As I mentioned, the vertical suborbital SOOF lift effaces the tear trough and periorbital V deformity. The BFP elevation gives a significant volumetric augmentation of the cheek, increases the convexity of the upper midface, and concomitantly increases the concavity of the lower midface. This will accentuate the reciprocal multicurvilinear line of beauty of the midface – the ogee line.

The cases in which BFP is excised, it will accentuate the concavity of the lower midface. Excision of BFP is done with a similar technique as its mobilization. The fat is extruded intact towards the intraoral incision. A moistened 2×2 gauze is applied in between the maxillary bone and the neck of the mobilized pedicle flap (BFP). Using a mono-polar needle point cautery, the pedicle is cauterized at the base of the extruded portion. This way there is no bleeding, associated facial ecchymosis or edema that is common with the piecemeal approach to remove this fat pad.

The modiolus stitch will lift the corner of the mouth and imbricates the lower cheek toward the upper cheek. The endpoint of lateral upper lip mobilization with the modiolus stitch is exposure of the entire canine tooth with the patient in a supine position. If this is done on both sides, it will secure symmetry of the corner of the lip elevation. Obviously, in cases of asymmetry, the lower lying lip and corner of the mouth are overcorrected. The lateral SOOF suspension also imbricates the cheek towards the zygomaxillary point, and suspends the entire cheek reducing the load of weight on the other suspension sutures.

Each one of the sutures except in the BFP suture is tied using the sliding locking endoscopic “Peruvian” fisherman’s knot [8]. This will provide graded tension on the elevated tissue until the desired level is attained. If the tension of the suture is excessive the initial loop of knot can be loosened and tissue will descend. After appropriate midface position is achieved, a single square knot will lock the entire system. The BFP suture is then anchored with its own square knot while the assistant locks the first knot to prevent excessive traction on this delicate structure. BFP is transposed freely without undue tension.

Using this technique in several hundred cases I have had only two cases of disruption of the fat pad. If this happens, remobilize the fat pad from the buccal space, apply two woven sutures from the center of the flap, and anchor it as a piggyback to the lateral SOOF suture.

Any residual asymmetry is usually due to a preexisting asymmetry that becomes more obvious after the cheek feature are elevated and imbricated. This can be addressed with microfat injection in the intermediate layer of the face. A 2 mm butterfly drain is guided to each cheek and the intraoral incisions are closed which will be described.

The temporal flap is suspended from the STF to the TFP using three interrupted 3–0 PDS suture. The suture placement has a trapezoidal shape with a larger base located at

the TFP and the shorter base at the superficial temporal fascia. If the shape is made quadrangular or the trapezoid inverted, the lifted temporal scalp will bunch up at or near the incision. The orientation of the flap tension is either vertical or vertico-medially oriented. This will give an effective vertical lift of the lateral cheek, zygomatic arch of soft tissues and temple. This will also open the crow’s feet area with forces directly opposite to the forces of contraction and ptosis. This particular orientation will also prevent lateral pull of the brows and excessive separation between the lateral periorbital soft tissues and the temporal hairline.

20.9Lower Eyelid Blepharoplasty

This is an added technique to midface rejuvenation that significantly enhances the final results. Treating the midface and the lower eyelid as one aesthetic and anatomical unit improves the aesthetic result and diminishes the complications of an isolated lower blepharoplasty. Younger patients may not require a lower blepharoplasty when undergoing a midface lift. In these cases, minimal excess skin can be treated with one pass of CO2 laser or a chemical peel. In older patients, the vertical lift of the cheek will recruit skin to the lower eyelid. In these cases, I perform skin-only lower eyelid blepharoplasty. The orbicularis oculi muscle is also suspended to maximize the periorbital aesthetic improvement. I take advantage of the fact that the attachments of the orbicularis oculi muscle to the orbital rim have been elevated during the endomidface lift, and the composite soft tissues can be redraped further with oblique traction on the preseptal portion of this muscle. Furthermore, the tensions exerted on the muscle will retro-place the herniated lower lid fat into the orbit, while simultaneously reducing inherent laxity of the muscle.

I make a horizontal incision 2 mm inferior to the subciliary margin and extend it in a horizontal direction into a temporal rhytid (crow’s feet). The skin is dissected off the pretarsal and preseptal orbicularis oculi muscle for approximately 1–1.2 cm inferiorly. The lateral orbicularis oculi muscle is spread open to create a tunnel into the most anterior portion of the TFP. The lateral extension of the preseptal orbicularis oculi muscle is grabbed with 5–0 Prolene suture. The suture is anchored to the TFP in a mattress fashion through the tunnel previously described. This allows superior and superolateral suspension of the muscle. This also creates a roll of muscle in the pretarsal area, which is a favorable feature typical of the youthful eye. If there is hypertrophy of the preseptal orbicularis muscle, then the muscle is trimmed in a tangential fashion preserving the vertically oriented motor nerves that travel deep to the orbicularis oculi

muscle. If the treatment of the crow’s feet is needed, the lateral orbital orbicularis oculi muscle can be excised as described by Viterbo [10].

The lower eyelid skin is now redraped in a vertical direction and its excess is removed conservatively. If significant laxity of the lower eyelid was present preoperatively, either a canthoplasty or canthopexy can be added through the same incision. I have found that the combination of a vertical orbicularis oculi muscle suspension and a canthopexy is usually adequate in the majority of patients. Very rarely I need to perform a canthoplasty or horizontal lid shortening type of procedure. The skin is closed with 6–0 Prolene suture with a vascular needle.

20.10 Fat Grafting

This is a technique that can be easily incorporated into the operation as fat can be injected at any level from the subdermis to the periosteum. Fat is usually obtained from the periumbilical area, spun in a centrifuge, and the fluid elements separated. Using a 1 cc Luer Lock syringe, with the Ramirez Super-Luer-Lock micro-cannulas (Tulip Medical, San Diego, CA), the fat is injected to correct any residual asymmetries, to erase the dermal creases resulting from the chronic folding of the nasolabial folds, and to inflate the brow area as needed. I use an average of 30 cc of fat for the entire face as an adjunctive technique. However, I do not typically rely on fat grafting for the volumetric augmentation of the cheek. I only do this when the patient’s face is too thin and does not have enough soft tissues (including BFP) to create volume with the imbrication techniques described.

20.11 Drains, Closure,Taping, and Dressing

In my technique there are no significant areas of closure because the incisions are small. However, taping of the face is a very important maneuver. The skin of the scalp in the temporal areas is closed in a single layer with skin staples. In this area, there is usually no tension due to the vertical advancement of the lower flap. It is important to evert the edges of the wound to prevent overlapping of the skin edges with subsequent in growth of hair into the wound. Generally, three to five staples are used to close the temporal wounds on each side. All staples but the central one are removed at the fourth or fifth postoperative day. The remaining staples are removed at the seventh to tenth postoperative day. The intraoral incision is closed in a looped mattress fashion using a 4–0 chromic suture. This will prevent inversion of the mucosal edges or potential cheese wiring of the mucosa.

Furthermore, this mattress closure provides a one-way valve (from internal to external), that in cases of excessive bleeding, or fluid collection, will allow fluid to seep out, but will prevent saliva from entering the wound. Prior to closure of the temporal incision, a 2 mm butterfly drain is introduced through a mini-puncture in the temporal scalp, with its tip left in the midface. The drain is fixated with an interlooped 4–0 PDS suture and connected to a Vacutainer tube. At 24–36 h postoperatively, the drain is advanced by pulling about 1 in. from the scalp exit. The drain is removed at 48–72 h postoperatively.

The forehead and midface are taped with half inch brown micropore tape. The initial taping is applied from the glabrous portion of the temple to the forehead in a superomedial direction. The lower eyelid and cheeks are taped horizontally and then in an oblique direction towards the temple. Both sites of taping are interconnected without creating creases or ripples in the skin of the lateral periorbital area. The facial taping is another stabilizing and splinting element that prevents motion, facial edema, and ecchymosis. The tape is left for about 10 days. The initial tape is removed at the fifth postoperative day, and a less aggressive taping is reapplied. Taping of the lower eyelid helps prevent edema and mechanical eyelid malposition by a swollen conjunctive (chemosis) if this exists. A circumferential helmet type dressing is applied to the forehead, face, and neck for about 24 h. This is mostly for comfort and to catch any fluid from the ice compresses to the cheeks and eyelids. These compresses are applied for 24–48 h.

20.12 Summary

The minimal incision midface lift is a safe and effective procedure for midface rejuvenation. It can be performed via only an intraoral incision. However, the endotemporo-midface lift (described herein), or the endoforehead-endomidface procedure, are more effective in remodeling the midface and periorbital areas. A wide subperiosteal dissection allows excellent surgical visualization, better remodeling of tissues, a safe plane of dissection, and improved outcomes. In addition, the imbrication of tissue and suture lift via this approach allows superior volume augmentation of the cheek. Bichat’s fat pad is an essential element needed to create the convexity in the cheek, and the concavity in the paracomissural area. This simultaneously creates the ogee of the midface (Figs. 20.10–20.25) The surgery can be incorporated with any additional techniques of facial rejuvenation and can be performed in conjunction with the use of facial implants and or fat grafting. The midface procedure also allows optimization of lower blepharoplasty surgery to obtain better aesthetic and functional results.

Fig.20.10 Preoperative view of a woman with a history of rhinoplasty, cervicoplasty, and silicone chin implant. Observe the sagging of the face particularly of the midface. Notice the tear trough deformity

Fig. 20.11 Following secondary rhinoplasty, endoforehead-endomidface lift, chin implant exchange, and secondary cervicofacial rhytidectomy. She also had conservative fat grafting to glabella, brows, and lips

Fig. 20.12 Preoperative 3/4 view. Observe the generalized sagging of the face, flattening of the cheek, and the baggy eyelids

Fig. 20.13 Following the mentioned procedures observe the generalized improvement particularly of the midface and lower eyelid. The tear trough area is smaller

Fig. 20.14 Preoperative view of a woman with sagging and flattening of the midface and a tear trough deformity

Fig. 20.15 Postoperative view after endoforehead and endomidface lift lower blepharoplasty, fat grafting, and cervicofacial rhytidectomy

Fig.20.16 Preoperative 3/4 view of the same patient. Observe the sagging of the cheek and the tear trough deformity

Fig. 20.17 Postoperative view. Notice the significant improvement particularly with the recreation of the Ogee line of the midface and the tear trough deformity. Also notice how natural the aesthetics and dynamics of the lower eyelids are

Fig. 20.18 Preoperative view of a woman who looks tired with midface sagging. Notice the bilateral eyelid ptosis

Fig. 20.19 Following ptosis repair, endoforehead and endomidface lift, lower blepharoplasty, fat grafting as well as cervicofacial lift

Fig. 20.20 Preoperative 3/4 view. Observe the subtle but generalized sagging of the face and the flattening of the cheeks

Fig. 20.21 Postoperative 3/4 view. Notice the subtle but definitive rejuvenation with the shape and beauty of a younger counterpart. There are no telltale signs of surgery

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Fig. 20.24 Preand postoperative views of a woman who underwent endoforeheadendomidface lift, lower blepharoplasty, and fat grafting. Observe the improvement of the periocular depressions (circles) and the volumetric improvement of the cheeks

Fig. 20.25 Preand postoperative 3/4 views (of patient from

Fig. 24) show the changes previously mentioned. Particularly observe the “ogee” of the midface and the correction of the lower eyelid deformities

O.M. Ramirez