Serdev Suture Techniques

MID FACE LIFT. THE PROTOCOL

Nikolay SERDEV, MD, PhD

Important fixations:

AA1 – nonmovable fixation (to periosteum and temporalis tendon)

BB1 – movable fixation (of the movable zygomatic extension of the SMAS) and lifting to AA1

Anatomy:

- The s.c. “temporal pocket” has a difficult to understand anatomy, because descriptions in

anatomy books and publications use different terms. In American books it is simplified:

superficial temporal fascia (galea aponeurotica) is movable and deep temporal fascia is no

movable. Such description is simple, but can lead to misunderstanding as described below.

- The movable galea aponeurotica described also as movable superficial temporal fascia is in

realty not only temporal. Above it is fixed to the vertex and covers parietal, frontal, temporal

and occipital areas, presenting the Upper SMAS.

- The Temporal fascia starts from the upper temporal line. Above, it is a single layer, attached

to the entire extent of the superior temporal line; but below, where it is fixed to the

zygomatic arch, it consists of two layers – superficial layer of temporal fascia and deep layer

of temporal fascia, both non movable, one of which is inserted into the lateral, and the other

into the medial border of the arch. A small quantity of fat covers the orbital branch of the

superficial temporal artery, and a filament from the zygomatic branch of the maxillary nerve,

are contained between these two layers. Splitting of the above single temporal fascia is

about 2 cm above the zygomatic bone. Movable superficial temporal fascia (galea

aponeurotica) should not be mixed with the non movable superficial layer of temporal fascia,

below which the nerve, artery and vein are located.

- The “danger area”, where perforation can lead to bleeding, hematoma, and nerve injury, is

the square of 2/2cm in front of the tragus and above the zygoma. In this “danger area” the

superficial layer of the temporal fascia is just below the galea aponeurotica and skin. The

superficial layer of the temporal fascia is non movable, covers vessels and nerves, and should

not be mixed with the movable galea aponeurotica that is described as superficial temporal

fascia in some books. In the “danger area” needle passes should be careful and superficial

just below the movable tissue (skin and galea aponeurotica). When performing a midface lift

in this area the needle should be able to move lateral and up. If fixed, it has perforated the

non movable superficial layer of the temporal fascia that is dangerous. Prolonged pressure

usually stops bleeding in this area.

Directions

- B-(A1)-B1. Point A1 is only a mark. It should be drown for orientation and should not be

perforated. NB. The needle pass B-A1 is in the “danger area” – should be superficially below the

skin. The needle passes over the zygomatic bone and in the line A1-B1 below the zygomatic mid

line to catch the movable zygomatic extension to the SMAS – the author has found this fascia

connecting the SMAS with the Zygoma to be movable).

- A-B1 is a connecting pass in the “danger area”. The needle should pass superficially below the

skin to bring the thread from point B1 to A.

- A-B is the stable fixation under the temporalis tendon.

Mid face suture lift means:

- lifting of the movable A1-B1 (zygomatic extension of the SMAS) to A-B (Temporalis tendon

and periosteum)

Vectors: 2 vectors are effective with this lift:

- Direction from the chin to point A (upper point of the ear where is the fixation to the

temporalis tendon) with strong effect on the marionette folds and additional effect on the

nasolabial folds

- Direction from the cheekbone to the point A with strong effect on the nasolabial and tear

trough folds with additional effect on marionette folds.