Key points

Introduction

The facial skeleton and bony structures of the face are thought to expand as we age. The orbital socket diameter increases in size as we age with particular recession of the inferomedial infraorbital rim. In the midface, the maxilla undergoes retrusion and resorption. The maxillary angle decreased by about 10° between young (aged <30 years) and old (aged >60 years) individuals. Moreover, there is significant development of elastosis of the overlying skin and superficial musculoaponeurotic system (SMAS). There are several telltale signs of aging noted in the midface that can be addressed during rhytidectomy to provide comprehensive and balanced facial rejuvenation. These changes include malar fat pad descent, increasing prominence of the tear trough, an enlarging infraorbicular crescent representing the ptotic inferior orbicularis as well as infraorbital fat, increasing nasolabial grooves, and ptotic and festooning jowls creating a prominent prejowl sulcus.

Various surgical and nonsurgical techniques have been proposed and practiced to rejuvenate the midface. Among the nonsurgical techniques, thermal, radiofrequency, ultrasonic, and various lasers have all been used to refresh the midface. Fillers and injectables including autologous fat transfer have also been used to replace midface volume and mask the descent of anatomic structures. Among surgical treatments, several approaches have been used to rejuvenate and lift the midface, including malar implants, direct lift, multi-vector approach, multi-plane approach, transconjunctival approach, and orbicularis suspension. Many of these techniques, both surgical and nonsurgical, have been used in conjunction with one another and are not mutually exclusive.

One thing remains clear: in order to achieve comprehensive cervicofacial rejuvenation, rhytidectomy remains the gold standard. Tightening and repositioning of redundant skin and the SMAS is paramount to cervicofacial rejuvenation. Unfortunately, too often the midface is neglected leading to suboptimal overall rejuvenation and a continued tired appearance. Posterior SMAS imbrication or plication provides mostly posterior pull and does not adequately address the midface fat pads, nasolabial groove, or commissure-mandibular fold. However, proper midface rejuvenation can be achieved at the same time as cervicofacial rhytidectomy.

Treatment goals and planned outcomes

Patients undergoing cervicofacial rhytidectomy nearly uniformly desire comprehensive facial rejuvenation. Midface rejuvenation can easily be improved concurrently with rhytidectomy via a multi-vector, multi-plane approach or an extended lower-lid midface lift. The goals of midface rejuvenation include, but are not limited to, improving the jowl-mandible contour, improving the commissure-mandibular groove, improvement in the nasolabial groove, improving all 4 midface fat pads with repositioning, preserving the temporal hair tuft and posterior hairline, maximizing the cosmetic result, and finally achieving a natural nonoperated appearance. While planning for a surgical procedure, the practitioner must anticipate that different parts of the face and neck require different vectors of pull to achieve an optimal result. The midface in particular requires primarily a vertical lift. The techniques described in this article, multi-vector high SMAS 3-layered facelift with midface lift and extended lower-lid midface lift, achieve all of these goals.

Introduction

The facial skeleton and bony structures of the face are thought to expand as we age. The orbital socket diameter increases in size as we age with particular recession of the inferomedial infraorbital rim. In the midface, the maxilla undergoes retrusion and resorption. The maxillary angle decreased by about 10° between young (aged <30 years) and old (aged >60 years) individuals. Moreover, there is significant development of elastosis of the overlying skin and superficial musculoaponeurotic system (SMAS). There are several telltale signs of aging noted in the midface that can be addressed during rhytidectomy to provide comprehensive and balanced facial rejuvenation. These changes include malar fat pad descent, increasing prominence of the tear trough, an enlarging infraorbicular crescent representing the ptotic inferior orbicularis as well as infraorbital fat, increasing nasolabial grooves, and ptotic and festooning jowls creating a prominent prejowl sulcus.

Various surgical and nonsurgical techniques have been proposed and practiced to rejuvenate the midface. Among the nonsurgical techniques, thermal, radiofrequency, ultrasonic, and various lasers have all been used to refresh the midface. Fillers and injectables including autologous fat transfer have also been used to replace midface volume and mask the descent of anatomic structures. Among surgical treatments, several approaches have been used to rejuvenate and lift the midface, including malar implants, direct lift, multi-vector approach, multi-plane approach, transconjunctival approach, and orbicularis suspension. Many of these techniques, both surgical and nonsurgical, have been used in conjunction with one another and are not mutually exclusive.

One thing remains clear: in order to achieve comprehensive cervicofacial rejuvenation, rhytidectomy remains the gold standard. Tightening and repositioning of redundant skin and the SMAS is paramount to cervicofacial rejuvenation. Unfortunately, too often the midface is neglected leading to suboptimal overall rejuvenation and a continued tired appearance. Posterior SMAS imbrication or plication provides mostly posterior pull and does not adequately address the midface fat pads, nasolabial groove, or commissure-mandibular fold. However, proper midface rejuvenation can be achieved at the same time as cervicofacial rhytidectomy.

Treatment goals and planned outcomes

Patients undergoing cervicofacial rhytidectomy nearly uniformly desire comprehensive facial rejuvenation. Midface rejuvenation can easily be improved concurrently with rhytidectomy via a multi-vector, multi-plane approach or an extended lower-lid midface lift. The goals of midface rejuvenation include, but are not limited to, improving the jowl-mandible contour, improving the commissure-mandibular groove, improvement in the nasolabial groove, improving all 4 midface fat pads with repositioning, preserving the temporal hair tuft and posterior hairline, maximizing the cosmetic result, and finally achieving a natural nonoperated appearance. While planning for a surgical procedure, the practitioner must anticipate that different parts of the face and neck require different vectors of pull to achieve an optimal result. The midface in particular requires primarily a vertical lift. The techniques described in this article, multi-vector high SMAS 3-layered facelift with midface lift and extended lower-lid midface lift, achieve all of these goals.

Preoperative planning and preparation

The ideal patient is 40 to 60 years old, in good health, without any medical comorbidities or increased bleeding tendencies with significant cervicofacial elastosis, descent of the midface with jowling, prominent jowl-mandibular irregularities, prominent commissure-mandibular grooves, and of course realistic expectations of improvement. Photographic documentation should be obtained preoperatively in the anterior-posterior frame with and without smiling, in a bilateral three-quarter view, and in bilateral side-profile views with particular attention to having each photograph viewing the Frankfort horizontal perpendicularly.