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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.

Dr. Barry Eppley

Indianapolis, Indiana

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