knots. The anchor Gore-Tex is covered with several square knots with an reabsorbable suture. The closure of the incision is done with 4–0 Prolene, and the dots at the nasolabial fold with 6–0 Prolene (Fig. 48.3).

48.4.6Elevation of the Vertical Vector C-D

This vector is done through a subciliary incision for a transcutaneous external blepharoplasty. Dissection is performed over the orbital septum to the orbital rim.

The periosteum is located and blunt dissected at the rim region between the medial cantus and the pupillary line, and a 4–5 mm curved cut is done. A small flap is elevated with a small sharp dissector. The Keith needle sutures system is set in place.

Starting in the C dot incision, as in the temporal vector, Keith needles are directed to the D flap in the orbital rim. The dimple is see-sawed using the 4–0 Vicryl suture and removed. The 3–0 Ethibond suture is pulled, also the Gore-Tex anchored in the soft tissues of the malar fold. The Ethibond is secured with eyed ½ circle French needles in each limb, passed through the 4 mm Gore-Tex anchor and secured to the periosteum flap (Fig. 48.5), first with a sliding knot pulling the cheek 3–4 mm, and three more knots. The knots are covered with soft tissue and reabsorbable 5–0 Vicryl.

Close the incisions as in the blepharoplasty technique and the dot incision with 6–0 Prolene.

48.5 Complications

There are almost no complications with these techniques. The pathways are safe and no permanent nerve lesions have been seen. Early transitory asymmetry that resolved by itself was observed in the first

Fig. 48.5 Orbital rim, anchoring Gore-Tex to periosteal flap

4–6 weeks and one spontaneous weakness of the zygomaticus major muscle.

Antibiotics are given to avoid Gore-Tex infection.

48.6 Conclusions

Repositioning of the cheek corrects most of the midface ptosis (Figs. 48.6 and 48.7). The closed procedure is minimally invasive and the temporal vector assures 4–6 mm of elevation by the time the vertical vector resolves or improves the nasojugal groove. Most of these patients combine meloplication with blepharoplasty or other procedures.

The temporal vector is versatile and can be as open technique during the rhytidectomy. Long-lasting results are seen after 3–5 years. More outcome studies are required for further evaluation.

Recommended Reading

Anderson RD, Lo MW. Endoscopic malar/midface suspension procedure. Plast Reconstr Surg. 1998;102(6):2196–208.

Freeman MS. Endoscopic techniques for rejuvenation of the mid face. Facial Plast Surg Clin North Am. 2005;13(1):141–55.

Gordon H. Sasaki MD. TACS meloplication of the malar fat by percutaneous cable sutures technique for midface rejovenation. Presented at new horizons symposium incosmetic surgery, La jolla, California, January 21, 2000.

Gunter JP, Hackney FL. A simplified transblepharoplasty subperiosteal cheek lift. Plast Reconstr Surg. 1999;103(7): 2029–35.

Larrabee WF, Makielski KH. Superficial musculoaponeurotic system. In: Larrabee WF, Makielski KH, editors. Surgical anatomy of the face. New York: Raven; 1993.

Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91(3): 463–74.

Ramirez OM. Endoscopic full face lift. Aesthetic Plast Surg. 1994;18(4):363–71.