Aging presents in various ways at different facial areas. It usually affects the eye area first through the development of wrinkles, loose skin and herniated lower eyelid fat. Eventually the aging process extends down onto the cheek with the weight of the lower eyelid creating a clear demarcation between the eyelid and the cheek known as the palpebromalar groove.
In the Surgical Pearls section of the May 2015 issue of JAMA Facial Plastic Surgery, an article entitled ‘Short Incision Midface Lift in Lower Blepharoplasty’. In this retropective review, 80 patients by two surgeons were evaluated for their results with this lower blepharoplasty technique that provides aesthetic improvement to the aging cheek area. This modified lower blepharoplasty technique uses a short subciliary incision (mid-pupillary medially to 5mms past the lateral canthus), orbicularius muscle dissection and isolation, cheek mobilization, lateral canthoplasty/canthopexy, orbicularis muscle elevation and fixation to the orbital rim and conservative lower eyelid skin removal. The majority of patients (83%) had excellent and complications were few. The most common complication (5%) was lateral skin mounding. Only one case of ectropion occurred.
The improvement of the cheek with this technique comes from the reduction/elimination of the palpebromalar groove. This groove which appears as one ages can not be improved by non-surgical methods such as laser resurfacing or Botox injections. Injection techniques using either hyaluronic acid fillers or fat into the palpebromalar groove can be done but has a high complication rate of irregularities and contour problems. A better solution is reversal of the cause with re-elevation of the soft tissue descent and the re-establishment of a single midface convexity.
There are many midface lifting techniques that have been described. They differ by the extent of their incisions and dissection and how/where the mobilized tissues are suspended. This paper describes a more limited incisional approach that creates an orbicularis muscle flap that is sutured to the orbital rim. This is a more limited midface lift but in the right patient can be a useful facial rejuvenation procedure.
The treatment of facial aging is done by established procedures with long track records of success. These include the browlift (upper face), blepharoplasties (eyes) and the lower face. (facelift) The one area of the face to treat for sagging and loose tissue is the midface or cheek area. It is challenging because none of the traditional anti-aging facial procedures are designed to directly treat this area and the proximity of the lower eyelid also poses some anatomic concerns.
The many procedures that have been developed to lift the cheek area is a testament to the fact that there is no one universal technique that works in all cases. Cheeklifts (through the lower eyelid or from a combined temporal/inytraoral approch, malar/submalar implants, fat grafting and fillers have all been used extensively and each cheek rejuvenation method has it advocates and indications.
One of the least spoken about cheeklift methods, and also the ‘simplest’ is the preauricular hairline technique. By making an incision along the lower temporal hairline and back into the sideburn/preauricular tuft of hair, temporal skin can be removed which directly lifts the cheek tissue which lies anterior and inferior to it. This is a very powerful cheeklifting method even though it may only consist of skin removal.
The preauricular hairline cheeklift can be done as part of a facelift, after a facelift for residual cheek sagging or as an isolated procedure. Its obvious drawback is that it leaves a fine line scar along the lower temporal hairline whose visibiity depends on numerous factors. As a result, it is almost always best done in older female patients who skin is more loose with less elasticity.
Rejuvenation of the aging lower face is done well by classic facelift techniques. And rejuvenation of the upper face is also done well by traditional browlift and blepharoplasty surgery. But the intervening middle of the face, the cheek area, is far more difficult to treat with surgical rejuvenation methods due to surgical access and the facial nerves which run through the cheeks.
Cheek aging is seen by the development of eye bags, tear troughs, a prominent lid-cheek line or junction and the overall sagging or decent of the cheek tissues. A wide variety of cheek lift procedures have been described and most employ a subperiosteal approach through a lower eyelid incision. This is popular because it is a safe plane of dissection being below the level of where buccal branches of the facial nerve may lie.
In the December 2015 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Midcheek Lift Using Facial Soft Tissue Spaces of the Midcheek’. In this paper the authors describe a preperiosteal midcheek lift technique that uses the micheek soft tissue spaces by precise release of its retaining ligaments that separate the spaces. Through a lower subciliary eyelid incision, a skin only lower eyelid flap is raised. This allows the orbicularis muscle to be used as a source of suspension. Through a window into the suborbicularis muscle plane blunt dissection is carried into the preseptal space. From this space dissection is carried into the premaxillary space where the tear trough ligament can be released. Out laterally release of the orbicularis retaining ligament allows entrance into the prezygomatic space where the zygomaticofacial nerve exiting from the bone is seen. Dissection is carried in this plane up to the lateral canthal region. This dissection connects the three soft tissue spaces of the midcheek, the preseptal, premaxillary and prezygomatic spaces. Opening up these spaces allows the overlying orbicularis muscle to be used as a source of traction and suspension for the entire midcheek. The muscle is suspended to the periosteum of the lateral orbital rim to create the cheeklift. Canthopexy was done for lower eyelid support.
Over a five year period, a total of 184 patients were treated with this cheeklift technique. The vast majority of patients (96%) were satisfied with the procedure. A significant rejuvenation of the cheek with elimination of eye bags, elevation of the lid-cheek junction and the cheek prominence and improvement in the depth of the nasoabial folds were seen. Ectropion only occurred in 1% of the patients. Lid retraction occurred in 2% of the patients. Prolonged chemosis occurred in 4% of the patients.
This cheeklift technique goes above the periosteum as opposed to below it as is traditionally done. It is a safe dissection that can be done rapidly and mobilizes the cheek tissues using the soft tissue spaces between the retaining ligaments. Like all cheeklifts the risk of lower eyelid malposition and etropion can occur. Prevention through lateral canthopexies and avoiding to much lower eyelid skin removal is important.
The one facial feature that is most associated with a youthful looking face is that of the cheeks. Firm uplifted and rounded cheeks are what is seen in younger people, flat deflated cheeks are usually seen as many people age. It is the loss of cheek volume that contributes to a tired looking and aged appearance. While browlifts and eyelid surgery for the upper face and neck and jawline lifts for the lower face have been around for decades, the intervening zone between the two has caught a lot more interest of late.
Cheek and midface rejuvenation is the last facial region to receive a lot of attention from both surgical and non-surgical treatments. Numerous good options exist today including the use of synthetic implants , cheek lifts , fat injections and expanded uses of injectable fillers. While each of these cheek enhancement treatments have their advocates and critics, it is important to realize that the controversy is more about indications and less about effectiveness.
One of the first treatments for midface rejuvenation was that of silicone cheek implants, specifically the submalar implant style. By adding volume to the underside of the cheekbone, a subtle but visible lift of the midface was obtained through a combined voluminization and positional effect. Restoring fullness to the ‘apple’ area of the cheek removes the midface flatness. The submalar cheek implant has now been expanded to incorporate more of the cheek area through a new style known as the malar shell. The biggest benefit of using implants is that they create permanent volume but yet can be completely and easily reversed if needed. Any concern about implant stability or shifting is removed by screw fixation to the bone. There is never any concern about implant settling/erosion in the cheek bones. Such facial implants have proven over the years to be very safe and effective when well placed with a very low risk of problems.
While cheek lifts (midface lifts) were the rage a decade ago for midface rejuvenation, they have fallen considerably out of favor. Beyond the complication risk of lower eyelid deformity (ectropion), the concept of lifting up fallen or sagging cheeks has not proven to be effective or sustainable alone over the long -term. Cheek lifts, as part of an extended blepharoplasty, still have a midface rejuvenation role but they need to be combined with the addition of volume through the concurrent insertion of cheek implants or with fat injections.
The real revolution in cheek enhancement has been through the use of injectable fillers. This has not only made it possible for a wide array of practititoners to engage in midfacial augmentation but the number of filler options is considerable. With injectable fillers, it is theoretical possible that just about every patient over 40 years of age could benefit by some degree of volume addition. Younger patients may only need a single syringe or less while older patients may need multiple syringes over broader areas.
The injection location for filler placement is based on an understanding of aesthetic cheek anatomy. A youthful cheek has a three-dimensional shape with the greatest projection producing a light reflex at the apex of the cheek. This point is often described by the intersection of lines drawn down from the lateral canthus of the eye to one drawn from the corner of the mouth to the tragus of the ear. But the injector must use an artistic assessment as to what looks best for each patient.
While many fillers exist for midface injection, the hyaluronic acid-based (HA) fillers are associated with the best safety profiles. The more robust HA fillers, such as Juvederm, works best as their higher G prime (stiffness) allows the cheek tissues to be lifted effectively with less volume than other fillers. A game changer in cheek fillers has been the introduction of Voluma late last year. As an extension of the HA product Juvederm, Voluma was specifically made and studied for the cheeks/midface. Its unique properties allow it to lift tissues effectively and it persists for over a year.
Fat injections has grown tremendously in popularity over the past decade and the cheeks is one of its prime targets in the face. It is a treatment option between injectable fillers and synthetic implants. It offers a more less invasive option than implants but with the potential for a longer-lasting result than injectable fillers. The key variable in this equation is the unpredictability of how well injected fat survives. While the cheek is one of the most favorable areas for fat survival in the face, it is still wildly unpredictable. The appeal of its natural composition is counterbalanced by the risk of partial or complete resorption.
When factoring all the advantages and disadvantages of every cheek enhancement option, it is a balance of the magnitude of the problem vs. how much effort one wants to invest in the treatment. For the younger patient with early facial aging concerns, injectable fillers are the best treatment unless they are having surgery for other aesthetic issues (e.g., rhinoplasty, breast augmentation, liposuction). Then fat injections would be worth the effort in the hope for a long lasting result. For the older patient with more moderate to more advanced midfacial aging, implants are the best treatment as other facial rejuvenation procedures are being simultaneously done. Fat injections are a good choice for those patients who are opposed to implants but they should not expect the same predictable volume result.
There are many signs of facial aging but most people are usually concerned with what happens around the eyes first. The classic presentation of periorbital aging is a progression of tissue changes including excess lower eyelid skin, protruding orbital fat (bags), lower eyelid instability and the falling of the adjacent cheek tissues. (malar descent) While the upper and lower eyelid ages similarly in any person, the scope of the lower eyelid is actually bigger if you include the surrounding cheek regions. Thus the lid-cheek region is a frequent target for facial rejuvenation efforts.
Traditionally, these aging changes were managed by a standard lower blepharoplasty operation which involved an elongated lower eyelid incision and removal of skin and fat. While this basic operation still works well for many lower eyelid concerns, it is known to have potential lid malpositioning problems with risks of ectropion (lid sagging) and separation of the globe-lid intimacy. The precarious suspension support of the lower eyelid is prone to being disrupted by incisional placement, delamination of the lower eyelid tisues with lack of orbicularis muscle integrity near the lid margin, unrecognized weakness of the lateral canthal tendon and over-resection of lower eyelid skin.
One lower eyelid rejuvenation trend that has become commonly used over the past decade, partially as a response to the risk of ectropion, is the transconjunctival approach. Avoiding skin resection and an external lid incision, herniated orbital fat can be removed or repositioned through button hole sized incisions on the inside of the lower eyelid. While protruding orbital fat was once uniformly removed, it is now frequently being preserved and used as a filler for tear troughs, nasojugal grooves and creating rim augmentation to smooth out the lid-cheek junction. Because the blood supply to the overlying lower eyelid skin is preserved, skin resurfacing for wrinkles can be done with lasers or chemical peels.
One evolution of lower eyelid rejuvenation, which is the opposite of a transconjunctival blepharoplasty, is the extension into simultaneous cheek rejuvenation as well. These so-called cheek or midface lifts are a collection of procedures whose technical differences can be as diverse as the surgeon who performs them. Lifting up sagging cheek tissues through a full lower blepharoplasty incision and securing to some location along the zygomaticorbital bone, or even higher to the temporal and forehead regions, allows them to sit back up or higher on the cheek bone. But because it is a more invasive and extensive procedure with much wider tissue dissection than a lower blepharoplasty, it ironically has an even higher risk of ectropion and lower lid scarring problems if not executed to technical perfection.
While it can cause it, these cheek lifts can also be used to treat lower eyelid retraction problems as well. Lifting and supporting the surrounding cheek tissues can relieve the tension on the repositioned lower eyelid at the lateral orbital wall. Releasing the lower eyelid scar, retightening or remaking the lateral canthus and some cheek tissue release and resuspension can be very effective for getting the outer aspect of a retracted lower lid back up against the globe.
As one ages, the entire face changes. Some parts of facial aging are more obvious than others as the face does differentially age. The forehead, brows, eyes, mouth, jawline and neck are all areas whose aging is well recognized. The aging of the midface and cheek areas, however, has only become more recently recognized.
With the aging process, the fatty tissue that normally drapes over the cheekbones can begin to sag. The result is less prominent cheekbones, and a droopy fold of skin and fat between the nose and the cheek (the nasolabial fold). The sagging cheek fat can also alter the appearance of the lower cheek. For example, bagginess of the lower eyelids often becomes more apparent after the fat of the upper cheek begins to sag. This in essence ‘unveils’ the bagginess of the lower lids, which have always been there. In addition to sagging of the skin and fat of the midface, there is also volume loss in the cheek due to loss of fat and muscle.
A number of cheek lift or midface lift procedures exist to address this aging area. The goal of all of them is to lift up droopy cheek tissue over the cheekbone restoring the more prominent youthful contour, improving the tear trough and bagginess of the lower lids, and softening the undesirable cheek fold. Fundamentally, they may be divided into lifting approaches vs volumetric addition. In some cases, they may even be done together.
Lifting approaches aim to reposition the sagging fat of the cheek over the cheekbone to restore the youthful fullness of the cheeks. Such midface lifts use differing access including the lower eyelid, scalp, and temporal incisions using open incisional or endoscopic instrumentation. Implants have also been devised to provide less invasive options including suspension sutures and bone-anchored lift devices. The plethora of differing lifting approaches suggests that no one of them is universally successful.
Contrarily, cheek implants have also been used to help create a degree of cheek lifting. By placing an implant through the mouth onto the cheek bone, some fullness is added to the volume-depleted cheek and the cheek tissue on top of the implant is pushed upward. While not creating as dramatic effect as a lifting procedure, it is far simpler and with fewer complications. This cheek lift approach, using a specially designed submalar implant which fits on the underside of the cheek bone, has been around for nearly two decades. When used in the right patient and properly sized, it can have a good cheek enhancement effect. But it is also easily overused and overdone (too large a size) as older celebrity faces are rife with examples of odd-looking and peculiar cheek prominences due to oversized implants.
Given the choices between cheek lifts and cheek implants, which is the most helpful for cheek rejuvenation? The answer is no one of them is best for all patients. Over the years, I have used almost of all of them in my Indianapolis plastic surgery practice….and have also seen and learned the downsides to each of them. Midface or cheek rejuvenation is as much an art form as almost any area of anti-aging facial surgery. Given the potential complications that can occur with lifting procedures, most specifically lower eyelid ectropion, their use should be reserved for the most severe sagging cheek problems. More moderate cases with less prominent cheekbones may benefit with a small to moderate-sized implant. In all cases, moderation is the key…not too much lift or too big of an implant. The midface is one area that does not look good overdone and is easy to do.
The cheek lift is a plastic surgery procedure designed to lift and tighten the cheek and a little of the jowl area. It is also referred to as numerous other names such as a short scar facelift, S-lift, J-lift, and trademarked names such as Lifestyle Lift and Quick Lift which are variations of the basic cheek lift procedure. It is suited for those who are looking for just a perk-up or light facial lift rather than a full facelift.
The cheek lift is best suited for younger patients (< 50 years of age) who have adequate or strong cheek bones, not a lot of loose skin, minimal jowling and maybe a little excess fat in the central neck area. This procedure is not a replacement for a cheek-neck lift or facelift if there is a lot of excess neck and jowl skin and fat.
For the cheek lift, thin incisions are made inside of the ear for women or in front of the ear for men . The incision is then carried up into the hairline, well back of the sideburn or temporal hairline. These incisions do, of course, result in scars although they are well-concealed within the hairline and inside of or in front of the ear. The skin in front of the incision is lifted after dissecting deep near the cheek area. This enables the loose cheek skin to be lifted up and back. I usually perform some SMAS elevation and imbrications as I don’t want to the long-term results to rely exclusively on the skin closure. These maneuvers provide for a long-lasting, natural results without a “pulled-back” look. Liposuction of the neck and other procedures such as blepharoplasty are often performed at the same time for a more complete rejuvenation or anti-aging effect. The cheek lift alone takes about an hour or so to complete.
Recovery after a cheek lift takes about a week at which time one can look fairly ‘non-surgical’.Swelling and bruising are quite minor. Showering is permitted the very next day with washing and blowdrying of hair. One can return to work in about one week but should wait for about two weeks before undertaking strenuous activities and exercise. The stitches are often dissolveable and require no removal.
The cheek lift is a nice gentle procedure that really is easier to go through and recover from than most would think. Do not confuse it with how most people envision as a facelift, which is a neck procedure primarily. It works best when it is combined with other facial procedures of which the list could be numerous nips and tucks, injectable fillers, or facial implants. In my Indianapolis plastic surgery practice, I find that it works well with a lot of other facial rejuvenation procedures and its effect is enhanced by doing so.
The earliest signs of facial aging often appear in the midface area, a triangle defined by the inner and outer corners of the eye and the corner of the mouth. There may be loose lower eyelid skin and bulging fat bags. The line of demarcation between the lower eyelid and the cheek (lid/cheek junction) begins to drift lower. In addition, the cheek tissues slowly fall downward, making the nasolabial fold more prominent. The aging midface area can look a little like wax melting off a candle.
Traditional plastic surgical procedures are ineffective in correcting these midface problems, even when a lower blepharoplasty and facelift are done at the same time.. The classic lower eyelid tuck could remove excess skin and fat bags, but could do nothing with the fallen cheek tissues. The traditional facelift, or neck-jowl lift, offers virtually no changes in the cheek, nose, and upper lip area despite that many patients believe that it will.
As a result, the midface lift (not a facelift) procedure has emerged to correct this historically unreacheable aging area. The midface lift is done through an incision immediately below the lashes of the lower eyelid and extends slightly out from the outer corner of the eye in a crease line. By dissecting down to the cheek bone, the fallen cheek tissues are separated from the bone, lifted vertically, and put back up in a higher position on the cheek bone. Excess lower eyelid skin and fat can also be removed if necessary after the cheek tissue is repositioned. (which is almost always needed) The eyelid incisions are closed with dissolving sutures under the lashline and very small sutures out into the crease skin.
One of the keys to a good and stable midface lift is where to secure the cheek tissues which are lifted up by sutures. Here is a point of plastic surgery debate and different surgeons have their own methods. In my Indianapolis plastic surgery practice, I prefer to use a high cranial suspension point which is immediately vertical to the direction of upward pull. This requires a small incision in the scalp above the temporal area.
Midface lifts result in a smoother lower eyelid, a fuller cheek bone prominence, and a less deep nasolabial fold. Many patients will look like they have had a small cheek implant placed. Such changes created a less tired look and a face that has a more youthful and full appearance. Remember that this operation is not a facelift, it will not improve the neck or jowl area. It may frequently be done at the same time as a facelift to create a more complete facial rejuvenation.
A midface lift is often done with upper and lower eyelid tucks (blepharoplasty) at the same time, or even a facelift. As a result, the eye and cheek area will get fairly swollen and bruised after and the corners of the eye will feel tight. One will not look fairly reasonable in most cases until about 7 to 10 days after surgery. (non-operated look) One should be capable of returning to sedentary-type work – perhaps with some camouflage makeup – within a week after surgery. More vigorous activites must usually await three to four weeks until one is ready.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.