Primary goal: Elevation and tightening of the soft tissues (primarily fat) 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 "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" may be accomplished during blepharoplasty without much added manipulation.
Operative technique: One midface lift technique is summarized, performed through a lower eyelid incision: The skin is incised just below the eyelid margin along its full length and slightly beyond into the lateral canthus. The exposed orbicularis muscle is incised along its length in a similar fashion. A skin-muscle "flap" is lifted off of the underlying orbital septum using blunt dissection with cotton-tipped applicators and sharp dissection with scissors. The skin-muscle flap dissection extends downward over the entire lower eyelid to a level approximately even with the orbital bony rim. Excess fat is either removed or repositioned. An incision is made through the periosteum (lining of the bone) just beneath the orbital rim and carried somewhat laterally. The cheek periosteum is lifted off of the bone by blunt dissection over a wide area extending from just below the orbit rim to a level approximately level with the nostril, at which the periosteum is cut thus allowing the attached cheek to become mobile. The lower eyelid lateral canthal attachments are reinforced by any of a number of techniques. The tissue in the area of the temporal cheek fat (SOOF) is grasped with forceps and lifted upward towards the lateral canthus and temple, where it is firmly sutured to underlying periosteum (lining of the bone) and/or dense muscle fascia of the temple. Any excess eyelid skin and orbicularis muscle are then trimmed, and the skin incisions are closed. Since the loosened periosteum and overlying cheek tissue are mobile, the net effect is to lift the entire cheek upward and towards the temple, thus repositioning it to a more youthful position.
Variations: There are a number of very different surgical approaches, each with its own set of strong advocates. The midface may be lifted from incisions made:
on the front of the lower eyelid (transcutaneous), on the back of the lower eyelid (transconjunctival), from within an upper eyelid blepharoplasty incision, from inside of the mouth (buccal), from the temple behind the hairline, over the periosteum (bone lining), under the periosteum, with or without the use of an endoscope, or, most simply, through tiny skin incisions used to place thick suture as a cable.
Such a diverse range of approaches suggests that there are built-in limitations to each method and that the operative technique is still evolving.
Advantages: Midface lift produces a more natural appearance (less pulled) around the cheek and mouth than with a "classical" face lift, which pulls tissue more towards the ear. Lifting the cheek upward restores a more youthful contour that is lost as the cheek descends under the influence of gravity. "Cheek bags" that are not helped by "pure" blepharoplasty respond well to SOOF lifting.
Limitations: In most patients, the improvement from a midface lift is subtle, and so the procedure is typically employed as as "add-on" to a more definitive operation 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). 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.
Care and recovery: Because of the extensive dissection, swelling and bruising may be pronounced; noticeable cheek and eyelid swelling may persist for as long as three months after surgery. Younger patients may find such a lengthy recovery period difficult to fit into an active work schedule.
Risks and complications: In addition to prolonged swelling, distortion or puckering in the region just beyond the lateral corner of the eye is not uncommon. Some techniques involve the removal of skin from just below the lashes of the lower eyelid, a step which could create future problems (ectropion or lid retraction) once the upward pull of the midface lift is eventually lost with time. A midface lift is, comparatively, not an easy operation for the surgeon; dissection is extensive and proper suture placement may be challenging.
Comments: Midface lift is an operation still in a state of flux. There are no long-term studies to document how long the elevation may last, but early indications suggest longevity on a par with traditional face lift (as long as the fixation of the lifted cheek tissue to the periosteum is firm, which may not always be the case in the "simplied" versions of the operation). We have treated two patients referred for lower eyelid reconstruction who underwent midface lifting only to have the cheek fall back down within a few months of surgery and take the lower eyelid with it. SOOF lift (a less aggressive procedure directed primarily at repositioning a single fat pad of the upper cheek rather than the entire midface ) is a helfpul addition to the blepharoplasty surgeon's repertoire of adjunctive procedures.
