Continuing Education Activity
Facelifting is a commonly performed procedure in patients wishing to have a more youthful appearing face. There are many different means by which surgery can address a patient's specific goals. This activity describes the relevant anatomy and standard techniques in approaching the aging mid-face. This activity also reviews the role of the healthcare team in evaluating and managing patients who decide to undergo surgical intervention.
- Describe the relevant anatomy of the face.
- Identify the equipment, personnel, preparation, and technical maneuvers necessary to perform a mid-face lift.
- Review the potential complications associated with mid-face lift.
- Review interprofessional team strategies for improving care coordination and communication to advance mid-face lift and improve outcomes.
As a person ages, there are visible changes occur within the structures of the face. There are descent and atrophy of the malar fat pads, deepening of the nasolabial folds (NLFs), loss of skin elasticity, and development of jowls. There is a wide variety of techniques that can be utilized to rejuvenate the mid-face. Lifting the mid-face can be accomplished during a deep plane facelift, as an addition to a superficial muscular aponeurotic system (SMAS) flap lift, or with a minimal access cranial suspension (MACS) lift. It can also be accomplished through a subciliary incision or with carefully placed incisions in the temporal hair tuft and gingivolabial sulcus. The method chosen should be tailored to patient-specific areas of concern.
Anatomy and Physiology
An understanding of the fascial planes is critical to performing safe and effective face surgery. From superficial to deep in the lateral cheek, these layers are skin, subcutaneous fat, SMAS, parotid masseteric fascia, and parotid gland. Medially, beyond the anterior border of the parotid gland, the SMAS becomes the mimetic muscles of the face, including the zygomaticus muscles, buccinator, risorius, and others. Superior to the zygomatic arch, the SMAS becomes the temporoparietal fascia (TPF), and inferiorly, overlying the body of the mandible, the SMAS becomes the platysma. The facial nerve courses deep to the SMAS layer and its contiguous fasciae (TPF, mimetic muscles, and platysma); therefore, dissection on the superficial surface of this layer will help to avoid complications. The course of the facial nerve frontal branch is approximated by a line described by Dr. Ivo Pitanguy in 1966; the line runs from 0.5 cm below the tragus diagonally to 1.5 cm above the lateral brow.
Similarly, the primary buccal branch that controls the zygomatic muscles can be found reliably at Zuker's point, midway along a line between the root of the helix and the oral commissure. The transverse facial vessels, which are branches of the superficial temporal vessels, and Stensen duct, are commonly located in the same plane, just inferior to this nerve branch.
Effective surgery not only requires avoidance of complications but also the achievement of the patient's goals; in the case of a mid-face lift, the goals are typically effacement of the NLFs and restoration of youthful malar volume. The NLFs are caused by close approximation of the mimetic muscles to the dermis without intervening fat, in a similar anatomic configuration to the dermal attachments of the levator aponeurosis of the upper eyelid. Because the malar fat pads are situated superiorly to the dermal attachments of the perioral mimetic muscles, when they descend, they reach those attachments and stop, producing NLFs. Because of this phenomenon and the facial fat atrophy that attends advancing age, anatomical rejuvenation of the mid-face may be more effectively achieved with repositioning and restoring volume to the malar fat pads rather than filling the NLFs directly with hyaluronic acid or calcium hydroxyapatite. Superior to the malar fat pads lie the medial and lateral sub-orbicularis oculi fat pads, which, when separated from a descending malar fat pad, contribute to the tear trough deformity seen in the aging face.
Restoring fat compartments to their youthful positions frequently requires identification and division of subdermal retaining ligaments, particularly the zygomatic retaining ligaments, also known as McGregor patch, and the mandibular retaining ligaments, which form the pre-jowl sulcus overlying the medial mandibular body as the buccal fat pad descends with age.
The most common presenting complaint leading to mid-face lifting is the descent of the malar fat pads with deepening of the NLFs, which is frequently accompanied by atrophy of the facial fat pads. The presence of festoons - hypertrophic and ptotic "bags" of orbicularis oculi muscle - may also necessitate a midface lift in conjunction with excision to help prevent the development of postoperative ectropion. Mid-face lifting may also accompany a more general face or neck lift when jowling or excess skin laxity, especially from significant weight loss, occur.
While mid-face lifting is not a particularly invasive procedure liable to produce a significant physiological impact on the patient, certain conditions may make the procedure less desirable. Patients with bleeding disorders or the inability to discontinue anticoagulant therapy are at a higher risk for developing a postoperative hematoma, which can result in prolonged ecchymosis and edema, infection, and poor scarring.
Likewise, patients with a history of unfavorable scarring or other healing problems may not be ideal candidates. Common reasons for poor wound healing include diabetes mellitus, immunosuppression, smoking, and autoimmune or collagen vascular diseases. Of course, patients at a high risk of cardiopulmonary complications from general anesthesia should be medically optimized before considering elective, aesthetic surgery.
Preoperatively, a marking pen is needed to denote the location of the tear troughs and NLFs. The patient, even under general anesthesia, will benefit from injection with local anesthetic or a tumescent solution to lessen the requirement for anesthetic drugs and to improve hemostasis. Surgical prep can be performed with either betadine or isopropyl alcohol, the latter of which provides the benefit of not obscuring the patient's skin color and texture subtleties, and does not need to be cleaned off after the procedure; however, it must not be allowed to make contact with the corneas, which it can damage severely.
Intraoperatively, a #15 blade scalpel is used for incisions and removal of excess skin. A set of facelift instruments with scissors, such as Gorney-Freeman or Goldman-Fox, a retractor and light source, fine and heavy forceps, needle drivers, and electrocautery are necessary as well. Several different sutures may be used, but many surgeons prefer heavy, 2-0 polyester or polydioxanone material to suspend the ptotic soft tissues, with 4-0, 5-0, and 6-0 sutures for skin closure.
Postoperatively, a bulky dressing is applied using fluff sponges, gauze rolls, and a compressive wrap, often in the form of a Barton dressing or similar. Ice packs are recommended to limit bruising and swelling, and drains may be placed, depending on the extent of dissection and the amount of bleeding encountered.
In the operating room, the surgeon is accompanied by an anesthesia provider, a circulating nurse, and a surgical technologist; there may be an additional surgical assistant, such as a provider assistant or a resident/fellow.
It is vital to verify the patient's surgical goals in the preoperative holding area at the time the consent form is signed to ensure the correct maneuvers are performed intraoperatively. Similarly, it is critical to post preoperative photographs of the patient in the operating room for reference during the case. The preoperative physical examination should identify and mark tear troughs, nasolabial folds, and jowls, and should identify any preexisting weakness of the facial nerve - particularly in the frontal and marginal mandibular branches - and any numbness in the distribution of the greater auricular nerve. Intraoperatively, the anesthesia provider may administer steroids to diminish postoperative edema and nausea, as well as antibiotics that cover skin flora, and some providers may prefer to run a total intravenous anesthetic with propofol and remifentanil rather than using volatile anesthetics to limit intraoperative bleeding and coughing during extubation.
SMAS Imbrication With Deep Plane Component 
A standard Blair incision should be marked. In men, the incision runs between the posterior border of the sideburn and the anterior margin of the tragus to avoid pulling hair-bearing skin too close to the auricle. Using a #15 blade, the incision is made through the dermis. A subcutaneous flap is elevated until the line between the lateral canthus and the angle of the mandible is reached. At this point, the plane of elevation dives deep to run between the malar fat pad and the zygomaticus major muscle. The zygomatic retaining ligaments are then released.
Once the fat pad is elevated, attention is turned to the SMAS. A strip of SMAS is incised starting 1 cm anterior to the tragus at the superior border of the zygomatic arch and carried inferiorly to the level of the angle of the mandible. This strip of SMAS should be about 1 cm in width and remain pedicled inferiorly. The SMAS flap is then rotated toward the mastoid and secured to the periosteum with a braided non-absorbable suture, such as coated polyester via half mattress sutures.
The malar fat pad is now be placed in a more youthful anatomic position along with the malar eminence and secured with a fibrin sealant or loose 4-0 sutures, taking care to ensure symmetry between the left and right cheeks.A drain can be placed in the occipital/temporal scalp near the incision or at the most posterior aspect of the incision and placed under bulb suction.
The skin is then re-draped over the face and tailored to the incision by excising the redundant skin. Deep dermal sutures are placed throughout the incision using an absorbable suture (e.g., 4-0 or 5-0 poliglecaprone). In the temporal hairline, either absorbable suture (5-0 plain gut) or staples may be used. The incision anterior to the ear should be closed with a non-absorbable suture (e.g., 6-0 polypropylene). The postauricular skin incision should be closed using an absorbable suture (e.g., 5-0 plain gut).
Bacitracin is then be applied to the incision. An external facelift dressing is placed using a combination of fluff sponges, a gauze wrap, a compressive elastic wrap, and ice packs.
Minimal Access Cranial Suspension Lift 
Using a similar incision to that described above, a subdermal elevation is completed over the midface, leaving the malar fat pad down in the wound bed. Then, an 0 polydioxanone suture is used to create a purse-string surrounding the malar fat pad and ultimately suspending it under tension to the deep temporal fascia just lateral to the lateral orbital rim via a window in the orbicularis oculi muscle. The muscle window must be closed before redraping and excision of excess skin to reduce the palpability of the knot. If necessary, similar purse-string sutures may be used to lift the remaining mid and lower face soft tissue, to reduce jowls and improve mandibular definition.
Subciliary Midface Lift 
A subciliary incision is made from the level of the lacrimal punctum laterally to a point 7-10 mm beyond the lateral canthus. A traction suture is applied through the eyelid margin for a superior retraction and corneal protection.
The orbicularis oculi muscle is incised inferior to the pretarsal portion to preserve eyelid function and lower the risk of postoperative ectropion. Dissection is carried inferiorly in a preseptal plane to the inferior orbital rim and the arcus marginalis. This can be done as a single skin-muscle flap or in separate layers according to surgeon preference. This approach also provides access to the lower eyelid fat pads if necessary for reduction or repositioning.
The orbicularis retaining ligament and the zygomatic retaining ligament must be released either via a preperiosteal or a suborbicularis approach. Dissection is carried down about 2 cm inferior to the inferior orbital rim for access to the SMAS. The orbicularis oculi and SMAS flap can then be elevated in a vertical vector or superolateral vector. If utilizing a vertical vector, the SMAS/orbicularis flap is fixated to the arcus marginalis with a mattress suture. If following a superolateral vector, dissection proceeds along the zygoma to the frontozygomatic suture. In this portion of the procedure, it is critical to stay along the bone to protect the facial nerve, with the goal being to reach the deep temporal fascia. The SMAS/orbicularis flap is then suspended to the deep temporal fascia with a mattress suture.
The orbicularis muscle is then redraped, and the excess skin excised. The subciliary incision is closed with an absorbable suture.
Implant-Assisted Midface Lift
Lastly, absorbable implants made of a polylactic-polyglycolic acid polymer that resorb over 6-8 months may be used to simplify mid-face lifting. An implant with multiple tines and a short stem may be used to anchor the SMAS and malar fat to the zygoma via a subciliary or transconjunctival incision; the latter approach typically requires an additional lateral canthotomy. Using an implant with a longer stem, the end with the tines may be placed deep to the midfacial soft tissues in a subperiosteal plane via an upper gingivobuccal sulcus incision, with the stem subsequently anchored to the deep temporal fascia via a tunnel and incision created behind the temporal hair tuft.
The most common complication of any facial cosmetic procedure is dissatisfaction, which is best minimized with appropriate preoperative counseling and patient selection, but numerous other adverse outcomes can occur.
Hematomas are comparatively common and more likely to occur within the first 24 hours of surgery; they are most common in males due to the relatively greater blood supply required to support facial hair follicles. Later in the course of healing, other fluid collections may arise, such as seromas or sialoceles. The former is best addressed with needle drainage and a compression dressing; the latter may also respond to a compression dressing and can be ameliorated with botulinum toxin injections into the parotid gland. Permanent facial nerve injury occurs in <1% of patients, but rates of temporary weakness are slightly higher, up to 2.6%.
Other complications include wound infection, pixie ear deformity - when the lobule is pulled inferiorly by excessive downward tension applied during the closure - poor scarring and alopecia, which may also result from closure under excessive tension, and skin necrosis from poor microcirculation in the flap. Ectropion may occur, particularly when a subciliary approach is employed if excessive tension or cautery are used. First bite syndrome has also been reported as an uncommon sequela of face lifting.
Enhancing Healthcare Team Outcomes
An interprofessional approach to these procedures will promote smooth surgery and improve patient satisfaction. This begins with thorough patient education regarding typical postoperative recovery and helps to manage expectations. Appropriate pain management and activity restrictions for four weeks after surgery should be discussed to optimize postoperative healing. A conversation regarding the role of adjunctive procedures, such as skin resurfacing, botulinum toxin, and dermal filler injection, to further augment a youthful appearance should occur as well.
Before starting the case, a meeting with all surgical teams (anesthesia, nursing, assistants, and surgeon) will delineate equipment needs and outline the flow of the operation. This will help minimize delays during the procedure. Thorough communication with the anesthesia provider regarding blood pressure control can reduce intraoperative bleeding and immediate postoperative hematoma. In the recovery room, the nurses should be aware of the blood pressure parameters.
The compressive head dressing should be kept in place for twenty-four hours. The dressing can then be changed to a jaw bra with ice on/off the area at twenty-minute intervals. The drain should be removed on a postoperative day one. Facial nerve function should be evaluated and documented. Patients should have a second follow-up appointment at one week for suture removal and wound check; another appointment should be scheduled one month after surgery for wound evaluation and to discuss overall patient satisfaction. Photos should be taken three months postoperatively and at every follow-up visit after that.