and inject the midface area with lidocaine 0.5% with epinephrine 1:200,000.
• Make a 12-mm temporal incision 2 cm behind the temporal hairline. The central aspect of the incision lies perpendicular to a line through the nasal ala and lateral canthus.
• Identify and incise the superficial temporal fascia. This is retracted by the assistant, and deep to this is an "angel hair pasta" plane (subgaleal fascia). This area can be spread easily with the scissors, and deep to this lies the TFP. A No. 4 periosteal elevator can be used to expose the TFP circumferentially.
• Insert a plastic port protector into the incision. If the need for a large vertical lift has been determined preoperatively, then the dissection also is carried superiorly toward the temporal line of fusion.
• Enter the subperiosteal plane at the temporal line of fusion with a No. 8 periosteal elevator. Then carry the dissection toward the mid line of the skull.
• Next, continue the dissection toward the zygomaticofrontal suture and down toward the arch. After several centimeters of dissection, with the TFP lying beneath the dissector, a color change is noted as the dissector passes over the intermediate temporal fascia with its underlying intermediate temporal fat pad.
• Approaching the zygomaticofrontal suture, use a zero elevator. This has a rounded tip and does not damage the veins and nerves found in this area. Perform gentle dissection in this area to isolate temporal vein 1. This vein often is divided. Traveling inferiorly along the lateral orbital rim, vein 2 (sentinel vein) is encountered. This is a large vein and should be preserved. Inferior to this, the zygomaticotemporal nerve may be found.
• Once the anterior one third of the zygomatic arch has been dissected, attention then is turned to the posterior one third. This also is dissected through the temporal incision using a No. 9 elevator and traveling over the intermediate temporal fascia to just above the zygomatic arch.
• Lastly, dissect the middle one third in the same plane. Approximately 2-3 mm above the zygomatic arch, incise the intermediate temporal fascia using this periosteal elevator. Raise this intermediate temporal fascia and some of the intermediate temporal fat pad superiorly.
• Dissection continues in the plane of the intermediate temporal fat pad to the zygomatic arch. Then, raise the periosteum of the zygomatic arch upward. This provides a cushion to the frontal nerve consisting of the intermediate temporal fascia and a portion of the intermediate temporal fat. Several windows can be made in this plane through the zygomatic arch periosteum and into the masseter muscle lying below.
• Dissect tunnels between the zygomaticotemporal nerve and temporal vein 3. Vein 3 is found at approximately the junction of the middle and posterior thirds of the zygomatic arch.
• At this point, the dissection of this area is halted. Place epinephrine-soaked pledgets in this region through the temporal incision and turn attention to the gingivobuccal sulcus.
• Again prepare the mouth with povidone-iodine solution and make an inverted "V" incision over the first premolar tooth.
• Incise the underlying muscle and use a No. 9 periosteal elevator to elevate the periosteum sharply and in a single plane.
• Continue this dissection almost to the pyriform aperture and superiorly up to the inferior orbital rim. This dissection can be performed without the aid of the endoscope up to malar bone.
• To dissect the zygomatic arch, using an endoscope and one of a series of narrow curved periosteal elevators (Ramirez Minus Series) is necessary. Using these periosteal elevators, elevating the periosteum of the entire length of the zygomatic arch without a periocular incision is possible.
• Continue the dissection slightly inferiorly to raise the masseter fascia from the masseter muscle for approximately 2-3 cm. This is performed to allow for a vertical translation of the superficial soft tissues.
• Redraping or removal of the orbital fat is performed at this time if indicated. This also is performed through the gingivobuccal incision. Use a No. 4 periosteal elevator to dissect the periosteum up and over the inferior orbital rim.
• At this point, the intraorbital fat can be identified, and the middle and lateral compartments carefully are freed with a spreading motion using endoscopic scissors. Light pressure on the globe permits prolapse of these fat pads. They then may be sutured over the rim to the malar periosteum/SOOF using 4-0 polydioxanone (PDS) suture.
• Place a suture in the SOOF through the gingivobuccal sulcus. Because it is thin at this point, and the suture may cause a dimple, it is important to avoid grasping too superiorly in the SOOF. The authors prefer to place the suture at or slightly inferior to the zygomaxillary point and use 3-0 PDS suture. Feed the free ends of this over the zygomatic arch and exit the temporal incision.
• The next structure to be suspended is the inferior malar soft tissue. This is a flimsy structure, which is grasped in a tangential weaving motion with 4-0 PDS. Of importance, do not include the multiple small branches of the long buccal nerve. Trauma to these branches may result in some paracommissural numbness. Both free ends of this suture also are passed over the zygomatic arch and exit the temporal incision. This suture lies superior and medial to the SOOF suspension suture.
• If a deficit is noted in the region of the malar bone or the submalar area, then the buccal fat pad may be released and repositioned to these areas. If additional augmentation is not required in the malar or submalar areas, the fat pad may be released or resected as necessary.
• The fat pads may be reached through the same intraoral incision by dissecting between the periosteum and buccinator muscle. Gentle teasing of the buccal fat pad can be performed using two smooth-tipped bayonet forceps. The fat pad can be teased gently from the overlying fascia. Importantly, do not tear the connective tissue covering of the fat pad while performing this maneuver. This connective tissue carries the blood supply to the fat pad and gives it structural integrity to support the sutures placed in it.
• Once the fat pad has been released, it herniates. If it is to be removed, it may be clamped and amputated using cautery. If it is to be suspended, then a 4-0 PDS suture is woven through the connective tissue overlying the fat pad and the fat itself.
• Placement of the free ends of this suture depends on the aesthetic goal. If more lateral fullness is required, pass the suture over the zygomatic arch medial and superior to both other sutures. If more anterior fullness is desired, the suture holding the fat pads may be knotted around the suture holding the SOOF.
• Retract the temporal incision inferiorly and suture the 3 sutures to the TFP in a position inferior and anterior to the incision.
• Place the SOOF suspension suture most laterally and place the buccal fat pad suture most medial and superior. Place the suture that suspends the inferior malar soft tissues between these two.
• When performing the procedure on the second side, tension can be adjusted as the sutures are being tied to achieve symmetry with the first side.
• Butterfly drains connected to Vacutainer tubes are placed on either side through a separate puncture incision. Direct the free end of the drain over the zygomatic arch and into the mid face. Then suspend the superficial temporal fascia superomedially to the TFP.
• The scalp is retracted in a superomedial direction by an assistant while the anterior edge of the superficial temporal fascia is sutured. Place two sutures of 4-0 PDS. Close the skin with interrupted 4-0 gut sutures. Prior to closing the mouth incision, irrigate the cavity with saline and then with antibiotic-containing solution.
• The V-shaped incisions are advanced superiorly and closed in a "Y" configuration. The authors use 4-0 chromic horizontal mattress sutures. This has the effect of everting the wound edges, creating a valve system and decreasing the probability of saliva entering within the wound.

Fat grafting is often used to augment facial volume or to correct asymmetry.

Postoperative Details

• Iced saline sponges are applied to the area 20 minutes on and 20 minutes off for the first 24 hours.
• Advance the drain at 24 hours and remove it at 48 hours.
• Continue perioperative antibiotics for 5 days.
• Ask the patient to avoid swishing liquids and brushing the upper teeth, since this may cause particles and saliva to enter the gingivobuccal incision.
• Instruct patients to clean the incision with povidone-iodine solution swabs twice daily for 1 week.
• Ask patients to keep their heads elevated at all times and to avoid chewing for the first week. Liquid and soft foods are given during this time.

Complications

This is a safe procedure with few complications. No permanent instances of frontal nerve palsy have occurred. One episode of temporary inferior orbital paraesthesia occurred due to irritation caused by a small hematoma adjacent to the nerve. Infection is rare and tends to occur in patients in whom an implant has been placed. Beaded nylon implants (Porex) are placed in the subperiosteal plane. While these implants are more technically difficult to place, they do not have problems with local tissue reactions and capsule formation. In addition, when these implants become infected, they can be salvaged by opening the gingivobuccal sulcus and irrigating the cavity with antibiotics. Unlike silastic implants, no bony erosion is associated.

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