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268 Part VII&Facial Surgery
PREOPERATIVE EVALUATION
4. When planning an eyelid ptosis repair, which of the following is the most important factor in choosing the
most appropriate procedure?
B. Levator function.
The answer is B, levator function, which guides the current treatment algorithmfor ptosis repair.Mild dysfunction
may only require an aponeurotic repair while poor levat or function may only be helped by frontalis suspension.
Dermatochalasis or excess skin in the eyelids can be associated with eyelid ptosis but does not help guide ptosis
repair techniques. Visual fields testing can help diagnose ptosis but not its severity. Epiphora may indicate a
nasolacrimal duct obstruction. Degree of dry eyes may help determine if someone is a surgical candidate or
not; however, this would not change the type of ptosis repair indicated as much as levator function would.
1,2
REFERENCES
1. McCord CD Jr, Codner MA, eds. Eyelid & Periorbital Surgery. New York: Thieme Publishers; 2008
2. Carraway J. Correction of blepharoptosis. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes. St Louis: Mosby–Year Book; 2000
COMPLICATIONS
5. A 50-year-old woman who underwent injection of her glabellar lines with 10 units of botulinum toxin type A 2
weeks ago is now complaining of left eyelid ptosis. Which intervention may help this patient's complaint?
C. Alpha-adrenergic eye drops.
The answer is C, prescription of alpha-adrenergic eye drops (apraclonidine). Periorbital injections of botulinum
toxin A can inadvertently paralyze the levator palpebrae superioris muscle, which is the main muscle responsible
for raising the eyelid. Alpha-adrenergic eye drops stimulate Müller's muscle, which is sympathetically innervated and contributes to eyelid elevation. Scar massage is unlikely to affect this new-onset ptosis, as is a steroid
injection. Gold weights are inserted as a treatment for lagophthalmos and would worsen ptosis. Repeat botulinum toxin injections may just worsen the underlying ptosis or provide no change.
1,2
REFERENCES
1. McCord CD Jr, Codner MA, eds. Eyelid & Periorbital Surgery. New York: Thieme Publishers; 2008
2. Carraway J. Correction of blepharoptosis. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes. St Louis: Mosby–Year Book; 2000
PREOPERATIVE EVALUATION
6. Which of the following preoperative findings places a patient at risk for corneal ulceration after
blepharoplasty?
B. Absent Bell's phenomenon.
The answer is B, absent Bell's phenomenon, a reflex which causes the eye to move upwards and outwards when
eyelid closure is attempted. When this reflex is absent, dry eyes and corneal ulcerations are potential complications if postoperative lagophthalmos occurs. Pupil abnormalities are unlikely to cause corneal ulcerations
after blepharoplasty or ptosis repair. Dermatochalasis refers to excess eyelid skin and should not affect corneal
exposure or ulceration after surgery. Hering's test reveals contralateral ptosis to help surgical planning.
1,2
REFERENCES
1. McCord CD Jr, Codner MA, eds. Eyelid & Periorbital Surgery. New York: Thieme Publishers; 2008
2. Carraway J. Correction of blepharoptosis. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes. St Louis: Mosby–Year Book; 2000
PREOPERATIVE EVALUATION
7. The levator palpebrae superioris is innervated by which of the following cranial nerves?
A. III.
The answer is A, the third cranial nerve or oculomotor nerve, which innervates the levator muscle, superior
rectus, medial rectus, inferior rectus, and inferior oblique muscles. The fourth cranial nerve, or trochlear
nerve, innervates the superior oblique muscle. The fifth cranial nerve, or trigeminal nerve, is mostly
Chapter 39&Blepharoptosis 269
responsible for sensation of the face but it also innervates the muscles of mastication. The sixth cranial nerve,
or abducens nerve, innervates the lateral rectus muscle. The seventh cranial nerve is responsible for innervating the muscles of facial expression.
1,2
REFERENCES
1. McCord CD Jr, Codner MA, eds. Eyelid & Periorbital Surgery. New York: Thieme Publishers; 2008
2. Carraway J. Correction of blepharoptosis. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes. St Louis: Mosby–Year Book; 2000
PREOPERATIVE EVALUATION
8. After bilateral upper eyelid blepharoplasty and ptosis repair of the right upper eyelid, a patient comes to the
office complaining with new-onset left upper eyelid ptosis. Which of the following explains this new ptosis?
D. Hering's law.
The answer is D, Hering's law, which provides the following explanation: after ptosis repair of the right eyelid, the signal for eyelid elevation decreased, causing new ptosis in the left eyelid. This is caused by equal
innervation to both upper eyelid levator muscles. Myogenic and involutional ptosis would not explain
new-onset postoperative ptosis. Ectropion is an outward turning of the eyelid usually caused by aging or
scarring.
1,2
REFERENCES
1. McCord CD Jr, Codner MA, eds. Eyelid & Periorbital Surgery. New York: Thieme Publishers; 2008
2. Carraway J. Correction of blepharoptosis. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes. St Louis: Mosby–Year Book; 2000
ANATOMY
9. In the upper eyelid, what structure separates the skin and orbicularis oculi (anterior lamella) from the tarsus
and conjunctiva (posterior lamella)?
D. Orbital septum.
The answer is D, orbital septum, also called the middle lamella. During blepharoplasty and ptosis repair,
violation of the septum places patients at higher risk of developing retrobulbar hematomas. Whitnall's
tubercle is located on the lateral orbital wall and is not part of the upper eyelid. Müller's muscle is in the
posterior lamella. The levator aponeurosis is posterior to the orbital septum. The frontalis is a muscle more
cranial than the eyelid.
1,2
REFERENCES
1. McCord CD Jr, Codner MA, eds. Eyelid & Periorbital Surgery. New York: Thieme Publishers; 2008
2. Carraway J. Correction of blepharoptosis. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes. St Louis: Mosby–Year Book; 2000
ANATOMY
10. What is the ideal position of the lower border of the upper eyelid?
C. Upper limbus.
The answer is C, upper limbus, also known as the border of the cornea and the sclera. Whitnall's tubercle is
on the lateral orbital wall and considered the ideal site of re-attachment of the lateral canthal tendon during
a canthoplasty. Positioning 5 mm above the lower eyelid is too low for ideal upper eyelid. The lower limbus
of the eye would also be too low for ideal positioning of the upper eyelid. The upper eyelid at the mid-pupil
line would denote severe ptosis and is not the ideal eyelid position.
1,2
REFERENCES
1. McCord CD Jr, Codner MA, eds. Eyelid & Periorbital Surgery. New York: Thieme Publishers; 2008
2. Carraway J. Correction of blepharoptosis. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes. St Louis: Mosby–Year Book; 2000
40. Midface Rejuvenation
David A. Sterling, Christopher C. Surek
See Essentials of Aesthetic Surgery, pp. 509–527
PERTINENT ANATOMY
1. With aging, the midcheek segments become separated by which of the following three cutaneous grooves?
A. Palpebromalar, nasolabial, midcheek.
B. Palpebromalar, nasojugal, midcheek.
C. Nasojugal, nasolabial, midcheek.
D. Palpebromalar, nasolabial, nasojugal.
E. Lateral malar, nasojugal, midcheek.
PERTINENT ANATOMY
2. With aging, the relationship between the anterior maxillary wall and the orbital rim leads to what vector
type and how does this influence the surgical outcome?
A. A positive vector; increased rates of ectropion.
B. A neutral vector; decreased rates of ectropion.
C. A negative vector; increased rates of ectropion.
D. A negative vector; decreased rates of ectropion.
E. A positive vector; decreased rates of ectropion.
PERTINENT ANATOMY
3. The prezygomatic space is bordered by which two retaining ligaments?
A. Orbicularis retaining ligament and upper masseteric ligament.
B. Orbicularis retaining ligament and zygomatic ligament.
C. Zygomatic ligament and upper masseteric ligament.
D. Upper masseteric ligament and mandibular ligament.
E. Upper masseteric ligament and orbicularis retaining ligament.
ASSESSMENT OF THE MIDFACE
4. A 62-year-old woman presents with concerns about her aging facial appearance, specifically her sagging
cheeks. What physical examination finding would be the biggest indication for operative intervention?
A. Soft tissue and fat atrophy.
B. Skeletal changes and bone loss.
C. Fat hypertrophy.
D. Skin pigmentary changes.
E. Inferior displacement of soft tissue from ligamentous attenuation.
SURGICAL PRINCIPLES
5. A 75-year-old male undergoes a skin-only rhytidectomy without fat grafting. The patient is unhappy with his
result 2 years af ter surgery and complains that his nasolabial folds and jowls are still present. Which of the
following is a reason for this patient's disappointing result?
A. Not performing concomitant fat grafting to nasolabial folds.
B. Releasing too many ligaments.
C. Not enough sutures used during the closure.
D. Not addressing the deeper foundation structures of the face.
E. Too much early postoperative swelling.
Chapter 40&Midface Rejuvenation 271
CHARACTERISTICS OF THE IDEAL MIDFACE
6. A 45-year-old female presents with concerns about the appearance of midface hollowing and a loss of defini-
tion in the lower eyelid– cheek area. On examination, she has mild scleral show, and malar descent with a
very pronounced V-shaped interface of the eyelid–cheek junction, including elements of herniated fat and
slight negative canthal tilt. Which of the following would best address her concerns?
A. Transcutaneous skin–muscle blepharoplasty with midface lift.
B. Transcutaneous skin–muscle blepharoplasty with fat repositioning and lateral canthopexy.
C. Fat grafting to the midface.
D. Fat excision of the herniated fat and fat grafting to the midface.
E. Fat excision of the herniated fat, fat grafting to the midface, and lateral canthopexy.
OPERATIVE TECHNIQUES
7. Regarding alloplastic implants for midface rejuvenation, the major body of the zygomatic bone is def ined by
which zone?
A. I.
B. II.
C. III.
D. IV.
E. V.
OPERATIVE TECHNIQUES
8. What are the appropriate anatomic planes or targets for fat grafting?
A. Subcutaneous, subperiosteal, muscle.
B. Subperiosteal, muscle, sub-SMAS.
C. Subcutaneous, subperiosteal, sub-SMAS.
D. Subcutaneous, muscle, sub-SMAS.
E. Dermal, muscle, supraperiosteal.
OPERATIVE TECHNIQUES
9. A 62-year-old male presents to your clinic for facial rejuvenation. He has noticeable descent of the malar fat
pads, resulting in a hollowed midface appearance. There is also a loss of skin elasticity and a mild mandibular
jowling. The surgeon discusses the possibility of an endoscopic midface lift. What specific aspect of this
patient's operation is most important to giving the patient a successful outcome?
A. Piecewise mobilization of midface structures.
B. Minimal periosteal release in the lower and medial boundaries of the cheek.
C. Strong suspensory element and release of ligaments.
D. Selective subperiosteal and subfascial dissection.
E. Sub-SMAS dissection.
SURGICAL COMPLICATIONS AND TREATMENT
10. After 2 days of completing a composite rhytidectomy with malar resuspension on a 58-year-old female, she
presents to the clinic with increasing pain and swelling of her left face. You suspect a hematoma. What could
have avoided this complication?
A. Use of cold compress postoperatively.
B. Use of a temporary Frost suture immediately postoperatively.
C. Strict blood pressure control and meticulous hemostasis.
D. Limited tension of skin closure.
E. Use of fibrin glue under advancement flap.
SURGICAL COMPLICATIONS AND TREATMENT
11. A 60-year-old male presents with visible swelling of his conjunctiva and a foreign body sensation 5 days fol-
lowing midface rejuvenation. What is the best initial management plan?
A. Steroid eye drops.
B. Antibiotic eye drops.
C. Placement of a temporary Frost suture.
D. Conjunctivotomy.
E. Observation.
272 Part VII&Facial Surgery
SURGICAL COMPLICATIONS AND TREATMENT
12. Your patient presents with mild lower eyelid malposition 3 weeks following midface rejuvenation. How
would you treat this patient?
A. No treatment required; this is expected.
B. Surgical canthopexy or canthoplasty.
C. Drill hole canthal anchoring.
D. Postoperative massage and eye lubrication.
E. Filler or fat grafting to support lower eyelid.
Chapter 40&Midface Rejuvenation 273
Answers
PERTINENT ANATOMY
1. With aging, the midcheek segments become separated by which of the following three cutaneous grooves?
B. Palpebromalar, nasojugal, midcheek.
The midface is divided into the anterior and lateral segments. The anterior segment, called the midcheek,
extends from the lower eyelid to the nasolabial groove and upper lip. The midcheek represents the aesthetically
pleasing fullness of the youthful cheek. As an individual ages, three cutaneous groove s separate the midcheek
into the lid–cheek segment, the malar segment, and the nasolabial segment. The nasojugal groove separates the
lid–cheek and nasolabial segments. The palpebromalar groove separates the lid–cheek and malar segments. The
midcheek groove separates the malar and nasolabial segments. These grooves intersect to form an obliquely oriented Y (Fig. 40.1).
1
Nasojugal groove
Lateral
aspect
ab
Anterior
aspect
Palpebromalar groove
Midcheek groove
Lid-cheek
Malar
Nasolabial
Fig. 40.1 (a,b) Subcutaneous compartments of the midcheek. (Source: Applied Anatomy. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Mendelson B, JacobsenS. Surgical anatomy of the midcheek:faciallayers,spaces,and the midcheek segments. Clin
Plast Surg 2008;35:395
PERTINENT ANATOMY
2. With aging, the relationship between the anterior maxillary wall and the orbital rim leads to what vector
type and how does this influence the surgical outcome?
C. A negative vector; increased rates of ectropion.
Aging of the midface includes changes in skin quality, loss of fat volume, attenuation of ligamentous
structures, and changes in the underlying skeletal support structure. Although historically it was believed
that facial skeleton aging consisted of growth and expansion, studies have identified retrusion of key
structures that result in the characteristic appearance of the aging face. For instance, there is retrusion of
the anterior maxillary wall in relation to the relatively fixed inferior orbital rim. This leads to a “negative
vector” appearance of the lid–cheek junct ion, which is defined as ocular globe located in a more anterior
position relative to the lower lid and malar eminence.
1,2,3,4
REFERENCES
1. Pessa JE, Desvigne LD, Lambros VS, et al. Changes in ocular globe-to-orbital rim position with age: implications for
aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast Surg 1999;23:337
2. Mendelson B, Hartley W, Scott M, et al. Age-related changes of the orbit and midcheek and the implications for
facial rejuvenation. Aesthetic Plast Surg 2007;31:419
274 Part VII&Facial Surgery
3. JelksGW, Glat PM. JelksEB, et al. The inferior retinacularlateral canthoplasty: a new technique.PlastReconstrSurg
1997;100:1262
4. Shaw RB, Kahn DM. Aging of the midface bony elements: a three-dimensionalcomputedtomographic study.Plast
Reconstr Surg 2007;119:675
PERTINENT ANATOMY
3. The prezygomatic space is bordered by which two retaining ligaments?
B. Orbicularis retaining ligament and zygomatic ligament.
The topographic anatomy of the midface can be likened to the layers of the scalp—skin, subcutaneous tissue,
musculoaponeurotic layer, loose areolar tissue, fixed periosteum, and deep fascia. The loose areolar tissue,which
allows gliding movement of the more superficial layers, is maintained in several areas by retaining ligaments.
These ligaments serve as fixation points between deep and superficial layers, and between them are specific
areas of loose areolar tissue that are important during midface rejuvenation. The roof of these spaces is the
underside of the superficial musculoaponeurotic system (SMAS), the floor the deep fascia or periosteum,
and the walls of the retaining ligaments. The three important retaining ligaments of the midface are the
orbicularis retainingligament, the zygomatic ligament, and the upper masseteric ligament. The four midface
spaces between these ligaments are the preseptal, prezygomatic, masticator, and oral cavity spaces.
Theprezygomatic space lies between the orbicularis retaining ligament and the zygomatic ligament (Fig. 40.2).
Orbicularis retaining ligament
1
Zygomatic ligament
Upper masseteric ligament
Preseptal
Prezygomatic
Masticator
Oral cavity
Fig. 40.2 Four major midface spaces. (Source: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, ed 2.
New York: Thieme Publishers, 2011.)
REFERENCE
1. Mendelson B, JacobsenS. Surgical anatomy of the midcheek:facial layers,spaces,and the midcheek segments. Clin
Plast Surg 2008;35:395
ASSESSMENT OF THE MIDFACE
4. A 62-year-old woman presents with concerns about her aging facial appearance, specifically her sagging
cheeks. What physical examination finding would be the biggest indication for operative intervention?
E. Inferior displacement of soft tissue from ligamentous attenuation.
Facial aging is the result of several factors, including skin laxity, ptosis of soft tissues, volume loss within the
soft tissues, and changes within the skeletal structures of the facial bones. According to Hester and Szczerba,
four important changes occur during the aging process: (1) There is gradual ptosis of the cheek skin below
the inferior orbital rim with descent of the attenuated lower eyelid skin, which creates a skeletonized appearance with infraorbital hollowness; (2) the malar fat pad descends, creating a loss of the malar prominence;
(3) the tear trough deepens; and (4) there is exaggeration of the nasolabial fold. In addition to these four
changes, there is also laxity and descent of the orbicular oculi muscle, laxity of the orbital septum, descent
of the lid–cheek junction, horizontal laxity of the lower eyelid tarsal plate, laxity of the orbitomalar ligament
Chapter 40&Midface Rejuvenation 275
resulting in descent of the cheek fat pad, and laxity of the zygomaticus muscles and otherlipelevators.
However, the most important of these is the inferior displacement of soft t issue from ligamentous
attenuation.
REFERENCE
1. Hester TR, Szczerba S. Midface rejuvenation. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles and
Techniques. New York: Thieme Publishers; 2005
SURGICAL PRINCIPLES
5. A 75-year-old male undergoes a skin-only rhytidectomy without fat grafting. The patient is unhappy with his
result 2 years af ter surgery and complains that his nasolabial folds and jowls are still present. Which of the
following is a reason for this patient's disappointing result?
D. Not addressing the deeper foundation structures of the face.
Historically, surgical facial rejuvenation consisted undermining and redraping skin flaps under tension
without addressing deeper struct ures. Inadequate results fueled a major shift toward the modern approach,
which focuses on adequately releasing soft tissues with resuspension along appropriate vectors to recreate a
youthful appearance while limiting tension on the reconstruction. Adequate mobilization of soft tissues
includes release of fixation points (ligamentous attachments). Compartments are then repositioned along
vectors that recreate a youthful anatomy, and multiple sutures are used to decrease the load exerted on any
one fixation point to improve the longevity of the result (Fig. 40.3, Fig. 40.4).
Superior
temporal septum
1,2
1
Orbicularis
retaining ligament
Zygomaticocutaneous
ligament
Masseteric
cutaneous ligament
Fig. 40.3 Regions of the face. (Source: Codner MA, McCord CD Jr, eds. Eyelid & Periorbital Surgery, ed 2. New York:
Thieme Publishers, 2016.)
Repositioning using
multiple vectors
Fig. 40.4 Principle of correction of laxity of the lower lid. (Source: Surgical principles. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
276 Part VII&Facial Surgery
REFERENCES
1. Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg
2008;35:569
2. Mendelson B. Surgery of the superficial musculo-aponeurotic system: principles of release, vectors, and fixation.
Plast Reconstr Surg 2001;107:1545
CHARACTERISTICS OF THE IDEAL MIDFACE
6. A 45-year-old female presents with concerns about the appearance of midface hollowing and a loss of defini-
tion in the lower eyelid– cheek area. On examination, she has mild scleral show, and malar descent with a
very pronounced V-shaped interface of the eyelid–cheek junction, including elements of herniated fat and
slight negative canthal tilt. Which of the following would best address her concerns?
E. Fat excision of the herniated fat, fat grafting to the midface, and lateral canthopexy.
Ramirez described a list of concepts that are integral to the ideal midface rejuvenation, which supplement
the principles of release, vectors, and fixation described by Mendelson.
volumetric remodeling of the cheek where the skeletal foundation is augmented or released while minimizing incisions and dissection planes, and fat may be injected without the risk of migration or need for
fixation or alternative grafts. Fat pad herniation of the lower eyelid and the V deformity of the eyelid–
cheek junction should be corrected. The corners of the mouth should be lifted as necessary. The skin
should be safely treated in the same operative setting if indicated. Facial edema should be minimized,
and nerve injury should be avoided.
Given these as ideals, in a patient with an extreme V-shaped cheek–lower eyelid, two main principles
apply: smoothing out the eyelid–cheek junction by excising herniated fat and fat grafting to blend that junction. Along with that, doing a lateral canthopexy for the mild scleral show and negative canthal tilt would
help her overall aesthetics. Doing a midface lift would not correct her severe midface V-shaped deformity. An
isolated blepharoplasty would not correct her midface ptosis and volumization issue. Fat transposition
works when fat redistribution is isolated to less than 2 cc; however, in this patient who requires severe
volumization, performing midface fat grafting would be the better solution.
2,3
1
The concepts include providing a
REFERENCES
1. Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 2002;109(1):329-340; discussion 341-349
2. Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg
2008;35:569
3. Mendelson B. Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation.
Plast Reconstr Surg 2001;107:1545
OPERATIVE TECHNIQUES
7. Regarding alloplastic implants for midface rejuvenation, the major body of the zygomatic bone is def ined by
which zone?
A. I.
Alloplastic augmentation of the midface is an option for volumization of this region during rejuvenation.
Terino popularized this method and developed the concept of anatomic zones of the face. Five distinct skeletal zones compromise the zygomatic region. The suborbital zygomatic region is defined specifically by Zone
I, the major body of the malar bone, and Zone III, the paranasal suborbital zone. Alloplastic augmentation
of the midface is usually combined with a subperiosteal lift to allow placement of the implant in this plane
(Fig. 40.5).
1
Chapter 40&Midface Rejuvenation 277
2
4
Fig. 40.5 Skeletal zones of the zygomatic region. 1, Major body of the malar bone. 2, Middle third of the zygomatic arch. 3, Paranasal suborbital zone. 4, Zone overlying the posterior third of the zygomatic arch. 5,
Submalar zonal triangle.
New York: Thieme; 2018.)
(Source: Alloplastic Implants. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition.
1
5
3
REFERENCE
1. Terino EO. Alloplastic contouring for suborbital, maxillary, zygomatic deficiencies. In: Fagien S, ed. Putterman's
Cosmetic Oculoplastic Surgery. 4th ed. Philadelphia: Saunders Elsevier; 2008
OPERATIVE TECHNIQUES
8. What are the appropriate anatomic planes or targets for fat grafting?
C. Subcutaneous, subperiosteal, sub-SMAS.
Fat grafting is a useful technique for addressing volume loss of the midface. Areas that often need augmentation include the tear trough and infraorbital areas, the malar eminence, the submalar region, and the
nasolabial crease. Coleman popularized the use of structural fat grafting employing a three-dimensional
approach to sof t tissue augmentation. Lipoinfiltration is performed in multiple planes, including the subcutaneous, sub-SMAS, and subperiosteal planes. Coleman cautioned against injection into muscle, as it can lead
to edema, distortion, undercorrection, muscle fibrosis, and thickening.
1
REFERENCE
1. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech Plast Reconstr Surg 1994;1:120
OPERATIVE TECHNIQUES
9. A 62-year-old male presents to your clinic for facial rejuvenation. He has noticeable descent of the malar fat
pads, resulting in a hollowed midface appearance. There is also a loss of skin elasticity and a mild mandibular
jowling. The surgeon discusses the possibility of an endoscopic midface lift. What specific aspect of this
patient's operation is most important to giving the patient a successful outcome?
C. Strong suspensory element and release of ligaments.
Endoscopic techniques for midface rejuvenation have been popularized by several surgeons. The main benefit to this approach is avoiding traumatic dissection of the orbicularis oculi. Ramirez outlined several key
principles of endoscopic midface surgery. They include wide subperiosteal and subfascial dissection, en bloc
mobilization of soft tissue, periosteal release of the lower and medial boundaries of the cheek, and a strong
suspensory element to maintain cheek repositioning.
1,2,3