Give proper attention to this key component of facial rejuvenation

Traditionally, facial rejuvenation has focused on the lower face using rhytidectomies and on the upper face using brow lifts. This approach, however, neglects the midface. With the passage of time and further aging, the uncorrected midface continues to descend. In patients who have undergone a traditional rhytidectomy, this creates a very unnatural appearance known as the lateral sweep, as described by Hamra.1 

To avoid these untoward sequelae and a face-lifted appearance,1 it is necessary to address the midface. The aged midface is the result of the descent of the malar fat pad, which creates hollowed lower lids, a skeletonized infraorbital rim, a prominent nasojugal fold, a deepening of the nasolabial fold, and a pronounced labiomandibular fold with jowling. Midface descent and aging occur in all patients, whether or not they have undergone prior rhytidectomy. In the patient who has not undergone previous surgery, the same midface aging occurs, but the lateral-sweep look does not occur because the lower face has descended.

Over the past 15 years, many approaches to the midface have been de­scribed, including the deep-plane rhytidectomy2; the composite rhytidectomy3; the transblepharoplasty subperiosteal midface lift, with4 or without5 formal canthoplasty; the transblepharoplasty endoscopic subperiosteal midface lift6; the direct suspension of the malar fat pad with sutures7,8; the transmalar subperiosteal midface lift9; and the percutaneous technique of malar fat pad elevation,10 among others.

A Daunting Challenge

With so many approaches described, it may seem daunting to tackle the midface, but the key is to find a reliable, safe technique that is sensible to the surgeon. One must clearly understand the anatomy of this region, however. This anatomical understanding of the temporal region is vital to success—and safety—in midface surgery.

Once the surgeon has an appreciation of the relevant anatomy, the choice of approach depends on his or her preferences and results. The advantages of each technique must be weighed against its limitations and potential risks.

Essentially, the parts of the face age in harmony. The brows lower, the midface descends, and jowls and neck laxity develop. In many patients, one area may age more quickly than another, but facial aging does not spare any particular region.

Therefore, it is important to address the face as a whole. The authors’ current strategy is to consider the brow and midface as a single unit and address them together. This may be the only procedure needed for patients 30 to 49 years old whose aging is seen mainly in the upper face and midface. A lower facelift can be performed subsequently.

In most patients 50 to 69 years old, however, the entire face has aged and requires a lower facelift in conjunction with a brow and midface lift. Because we consider the brow and midface a single unit, the most sensible approach is for us to correct these areas together.

The operation is performed using a minimal-incision brow-lift approach relying on tactile feedback (the “smart-hand” technique) without the use of endoscopic guidance. The midface dissection and elevation, however, are performed under direct visualization through a temporoparietal incision with the use of appropriate retraction and headlight illumination. This technique has now been performed on more than 1,000 patients over a 10-year period by one author (EFW); it was found to be safe, reliable, and effective.11

Potential sequelae and complications associated with midface lifting include temporary or permanent injury to the temporal, zygomatic, or buccal branches of the facial nerve; decreased sensation over the malar region; lateral canthal distortion; lower-lid malpositioning; temporal wasting; incisional alopecia; and prolonged postoperative edema.12–14 With judicious patient selection, attention to the appropriate surgical planes, and gentle handling of tissues, however, the incidence of these morbidities has decreased significantly.11

Start at the Brow

Five standard endoscopic brow-lift incisions are marked out, with one situated in the midline, two lateral to the midline in the paramedian position (approximately at the lateral canthus) just posterior to the hairline, and two longer incisions (located more temporally) camouflaged by the hairline and extending over a 4-cm distance above the helical crus and over the temporalis muscle and fascia.

The midline brow incision is made first, extending through the periosteum. A small, sharp, flat periosteal elevator is used to dissect subperiosteally for a distance of a few centimeters around the incision site. Posterior elevation is limited to approximately 4 to 5 cm; as more extensive dissection toward the occiput provides limited additional benefit in upward transposition of the brow. A larger, sharp, flat periosteal elevator that reduces the risk of injury to the periosteum is then introduced to elevate the central pocket down to the orbital rim to release the arcus marginalis, but no aggressive dissection of the glabellar musculature is undertaken.

After the surgical maneuvers have been completed through the midline-brow incision, the same technique of subperiosteal dissection is carried out via the two paramedian ports. Again, the sharp, flat periosteal elevator is used to carry out blind dissection down to the arcus marginalis for proper periosteal release at the orbital rim. The elevator, however, is handled only in an upward, gentle lifting motion when the elevator tip approaches within 1 to 2 cm above the supraorbital notch; this is done to avoid any paresthesias or neuropraxias that might ensue from violating the supraorbital neurovascular bundle.

With proper wound retraction using wide, double-pronged hooks, a hand drill outfitted with a 1.5- x 6-mm drill bit is used to enter the outer calvarial table at a 30° angle to the horizontal. This opening is joined by an opposing entry of the drill to form a bone tunnel through which the brow-fixation suture may be passed at the end of the case. The bone tunnel should be made in the posterior aspect of the incision, because suspension of the brow upward will cover the bone tunnel if the tunnel is created too anteriorly, relative to the incision.

Temporoparietal Incisions

The longer, lateral temporoparietal incisions are then addressed (Figure 1). Dissection is carried down through the temporoparietal fascia so that a proper tissue plane may be achieved between the temporoparietal fascia and the true temporalis fascia (to avoid injury to the temporal branch of the facial nerve). The incision should be situated approximately 1 cm behind the hairline, to lie over the temporalis muscle, and not more posteriorly; this will help the surgeon avoid transection of the superficial temporal artery and will minimize the long trajectory of dissection needed to reach the midface.

Initial dissection is performed with a large, blunt elevator over the true temporalis fascia; then, the larger, flat periosteal elevator is used to break the conjoined tendon of the temporalis muscle that divides the central and lateral pockets.

Under direct vision with a headlight and a Converse retractor, dissection is taken downward to the orbital rim with the small, sharp periosteal elevator. The arcus marginalis is then released from the superolateral orbital rim near the lateral canthus with the periosteal elevator.

The assistant places a finger along the lateral margin of the orbital rim to limit the surgeon’s dissection and to avoid excessive release of periosteum from the lateral canthus. This 1-cm cuff of periosteum around the lateral canthus is retained to avoid undesirable lateral-canthal elevation or distortion.

Again, under direct vision, the large, sharp periosteal elevator is guided downward gently to enter the superficial temporal fat pad and then to release the periosteal attachments overlying the zygomatic arch itself. This technique allows direct access to the midfacial structures. An angled periosteal elevator is used to continue the dissection inferiorly over the malar eminence to release the zygomaticus major and minor muscular attachments and the malar fat pad from the underlying zygomatic and maxillary bone (Figure 2).

Release All Structures

The dissection proceeds inferiorly over the masseter muscle until all midfacial structures are adequately released. A microporous, nonabsorbable suture is passed through the temporalis fascia and muscle just anteroinferior to the temporoparietal incision, and then it is passed through the malar fat pad with a long needle driver. The suture is pulled superiorly to test whether sufficient release of the midfacial tissues has been achieved. If not, further dissection medially and inferiorly is carried out until appropriate release of the midface is observed. The paramedian suture on the same side is tied down before the suture in the malar fat pad is fastened superiorly to the temporalis fascia.

Fixation of the paramedian suture is performed first to relieve any tension on the suture that elevates the midface, as well as to permit better brow positioning by suspending the most superior suture initially. A microporous, nonabsorbable suture is used to secure the overlying frontalis muscle through the bone tunnel in the paramedian incision.

After the paramedian suspension has been completed and the incision has been closed, the surgeon should return to the lateral temporal incision to suspend the suture already distally placed through the malar fat pad to the proximal temporalis muscle and fascia at the incision site. The vector of suspension should be essentially vertical (with approximately 15° of posterior angulation), and the suture through the malar fat pad should be situated more laterally over the malar prominence. Both actions minimize untoward distortion of the lateral canthus.

Next, the temporoparietal fascia just anterior to the temporoparietal incision will be sutured to the temporalis muscle and fascia with a microporous, nonabsorbable suture to pull the overlying brow and soft tissue superolaterally. This suture placement is undertaken twice. All incisions are closed with surgical clips. Antibiotic ointment is applied to the external incisions, and a pressure dressing is fashioned and applied.

Minimize Problems

Problems associated with rejuvenation of the upper face and midface can be minimized with meticulous attention to proper tissue handling and attention to the proper plane of dissection. Asymmetry in brow elevation may be noted by the patient postoperatively, but this is most commonly secondary to an unnoticed preoperative asymmetry.

Of most concern to patient and surgeon alike is the postoperative development of a motor-nerve or sensory-nerve deficit. The most common causes of this outcome include excessive retraction on the temporoparietal flap, dissection in an improper plane in the temporoparietal region (temporal-branch injury) or midfacial region (zygomatic-branch or buccal-branch injury), injudicious use of bipolar cautery in the region of the sentinel vessel, and injury during the midface dissection.

In addition, aggressive midfacial dissection medially toward the nasolabial sulcus has been associated with a greater likelihood of buccal-branch paresis. Peri-incisional alopecia and unfavorable scars on the scalp can be minimized through proper handling of tissues and attention to avoiding transection of the hair follicles by beveling the knife blade according to the direction of hair growth. Excessive monopolar cautery should be minimized at the wound edges, and undue tension on wound closure should be avoided.

Multiple procedures have been developed over the years to rejuvenate the midface. There is no perfect procedure that is without its own set of limitations. One of the limitations of the minimal-incision brow-lift approach to the midface (and the majority of midface techniques) is the modest improvement seen in the region of the nasolabial fold. Representative before-and-after patient photos can be seen in Figure 3. Consistent use of this technique in appropriately selected patients will provide the surgeon and patient with significant benefits and a low risk of complications. PSP

Allison T. Pontius, MD, is in private practice at Plastic Surgery Associates in New York City. Edwin F. Williams, III, MD, FACS, is the medical director of the Williams Center for Excellence, Latham, NY, and the chief of facial plastic and reconstructive surgery and a clinical assistant professor in the Division of Otolaryngology—Head and Neck Sur­gery, Department of Surgery of Albany Medical Center, Albany, NY. Alain Polynice, MD, is in private practice at Plastic Surgery Associates of New York and an assistant clinical professor in the Division of Plastic Surgery, New York Medical College, Valhalla, NY. The authors can be reached at (917) 379-8600 or [email protected].


 1. Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair. Plast Reconstr Surg. 1998;102:1658–1666.

 2. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86: 53–61.

 3. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90: 1-13.

 4. Hester Jr TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial aging using the transblepharoplasty subperiosteal cheek lift. Aesthetic Surg Q. 1996;16: 51–58.

 5. Gunter JP, Hackney FL. A simplified transblepharoplasty subperiosteal cheek lift. Plast Reconstr Surg. 1999;103:2029–2041.

 6. Williams JV. Transblepharoplasty endoscopic subperiosteal midface lift. Plast Reconstr Surg. 2002;110:1769–1777.

 7. Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91:463–474.

 8. Byrd HS, Andochick SE. The deep temporal lift: A multiplanar, lateral brow, temporal and upper facelift. Plast Reconstr Surg. 1996;97: 928–937.

 9. Finger ER. A 5-year study of the transmalar subperiosteal midface lift with minimal skin and superficial musculoaponeurotic system dissection: A durable, natural-appearing lift with less surgery and recovery time. Plast Reconstr Surg. 2001;107:1273–1284.

10. Keller GS, Namazie A, Blackwell K, et al. Elevation of the malar fat pad with a percutaneous technique. Arch Facial Plast Surg. 2002;4: 20–25.

11. Williams EF III, Vargas H, Dahiya R, Hove CR, Rodgers BJ, Lam SM. Midfacial rejuvenation via a minimal-incision brow-lift approach. Arch Facial Plast Surg. 2003;9:470–478.

12. Kaye B. A subperiosteal approach as an improved concept for correction of the aging face. Plast Reconstr Surg. 1988;82:393–398.

13. Psillakis JF, Rumlay TO, Comargo A. Subperiosteal approach as an improved concept for correction of the aging face. Plast Reconstr Surg. 1988;82: 383–389.

14. Maillard GF, Cornette de St Cyr B, Scheflan M. The subperiosteal bicoronal approach to total facelifting: the DMAS–deep musculoaponeurotic system. Aesthetic Plast Surg. 1991;15:285–289.