WHAT IS THE MIDFACE AND WHY WOULD IT BENEFIT FROM BEING LIFTED?
The midface lift is a much misunderstood procedure. Those who consider it a sole procedure for simply elevating and rejuvenating the midface are missing the entire point of it – its effects are far greater in conjunction with fat redraping blepharoplasty and can really be breathtaking. Just as endoscopic browlift is a wonderful adjunct for upper eyelid rejuvenation in certain patients, midface lift is the corollary for the lower eyelid in patients with midfacial ptosis.
The midface is the area of the cheek immediately below the lower eyelid, to the side of the nose and above the nasolabial fold.
The soft tissues here are partly fatty (malar fat pad and SOOF – sub orbicularis oculi fat) and part fibromuscular (SMAS – superficial musculo aponeurotic system).
The bony foundation that provides projection for the midfacial tissues is the maxilla, the upper jawbone.
Sometimes the maxilla may be retrusive or under developed (see malar implants section under facial implants). This can manifest itself more in the lower eyelid region where the lower eyelid fat pockets may look particularly prominent. In these cases it is not the lower eyelid fat pockets that are especially prominent but rather that the cheek tissues immediately below them are not camofluaging them as much as they usually do. If lack of bony projection is the cause of the problem then the answer is a malar implant.
NORMAL BONY PROJECTION WITH DROOPY SOFT TISSUES
More frequently the maxilla has normal projection but the soft tissues have drooped downwards exposing the “tear trough” between prominent orbital fat pads and the midfacial soft tissues. In these cases a midface lift is a sine-qua-non for effective rejuvenation. Simply correcting orbital fat prominence will not correct a tear trough and may risk lower eyelid malposition problems if the support is not restored. See the effect on your own lower eyelid by pushing the midface area vertically upwards, if you have eyebags they are immediately reduced in size.
The main function of a midface lift is to provide support to the lower eyelid by pushing the midfacial soft tissues upwards and filling out the tear trough. In Mr McDiarmid’s opinion the most dramatic effects can be gained by performing simultaneous midface lift and fat redraping lower eyelid blepharoplasty (see animation in blepharoplasty section to understand how this combination of procedures can dramatically efface the tear trough).
Occasionally bony underprojection and droopy midfacial tissues may co-exist necessitating simultaneous malar implant placement and midface lift in order to attain the most dramatic facial rejuvenation.
MIDFACE LIFT WITH FACELIFT
Unlike almost every other kind of facelift, high lamellar SMAS facelift (see animation in facelift section) incorporates a midface lift. This is one of the reasons why Mr McDiarmid favours the high lamellar SMAS type of facelift. In high lamellar SMAS facelift the strong vertical vector of pull on the midfacial tissues is conferred by the high horizontal incision in the SMAS (level with and parallel to the upper border of the zygoma or cheekbone) and definitive refixation of this layer vertically upwards to the deep temporal fascia.
Mr McDiarmid always wondered why patients having a facelift got better lower eyelid results after he switched to the high lamellar SMAS lift. Incorporating fat redraping blepharoplasty with canthopexy allowed him to set a different standard and he has almost completely abandoned conventional blepharoplasty from his practice. He feels it is relatively ineffective at correcting the underlying contour problems and it is also associated with a far greater risk of lower eyellid malposition. If his patients have minimal lower eyelid contour issues then he addresses them by means of a transconjunctival laser blepharoplasty. Older patients who may also be presenting for facial rejuvenation surgery almost always benefit from canthopexy (lower lid retightening).
WHAT DOES THE SURGERY INVOLVE?
Midface lift (when not part of a High Lamellar SMAS Facelift) is performed through a lower blepharoplasty incision. The lower eyelid incision is deepened in the standard way as far as the bony orbital rim. After the arcus marginalis (see animation in blepharoplasty section) has been released, allowing the orbital fat to redrape downwards, dissection is continued downwards under the maxillary periosteum (fibrous layer covering the maxilla) to release the attachments of the midfacial soft tissues from the bone. The infraorbital nerve, (the sensory nerve to the upper lip, lower eyelid and side of the nose) is carefully preserved and dissected carefully around. Dissection is continued to release preiosteum from the entire maxilla stopping at the lateral rim of the nasal cavity and the upper gum. At this point a malar implant may be inserted if the facial skeleton is underprojecting. A suture is then passed through the midfacial periosteum to pull it upwards and tied up to a firm fixation point (the deep temporal fascia, the bony orbital rim or a midfacial endotine device).
The periosteum has a remarkable ability to re-adhere rather quickly to the bone (in a higher position) and very robustly almost as though it had been superglued in place. The role of the suture in providing a vertically elevating force is quite short lived and this is why Mr McDiarmid favours a long lasting but dissolvable suture – usually a 3O PDS.
For a short period following this surgery it is normal for patients to experience mild (transient) upper lip dysfunction while the musculature re-adheres through the periosteum at a higher level. Its default position has been effectively reset at a higher level. Usually very temporary sensory changes may also be experienced in the distribution of the infraorbital nerve.
Because of the remarkable adherence seen following subperiosteal dissection the effects of this surgery are very long lasting.