Chapter 83 Soft Tissue Augmentation of the Temporal Brow in Browlifting Surgery 271
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Figure 83.5. Preand 6-month postoperative view demonstrating elevation of the temporal brow with soft tissue volume augmentation.
References
1.Whitaker LA, Bartlett SP. Skeletal alterations as a basis for facial rejuvenation. Clin Plast Surg 1991;18(1):197–203.
2.Pessa JE, Chen Y. Curve analysis of the aging orbital aperature. Plast Reconstr Surg 2002;111(2):751–755.
3.Kerth JD, Toriumi DM. Management of the aging forehead. Arch Otolaryngol Head Neck Surg 1990;116(10):1137–1142.
4.Holck DE, Ng JD, Wiseman JB, Foster JA. The endoscopic browlift for forehead rejuvenation. Semin Ophthalmol 1998;13(3):149–157.
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5.Burroughs JR, Bearden WH, Anderson RL, McCann JD. Internal brow elevation at blepharoplasty. Arch Facial Plast Surg 2006;8(1):36–41.
6.Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002;110(3):873–884.
7.McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct to blepharoplasty. Plast Reconstr Surg 1990;86(2):248–254.
8.May JW Jr, Fearon J, Zingarelli P. Retro-orbicularis oculus fat (ROOF) resection in aesthetic blepharoplasty: a 6-year study in 63 patients. Plast Reconstr Surg 1990;86(4):682–689.
9.Ramirez OM. High-tech facelift. Aesthetic Plast Surg 1998;22(5):318–328.
10.Carruthers JD, Carruthers A. Facial sculpting and tissue augmentation. Dermatol Surg 2005;31(11 Pt 2):1604–1612.
Part VI
Mid-Face Lift
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Mid-Face Lift: General Considerations
and How I Do It
Guy G. Massry
The endoscopic mid-face lift is a great volumizing procedure, but a poor lifting procedure:
•It can be done with or without browlift.
•Standard temporal posthairline incisions—like browlift.
•Dissect over white glistening surface of deep temporal fascia (DTF) to lateral canthus.
•Stay subperiosteal over zygomatic arch. Dissect over the medial third of the arch to reduce incidence of damage to the fascial nerve branch.
•Avoid sacrifi cing sentinel vein (potential arborization of new vessels— lower lids).
•This can all be done blindly in most patients. It helps to use bimanual technique (one hand guiding elevator, the other applying external guidance over arch), especially when there is thick tissue or in redo cases
•Remove scope, advance with elevator while feeling and guiding with other hand over skin. Make sure tip of elevator rubs on bone to stay subperiosteal. When entering mid-face will feel a “pop.” Advance radially over the face of the maxilla.
•Place a 4 × 4 gauze deeply into the temporal pocket for hemostasis before continuing with oral dissection. This also elevates tissue over zygoma so that there is less chance of entering wrong plane when connecting subperiosteal maxillary dissection with temporal pocket.
•In ltrate gingivobuccal sulcus with same 1% anesthetic.
•Make a small 1/2-inch vertical incision over 2nd premolar (in line with infraorbital nerve).
•Use a small, hooked retractor to elevate all tissue off of the maxilla and begin subperiosteal dissection.
•Dissect all the way to the arcus marginalis of orbital rim—around infraorbital neurovascular bundle. Visualize inrafraorbital foramen and nerve. I use a small Freer elevator medial to nerve to get to arcus and then release it. Temporal to nerve I use any one of a number of larger elevators to release arcus to canthus.
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•At canthus I connect to temporal pocket subperiosteally.
•Important to continue dissection over zygoma to insertion of masseter muscle (visualize origin of fibers). This is necessary for proper mobilization
•Equally as important is lysing the arcus marginalis. This breaks the xed attachments and allows elevation. If this is not done we will only
achieve the tissue-folding effect and volume augmentation. Also, if this is not done the tear trough may become deeper.
•Place a long 1 1/2 -inch 25-gauge needle at my suture placement site from skin to subperiosteal space. The higher the placement, the more lift achieved—the lower, the more volume (differences are dramatic).
•Engage the superfi cial tissue at the suture demarcation site (get a good bite). I use a long tonsil through the temporal pocket to the gingivobuccal opening to engage the suture (grab ends of suture) and pull it through.
•Retract the temporal wound and engage suture (double bite) to DTF as low as you can. I cinch up in a slip knot. I then check mid-face volume and lift and adjust as necessary before securing knot.
•I then use a tonsil to guide a 10-French drain from temple to mouth and fix it with externalized suture.
•Irrigate temple wound to mouth with antibiotic/saline solution, and then mouth with same.
85
Ten Rules for Mid-Face Lifting for the Repair of Lid Retraction
Morris E. Hartstein and Guy G. Massry
1. Get real: Counsel the patient preoperatively as to the difficulty in xing this problem—both doctor and patient need realistic
expectations.
2.What is the culprit? Septal scar will tether the lid on upgaze. Anterior lamellar shortage will limit a mobile lid in upgaze. There may be components of both.
3.Stay clean: Dissect in a virgin plane so as not to disturb previous scar tissue. The subperiosteal plane is often undisturbed.
4.Deglove: Complete release and mobilization of the mid-face through the lid and/or mouth.
5.Take a load off: Elevating the mid-face, in addition to augmenting the skin, will take the gravitational burden off the eyelid and reduce the negative vector.
6.Avoid the poor man’s mid-face lift: An orbicularis strap, while useful in routine blepharoplasty, is not helpful in this situation and may cause more cicatrization.
7.Aim high: The cheek flap should be secured higher than just the inferior orbital rim. Consider multiple point cheek flap fixation in a vertical direction to the orbital rim, ZF suture, and DTF.
8.Don’t go it alone: For cicatricial lid retraction, elevation of the mid-face alone will not suffice—a spacer graft is usually required to support the lid. Choices of spacer grafts include hard palate, dermis fat, and processed collagen.
9.What goes up, must come down: No matter how high the fixation, all cheek flaps will fall postoperatively. Frost sutures, keeping the lid on upward stretch for 5–7 days, are crucial.
10.Wait to exhale: There are many forces influencing the healing and position of the lid. It may be several months before the lid settles to its nal position. Wait at least 1 month postoperatively before even thinking
that the procedure was successful.
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