Primary goal: Elevation and tightening of the soft tissues (primarily fat) of the cheek

Secondary goals: Restoration of a more youthful lower eyelid-cheek “continuum”, with lifting of the nasolabial fold (fold of tissue between nostril and cheek), partial softening of the hollowness between the lower eyelid and upper cheek, and improvement in the appearance of cheek bags.

Anesthesia: Because of the extensive dissection and/or complex instrumentation, deep intravenous local sedation or general anesthesia is usually employed. A less invasive “SOOF lift” may be accomplished during blepharoplasty without much added manipulation.

Operative technique: Only one midface lift technique is summarized, performed through a lower eyelid incision: The skin is incised just below the eyelid margin along its full length and slightly beyond into the lateral canthus. The exposed orbicularis muscle is incised along its length in a similar fashion. A skin-muscle “flap” is lifted off of the underlying orbital septum using blunt dissection with cotton-tipped applicators and sharp dissection with scissors. The skin-muscle flap dissection extends downward over the entire lower eyelid to a level approximately even with the orbital bony rim. Excess fat is either removed or repositioned. An incision is made through the periosteum (lining of the bone) just beneath the orbital rim and carried somewhat laterally. The cheek periosteum is lifted off of the bone by blunt dissection over a wide area extending from just below the orbit rim to a level approximately level with the nostril, at which the periosteum is cut thus allowing the attached cheek to become mobile. The lower eyelid lateral canthal attachments are reinforced by any of a number of techniques. The tissue in the area of the temporal cheek fat (SOOF) is grasped with forceps and lifted upward towards the lateral canthus and temple, where it is firmly sutured to underlying periosteum (lining of the bone) and/or dense muscle fascia of the temple. Any excess eyelid skin and orbicularis muscle are then trimmed, and the skin incisions are closed. Since the loosened periosteum and overlying cheek tissue are mobile, the net effect is to lift the entire cheek upward and towards the temple.

Variations: There are a number of very different surgical approaches, each with its own set of advocates. The midface may be lifted from incisions made:

on the front of the lower eyelid (transcutaneous), on the back of the lower eyelid (transconjunctival), from within an upper eyelid blepharoplasty incision, from inside of the mouth (buccal), from the temple behind the hairline, over the periosteum (bone lining), under the periosteum, with or without the use of an endoscope, or, most simply, through tiny skin incisions used to place thick suture as a cable.

Advantages: Midface lift produces a more natural appearance (less pulled) around the cheek and mouth than with a “classical” face lift, which pulls tissue more towards the ear. Lifting the cheek upward restores a more youthful contour that is lost as the cheek descends under the influence of gravity.

Limitations: The improvement from a midface lift is subtle, and so the procedure is typically employed as as “add-on” to other operations such as blepharoplasty and/or a “classical” lower face lift. In contrast to the traditional face lift, a midface lift has very little effect on the sagging tissues of the chin and neck.

Care and recovery: Swelling and bruising may be pronounced; noticeable cheek and eyelid swelling may persist for as long as three months after surgery. Younger patients may find such a lengthy recovery period difficult to fit into an active work schedule.

Risks and complications: In addition to swelling, distortion or puckering in the region just beyond the lateral corner of the eye is not uncommon. A midface lift is, comparatively, not an easy operation for the surgeon; dissection is more extensive and suture placement may be challenging.

Comments: There are no long-term studies to document how long the elevation may last, but early indications suggest longevity on a par with traditional face lift.