Fig. 39.4 Systematization of the three main points for midface lifting: Bichat’s fat pad (“B point”), malar fat pad (“M point”), and sub-orbicularis oculi fat (“S point”)

Fig. 39.5 Midface suspension by sutures anchored to the deep temporalis fascia

mouth, and restoration of a triangular face. The second point is the “M point” (malar fat pad) and it is located in a point of intersection of the same previous vertical line and a horizontal line from the superior margin of the nasal ala. The third point is the “S point” (SOOF). This point is located in a point of intersection of a vertical line form the most lateral portion of the brow and a horizontal line from the inferior orbital rim.

These three previously marked points are lifted using Casagrande needle (similar to Reverdin needle) for passing the 2–0 polyester suture (Fig. 39.4). The needle is introduced transcutaneous through the “B point” and, with endoscopic view, is driven through the temporal incision. Then, the polyester suture is passed through the needle’s guide-hole and is returned to the Bichat’s fat pad area. Keeping the needle inside the soft tissues, a change of direction is performed to grasp more tissue, and the needle is driven to the temporal incision again. There, the suture is removed from the needle and sutured to the deep temporalis fascia. The same procedure is performed at the “M point” and the “S point,” bilaterally (Fig. 39.5).

At the deep temporalis fascia, the Bichat’s fat pad is suspended and sutured medially, the malar fat pad centrally, and the SOOF laterally. Such fixation lengthens

the zygomatic muscles and the soft tissue of the cheeks, correcting tear-trough deformity, softening the nasolabial fold. The zygomatic area is also well modeled because the zygomatic muscle insertions are reinserted in a higher position (Fig. 39.6).

The temporal scalp incision is closed by securing the temporoparietal fascia from the anterior edge of the incision to the deep temporalis fascia posteriorly. The skin is sutured with uninterrupted 4–0 nylon (Ethilon, Ethicon, Inc., Somerville, NJ). A compressive bandage is kept on during the first 6–10 h postoperatively. Supportive taping is placed for 7 days, when the skin sutures are removed. Antibiotics are started prior to surgery and continued for 7 days after surgery.

39.3 Complications

In spite of all care during the surgery, complications can occur. Well-recognized complications of face-lift surgery include hematoma, hair loss, skin slough, hypertrophic scarring, infection, and motor nerve or sensory nerve injury. Major complications including cardiopulmonary emergency, anesthetic disaster, or death are fortunately extremely rare [13, 14].

Hematoma and seroma are the commonest complication after face-lift. Major hematomas occur in the first 10–12 h postoperatively, due to hypertension, medication use, bleeding abnormality, intraoperative technique, cough, retching, and agitation. Expanding hematoma is a feared complication requiring prompt return to operative room for inspection, hemostasis, supportive taping, and compressive dressing. Due to the bloodless plane of dissection, hematomas are extremely rare. Small hematomas and seromas can be either observed, needle aspirated, or rolled through openings in the incision within the postauricular hairline.

Long-lasting edema, sometimes more than 1 month, may occur and is due to the extensive undermining, especially at the zygomatic arch. It is advocated to avoid dissection over the whole zygomatic arch. Massage is recommended after 7 days of surgery.

Nerve injury is one of the frightening complications for patients. Nerve damage is frequently transient as a result of anesthetic infiltration, direct injection into the nerve, blunt dissection injury, edema of the nerve sheath, traction, or cautery trauma. Injury of branches of the facial nerve can be prevented with a careful dissection under the superficial layer of the deep temporal fascia, as the temporal branch of the facial nerve is located superficially within the temporoparietal fascia. Temporary numbness is caused by interruption of small sensory branches. Sensibility always recovers although it may take months to do so.

Hypertrophic scarring is frequently attributable to excessive tension on the incision closure. Nevertheless,

some patients develop hypertrophic scars despite the best efforts of the surgeon. Diluted triamcinolone can be injected into the scars, and usually improves the appearance of the scar considerably.

Asymmetries are rare. They are usually due to the learning curve of the procedure. Careful bilateral suture of the three points of suspension, using the lateral canthus as a parameter is an important rule to follow. An augmentation of the face width may be noted, due to fat pads repositioning in a superior and lateral position.

Patient satisfaction is imperative for face-lift surgery. Although physicians try to help patients understand why complications occur, patients do not fully expect that complications will happen to them. Indeed, any complication detracts from the quality of the outcome. As such, it is difficult for both surgeons and patients to accept complications.

39.4 Discussion

The earliest recorded contributions to the field of facial plastic surgery came from ancient Egypt and India over 2,500 years ago. In 1901, surgeons in Germany performed the first modern face-lift [15]. In these procedures, they excised ellipses of facial skin without any tissue undermining. In 1920 and 1921, Bettman [16] and Bourguet [17] were independently credited with the first subcutaneous rhytidectomy. Unlike previous

procedures, this one consisted of extensive undermining and lipectomy. This subcutaneous face-lift was the face-lift most commonly performed prior to the 1970s. Subcutaneous dissection of a variably sized skin flap in the face and neck is performed, followed by redraping of the skin flap, excising the excess skin, and closing the incisions, mostly indicated on young, thin individuals with minimal ptosis of deep structures and no submental fullness. Advantages of this technique include ease of operation, limited postoperative edema due to limited dissection, no risk of facial nerve injury, and a smooth contour of the face immediately following the procedure. The major disadvantage of the subcutaneous lift is the fact that the deeper tissues of the neck have not been lifted.

More recently, technique modifications have occurred to address the dissatisfaction with the lack of long-term correction that occurred with the “classic” skin undermining from the procedures described in the early 1900s. In 1974, Skoog [18] described a technique in which the fascia and platysma muscle were undermined to the level of the nasolabial fold and jowl in an attempt to address the lower third of the face. In 1976, the discovery of the superficial musculoaponeurotic system (SMAS) by Mitz and Peyronie [19] confirmed the existence of a fascial layer investing the facial mimetic musculature. It is also important to note that this was the first approach that advocated the effectiveness of imbrication as a rhytidectomy technique. The SMAS may be incorporated into the face-lift operation in several ways. Making an effort for a longer-lasting procedure, the SMAS dissection and plication, or partial sectioning, can be done; however, this procedure has a longer learning period.

During the past 30 years, various modifications and changes to these traditional face-lift techniques have been developed. These have varied in scope, incisions, and level of tissue dissection. In the 1980s, the emphasis turned to improving the midface, traditionally the most difficult region of the face to effectively address. This was accomplished through the introduction of the deep plane and composite rhytidectomy, which was pioneered by Hamra [20]. He realized that by undermining the orbicularis oculi muscle through a lower blepharoplasty approach and joining this with the face-lift dissection, he could create a composite flap that was composed of the orbicularis oculi, cheek fat, and platysma muscle. Repositioning the composite flap corrected these three ptotic areas while maintaining their relationship with each other and the skin. The SMAS and skin are dissected together as a single flap, rather than independently.

The advantage of this procedure is that theoretically the flap is better vascularized and less likely to slough. The disadvantage of the technique is the magnitude of the procedure and the prolonged recovery period and a higher risk of nerve damage.

Psillakis et al. [6, 7] were the first to describe the subperiosteal midface-lift as an open, nonendoscopic procedure. Their technique involved subperiosteal dissection of the midface through a coronal incision in combination with an eyebrow-lift. They thought that since the SMAS was firmly attached to the periosteum through the facial muscles subperiosteal undermining was necessary for adequate mobilization of the cheek.

Ramirez [9, 10] was one of the pioneers in developing the endoscopic approach to the midface. He noted that the midface dissection had several components, which required careful elevation of the suborbicularis oculi fat pad with the underlying periosteum along the inferior orbital rim and malar areas. By starting his dissection in the temporal area and creating a tunnel between the malar-zygomatic arch and the temporal pocket, he was able to suspend the midface suborbicularis oculi fat pad to the temporal fascia. He approached the zygoma from the superior direction along the deep temporalis fascia as Psillakis did. However, at 2–3 cm above the arch, he incised both the superficial and deep layers of the deep temporalis fascia to gain access to the zygomatic arch to separate the periosteum and overlying soft tissue, as the frontal branch of the seventh nerve remained superficial to their dissection. He suspended the midface by placing sutures through the periosteum and the SOOF and the periosteum just superior to the zygomaticus major origin. Each suture was then secured to the deep temporalis fascia.

Several authors have advocated the nonendoscopic elevation of the midface though lower eyelid blepharoplasty incisions. Moelleken [21] described a superficial subciliary cheek-lift with the use of a single subciliary incision with suborbicularis dissection of the malar fat pad (superficial to the zygomaticus major and minor muscles) and fixation to the “intermediate” temporalis fascia located just lateral to the lateral orbital rim. Gunter and Hackney [22] presented a technique in which the cheek is undermined in the subperiosteal plane with fixation of the ptotic malar fat pad to the thick periosteum over the lateral orbital rim. Hester et al. [23] advocate subperiosteal elevation of the midface through an infraciliary incision with suspension of the midface to the lateral orbital rim and deep temporalis fascia.

Subperiosteal face-lift fascinated many authors, since it raises the eyebrows, eyelid lateral corner, forehead, glabella, cheeks, and nasolabial fold, reaching the middle third of the face. This technique includes less incision, use of endoscope, better fixation (especially of the cheeks), and allows for more ancillary procedures, repositioning of the Bichat’s fat pad, and jowl treatment.

Subperiosteal face-lift is indicated for patients with significant aging and ptosis of the oval center of the face, tear-trough deformity, sclera-show in severe malar pockets, cases of past facial fractures, when there is the need for simultaneous resurfacing, in cases of facial implants that need to be changed, when there is a need for soft tissue augmentation with fat transfer and even in smokers.

As a result of the procedure the cheek advances upward and backward and a tremendous amount of vertical lift is produced. The fat pad is repositioned, reducing the orbital hollow and the “double contour deformity.” A volume augmentation is enhanced by meloplication that fills in both the “orbital hollow” and the “cheek hollow.” The nasolabial fold is diminished. The “oral frown” is diminished, to a degree. Malar bags are diminished, to a degree.

The advantages of the subperiosteal face-lift include: easier correction of prominent midface wrinkles, lateral orbital bulging caused by brow ptosis, and ptosis of deep soft tissue and orbital festoons; not compromising the blood supply to overlying tissue, especially for

cigarette smokers and those who have thinner tissue; and reduced possibility of facial nerve injury when compared with any other intermediate plane.

The subperiosteal face-lift technique, as originally described by Tessier [5], has benefited from significant technologic advances in medicine. The endoscope now allows extensive subperiosteal undermining of facial soft tissue through minimal access incisions. Improved understanding of facial anatomy and the facial aging process now allows surgeons to reposition and remodel the soft-tissue envelope with excellent aesthetic results. Restoration of facial volume can be achieved with the subperiosteal techniques described and can be applied to the full spectrum of patients with long-lasting results.

Correct diagnosis of the aging changes in the midface, therefore, dictates the most appropriate choice of surgical approach. If the findings are confined predominantly to the periorbital area, with only mild descent of the cheek structures evident, blepharoplasty utilizing a variety of techniques may be all that is required to restore a youthful appearance to the midface. Classical transconjunctival or skin–muscle blepharoplasty is effective when the problem is confined to fat pseudoherniation and skin excess, without deepening of the nasolabial fold. When mild cheek descent is present with resultant thinning of the soft tissues over the infraorbital rim and/or deep nasolabial folds are present, blepharoplasty with fat repositioning is more appropriate (Fig. 39.7). Fat repositioning is especially

indicated when a negative vector is present, and the bony orbital rim lies posterior to the plane of the cornea. These patients often have scleral show preoperatively, which will often be exacerbated with fat removal as in the traditional blepharoplasty.

As the distance from the infraorbital rim to the malar fat pad increases, the nasolabial folds deepen, and the aging perioral changes are evident, midface lifting should be considered along with blepharoplasty. The

subperiosteal face-lift is ideal because all areas of midface aging, from the lower eyelid to the perioral area, can be addressed with a single exposure, and the effects of gravity can be directly opposed by a 180° vertical vector. The transblepharoplasty approach should be restricted to those patients in whom a lesser degree of these aging changes are evident. On the other hand, the transtemporal approach offers the best possible reversion of the aging effects on the midface (Figs. 39.8–39.10).

Subperiosteal midface-lift can be enhanced with injection of fat graft (lipotransfer) [24]. The graft helps to restore the youthful appearance in more cases with more severe loss of midface volume (Fig. 39.11).

The demand for face-lift surgery has increased dramatically in recent years as people from all socioeconomic levels become interested in facial rejuvenation. The evolution through surgical correction of the aging midface began with peripheral approaches and, as we

began to understand the dynamics of midface aging, moved to a vector-based attempt to reposition ptotic soft tissues. Only later did the volumetric component of midface aging become a recognized essential clinical finding. The pathways developed to correct this component were repositioning of soft tissues when the displaced volume was adequate and additive when more volume was required to recapture the soft-tissue fullness of youth.

Anatomic knowledge combined with a thorough understanding of the variety of techniques available will permit to continue serving patients with the best care possible. An important point to understand is that all techniques are simple to those familiar with it, and regardless of the procedure, the results will be better for those who adhere to the fine details and the art of the objective.