Well-planned and well-performed surgery is the key to facial rejuvenation

Analysis of the aging face requires attention to the midface and its influence on a person’s overall appearance. Certainly, avoiding this central component to facial aging detracts from a harmonious surgical effort to return to a youthful, balanced face.

Historically, early attempts at facial rejuvenation had little, if any, effect on the anatomical area that frames the midface. Peripheral approaches used in facelifts could not be expected to produce changes far medial to the areas accessed by laterally placed incisions. They simply were too far from the target area, and the direction of pull was found to be ineffective and, in fact, inappropriate for improving the appearance of the midface.

Later, when all of the components of the aging face were analyzed, it became obvious that central facial rejuvenation could not be obtained via traditional methods. Various approaches and planes of dissection were described in an attempt to access this area and perform a surgical correction that was safe, reliable, and consistent with panfacial rejuvenation. 

As in any surgical plan, an accurate diagnosis must precede the development of an approach that can reliably be expected to obtain the desired results. Therefore, the anatomical elements of the aging midface must be thoroughly examined and documented. The relevant structures and factors are shown in the box below.

Midface Rejuvenation:
Structures and Factors
Lower eyelids Tarsoligamentous support
Amount of redundant skin Prominence of the arcus marginalis relative to the orbital fat
Orbicularis oculi muscle thickness Prominence of the tear-trough deformity
Suborbicularis oculi fat thickness Position of the malar fat pad
Distribution of subseptal fat Bony support: the zygoma and maxilla
Quality of the skin Nasolabial fold and crease, including the thickness of the fold and the depth of the crease

The proposed surgical plan must be thoroughly discussed with and accepted by the patient. Patients must understand that more aggressive surgical maneuvers deliver impressive results, but require longer recovery periods. Patients must allow enough time to recover and may need to adjust their schedules accordingly.

In discussing the surgical alternatives, I adjust my template for panfacial rejuvenation to the patient’s age. Only younger individuals (under age 45) can achieve the results that they are seeking with procedures limited to the midface. Older pa­tients typically re­quire correction of ptotic eyebrows, re­dundant upper-eyelid skin, the jawline, the neck, and possibly the perioral area for a harmonious rejuvenation of their faces. The situation is analogous to redecorating a living room: Painting and recarpeting without re­placing an old sofa or chairs detracts from the room’s appearance.

The Younger Set

There is a subset of patients under age 45 who, because of strong bony and soft-tissue support, show almost no aging along the jawline and neck, and have good brow position, attractive upper eyelids, and a youthful perioral area. These patients may also have full malar eminences and do not need skeletal augmentation. Patients with a prominent arcus marginalis or a tear-trough deformity can be treated using an isolated procedure performed through the lower eyelid. The procedure involves repositioning the orbital septum and, when indicated, redraping the periorbital fat over the orbital rim. This improves the lid–cheek junction and the tear-trough deformity and is the less aggressive form of a midface lift.

When there is descent of the malar fat pad and elongation of the lid–cheek junction, the cheek can be elevated using a sling of orbicularis oculi muscle as a handle to elevate the malar fat pad. Some patients merely require the placement of an alloplastic implant for the malar and submalar areas to rejuvenate the midface. They do not show a prominent arcus marginalis or a tear-trough deformity. Rather, they present with midface flattening because of poor skeletal support that was always present.

More Aggressive Maneuvers

Many patients above age 45 require more aggressive surgical maneuvers to obtain the desired result. In addition to an endoscopic brow lift, with or without an upper-eyelid blepharoplasty, temporal-access and buccal-access incisions can be made to the midface to reposition the entire soft tissue (including skin, orbicularis oculi muscle, other muscles, suborbicularis oculi fat, superfical musculoaponeurotic system, and periosteum) at a higher level. (See the sequence in Figure 1.) The results of this powerful procedure have, in my experience, lasted many years.

It is true that the periosteum probably does not age. However, raising this nonmobile structure repositions the origins of the zygomaticus major and minor muscles, pro­ducing a shortening of the lid–cheek junction and providing a youthful appearance. At the same time, when indicated, redundant lower-eyelid skin can be safely and conservatively excised, along with periorbital fat if necessary. En­suring adequate lower-eyelid support incorporating a muscle sling at the lateral canthal area is routine in cases in which more than a “skin pinch” lower-eyelid blepharoplasty is performed; this should prevent lower-eyelid malposition (Figure 2, page 22). In cases of true horizontal-eyelid laxity, the eyelid may require tightening with a full-thickness wedge resection.

The box at the right highlights important elements of postoperative care. Frequent office visits are necessary during the crucial healing period from day 1 to day 14. Occasionally, secondary procedures are required, such as carefully excising redundant lower-eyelid skin (if observed after the edema has subsided) with the “skin pinch” technique. A waiting period of 3 months is suggested to allow settling of the soft tissues, which may influence the amount of lower-eyelid skin to be removed. The results for one patient are shown in Figure 3 (page 22).

When an accurate diagnosis is made, a plan is developed by the surgeon and agreed to by the patient, the procedures are meticulously performed, and follow-up care is adequate, the midface lift is an important, safe, and reliable component to surgical rejuvenation of the aging face.

Malcolm D. Paul, MD, FACS, is in private practice in Newport Beach, Calif. He can be reached at [email protected].