The Transeyelid MidfaceLift

Vivian T. Yin, MD, FRCSCa,b, Eva Chou, MDa, Tanuj Nakra, MDa,*

KEYWORDS

� Midface lift � Midface rejuvenation � Facial rejuvenation � Transeyelid SMAS lift� Transeyelid SOOF lift � Transconjunctival SMAS lift � Blepharoplasty

KEY POINTS

� Preoperative evaluation involves open communication and delineation of patient expectations andclinical assessment.

� Careful analysis of the patient’s individual anatomy in the periocular and midface region decreasescomplication risk.

� Creation of a composite flap in midface elevation can be achieved through a transeyelid or trans-conjunctival approach.

� Complete release of the orbicularis retaining ligament and zygomaticocutaneous ligament isrequired for elevation of the midface.

� Transeyelid midface lift can be combined with other periocular or facial rejuvenation procedures.

INTRODUCTION

The midface extends from the lower eyelid to theoral commissure. There are three aging changesthat occur in the midface: (1) skin aging, (2) soft tis-sue volume loss, and (3) gravitational descent.Surgical midface rejuvenation can be a powerfulrejuvenation tool for volume loss and gravitationalchanges in the lower eyelid and midface. Shorrand Fallor1 first described transeyelid midface lift-ing in 1985 as a cosmetic and functional repairtechnique in patients with lower eyelid retraction.In addition to surgical elevation techniques, vol-ume augmentation and skin rejuvenation of themidface play an equally important role in the over-all management of the aging face. This article de-scribes midface surgical elevation techniques.

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SURGICAL ANATOMY

Transeyelid midface elevation requires thoroughunderstanding of the anatomic planes and

Disclosures: No financial disclosures.a Texas Oculoplastic Consultants, 3705 Medical Parkway,& Ophthalmic Plastic Surgery Program, Department of PCancer Center, 1515 Holcomb Boulevard, Unit 1488, Hou* Corresponding author.E-mail address: TNakra@tocaustin.com

Clin Plastic Surg 42 (2015) 95–101http://dx.doi.org/10.1016/j.cps.2014.09.0040094-1298/15/$ – see front matter � 2015 Elsevier Inc. All

retaining ligaments of the lower eyelid and cheek.Immediately deep to the lower eyelid skin, the or-bicularis oculi muscle consists of three parts (pre-tarsal, preseptal, and orbital) to form the palpebralfissure sphincter (Fig. 1). Deep to the orbicularisoculi muscle is the suborbicularis oculi fat(SOOF), which drapes over the inferior and lateralthree-quarters of the orbital rim (Fig. 2).2 TheSOOF extends inferiorly within the zygomaticusmuscle system and is continuous with the superfi-cial musculoaponeurotic system (SMAS) (Fig. 3).The orbicularis retaining ligament extends fromthe dermis through the orbicularis muscle at thepreseptal and orbital transition, and forms afibrous insertion to the arcus marginalis, the fusionof maxillary bone periosteum and the orbitalseptum. This fibrous condensation divides theSOOF into superior and inferior compartments.3

The superior compartment contains the malarmound. This fibrous osseocutaneous retaining lig-ament extends caudally and laterally to becomethe zygomatic ligament. The strongest points of

Suite 120, Austin, TX 78705, USA; b Orbital Oncologylastic Surgery, The University of Texas MD Andersonston, TX 77037, USA

rights reserved. plasticsurgery.th

eclinics

Fig. 1. Lower eyelid anatomy. (Adapted from AlamM,White LE. Anatomy in dermatologic surgery. In:Nouri K, ed. Complications in dermatologic surgery.Philadelphia: Mosby/ Elsevier, 2008; with permission.)

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attachment for the midface soft tissue are at theseosseocutaneous ligaments.4,5 This highlights theimportance of releasing these ligaments toachieve effective elevation of the malar fat padand midface soft tissue envelope.During flap dissection for midface elevation,

care must be taken to preserve the infraorbitalnerve and zygomaticofacial branches of V2. Theinfraorbital nerve exits the infraorbital canalapproximately 1 cm below the medial third ofthe inferior orbital rim. The zygomaticofacial fora-men is approximately 6 mm inferior to the inferiororbital rim, but it is highly variable in location andnumber.6 The facial nerve has significant variationin distal branching pattern with conservation of

Fig. 2. (A) Relevant anatomy for SOOF lifting. (B) Movemeinfraorbital rim and nasal jugal groove. (From Grant JR,blepharoplasty with fat repositioning and the suborb2010;18(3):399–409.)

branching of the main trunk only. The zygomaticand orbicularis branches of the facial nerveemerge from the parotid gland deep in the facialfascia approximately 34 mm anterior to thetragus.7 The temporal branches cross the zygo-matic arch 32 to 37 mm lateral to the orbital rimand diverge (Fig. 4).8 The orbicularis oculi, zygo-maticus major, levator labii superioris, anddepressor anguli oris are supplied from thedeeper surface by the facial nerve. The superioraspect of the orbicularis oculi is innervated bythe temporal braches 3 to 4 mm medial to thefree edge of the muscle, whereas inferior aspectis innervated by the zygomatic branches.9 The su-perior of the zygomatic branches innervate thezygomatic major muscle in the lower third,whereas the lower branches run underneath thezygomatic major muscle to innervate the levatorlabii superioris in the undersurface.9 The lowerzygomatic branches also innervate the buccina-tors and levator anguli oris from the superficialsurface of the muscle.9

PATIENT EVALUATION

A cardinal component of the cosmetic evaluationis management of patient expectations. It is impor-tant to clearly understand the goals of the patientand to build rapport through open communication.A thorough medical history should be obtainedincluding risk factors for surgery and anesthesia.Active smokers are not ideal candidates for sur-gery because of the increased risk for anesthesiaand poor wound healing. History of previous facialfractures, eyelid surgery, or midface surgery af-fects the anatomy of the midface and introducesthe additional variables of scar tissue and orbicula-ris apraxia.

nt of the SOOF to fill the paucity of soft tissue at theLaFerriere KA. Periocular rejuvenation: lower eyelidicularis oculi fat. Facial Plast Surg Clin North Am

Fig. 3. (A) SMAS relation to platysma. (B) SMAS connected to platysma. (From Perkins SW, Waters HH. Theextended SMAS approach to neck rejuvenation. Facial Plast Surg Clin North Am 2014;22(2):253–68.)

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There are three main indications for surgicalmidface elevation: (1) gravitational descent, (2)anterior lamellar insufficiency with lid malposition,and (3) acquired soft tissue defect. Patients withgravitational descent as their primary midface

Fig. 4. Trajectory of the temporal branch of the facialnerve. (From Lam VB, Czyz CN, Wulc AE. The bro-weyelid continuum: an anatomic perspective. ClinPlast Surg 2013;40:1–19.)

aging change are good candidates and can bedone in conjunction with volume augmentationor skin rejuvenation. Midface elevation can alsoaddress post blepharoplasty sequelae of lowereyelid retraction, anterior lamellar skin insuffi-ciency, and volume collapse through recruitmentof soft tissue from the midafce. These patientsmay also benefit from concurrent lower eyelidand canthal technique, such as hard palategrafting to the posterior lamella of the eyelid andcanthoplasty, to provide additional support incountering lower lid retraction. Lastly, midfaceelevation can recruit soft tissue and skin to enablerepair of acquired defect fromMohs micrographicsurgery or trauma.

It is useful to highlight the three components ofaging during initial consultation to the patient forrealistic expectations. Besides gravitationaldescent and soft tissue volume loss, agingchanges also include solar skin damage. Underly-ing bony asymmetry between the sides should beobserved and discussed with the patient. In addi-tion, the patient’s underlying maxillary boneprominence relative to the globe also contributesto the final effect of soft tissue lifting. When therelative position of the globe to the malar promi-nence creates a negative vector,10 with the mostanterior portion of the globe protruding past themalar eminence, soft tissue lifting alone is not

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sufficient to produce malar projection. An adjunctwith orbital rim11 or maxillary-zygomatic archimplant12 may be needed to achieve the desiredelevation in these patients.In the periocular area, assessment of lower lid

position, lower lid laxity, canthal position andshape, upper lid dermatochalsis, upper lid ptosis,lagophthalmos, and orbicularis weakness shouldbe recorded. Even in primary cosmetic cases,achieving optimal results may require concurrentcanthoplasty, blepharoplasty, or lid tightening pro-cedures. An external ocular examination to eval-uate for pathology and dry eye syndrome shouldbe performed. Pre-existing brow ptosis shouldbe identified, as the elevation of the midface inthese cases may cause the appearance of asmaller palpebral fissure.Careful, consistent preoperative photography

documents these preoperative findings for subse-quent postoperative comparisons. Standardphoto-graphic documentation is strongly recommendedwith and without flash in five cardinal positions:frontal, right/left lateral, and right/left oblique(45-degree angle). Photographs serve several pur-poses: critical analysis and preoperative planning,demonstration of asymmetry for counseling, insur-ance preauthorization, medicolegal documenta-tion, and postoperative comparison.

PATIENT PERSPECTIVE

As with any surgery, thorough preoperative coun-seling is critical. Appropriate expectations for reju-venation of the middle third of the face are lift in thecheek area, filling of the tear trough, and softeningof the nasolabial prominence. Patients should un-derstand that midface elevation does not changethe appearance of the brow or upper eyelid, oraddress gravitational descent that leads to jowlingalong the jawline or neck laxity. In addition, mid-face elevation does not replace the role of volumeaugmentation.The preoperative visit should also include

detailed informed consent, ensuring that the pa-tient understands fully the risks, benefits, indica-tions, and alternatives of the procedure. Patientsshould be counseled that, although symmetry iscertainly the goal, minor asymmetry after surgeryshould be the expectation. Congenital skeletaland soft tissue variations render perfect symmetryespecially difficult.

SURGICAL PROCEDURE

Over the past decade, multiple surgical tech-niques have been described to achieve elevationof the midface through a transeyelid approach.

Subciliary incision is most commonly describedfollowed by transconjunctival approach; however,techniques on creation of flap, direction of eleva-tion, and location of suture anchorage vary. Theprocedure is best performed under general anes-thesia or monitored anesthesia care for patientcomfort, but it can also be performed under oralsedation with local anesthesia in select cases. Ifno sedation is to be used, tumescent can beused in the midface area to reduce the risk of localanesthetic toxicity.

Transcutaneous Approach

The transcutaneous approach to midface eleva-tion is performed when lower blepharoplastyrequiring skin redraping and excision is performedconcurrently.

� A subciliary incision is created with a #15blade, CO2 laser, “pure cut” electrocautery,Westcott scissors, or an inverted #11 bladein the standard fashion for lower blepharo-plasty extending 7 to 10 mm beyond thelateral canthal angle or orbital rim.

� A traction suture is placed in the eyelid marginor preseptal orbicularis at the midpoint to pro-vide superior traction in addition to protectingthe cornea. Preservation of the pretarsal orbi-cularis is recommended to protect the func-tional integrity of the eyelids.

� The suborbicularis preseptal dissection canbe carried inferiorly to the level of the orbitalrim and arcus marginalis with blunt Stevensscissors either as a single skin-muscle flapor separately in layers. Care should be takento avoid aggressive manipulation of theorbicularis muscle to avoid postoperativecomplications, such as lower eyelid retrac-tion, ectropion, lagophthalmos, and inade-quate blink leading to dry eye and exposure.

� Alternatively, the orbicularis muscle can beleft intact, and the transconjunctival routecan be used to manipulate the fat pads only.

� In either case, once the septum is exposed,the lower eyelid fat pockets are visible deepto the septum, which can be easily openedto access the three lower eyelid fat pads.

Surgical Insight: Depending on the patient’sanatomy, the fat can be redraped over the orbitalrim or resected as needed.13 As described previ-ously, the upper extent of the SMAS is the orbicu-laris muscle. It is important to obtain completerelease of the orbicularis retaining ligament and zy-gomaticocutaneous ligament so that, with eleva-tion of the orbicularis, the midface is elevated viathe SMAS.14

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� Orbicularis retaining ligament and zygomati-cocutaneous ligament are released via bluntdissection with Stevens scissors through asuborbicularis or preperiosteal dissection to2 cm below the orbital rim into the area ofthe malar fat pad.

� The orbicularis/SMAS flap can be elevated ina predominantly vertical vector or in asuperior-lateral vector. When elevating theflap in a pure vertical vector, purchase canbe made with four 4-0 polypropylene suturesthrough the SOOF/orbicularis in a horizontalmattress fashion and sutured to the arcusmarginalis.15

� This vertical elevation, if used with a subper-iosteal dissection plane for the composite, isbest combined with release of the distalportion of the periosteum to allow properelevation of the flap. This can be accom-plished with a needle tip cautery.

� Alternatively a lateral retinacular suspension isaccomplished by elevation of the lateral edgeof the composite flap using a 4-0 polyglactinsuture in an interrupted fashion through theorbicularis and suturing to the periosteum atthe lateral orbital rim at the level of the lateralcanthus16 or the level of the frontal zygomaticsuture.13

� When combined with upper blepharoplasty,the composite flap can be tunneled under thebridge of skin following blunt dissection withStevens scissors to create a suborbicularispocket along the area of the lateral orbital rim.

Surgical Insight: Our preference is for securingthe composite flap to the deep temporalis fasciavia this combined upper blepharoplasty incisionoption.

� After creating the composite flap, bluntdissection can be accomplished with Stevensscissors in a cephalic direction along the fron-tal process of zygoma to the level of thefrontal-zygomatic suture. The dissectionshould be deep along the bone to avoid dam-age to the zygomatic branches of the facialnerve.

� Blunt dissection with cotton-tip applicators ina dorsal fashion at the level of the frontal-zygomatic suture unveils the temporalis fascia.

� Thecomposite flap canbe sutured in a supero-lateral direction using a 4-0 polyglactin or poli-glecaprone suture in a horizontal mattressfashion to the deep temporalis fascia.

� After securing the malar soft tissue to a moreyouthful position, redundant skin and musclemay be noted.

� Excessive skin can be trimmed conserva-tively, and muscle redraped using smallmattress sutures.

� The subciliary incision can be closed with in-terrupted or running 6-0 fast-absorbing gutsuture.

Transconjunctival Approach

The transconjunctival approach can also allow foran effective midface lift. Options include subper-iosteal midface elevation with multipoint fixationto the arcus marginalis, or SMAS elevation byrelease of the orbicularis retaining ligament.17,18

� If the eyelid has sufficient laxity to allow foradequate visualization into the midface, thena simple conjunctival incision can allow ac-cess to the midface. However, if this is notthe case, then an open lateral canthotomy/cantholysis (the “swinging eyelid approach”),or a closed cantholysis19 via an upper eyelidcrease incision20 can be performed.

� The conjunctival incision is made with insu-lated needle tip monopolar cautery in the in-fratarsal space along the entire length of thelower lid.

� A malleable retractor or stainless steel eyeshield is used to protect the globe.

� The lower eyelid retractor-septal-conjunctivalcomplex can be brought up on stretch by tem-porary retaining sutures secured to the drapeto further protect the globe, orbit, and exposethe septum.

� A preseptal dissection can be extended to theorbital rim using blunt dissection with cottontip applicators.

� At the orbital rim, after an incision is made withthe sharp tip cautery, a subperiosteal dissec-tion can be performed with a Freer elevator torelease the orbicularis retaining ligamentsand the periosteum medially to the piriformaperture/nasal bone and laterally toward themassetermuscle.1 Care is taken to avoid dam-age to the infraorbital and zygomatic nerve.

� The periosteum is incised inferiorly using ablade or cautery to allow the midface flap toelevate.

� Multipoint fixation of the midface periosteumcan be performed to the arcus marginalis,where a rim of periosteum should be leftintact.

Similarly to the subcutaneous approach, a pre-periosteal dissection can also be accomplishedthrough the transconjunctival approach. At theorbital rim, the SOOF is separated from the

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surrounding support structures via blunt scissorspreading dissection, to create a composite flapthat includes the mimetic muscles. This compositeflap can be elevated in a vertical fashion to theorbital rim periosteum-arcus marginalis complex.

� Closure of the conjunctiva is not necessary incases where there is no tension on the con-junctiva. Furthermore, suture closure canresult in postoperative patient discomfortand risk of corneal abrasions.

� If the canthus was released via an open21 orclosed1 approach, it is then reconstructed atthe end of the case. In most cases, the goalis to resuspend the canthus in the same loca-tion. If appropriate, the canthus can be resus-pended in a more superior, a more inferior, ora more intraorbital location.

Combining with Endoscopic Forehead Lift

Components of the techniques described previ-ously for transconjunctival approach can be com-bined with concurrent endoscopic forehead lift oras a stand-alone transtemporal midface lift. Thestandard temporal incision for endoscopic fore-head lift creates a dissection plane along thedeep temporalis fascia down to the lateral orbitalrim. Once a temporal pocket is formed, the endo-scope can be introduced. We limit our discussionto using the temporal incision for forehead lift toassist in midface elevation.

� This dissection along the lateral orbital rim orfrontal process of the zygoma can be carriedin the preperiosteum plane down to the ante-rior maxillary face, connecting with the previ-ously dissected orbicularis/SOOF/SMASflap. It is important to stay within the medialthird of the zygomatic arch to avoid damageto the facial nerve.

� The zygomaticotemporal sentinel vein can beidentified close to the frontozygomatic sutureand cauterized when necessary.

� The flap can be sutured using 3-0 or 4-0 poli-glecaprone suture at 5 to 5.5 cm from themidline at the level of the alar to the deep tem-poralis fashion in a superotemporal vectorplane.22

� Alternatively an additional suture can beplaced through the lateral aspect of the infe-rior orbicularis oculi to the deep temporalisfascia.23

AFTER CARE

Patients should be counseled preoperatively toexpect temporary swelling, bruising, and

numbness and tightness of the lower eyelids,cheeks, and lateral canthus in the early postoper-ative period. The extent of postsurgical healing de-pends on the extent of dissection and the patient’sindividual inflammatory milieu. Edema typicallyworsens in the first 24 to 72 hours and can be miti-gated with cold compresses and judicious use oforal corticosteroids to aid with comfort and edemareduction. To minimize edema, patients are alsoadvised to sleep in a head-elevated position andreduce sodium intake. Patients should expectthe palpebral fissure to appear smaller for severalweeks because of periorbital edema. Most pa-tients return to normal activities within a fewweeks, but they should be counseled that the finalhealing of the surgery takes 6 to 12 months.

COMPLICATIONSAsymmetry

Themost common complication is asymmetry. It isimportant to discuss openly with patientsregarding their underlying asymmetry before thesurgery, because most postoperative apparentasymmetry is closely related to congenital preop-erative asymmetry. In cases of significant andunanticipated asymmetry, surgical attempt atcorrection is indicated.

Malposition of Lower Eyelid

Malposition of the lower eyelid resulting in ectro-pion, scleral show, canthal dystopia, and lateralcanthal webbing can lead to significant dry eyesymptoms.13,17,21,23 Initial conservative manage-ment with artificial tear supplementation andlubricating ophthalmic ointment is the mainstayof therapy. Long-term healing can resolve tempo-rary postoperative cicatricial changes. However,surgical correction is occasionally required: can-thoplasty, correction of horizontal laxity, and alower eyelid spacer graft are possible options.

Hematoma

Hematoma is a rare complication (less than0.1%)21 that typically occurs in the first 24 hoursafter surgery, and may require surgical drainage.Nerve injury is usually temporary and can affecteither sensory or motor nerves of the face. Tempo-rary neuroapraxia of the infraorbital nerve as man-ifest by temporary anesthesia of the upper lip wasobserved in up to 25% of patients in one series.However, permanent injury to the infraorbitalnerve, zygomaticofacial nerve, and the facial nervebranches is very rare. The rate of cosmetic scarrevision was reported from 1% to 4%.13

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Infection

Surgical site infections, although uncommon, aremost likely caused by Staphylococcus andrequires systemic antibiotic treatment. Periopera-tive antibiotics can be considered when extensivedissection and/or lengthy surgical time length isexpected.

SUMMARY

The transeyelid approach to midface lift is anelegant approach for mild descent of malar softtissue. The subciliary approach is the mostcommonly used and technically less challengingfor surgeons experienced in facelift techniques.This technique in midface rejuvenation also hasthe advantage of ease of combining with otherperiocular and mid and upper face rejuvenation,such as blepharoplasty and forehead lift. Compli-cation is rare with lid malposition, scaring, andtemporary nerve function impairment being themost common.

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