Minimally Invasive Midface Lift

48.1 Introduction

Aesthetic facial rejuvenation has gained widespread acceptance among the general public. As more younger patients have requested facial invigoration, surgeons have rushed to find improved techniques amended in the sense of providing longer lasting, natural-appearing results with decreasing perioperative and postoperative sequels.

The youthful midface is described as triangular shape with high cheeks, smoothness toward the midface, and minimal nasolabial folds. The aged midface is represented by a more rectangular shape due to sagging of not only the skin but also the malar fat pad (cheek).

As the malar fat pad descends inward and downward against the nasolabial line, at least four signs of midface aging occur. These include: the full nasolabial fold, hollowness to the midface, tear-trough hollow at the lower lid–cheek interface, and a slight prominence of the cheek profile.

lesser degree. A secondary benefit can be a slightly improved reduction of the fullness contour at the jowl and sagging of the labial–mandibular fold above the mandibular margin. This procedure may be used as a “closed” technique to correct an isolated malar fat pad ptosis in cases without excess of the facial skin. Meloplication may also be incorporated in an “open” rhytidoplasty, as one of the maneuvers to correct the midface ptosis, as in the lower lid blepharoplasty, a transcutaneous approach to performing a vertical fat pad elevation.

48.3 Indications and Contraindications

The ideal candidate for “closed” meloplication is a 35–45 year-old patient with early midface laxity involving primarily ptosis of the malar fat pad. Such a patient has exhibited an incipient facial skin excess, jowls, labial mandibular folds, or platysmal bands.

48.2 Surgical Goals

Meloplication goals are to elevate volumetrically the malar fat pad, thereby recreating a more youthful triangular midface shape, lessening the fullness lateral to the nasolabial line, filling the hollow from the midface, and smoothing out the infraorbital areas in a

E. Andrade

Plaza Corporativa Zapopan, Blvd. Puerta de Hierro 5150 suite 404-B, Zapopan, Jalisco CP 45116, Mexico e-mail: eandrade99@hotmail.com

48.4 Surgical Technique

48.4.1 Preoperative Markings

“Closed” meloplication technique was introduced in 2000 by using two permanent sutures, each fixed by Gore-Tex anchor grafts. The fan-shaped malar fat pad and the anterior ramus of the temporal branch of the facial nerve are marked on the upright patient. The classical course of the anterior ramus of the temporal nerve is drawn to extend from 0.5 cm inferior to the antihelix-tragus landmark toward 1.5 cm superolateral

Fig. 48.1 Two point incisions on the nasolabial fold on dots A and C. One 1–1.5 cm incision is done behind B, 1 cm behind the hair line (temporal zone incision). Letter D shows the point of attachment of the vertical suture, in the orbital rim periosteum by an external incision for blepharoplasty

to the tail of the eyebrow; however, determination pathway of the anterior branch of the temporal nerve to bony landmarks is variable.

As shown in Fig. 48.1, dot C is marked lateral to the nasal alae, on the nasolabial fold. Dot A is marked 1 cm inferior to dot C. Line B passes 1 cm lateral to the lateral orbital cantus, going behind into the hair line 1 or 2 cm. Incisions A and C are performed using an 11 blade knife tip. Incision B is done and dissected toward the temporalis fascia. Incision D is done as an external blepharoplasty in the traditional way; a mark is drawn over the infraorbital nerve. Infraorbital rim is located and dissected leaving the periosteum intact. Once the midpart between the internal cantus and the infraorbital nerve is set, place dot D here.

Two vectors are marked, A-B and C-D, the Temporal Vector and the Vertical Vector. Draw lines from A-B

and from C-D – these will be the pathways for suspension sutures of one of the two lifting vectors.

48.4.2 Anesthesia

The “closed” meloplication suspensions may be done under local anesthesia. A 5–10 ml buffered 1% Xylocaine with 1:400,000 epinephrine solution is injected into the subcutaneous layer of the midface, extending from the nasolabial fold to the temporal region and following the line from A-B. Selective nerve blocks from the zygomatic–facial, zygomatic–temporal, and infraorbital nerves with 0.5% Marcaine (1:200,000 epinephrine) complete the anesthetic requirement.

48.4.3Sutures and Gore-Tex Suspension System

Figure 48.2 shows the sutures and suspension system: 3–0 Ethibond at the main suture and 4–0 Vicryl for the suture guide. Both suture endings are tied together at 10 cm. Keith needles. Two small pieces of Gore-Tex 4 × 4 mm are used. One is inserted in the 3–0 Ethibond tied in the Keith needle. The other Gore-Tex is used to anchor the sutures up to the temporalis fascia. For vertical vector 6 cm Keith needles are preferred because of a minor distance. The 4–0 Vicryl is used to guide and seesaw the tissue to avoid forming a dimple at the place the Gore-Tex is anchored, in the soft tissues at the nasolabial fold.

Four sets of sutures and needles are used if the two vectors are placed, two sets per side.

48.4.4Elevation of the Temporalis Vector A-B

The surgical procedure begins first by incising 1–1.5 cm (Fig. 48.3) within the temporal hairline using a #15 blade at an angle through the 1 cm. temporal marking. A small pocket is created with Iris scissors between the temporoparietal fascia and the deep temporal fascia. Then, the dot incisions A-C on the nasolabial fold, are done using the tip of an 11 blade, making it a little deep and wide with the tip of an iris scissors.

Fig. 48.2 Keith needles 10 and 6 cm, 3–0 Ethibond, 4–0 Vicryl, Gore-Tex 4 × 4 mm, and eyed ½ circle French needle

Fig. 48.4 Pathway from nasolabial fold to temporal incision

The first Keith needle is introduced into dot incision A, deeply touching the bone, then lifted a few millimeters, and then oriented laterally following the line toward the temporal incision. The subcutaneous tissue is pinched along the safe pathway upward along the temporal incision B. This maneuver allows the needle to remain safe until is retrieved at the temporalis pocket (Fig. 48.4).

The other Keith needle is passed through the same incision in a similar way but slightly inferior to the previous one and retrieved at the temporal pocket tract.

Working with the 4–0 Vicryl, each limb of the suture is grasped and see-sawed through the soft tissue until the dimpling at the nasolabial fold is eliminated. The Vicryl suture is then removed. The permanent 3–0 Ethibond suture is pulled and the anchor Gore-Tex is passed into the incision, so that the fat malar pad can be elevated; a mosquito clamp secures the suture end.

Fig. 48.3 Temporal incision with anchoring the Gore-Tex to deep temporalis fascia

48.4.5Anchoring the Suture to the Deep Temporalis Fascia

An eyed ½ circle French needle is used, securing each end of the suture, and passed through the previously pinched Gore-Tex 5 × 5 mm. A sliding knot elevates the nasolabial fold 3–5 mm and it is fixed with several