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Topic 21 - 1
and Midface Lift
lower fat repositioning surgery photos   tear trough depression


21: Cheek and midface lift
- Cheek and midface lift
- Upper cheek depressions
- Fat, fillers, and implants

lower eyelid blepharoplastyeyelid chemical peel

Other names: Midface suspension, SOOF lift (a less comprehensive but related procedure), meloplication

Primary goal: Elevation and tightening of the soft tissues (fat, muscle) of the cheek

Secondary goals: Restoration of a more youthful lower eyelid-cheek "continuum", with lifting of the nasolabial fold (fold of tissue between nostril and cheek), partial softening of the "tear trough deformity" (hollowness between the lower eyelid and upper cheek), and improvement in the appearance of malar bags ("cheek bags").

Anesthesia: Because of the extensive dissection and/or complex instrumentation, deep intravenous local sedation or general anesthesia is usually employed. The less invasive "SOOF lift" (shown below) may be accomplished during blepharoplasty without much added manipulation.

Before and After: Upper and lower blepharoplasty,
canthoplasty, SOOF lift, and chemical peel

Variations: There are a number of very different surgical approaches:

-- The midface may be lifted from incisions placed on the front of the lower eyelid (transcutaneous), on the back of the lower eyelid (transconjunctival), above the brow, inside of the mouth (buccal), on the temple behind the hairline, or at the canthus.

-- The plane of dissection may be above the periosteum (preperiosteal, in the plane of the orbicularis muscle or in the plane of the SOOF) or below the periosteum (subperiosteal).

-- The operation may be accomplished under direct exposure utilizing large incisions or through the endoscope using smaller incisions.

-- Most typically large tissue flaps must be elevated, while in its least invasive incarnation the lift may be accomplished through tiny cheek skin incisions into which thick suture is passed as a suspension cable.

-- Fixation of elevated tissue may be made at the orbital rim or into the fascia overlying the muscle of the temple.

Such a diverse range of approaches indicates that there are built-in limitations to each method and that the operative technique is still evolving. For instance, while the approach through the eyelid was until quite recently the most common, it is now avoided by many surgeons because of postoperative distortion at the outer junction of the eyelids (canthus) and a significant risk of lower eyelid retraction.

Advantages: Midface lift may result in less pulling around the mouth and cheek than with a "classical" face lift, which pulls tissue more towards the ear. Lifting the cheek obliquely upward may help to restore a more youthful contour (but see below). "Cheek bags" that are not helped by blepharoplasty alone may respond better to SOOF lifting (photos).

Limitations: In most patients, the improvement from a midface lift is subtle, and so the procedure is typically employed as as "add-on" to other surgery such as blepharoplasty and/or a "classical" lower face lift (although in patients under the age of 45, the surgery may be performed as a "stand alone" procedure) or fat transfer.

In contrast to the traditional face lift, a midface lift has almost no effect on the sagging tissues of the chin and neck (the "jowls").

Especially when performed through an eyelid incision, the midface lift may render the lower lid unstable; a lateral canthal tightening procedure is often necessary to prevent the lid from pulling away from the eyeball (eyelid retraction). Variations utilizing soft tissue planes (rather than subperiosteal dissection) seldom result in more than short-term improvement.

Care and recovery: Swelling and bruising may be pronounced; subperiosteal dissections may result in swelling lasting up to three months. Younger patients may find such a lengthy recovery period difficult to fit into an active work schedule.

Risks and complications: Distortion or puckering in the region just beyond the lateral corner of the eye is not uncommon. Some techniques involve the removal of eyelid skin, alteration at the lateral canthus, and disruption of the orbital septum, steps which could lead to future problems (lid retraction, ectropion) once the upward pull of the lift is eventually lost over time. Because large flaps are created, there is a risk of infection, poor perfusion, bleeding, and scarring.

A well-performed midface lift is, comparatively, not an easy operation for the surgeon; proper suture placement may be challenging. A poorly-performed midface lift without attention to detail accomplishes little and can cause harm. Most surgeons now believe that the risks of midface lifting through an eyelid incision outweigh any benefits.

Comments: SOOF lift (a related but less aggressive procedure directed primarily at repositioning a single smaller fat pad of the upper cheek rather than the entire midface) is a helpful addition to the blepharoplasty surgeon's repertoire of adjunctive procedures.

Because of the technical complexity of midface surgery, its potential for complications, and the unknown duration of any improvement, there has been much recent interest in developing less invasive, non-incisional "quickie" techniques utilizing suture (cable lift, feather lift, lunchtime lift, meloplication, etc.) to suspend the soft tissues without creation of extensive surgical flaps. Whether such seemingly simple (but not inexpensive) techniques yield any real lasting change has not been proven. Because of their vector of pull (from the cheek towards the temple), they do little to alleviate a tear trough depression.

Something to Consider: Lifting tissues against the pull of gravity should probably be viewed as a (often quite) temporary fix. Regardless of the technique employed, soft tissues are by nature . . . soft, which means they will once again yield to the hard force of gravity, sometimes within months, often within a year or two, sometimes a little longer down the line.

Here's the rub: When the midface does eventually fall, it may leave the eyelids in worse position than they were before cheek surgery. Why? Because the tissue invasion required by most such operations distorts and/or weakens natural eyelid support and may turn a part of the eyelid's closing muscle (orbicularis muscle) into scar.

"Fixing" such secondary problems by repeating the surgery can be an exercise in futility. The same long-term scenario is likely to repeat itself (only more so), compounding the impact on the eyelid with each ensuing lift.

Besides, the biggest issue in mid-facial aging is not skin or muscle sagging but rather loss of underlying fat. If ignored, a midface lift can yield a result just as pulled and distorted as with overdone traditional facelift. Recently, fat transfer techniques to the hollowed cheek have gained in popularity, even among some facial surgeons who were once the most enthusiastic advocates of midface lifting.

Who Performs Face Lifting? If you are contemplating a midface or face lift, we recommend consulting a facial plastic surgeon or a general plastic surgeon. While some oculoplastic surgeons do perform face lifting with skill, most place their primary emphasis on eyelid surgery, which is where they excel.

Next: Depressions of The Upper Cheek:
Trough, Hollows & Descent

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