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.
While facelift surgery is often viewed as a total facial rejuvenation procedure, in the truest sense of the term it is really a lower facial surgical procedure. (neck-jowl lift) And while it has numerous variations and surgeon advocates for them, the fundamental techniques for doing it are fairly well accepted. The same can be said for the upper part of the face in regards to browlift surgery. But rejuvenation of the middle part of the face, the midface or cheek lift, has much greater controversy in both indications for it and surgical techniques to do it.
While the midface does get some mild rejuvenative effects from browlift and lower facelift procedures, more profound effects require a direct approach. In considering a midface lift the single most important questions are the vector that the tissues needs to be suspended and how to do it. Such considerations have led to a wide variety if espoused midface lift techniques none of which have been shown to provide unequivocal outcomes.
In the May 2015 issue of the journal Plastic and Reconstructive Surgery, an article entitled ‘Midface Rejuvenation: A Critical Evaluation of a 7-Year Experience’ was published. In this paper the authors review their midface lifting experience in 350 patients over a 7 year period. It should be noted that the majority of the patients (73%) had a midface lift combined with a facelift while the minority (27%) had it as an isolated procedure. Two basic midface lift procedures were used, a superolateral vector with temporal suture suspension or a superomedial vector with bone fixation to the inferior orbital rim. The results of both techniques was assessed improvements in the malar eminence, nasojugal groove, nasolabial fold and jowl areas after 24 months. The midface lift with temporal anchoring more effectively treated the malar eminence while the midface lift with orbital rim fixation more effectively treated the nasojugal groove.
While the midface lift has been labeled as a ‘problematic’ procedure that is prone to a significant risk of lower eyelid problems, this large patient series showed high satisfaction rates. They did demonstrate that there is significant swelling around the eyes that took 2 to 3 weeks to get a lot better and really a full two months for a complete recovery. This is a critical issue to point out to patients before surgery as weeks of an abnormal and distorted appearance can be very distressing to most patients. In short a midface lift has a longer recovery than a lower facelift due to its periorbital location.
This paper also demonstrates that the vector of a midface lift needs to be individualized for each patient based on the most pronounced sagging area. It is no surprise that a superolateral vector of suspension works better for lateral orbital areas while a more superior vector improves the medial orbital sag. The authors did not address that a combination of superolateral and superior suspension can be used in the same patient if so indicated.
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.
Rejuvenation of the aging face has well established methods for correcting the upper (browlift) and lower face (lower facelift/necklift) that produces consistent and satisfying results. But the face does not age in just individual subunits and the midface has similar aging issues that are uniquely different. Sagging cheeks, lower eyelid hollowness and lines and folds under the eyes present challenges for successful rejuvenation.
The development of midface rejuvenation techniques has historically lagged behind that of the upper and lower face. Only in the past decade has the concept of midface lifting emerged. The vector of the midface lift is different than that of a facelift being more vertical than oblique in orientation and more closely resembles the direction of a browlift. But it has been associated with significantly more complications and dissatisfaction than either browlifts or facelifts.
The factors that contribute to midface rejuvenation complications are several fold. First, most midface lifting techniques go through the lower eyelid and require resuspension after the tissues are lifted. This places the lower eyelid at risk for sagging or ectropion due to the tension placed on it and the very delicate suspension system of the lower eyelid which is easily disrupted. Secondly, where to attach the lifted cheek tissues to is limited and adequate bony support may be lacking.
As a result of this midface conundrum, a wide variety of open and endoscopic midface lifting techniques has developed. There is no consistent midface rejuvenation technique and this has lead to a lot of confusion on the part of both surgeons and patients alike.
To aid surgeons in midface analysis and in the selection of the most successful rejuvenation strategy, a paper on this topic published in the March 2013 issue of the journal of Facial Plastic and Reconstructive Surgery. A retrospective review was done on 150 patients who had midface rejuvenation procedures done by a single surgeon. The procedures included cheek implants, fat injections, limited and full midface lifts and facelifts. The vast majority were women (93%) with an average age of 51 years as would be expected. About one-third of patients had more than one treatment for their midface aging. Patient dissatisfaction in this study was 14%. Fat grafting alone had the highest rate of dissatisfaction of all treatments. The rate of patient dissatisfaction was associated with malar hypoplasia (skeletal deficiency) and loss of skin elasticity.
What makes midface rejuvenation unique from a facelift is that the degree of skeletal support is significant. No matter how well the cheke tissues are lifted, failure to achieve an aesthetically pleasing or a sustained result is doomed if the cheek bone does not have adequate projection to support it. The use of cheek volumizing through implants is needed in such cases. When the cheek skin has poor elasticity, pulling up alone again is inadequate and adding skeletal support needs to be considered.
The midface is the most difficult part of the face in which to reverse the effects of aging. While the upper face (forehead) can be very successfully treated by different forms of a browlift and the lower face (neck and jowl) with facelift variations, improving sagging cheeks poses different challenges. The presences of the eyes and the bony orbit prevents a straightforward upward vector for soft tissue re-suspension and easy incisional access.
While the cheek tissues sag and falls vertically, any method of soft tissue re-suspension must be in an oblique and not vertical vector because of the eye above it. In addition, the lower eyelid and its rather delicate suspension system holds it uptightly against the eye. While eyelid incisions are commonly used for midface lifts, they definitely pose risks for lower eyelid sag problems if any tension is placed upon them or they are not meticulously put back together.
This is why the endoscopic approach for midface lifts can often be the best and safest approach. Through a combination of a temporal hairline incision and a mucosal incision inside the mouth, an uncomplicated dissection can be done in the subperiosteal plane. Such an approach avoids the problems associated with eyelid incisions and potential postoperative ectropion. Dissection between these two points is joined over the body of the zygoma. The wide connection between the temporal and intraoral pockets allows for tissues to be lifted for a volumetric change at the zygomaticomaxillary point.
One complement to a midface lift is cheek or malar augmentation. There are two approaches, synthetic or a natural source of cheek augmentation. Before suspension, a small cheek implant can be used to add further volume at the height of the existing cheekbone. It would be important to screw this implant into position given the wide open tunnel from the endoscopic dissection. The other option that I have used in some cases would be to use the buccal fat pad as the implant. By mobilizing it from its submalar location, it can be draped up over the cheek by an additional suture passed up to the temporal region.
In the world of facelifting, emphasis has been finally placed on rejuvenating the midface and improving the eyelid-cheek interface. Unlike other areas of facial rejuvenation, however, there are real risks from problems caused by incisions to do the procedure. This makes doing a midface lift using non-eyelid incisions appealing if possible. A lower blepharoplasty can be done with the midface lift and often some skin removal may be necessary as the cheek tissues are pushed upward.
Lifting of aging and sagging facial tissues is often perceived as a facelift. In reality, a traditional facelift only affects the lower third of the face…the neck and jowls. That leaves out the two other major facial areas which can be lifted, the forehead (brows) and cheeks. Browlifts are well known and very effective facial rejuvenation procedures whose numerous techniques and methods are well established. Browlifts are often done in combination with a facelift. The cheek area, while aging as much as the brows and the neck, does not have a simpleand consistently effective surgical lifting procedure.
Cheek lifts, also known as midface lifts, are intended to lift sagging tissues that were once on top of the cheeks. When the soft tissue falls off of the bony cheek due to loosening of its ligamentous attachments to the skin, it creates what are known as malar festoons. These are bags or bunching of tissue that often creates a ‘double bubble’ look to the midface. Or the midface can look like wax melting off of candle. Most people think that a facelift or a browlift will somehow correct this cheek sagging but it will not.
Midface lifts are relatively new compared to facelifts and numerous techniques have been used. The fundamental midface lift approach can be ascertained based on the vector of pull and incisional access. The traditional midface lifts is done through a lower eyelid incision and pull the cheek tissues directly upward. When using this technique, I will fix the cheek tissues to a cranial fixation point directly above a vertical line up from the cheek. This is a very powerful method for lifting sagging cheek tissues but involves manipulation around and through the eyelid. The eyelid is very unforgiving and numerous complications can result. Eyelid deformities, particularly ectropion, is not rare with this type of midface lift. This cheek lift requires absolute precision and is very unforgiving of any slight technical deviation.
An alternative and less problematic approach is that of the temporal cheek lift. The incision is right at the junction of thepreauricular and temporal hairline. By placing it here, the hairline will not be shifted upward and the delicate lateral eyelid area is completely avoided. Skin flaps elevated for about an inch or inch and a half downward so that its pull lifts the cheek tissues. This is then combined with the use of barbed sutures or threads which are inserted underneath the skin flaps. They are directly toward the sagging cheeks and then tied together to further lift the cheeks. The combination of the skin pull and the barbed sutures creates a very nice cheek tuck-up. The excess raised skin, now lying over the incision is trimmed and closed.
This temporal cheek tuck-up has numerous advantages including ease of execution, lack of any problems in the eye area, and very minimal recovery. It can be performed in the office under local anesthesia. Its disadvantage is that it is not as powerful as the cranially-directed midface lift so patient selection and expectations are critical. I have found it useful for those patients with more mild forms of cheek sagging, after a facelift procedure, and when a conventional midface lift needs further improvement.
Recent internet blogs purport that Sarah Palin has had some plastic surgery done recently. Using some apparent inside information, it is stated that she had a ‘nasolabial fold lift, cheek implants, midface lift, eyebrows fixed and a sideburn graft.’ A series of photographs are shown which are supposed to support these contentions.
Normally, I wouldn’t waste valuable computer time on a topic that, while interesting to some, doesn’t add any facts to those truly interested in what plastic surgery has to offer. And there are lots of tabloids, websites and even TV shows that analyze celebrities and what they may have had done. But there is some educational value in assessing some of this content to separate procedures that do exist from those that don’t. And when and why they are used.
I will preface these comments by saying that I have no knowledge of whether Sarah Palin had plastic surgery or not. Nor it is this a negative commentary on those that purport that she did. Nor am I a supporter or detractor of hers.
A ‘nasolabial fold lift’ is a misstated procedure. The deepening of one’s cheek-lip groove, also known as the nasolabial fold, is a function of one’s cheek tissues beginning to sag downward against upper lip tissues which do not sag with age. A deep or prominent nasolabial fold can be softened with injectable fillers and this simple office procedure is one of the main uses of filler products.
Cheek implants are used to highlight cheek and midfacial prominences and are often overdone and easy to spot. But Sarah Palin is about the last person who would need them. She has the congenital benefit of a naturally strong facial bone structure with high cheek bones. This is one of the main reasons for her facial attractiveness.
Midface lifts are designed to lift sagging cheek tissues. They can be done open or from an endoscopic approach. As previously mentioned and for reasons similar to that of cheek implants, there is nothing in Sarah Palin’s photos that would remotely suggest she would benefit from such a procedure. An open midface lift involves incisions across the lower eyelid and sometimes inside the mouth. When properly used, it is a very effective procedure but it can cause problems of prolonged swelling and potential lower eyelid problems. An endoscopic midface lift is different as it is done from incisions up in the scalp and is used when the midface sagging is less severe. She may have had this done but the benefits of doing so, and the results obtained if done, are certainly suspect.
The ‘eyebrows fixed’ procedure could very well mean that an endoscopic browlift was done. This is a very frequently used procedure done from behind the frontal hairline. It can lift sagging or flat eyebrows and create more of an eyebrow arch and open up the eyes. But injectable Botox can create in some patients very much of the same result. While the pictures later in the year of Sarah Palin show higher arched eyebrows, that photo was taken from a different angle and the facial expression is not the same. More on photos later.
The alleged ‘sideburn graft’ procedure does not exist. There would be no reason to graft a sideburn and skin grafts are never used in any form of facial plastic surgery. What they undoubtably mean is that the sideburn has been altered. This would be due to a form of a facelift known as a limited or mini-facelift, also called a Lifestyle Lift by some. This simple tuck-up procedure uses an incision from inside the ear, around the earlobe below, and up into the hairline above. The one side view photo does show a very straight back part of her sideburn (preauricular tuft of hair) which is a likely sign that it is from an incision. There is also a lump in front of her ear, which is certainly unnatural, and could be a small residual fluid collection or swelling from the procedure. This ‘mini-facelift’ is a common little jowl tuck-up method that is best used when onlya small amount of jowling (early facial aging) is present. This would be believeable from my perspective on her as, at best, she would only need such a limited procedure.
A comment on photographs.One thing that plastic surgeons are acutely aware of is the influence of photographs on how the face can look.You can take a patient, change the lighting and angle, and one can look like they have had some procedure that has changed their appearance. It is for this reason that the sentinel journal of plastic surgery, Plastic and Reconstructive Surgery, has specific photographic standards so that the results of procedures can be accurately judged. Many commercial cosmetic products and devices take advantage of these photographic nuances to promote sales.
Did Sarah Palin have plastic surgery? Maybe… but the procedures would not be as many or of the magnitude that have been suggested. She may have taken advantage of some of today’s minimally-invasive techniques such as an endoscopic browlift and a tuck-up facelift. The recovery from these would be very quick, less than 7 to 10 days, until one is able to be back in front of the public again.
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.