CHAPTER 17 Cheek–Midface Lift

With age, the cheek migrates inferiorly and nasally (Fig. 17-1). This contributes to inferior orbital rim hollowing, a circle effect of the lower eyelids and cheek, a flattening of the cheek, cheek bags (festoons), and nasolabial fold. In the past, these problems have been treated with facelifts, excision of cheek bags, and cheek implants.

Hester and McCord ^1,² popularized the cheek–midface lift through an external lower blepharoplasty approach. This procedure originally was done by reattaching the suborbicularis orbital fat (SOOF) in a more normal position along with a full thickness resection of the lower eyelid to stabilize the lid. The procedure has been modified multiple times and at present, I perform the procedure by suspending an orbicularis muscle flap along with tarsal strip and skin flap procedures. The operation places the ptotic cheek in a more normal position, relieves cheek bags, fills in the hollow inferior orbital rim with cheek fat, makes the midface more convex, and decreases the nasolabial fold depression. It also gives the effect of cheek implantation, adds skin to the lower eyelids for the treatment of cicatricial ectropion, and reduces the hollowing of the lower eyelid that sometimes occurs secondary to overzealous fat removal in lower blepharoplasty.

At times the procedure is performed with lower eyelid fat excision, and at times it is done with repositioning of the nasal and central lower eyelid fat pads into the inferior orbital rim hollowing area along with temporal fat resection. The tarsal strip procedure is performed to stabilize the lower eyelid and to prevent retraction and ectropion of the lower lid.

Allen M. Putterman

Figure 17-1 Inferior and nasal descent of the cheek fat that occurs with aging. The more superior outlined area depicts the normal position of the cheek fat.

Preparation for surgery

The patient’s entire face is prepared with povidone-iodine (Betadine), soap, and paint. The patient is draped so that the entire face is exposed. Topical tetracaine is applied over each eye. A scleral contact lens is placed over the eyes and under the eyelids to protect the eyes from foreign objects, to prevent the operating lights from bothering the patient, and to avoid causing the patient stress from seeing the procedure being performed. A marking pen is used to create a lateral canthal line, which begins at the lateral canthus and extends in a horizontal direction for approximately 1–1½ cm.

Surgical technique

A mixture of 40 ml of 0.5 percent lidocaine (Xylocaine) with 1 : 200,000 epinephrine, and 4 ml of 0.5 percent plain bupivacaine (Marcaine) is prepared. Several milliliters of the mixture is injected subcutaneously and diffusely across the lower eyelids.

A 25-gauge 1.5 cm needle is passed through the nasal lower eyelid just above the inferior orbital rim and then over the inferior orbital rim slightly in a downward direction to avoid penetrating the eye. The needle is inserted for approximately 1 cm and 0.5–1 ml of the anesthetic mixture is injected. This is repeated centrally and temporally.

A mark is applied with a blue marking pen to the area of the infraorbital foramen and several milliliters of the same anesthetic mixture is injected around the exit of the infraorbital nerve. Approximately 20 ml of the solution is injected subperiosteally over the cheek down to the upper gum and nasolabial fold areas. Approximately ½ cc of the anesthetic is also injected subcutaneously at the center of the upper eyelid just above the lid margin.

A 4-0 black silk suture is passed through skin, orbicularis and superficial tarsus at the center of the upper eyelids and the sutures are left long so that they can be attached to the drape with hemostats to lift the upper lid upward. A similar 4-0 black silk suture is placed through skin orbicularis and superficial tarsus of the center of the lower eyelid just adjacent to the lid margin, and again left long for traction.

A #15 Bard-Parker blade is then used to make an incision through skin over the lateral canthal mark from the lateral canthus temporally in a horizontal direction for 1 to 1½ cm. A Westcott scissors is then used to sever the lateral canthus (Fig. 17-2). A Colorado needle then incises the orbicularis muscle from the lateral canthus throughout the length of the skin incision (Fig. 17-3). The lower limb of the lateral canthal tendon is severed (Fig. 17-4). A small Desmarres retractor everts the lower eyelid. One to two cubic centimeters of the anesthetic mixture is then injected subconjunctivally from the inferior tarsal border to the inferior fornix across the eyelid. The Colorado needle is then used to cut conjunctiva from the caruncle to the temporal aspect of the eyelid midway between the inferior tarsal border and the inferior fornix (Fig. 17-5). The surgeon grasps the central inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent, more superior edge, with another forceps. The two forceps are pulled apart, and then the Colorado needle is applied across the eyelid between the two severed conjunctival layers through Müller’s muscle and capsulopalpebral fascia until fat is seen (Fig. 17-6).

Figure 17-2 A Westcott scissors is used to sever the lateral canthus.

Figure 17-3 Incision of skin and orbicularis from the lateral canthus to approximately 1–1.5 cm temporal to the lateral canthus.

Figure 17-4 The lower limb of the lateral canthal tendon is severed.

Figure 17-5 A Colorado needle is used to cut through lower palpebral conjunctiva from the caruncle to the temporal end of the eyelid midway between inferior tarsal border and inferior fornix.

Figure 17-6 The surgeon grasps the central inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent more superior edge with forceps. The forceps are pulled apart and the Colorado needle severs Müller’s muscle and capsulopalpebral fascia along the course of the severed palpebral conjunctiva.

A 4-0 double arm black silk suture is passed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia with each suture arm. The sutures are then drawn upward and attached to the drape with a hemostat (Fig. 17-7). A small piece of tape is applied over any exposed needle to avoid needle sticks and to allow the suture to be reused, if needed. Usually the needle is cut and removed from the operating field.

Figure 17-7 A 4-0 double arm silk suture has each arm passed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and the suture ends are secured to the superior drape to pull these structures upward. A small Desmarre retractor is placed over the superior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and is pulled downward and outward to expose the orbital fat.

A small Desmarres retractor is placed over the superior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and is pulled downward and outward to expose the orbital fat. With the use of cotton-tipped applicators and Westcott scissors, blunt dissection is carried out to isolate the three orbital fat pads. The central and nasal fat pads are divided by the inferior oblique muscle, which can easily be seen through the internal approach and should be identified to avoid injury to this structure. Also, the nasal and central fat pads are found in a slightly more temporal position than when they are isolated through an external approach.

The temporal herniated orbital fat is isolated, and the fat that prolapses with general pressure on the eye is clamped with a hemostat and cut along the hemostat with a #15 Bard-Parker blade (Fig. 17-8). Then cotton tip applicators are placed under the hemostat and a Bovie cautery is applied over the fat stump. The surgeon grasps the fat with the forceps before it is allowed to slide back into the orbit to make sure there is no residual bleeding that might cause a retrobulbar hemorrhage. After the first temporal fat pad is removed, the surgeon applies additional pressure to the eye to determine whether there is a second temporal fat pad.⁴ If found, it is removed in a similar manner.