The midface has suffered vigorous challenges in terms of rejuvenation techniques. Various alternatives are available for facial skeletal and soft tissue volume enhancement. After a thorough facial analysis, the surgeon must consider the advantages and disadvantages of implant-based volume enhancement in the context of each individual patient to determine the most appropriate option. Computer modeling provides improved methods to assess volumetric changes to augment and restore the facial volume. The multiple planes of dissection offered by the midface allow us to redrape the soft tissues 3-dimensionally and to continue to offer the consistency and longevity with implant-based midface rejuvenation.
Key points
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Midface rejuvenation may be performed on its own or, as is more commonly done, as a component of total facial rejuvenation.
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The major limitation to midfacial lift is the difficulty in providing long-term correction of the nasolabial fold and the malar descent.
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The osteocutaneous ligament must be released with any effective midfacial rejuvenation technique; this firm ligament anchors the skin over the body of the zygoma.
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Ptosis alone does not account for the changes observed in the aging midface; in addition, selective hypertrophy of the upper portion of the cheek fat pad is also observed in the aged face.
Introduction
The promise for a more natural rejuvenation of the midface, along with the quest for less-invasive eyelid incisions, has led to the refinement of midfacial rejuvenation techniques.
Only recently has the volumetric component of midface aging become a recognized essential clinical finding. The pathways developed to correct this component were repositioning of soft tissues when the displaced volume was adequate and additive when more volume was required to recapture the soft tissue fullness of youth. Recognizing that facial skeletal augmentation remains an essential aspect of cosmetic and reconstructive surgery, most facial plastic surgeons still perform predominantly soft tissue procedures. Skeletal volume enhancement represents the underlying framework, and, therefore, remains an essential aspect of esthetic and reconstructive facial plastic surgery.
Midface rejuvenation may be performed on its own or, as is more commonly done, as a component of total facial rejuvenation. With age, the convex contour of a youthful face is lost as the malar fat pad descends in an inferomedial direction, resulting in the following:
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Hollowed appearance to the lower eyelids
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Skeletonized infraorbital rim
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Prominent nasojugal fold
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Deepening of the nasolabial fold
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Pronounced labiomandibular fold
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Jowling
Correction of ptosis of the malar fat pad and orbicularis oculi muscle is essential in the correction of midface aging.
The major limitation to midfacial lift is the difficulty in providing long-term correction of the nasolabial fold and the malar descent. Failure to address skeletal deficiencies with this will compromise final form and function. Technologic advances in biomaterials and implant design have provided surgeons with a variety of different alloplastic options to enhance the facial skeleton. Long-term clinical results have begun to demonstrate the applicability and low complication rate associated with these materials.
Consistent manipulation of the facial skeleton, using a variety of techniques in more than 150 patients over the past 8 years by the senior author, shows that complications have been minimal, with no cases of paresis, minimal degree of facial edema, and, in most cases, patients can return to work within 1 week after surgery.
Introduction
The promise for a more natural rejuvenation of the midface, along with the quest for less-invasive eyelid incisions, has led to the refinement of midfacial rejuvenation techniques.
Only recently has the volumetric component of midface aging become a recognized essential clinical finding. The pathways developed to correct this component were repositioning of soft tissues when the displaced volume was adequate and additive when more volume was required to recapture the soft tissue fullness of youth. Recognizing that facial skeletal augmentation remains an essential aspect of cosmetic and reconstructive surgery, most facial plastic surgeons still perform predominantly soft tissue procedures. Skeletal volume enhancement represents the underlying framework, and, therefore, remains an essential aspect of esthetic and reconstructive facial plastic surgery.
Midface rejuvenation may be performed on its own or, as is more commonly done, as a component of total facial rejuvenation. With age, the convex contour of a youthful face is lost as the malar fat pad descends in an inferomedial direction, resulting in the following:
- •
Hollowed appearance to the lower eyelids
- •
Skeletonized infraorbital rim
- •
Prominent nasojugal fold
- •
Deepening of the nasolabial fold
- •
Pronounced labiomandibular fold
- •
Jowling
Correction of ptosis of the malar fat pad and orbicularis oculi muscle is essential in the correction of midface aging.
The major limitation to midfacial lift is the difficulty in providing long-term correction of the nasolabial fold and the malar descent. Failure to address skeletal deficiencies with this will compromise final form and function. Technologic advances in biomaterials and implant design have provided surgeons with a variety of different alloplastic options to enhance the facial skeleton. Long-term clinical results have begun to demonstrate the applicability and low complication rate associated with these materials.
Consistent manipulation of the facial skeleton, using a variety of techniques in more than 150 patients over the past 8 years by the senior author, shows that complications have been minimal, with no cases of paresis, minimal degree of facial edema, and, in most cases, patients can return to work within 1 week after surgery.
Historical perspective
Historically, skin excision with direct closure was the mainstay of facial rejuvenation procedures in the early part of the twentieth century; however, this was proven ineffective. Standard face-lift techniques described midface rejuvenation and lower lid laxity management through a standard or extended face-lift incision, which was somewhat progress; however, with aging, this process proved to be ineffective as well. Periorbitoplasty was first described by Tessier using a subperiosteal face lift. The beneficial effect of the subperiosteal face lift was extended to the entire periorbita, involving the origins of the midface musculature, and the orbicularis oculi muscle. Other techniques required a full blepharoplasty incision and a canthopexy for suspension of the midface and for prevention of ectropion and eyelid malposition.
Ortiz-Monasterio, Tapia and colleagues, and Ramirez and Pozner, proponents of the subperiosteal plane of dissection, published their techniques of liberating the facial soft tissues from the underlying skeleton. They used principles of osteotomies to recreate volumetric changes in the facial skeleton.
Three-dimensional rejuvenation of the midface and volumetric resculpturing was pioneered by William Little, as he recognized architectural reshaping of the face for rejuvenation and in the replacement of lost volume during facelift.
Relevant Surgical Anatomy
The malar fat pad is to be addressed in any midface operation. It is a triangular structure that borders the inferior lower eyelid at its waist and the zygomatic arch laterally, down to the modiolus. Aging causes the malar fat pad to flatten, lose volume, and pull downward.
A structure that must be released with any effective midfacial rejuvenation technique is the osteocutaneous ligament. This firm ligament anchors the skin over the body of the zygoma. Another relevant structure is the trough deformity, which we adhere to the definition as the area located at a position inferior to the orbital rim, where volume loss has allowed the surface anatomy to show the triangular confluence of the inferomedial aspect of the orbicularis oculi muscle, the levator alaeque nasi muscle, and the levator labii superioris muscle.
Attention to the relevant anatomy of the region and careful handling of tissues can minimize any complications. Poor outcomes can lead to functional anatomic deformities that can be devastating to the patient and the surgeon alike.
Volumetric Analysis and Types of Implants for the Midface
In addition to the standard physical assessment done of the lower lid tone, canthal tilt, lid shape and tear-trough deformity, and nasojugal groove, which is beyond the scope of this discussion. Various methods have been introduced into the literature for midface volumetric analysis of the malar fat pads, suborbicularis oculi fat pad, and the orbital fat, although all depend on the experience of the surgeon to infer a translation of this volume intraoperatively.
A recent study of volumetric analysis of soft tissue changes in the aging midface using high-resolution MRI indicated that ptosis alone does not account for the changes observed in the aging midface. Selective hypertrophy of the upper portion of the cheek fat pad also was observed in the aged face.
Advances in computer and graphic imaging technology are rapidly making an impact on facial plastic and reconstructive surgery. Computer simulation of complex surgical procedures can be obtained in 3 dimensions. Surface volume can be obtained with a laser surface scanner, processed by a computer to create the image. However, because of the financial costs, the verdict is still out regarding the potential uses of this technology. In short, there is no substitute for sound clinical judgment, thorough preoperative facial analysis, and strict adherence to fundamental surgical principles.
Ideal implant technology does not yet exist. The qualities of which are biocompatible, chemically inert, no foreign body or hypersensitivity reaction, noncarcinogenic, and easily shaped. However, a variety of materials are available for facial skeletal augmentation. The most commonly used are discussed further in this article.
Autogenous Bone Grafts
Autogenous bone grafts are traditionally the implants of choice for skeletal augmentation. Unfortunately, their use is often precluded by their disadvantages, which include donor site morbidity, limited availability, limited moldability, and unpredictable resorption.
Silicone
Silicone is relatively inert, and its safety has been studied over the years. A variety of preformed shapes and sizes are available that are applicable to facial esthetic subunits, such as malar, nasal, and chin implants. The cons of using these implants are contraction of the surrounding avascular fibrous capsule, infection, and extrusion. Silicone implants should be fixed at the time of placement with nonresorbable sutures, either in a supraperiosteal pocket or less commonly in the subperiosteal plane. Silicone has been associated with underlying bone resorption attributed to implant motion caused by overlying muscle (eg, mentalis) activity.
Expanded polytetrafluoroethylene
Expanded polytetrafluoroethylene (ePTFE) (Gore-Tex; W.L. Gore & Associates Inc, Flagstaff, AZ) is used commonly in lip enhancement, facial contouring, and facial reanimation. Many surgeons to advocate the use of a more softer feel with less shrinkage and migration type of ePTFE because of better biointegration and tissue ingrowth, Advanta ePTFE (Atrium Medical Corporation, Hudson, NH) 19. Preliminary data suggest that Advanta ePTFE, which has a high-porosity inner core of 100 μm surrounded by a smooth medium-porosity outer surface of 40 μm. Complications associated with ePTFE include infection, extrusion, migration, shrinkage, and scarring.
High-density porous polyethylene
High-density porous polyethylene (MedPore; Porex Industries, Fairburn, GA) has a larger pore size of 100 to 300 μm. Polyethylene allows considerable fibrous tissue ingrowth instead of surrounding fibrous tissue capsule formation, thereby limiting movement and stabilizing fixation of the implant. Its major drawback is encapsulation with subsequent predisposition to movement, infection, and extrusion. Yaremchuk presented data from a large number of consecutive patients undergoing facial skeletal augmentation using porous polyethylene implants with long-term follow-up that demonstrated no problems related to bioincompatibility and a minimal complication rate (3% infection and 8% displeasing contours). The material is easily carved and is somewhat flexible. Predictable intraoperative contouring and placement of the implant in the subperiosteal plane of the bony area to be augmented allows precise facial skeletal augmentation.
Tissue-engineered adipose-derived stem cells and autologous fat grafting
Tissue-engineered adipose-derived stem cells and autologous fat grafting have been shown to have a high rate of success. And although unpredictable resorption occurs, this remains a very important adjunct to facial volume enhancement, as this can be repeated in the office setting to offer a more dynamic enhancement of facial rejuvenation as the patient returns for postoperative visits and requests volume fill.
Related posts:
An Algorithmic Approach to Multimodality Midfacial Rejuvenation Using a New Classification System for Midfacial Aging
Dark Circles
Transconjunctival Lower Lid Blepharoplasty with and Without Fat Repositioning
The Management of Festoons
The Transeyelid Midface Lift
Transtemporal Midface Lifting to Blend the Lower Eyelid-Cheek Junction
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