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. [2, 3, 4, 5, 6]
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. [7, 8]
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.
Mid face lifting has the following aesthetic and reconstructive applications:
Reversal of aging changes
Increasing the anteroposterior cheek dimensions
Correction of asymmetries
Recruitment of anterior lamellar tissue of eyelid for eyelid malposition, cicatricial changes, and reconstruction
Camouflage of implant materials for maxillary augmentation
In all patients, the suborbicularis oculi fat (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.
This procedure is contraindicated in patients with previous zygomaticomaxillary fractures and patients with unrealistic expectations.
The subperiosteal plane is relatively bloodless and straightforward to dissect. Chance of injury to the facial nerve is minimal, although if a lower eyelid approach is taken the infraorbital nerve can be damaged. 
The suborbicularis oculi fat (SOOF) is a fibrous portion of septate, thick fat located at the inferolateral quadrant of the orbital rim. The SOOF descends as one ages because the lateral canthus descends so that it comes to lie at a level inferior to that of the medial canthus. This dystopia leads to less lateral support and inferior and medial displacement for the orbicularis oculi muscle and weakening of the orbital septum. The result is partial prolapse of the posteriorly located SOOF.
The buccal fat pad is an encapsulated structure. It has subunits extending to the buccal, pterygoid, parotid duct, and deep temporal areas. The pad weighs approximately 9 g in adults and receives its main blood supply from the maxillary artery.
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, with resultant eyelid retraction. Sensory innervation of the infraorbital and midfacial region is supplied by the infraorbital and zygomaticofacial nerves. 
The path of dissection taken to raise the periosteum of the zygomatic arch starts over the temporal fat pad (TFP). Traveling inferiorly, the intermediate temporal fascia is crossed, with the yellow-colored TPF 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.
Analyze the mid face for asymmetries. Note the position of the lateral canthi, the amount of anterior and lateral projection of the cheek, the depth of the nasolabial creases, and the volume of Bichat fat pads.
Determine whether most of mid facial volume deficit lies laterally, medially, or in the submalar region. The fat pads then can be placed to address the deficient area and improve asymmetry.
Determine if alloplastic implants are needed.
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.
Take preoperative photographs.
Preoperatively, mark the patient's zygomaxillary point 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 3-quarter view.
Mark the nasolabial creases and the position of the Bichat fat pad and note asymmetry of the mid face.
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. [11, 12]
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.
A study by Stevens et al described the successful use of a triple-layer mid face facelift, which included the lower eyelid and was effectively used to reverse mid facial ptosis and volume changes. The surgery, performed on 512 patients in the study, involved the use of a subciliary incision, with the postseptal and suborbicularis oculi fat, as well as the musculocutaneous layer of skin and orbicularis oculi, separately repositioned. Complications requiring surgical reintervention occurred in 44 patients (8.6%). 
Iced saline sponges are applied to the area 20 minutes on and 20 minutes off for the first 48 hours.
Advance the drain at 24 hours and remove it at 48 hours.
Continue postoperative 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 heavy chewing for the first week. Liquid and soft foods are given during this time.
Outcome and prognosis
The authors have performed the endoscopic midface lift since 1993. This operation can produce reliable and reproducible results and can improve the tear trough, refine the projection of the cheek, elevate the jowls, and lift both the corner of the mouth and the lateral canthus of the eye. Asymmetry of the cheek mound also can be addressed by placing a larger volume of Bichat fat pad to the smaller cheek. Fine-tuning of this area and of the nasolabial crease also can be accomplished using fat-grafting techniques.
The images below depict before and after pictures for the midface lift. For additional relevant images, see the Medscape Reference article Subperiosteal Facelift.
A study by Jacono et al indicated that patients with low self-esteem prior to facelift, as measured on the Rosenberg Self-Esteem Scale, tend to experience a postsurgical increase in self-esteem, while those with high self-esteem often suffer a decrease in these feelings after rhytidectomy. The study, which involved 50 patients, also found that individuals with average self-esteem tended to experience no significant change in this state. 
While this procedure is very appealing to the patient (addressing the cheek mound through 2 small nonvisible scars), it may not be as appealing to the surgeon because of the steep learning curve. Once mastered, the technique is safe and reliable. It is technically more challenging than the endoscopic forehead lift. Although it involves dissection millimeters away from the frontal branch of the facial nerve, it is much safer than the intermediate plane techniques.
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.