How Can I Address Midface Descent and Volume Depletion?
Roger A.
Dailey,
MD, FACS
What is the role of the midfacial tissues in supporting the lower eyelid? What can be done to address aging changes of the midface at the time of lower blepharoplasty?
Patients who need or request improvement of the periocular region may benefit from surgery to address volume depletion and descent of the midface. Although these changes can occur for a variety of reasons, the focus of this discussion will be on involution midface changes. A complete understanding of the involved anatomy will then allow the surgeon to choose from a myriad of treatment possibilities. The importance of an informed patient with realistic expectations in achieving a successful outcome should not be underestimated.
The 2 main factors that occur with aging of the facial soft tissues are descent and deflation. Descent has long been considered the main factor in aging. Many surgeries have been described to “lift” the face. More recently, surgeons have come to understand that loss of volume occurs with aging. This too should be addressed to achieve better aesthetic and functional results. Indications for surgical repair include cosmetic correction of midface volume loss relative to the lower face, lower eyelid retraction or ectropion (especially cicatricial), and facial muscle weakness with paralytic ectropion and midface descent.
Correction of Midface Descent
The midface extends from the lower eyelid margin approximately at the level of the root of the nose to the inferior aspect of the cheek at approximately the level of the nasolabial angle. The basic anatomy of this area is shown in Figure 43-1. The subcutaneous fat overlying the malar eminence is referred to as the suborbicularis oculi fat pad (SOOF).1,2 The surgical approaches to the midface (prezygomatic area) are shown in Figure 43-2. This area can be approached from 4 different routes: 1) superiorly via a transconjunctival inferior fornix incision, 2) temporally via the temporalis fossa, 3) inferotemporally concurrent with a superficial musculoaponeurotic system (SMAS) facelift procedure, or 4) inferiorly via an intraoral mucosa incision in the superior gingival sulcus.3
Figure 43-1. Generalized anatomy of the midface region. Make particular note of the orbitomalar ligament, zygomatic-cutaneous ligament, and the SOOF.
Figure 43-2. The midface (prezygomatic area) can be approached from 4 different routes: 1) superiorly via a transconjunctival inferior fornix incision, 2) temporally via the temporalis fossa, 3) inferotemporally concurrent with a SMAS facelift procedure, or 4) inferiorly via an intraoral mucosa incision in the superior gingival sulcus.
In general, the more midface elevation and volume needed, the more extensive the procedure. The SOOF often descends with aging and can lead to a visible soft tissue depression over the inferior orbital rim, which is referred to as a “tear trough deformity” (Figure 43-3). This often needs to be addressed at the time of lower blepharoplasty, which can be combined with midface lifting. In aesthetic patients requiring mild elevation and volume, a lateral canthal incision with swinging lower eyelid flap approach can be used. Preperiosteal dissection over the face of the maxilla results in release of the orbitomalar and zygomatic-cutaneous ligaments, which then allows adequate mobility of the SOOF. Two 3-0 monocryl sutures are then used to anchor the SOOF to the intermediate temporalis fascia just above the zygomatic arch and periosteum overlying the zygoma. Excess orbicularis can be resected and then further suspended to the periosteum with absorbable suture laterally (Figures 43-4 through 43-7).
Figure 43-3. Typical appearance of a tear trough deformity associated with fat herniation and midface descent.
Figure 43-4. Skin flap is elevated from infraciliary crease.
Figure 43-5. The orbital fat is accessed via a transconjunctival-swinging lower eyelid flap that contains the orbital septum and orbicularis muscle.
Figure 43-6. The scissors are being used to release the orbitomalar ligament and the zygomatic-cutaneous ligaments prior to supraperiosteal midface elevation.
Figure 43-7. Supraperiosteal dissection view from superiorly.
In cases where a more robust elevation is desired, the prezygomatic area can be reached via a subconjunctival incision, a temporal brow incision, and even an intraoral incision. The temporal brow incision allows elevation of the upper, lateral face so that a “standing wave” does not occur at the lateral canthus due to excessive elevation of the midface relative to lax temporal scalp. The temporal dissection occurs in the subtemporoparietal plane just above the deep temporalis fascia and then enters the midface in a subperiosteal plane.4 A transconjunctival incision is added if a lower lid fat transposition over the rim is going to be done in conjunction, or a posterior lamellar graft such as Enduragen, Alloderm, or autogenous hard palate graft is going to be placed. A lateral canthal incision can be added if a lower lid blepharoplasty requiring lid shortening and skin or muscle resection is going to done concurrently. The intraoral incision can facilitate the placement of periosteal cheek sutures for suspension but is not necessary.
In certain patients particularly short of anterior lamellar skin, in need of some midface volume, or unlikely to have good supporting tissue for some reason (eg, age > 60, “poor protoplasm,” or connective tissue disease), a hand-carved, expanded polytetrafluoroethylene orbital rim implant can be placed.5 The advantage of this, in addition to providing volume, is that the sutures that can be placed from the SOOF to the Gore-tex (W. L. Gore and Associates Inc, Flagstaff, AZ) along the entire superior midface to give excellent and lasting vertical lift of the central and nasal midface. The implant should be rigidly fixed to the rim prior to attaching the soft tissues of the mid face with suture (Figure 43-8).
Figure 43-8. The hand-carved Gore-tex block is rigidly fixed just below the orbital rim and is ready for sutures to be placed from the SOOF to the Gore-tex to provide excellent and lasting vertical lift.
Correction of Volume Depletion
Techniques for volume restoration include fillers, fat grafting, surgical elevation of soft tissues into the midface, and placement of midface implants. Volume enhancement via surgery, with or without cheek implants, has already been discussed. Fillers are commonly used in the midface. In general, it is a reasonable idea to start off with a hyaluronic acid filler such as Restylane or Juvederm to ensure the patient likes the change. If not, hyaluronidase can be injected into the filled area and resolve any unwanted effects usually within 24 hours. Once it is clear that the fill is appreciated, a longer lasting filler such as Perlane, Radiesse, or Sculptra can be used.6 These fillers should be used below the orbicularis initially to avoid lumpiness. Postinjection massage by the injector is important to obtain a smooth result. In patients with reasonably thick skin, the hyaluronic acid fillers can be used more superficially if placed by an experienced injector.
Autogenous fat injections can also be used to create volume in the midface.7 Once the fat is harvested from the surgeon’s area of choice, it is injected into the deep tissues of the midface below the orbicularis in a fan-like fashion. If the lower eyelid is to be included, the approach should be performed in such a way that the tunnels made by the injection cannula are oriented vertically and not horizontally to avoid a “sausage” roll appearance in the lid. If you would like to read further about fillers, it is covered in more detail in Question 44.
In summary, aging and functional changes of the midface that involve descent and depletion can be corrected by several different surgical interventions to reposition the tissues anatomically into a more youthful and functional position and provide appropriate volume. Further volume can be added with cheek implants, fillers, or autogenous fat.
References
1. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg. 1996;12(2):77-88.
2. Lucarelli MJ, Khwarg SI, Lemke BN, Kozel JS, Dortzbach RK. The anatomy of midface ptosis. Ophthal Plast Reconstr Surg. 2000;16(1):7-22.
3. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110(3):885-896.
4. Sullivan SA, Dailey RA. Endoscopic subperiosteal midface lift. Ophthal Plast Reconstr Surg. 2002;18(5):319-330.
5. Steinsapir KD, Aesthetic and restorative midface lifting with hand-carved, expanded polytetrafluoroethylene orbital rim implants. Plast Reconstr Surg. 2003;111(5):1727-1737.
6. O’Hara KL, Urrego AF, Garri JI, O’Hara CM, Bradley JP, Kawamoto HK. Improved malar projection with transconjunctival hydroxyapatite granules. Plast Reconstr Surg. 2006;117(6):1956-1963.
7. Pontius AT, Williams EF. The evolution of midface rejuvenation. Combining the midface-lift and fat transfer. Arch Facial Plast Surg. 2006;8:300-305.