The midface is of central importance in facial aging as this is the first site where its signs manifest themselves. These signs comprise volume loss, deflation, malar prominence flattening, baggy eyes, and development of nasolabial and nasojugal folds due to ptosis and laxity. The midface lift reverses the ptosis by reposition of the sagging tissues and has even been dubbed the facelift of the 21st century by Botti and Ceravolo due to its effectiveness. The midface lift has been performed using the transblepharoplasty, trans-oral, trans-temporal or brow-lift approach. The trans-blepharoplasty approach has all the associated disadvantages of lower lid surgery including a canthopexy requirement and risks of asymmetry, scleral show, lagophtalmus and ectropion development. With the transtemporal subperiosteal midface lift, dissection is extensive, technically demanding, has greater risks and a longer recovery. The dissection plane has to bedeveloped under the superficial temporal fascia and then transitioned to the subperiosteal plane over the zygoma. The surfaces of the zygoma and malar bone then need to be connected through subperiosteal dissection. Subsequent anchorage of the malar tissues are achieved only by suspension of the malar fat pad, and its longevity is questionable. Other alternative procedures such as the minimal access cranial suspension (MACS) lift with a third suture cause a visible facial scar of 14-16 cm in length.
METHODS: The temporal endoscopic midface (TEM) lift is a new minimal-access facelift that uses exclusively temporal access incisions thereby sparing any scars on the face itself. This utilizes endoscopic dissection and a suturing technique that was developed by the author. An incision measuring 5-6 cm is made and hidden in the hair-bearing part of the temple. Common pitfalls such as damaging the hair roots or making the flap excessively thin must be avoided at this stage. The dissection plane is developed over the superficial surface of the common facial and temporal superficial musculoaponeurotic system (SMAS). It is important to completely avoid violating the integrity of the SMAS by either inadvertent incisions or diathermy. An alternative initial approach through the same
incision is a dual plane dissection. In this approach, the plane between the superficial and deep layers of the temporal fascia is first developed and dissected towards the non-hair bearing skin of the face. When or before the junction of the hairline is reached, an incision is made on the deep surface of thesuperficial layer of the temporal fascia. The dissecting plane is then transitioned onto the superficial surface of the superficial layer of the temporal fascia.
The subsequent surgical steps are common to both approaches. As dissection proceeds over the zygoma, the temporal branch of the facial nerve remains protected, it is deep to the superficial layer of the temporal fascia. Both the mid-facial (malar) SMAS andthe lateral facial SMAS can be easily reached this way.
Pertinent anatomy: The temporal and facial portions of the SMAS fuse over the malar bone. The facial SMAS continues in the temple as the superficial temporal fascia and the frontal branch of the facial nerve lies deep to it. Limiting dissection to the plane above this fascia without violating it will ensure avoidance of nerve injury. The facial SMAS continues in the midface as the malar SMAS and is incorporated by the thick malar fat pad.
The anatomy of the facial fat compartments and that of the malar fat pad was best described by Botti and Ceravolo through cadaveric studies. The malar fat pad was found to be divided into two parts, asuperficial part and a deeper part. The author´s clinical experience is consistent with these findings. The midface can be well visualised through a medial extended facelift and the parts of the malar fat pad can be easily distinguished. The superficial part originates from the skin and can be conceptualised as a condensation of the malar thickening of skin fat with the strong Camper´s fascia. Under this, the deep part of the malar fat pad is found enmeshed and reinforced by the fibres of the SMAS. Both the superficial and deep parts of the fat pad hold sutures well as the intertwined Camper’s fascia and SMAS fibres respectively, lend them strength. This unique anatomical construct of the reinforced malar fat pad serves as an effective pole for which lifting and anchoring threads can be secured to with effectiveness and longevity.
The key elements of the method are the endoscopic dissection in the superficial plane, the high malar SMAS anchor, the direct internal flap anchor and the author’s suture technique in the tunnel and keyhole access.
DISCUSSION: Aging process is a combination of ptosis, deflation and wrinkling. A facelift corrects the ptosis of the lateral facial parts and of the jaws and neck, but not really works against centrofacial aging. As it described before the mid facial structures are not sufficient repositioned by a conventional facelift – they are too far from the large lateral acces and the scar means a stigma forever. By the MACS lift the lateral face and the jawline can be well corrected, howewer on the cost of a pretrichal and praearicular scar. The so-called “third suture” of the midface is also an additive element by the necessity of midface restoration even by young individuals. There are many subperiosteal ways of accesses to the midface to reposition andrestore it efficient. All of them lack to generate a unity of the SMAS and also of the skin layer lifting each of them in one block, in one common layer.
Resources: Botti G, Ceravolo MP. Midface and Neck Aesthetic Plastic Surgery, ACADEMIA