Midface and Lower Eyelid Rejuvenation

Key Points

•Endoscopic midface rejuvenation is a scarless procedure accessed through small hidden incisions.

•It can be performed on the young, middle aged, and elderly. In middle aged and elderly individuals, it is often part of a larger procedure (brow lift, facelift, blepharoplasty, etc).

in this small area of facial anatomy. The aging process tends to produce an appearance of sadness and anger. This occurs despite that fact that the individual may have different feelings internally. Occasionally, some younger individuals may have this expression of sadness as a natural or acquired trait. However, when patients come for consultation to correct these

nique, is critical to the success of surgery.

•Surgery is performed in the subperiosteal plane which provides excellent safety, visualization, and access for tissue remodeling.

•In my technique, multiple tissues (SOOF, Bichat’s fat pad, etc.) are sequentially engaged, elevated, and secured to a common fixation point (temporal fascia proper).

•This imbrication of tissue cumulatively creates the youthful convexity of the midface and reestablishes the natural cheek contour (ogee line).

•Adjunctive procedures such as placement of facial implants, autologous fat grafting, and laser skin resurfacing can be safely and effectively added to surgery.

•Midface rejuvenation is often combined with lower lid blepharoplasty. I have found that the combined procedures act synergistically to improve the overall surgical outcome, and to enhance the individual results of each procedure.

ging, etc. It is up to the surgeon to approach surgical rejuvenation in a dimension beyond the static morphology to which we are accustomed. It is also imperative that the surgeon does not worsen existing positive facial expressions and does aim to restore the happy face that is inherent to the young person.

From the surgical point of view, the aging manifestations on the face should be corrected by functional and anatomical units. From my personal perspective, the forehead and upper eyelids are one unit. The lower eyelids and midface another unit. The lower face and neck is the last unit. Surgery on one unit usually facilitates and enhances the correction of an adjacent unit. With this in mind, my approach to midface rejuvenation usually involves some procedure on the lower eyelid. Conversely, surgery of the lower eyelid may require a procedure on the adjacent midface. These combined procedures act synergistically to attain superior correction and rejuvenation of any one unit. Therefore, to be complete, I will describe my combined technique of endoscopic midface lift with lower blepharoplasty.

20.1Introduction

The periorbital region is the area of the face that people focus on when they engage socially and intimately. It is also the most expressive area of the face. All the natural human feelings of anger, sorrow, happiness, despair, etc. are manifested

O.M. Ramirez (*)

Director, Sanctuary Plastic Surgery, Boca Raton, FL, USA e-mail: drramirez@spsboca.com

20.2The Midface

Despite the numerous techniques described over the decades, the best approach to midface rejuvenation has, and continues to be, an area of constant surgical debate. The endoscopic technique that I described in the early 1990 approaches the deep layers of the midface in the safest plane of dissection using only small incisions. This approach allows moresoft tissue remodeling than any other technique. While I have used multiple access points for surgery, I have consistently performed this procedure in the subperiosteal plane. My current

preference to access the midface involves a temporal slit incision (2 cm) and an intraoral mucosal incision (2 cm). These approaches prevent all the potential complications of prior techniques using eyelid incisions [1].

of suspension. However, I have not seen that they offer any significant advantages over the simplest and less expensive methods of tissue fixation that I described originally: percutaneous screw fixation for the forehead, and polydioxanone (PDS) suture suspension for the midface. Of critical importance is to allow this en-block mobilization lift and fixation

I have been performing subperiosteal facelifts since my years as a Senior Resident at the University of Pittsburgh (1983–1984). I have not changed my preference for this approach since that time. Moreover, continued evolution, refinement, and improvement in the technique have occurred over the years [2–5] which has further substantiated my belief in this approach. I will enumerate what I have learned over time.

The subperiosteal dissection allows en-block mobilization of the soft tissues. Once dissection is done, in the forehead, the midface or the entire jaw line, the tissues are lifted in a vertical or superolateral direction. Key suspension sutures are applied to maintain the desired elevation. Some surgeons prefer the use of fixation devices such as endotine (Coapt), or barbed sutures such as the Quill brand etc., to anchor mobilized tissue. I have tried these and other methods

periosteal attachments in key anatomical areas usually in the lowermost boundaries of the area of dissection.

The subperiosteal dissection facilitates soft tissue remodeling. This can be accomplished by imbricating the entire mass of the dissected tissues, by transposition of vascularized fat flaps, or by injection of free fat to the entire thickness of the elevated soft tissues (Fig. 20.1).

The subperiosteal dissection leaves exposed the underlying bony skeleton. This allows skeletal contouring by bone reduction with osteotomies or by augmentation with implants (Fig. 20.1). There is no need for dissection in different planes, which is the case if one proceeds with a subcutaneous, sub-SMAS (sub-superficial-musculo-aponeurotic system), or intermuscular dissection.

The subperiosteal plane has better visibility and orientation than the more superficial planes, particularly when one

Fig. 20.2 My biplanar technique combines the safest planes of dissection: the subperiosteal dissection in the central oval of the face (black arrows) and the subcutaneous dissection in the periphery (red arrow)

uses endoscopic techniques. The bony surface reflects the light better and the bone surface provides good landmarks for orientation.

The subperiosteal plane is a safer plane for the facial nerves. Despite the unfounded claims that the subperiosteal plane of dissection has a high incidence of nerve injury, I strongly believe that this plane is as safe as the subcutaneous plane of dissection and definitively safer than the intermediate plane of dissection. This assumption is based on my vast experience of many years of surgery with this technique. My personal rate of nerve injury is about 2%, and all injuries have been temporary. For this reason, in my biplanar techniques, I combine the safest planes of dissection: subperiosteal and subcutaneous (Fig. 20.2).

The subperiosteal approach is probably more durable than other more superficial techniques. Once you have repositioned the block of soft tissues, and allow healing in the elevated position, the result will remain over time. In over 25 years of performing subperiosteal facelifts (open and endoscopic), I have seen that the operation on the central oval of the face, the forehead, and the midface, lasts for over 10 years at a minimum. The area that tends to relapse earlier is the lower face and the neck, in which a more superficial dissection has been performed. This usually last about 5 years.

Finally, the more superficial planes of dissection in this surgery usually pull the soft tissues in a horizontal or oblique direction. Using these techniques the central midface soft tissues are pulled indirectly by the tension applied to the peripherally dissected flaps. These two characteristics create tension bands and more pull on the periphery than in the centrally located tissues giving the typical “windswept” or “motorcyclist” appearance to the face.

20.4Patient Selection

Most patients are candidates for minimal incision midface rejuvenation including young, middle aged, and elderly individuals. It is equally applicable to male and female patients, and can be performed on those with good as well as poor skeletal support.

In young individuals, I apply the principles of three dimensional facial rejuvenation of the midface for purposes of enhancement. For strategic and conceptual reasons, I do not call this facial rejuvenation. Instead I use the term of “facial beautification.” I have performed these procedures of lifting and reshaping the face for beautification purposes on individuals as young as 18 years of age.

When a man or woman starts developing the first signs of aging in their middle thirties, it usually manifests with the development of an early tear trough deformity (naso-jugal groove), sagging of the cheeks, and the presence of a nasolabial fold. These are the group of patients that benefit the most from the endoscopic midface rejuvenation. This is because the results to surgery are superior, yet not dramatic or obvious to the casual observer. Even in those with more dramatic changes, the natural results and the lack of telltale signs of “face lifting” are advantageous when patients want to integrate to their working activities as quickly as possible.

Individuals of middle age, late middle age, and the elderly, are also excellent candidates for the procedure, because the endoscopic midface lift can be easily incorporated into more extensive and complete facial rejuvenation procedures. For those requiring additional volume augmentation, or correction of soft tissue asymmetries, fat grafting techniques are added. For those requiring skeletal augmentation in the pyriformis, malar or orbital areas, facial implants fabricated for these areas are used during surgery. Males are equally good candidates for the procedure. The only difference with the female counterpart is that the final aesthetic shape of the cheek is a bit different. This will be elaborated on later.

20.5Indications

Patients with either early or considerable aging or ptosis of the structures of the central oval of the face can benefit from the endoscopic minimal incision midface lift. Eyelid commissures, nasolabial folds, cheeks, the angle of the mouth etc. are effectively addressed with this approach. Moderate tear trough deformities and infraorbital hollows are also correctable with endoscopic techniques. Endoscopic midface procedure allows recreation of the “ogee” of the midface [5]. This reciprocal multicurvilinear line is associated with a youthful and beautiful appearance. The endoscopic minimal

incision midface lift is quite effective in conjunction with patients requiring secondary or tertiary face lift procedures, for those patients requiring deep chemical peel or CO2 laser resurfacing, and for patients requiring soft tissue augmentation via fat grafting. In the first case, dissection of the midface is performed in areas usually not touched by prior procedures; therefore dissection is done in a virgin (subperiosteal) plane. In the second case, the thick composite flaps fashioned in surgery have excellent vascularity, and ablative procedures on the skin do not affect the skins survival. In the last case, the intermediate and superficial lamellae of the face are intact, and fat can be injected in as many tunnels as needed.

Patients with skeletal/soft tissue disproportion can also benefit from endoscopic techniques of the midface. The exposed bony structures can be augmented via implants or reduced by osteotomies or bone burring without the need to open a different plane of dissection, as is the case when one performs surgery in the superficial or the intermediate planes of the face.

20.6Preoperative Preparation

A full medical workup and cardiac clearance are requested as needed. In this age of significant influence by fashion and the media, patients will do anything to maintain their slim figures, including restrictive diets. In this respect, many young patients present to their plastic surgeons with an undiagnosed or untreated condition of anorexia and/or bulimia. These patients, despite a deceptively normal appearance, might be in severe metabolic and electrolyte imbalance, including hypokalemia and hypomagnesaemia. These disorders can lead to an unexpected cardiac arrest during or after surgery, among other complications. Surgeons, particularly plastic surgeons, should be aware of this potential situation. They should also be aware of the ever-increasing incidence of patients with body dysmorphia syndrome.

Photographs are taken several days before surgery without, or with minimal makeup. The hair is moved from the face with hair bands, clips and elastic “ponytail” bands. No superior tension of the brows or temples should be exerted to prevent “photo-surgery.” The ears, temples, forehead, and neck should be fully exposed in the photographs. For the neck, a low-cut V, a circular T-shirt or no shirt at all should be used.

Markings are made with the patient in a standing or sitting position. The orbital rim outline is marked in blue. The area of maximal midface projection, which is at the zygomaxillary point, is marked in green. The nasolabial fold, tear trough deformities, and other areas of contour deficit are marked in red. Areas of contour excess are marked in black. The jaw line and the cervicomental break are marked in blue.

20.7Aesthetic Considerations

The goals of the surgical procedure are to: efface the tear trough deformity, lift the cheek, efface the nasolabial fold, enhance the projection of the cheek, and lift the corner of the mouth. Most importantly is to recreate the aesthetic and youthful appearance of the cheek mound. The cheek seen in a three quarter view has a specific outline that has the shape of Sigma or Greek S also called the “ogee line”. In reality the entire facial outline is a “double Ogee-line” (Fig. 20.3). This starts with a slight concavity on the forehead, continues with a convexity on the lateral brow, a concavity on the lateral orbital area, and gradually changing to a significant convexity on the cheek. This convexity gradually goes down at the level of the upper lip to converge into a slight concavity lateral to the paracomissural area. The highest point of the cheek convexity seen in a three quarter view is located at the so-called “zygomaxillary point.” This is a new anthropometric soft tissue point that can be located by the intersection of two lines: one traced vertically on the lateral external orbital rim and another line horizontally oriented extending from the upper lateral cartilage of the nose to the tragus. The intersection of these two lines determines the maximum point of projection of the convexity, the zygomaxillary point [5–7].

Fig. 20.3 Observe the reciprocal multicurvilinear outline of the face that I have been calling the double ogee-line of the face. This is seen better in a 3/4 view (left side of photo, right side of face). For many decades, artists, photographers, and glamor models have been using this view to emphasize beauty and youth. Photo © Shutterstock Images LLC; used with permission