Research Article
Midface Lift through Lower Lid Blepharoplasty Incision
Ruth M. Graf1*, Maria Cecilia Closs Ono1, Isis Scomação3, Ofer Arnon4, Daniele Tanuri Pace3 and Priscilla Balbinot3
1Department of Plastic and Reconstructive Surgery, Federal University, Brazil
2Department of Plastic Surgery, Pietà Medical Center, Brazil
3Department of Plastic and Reconstructive Surgery, Soroka University Medical Center, Israel
*Corresponding author: and Reconstructive Surgery, Federal University of Paraná, Clinical Director of Pietà Medical Center, Rua Solimoes, 1175, Curitiba, PR 80810-070, Brazil
Published: 22 Dec, 2016
Cite this article as: Graf RM, Ono MCC, Scomação I,
Arnon O, Pace DT, Balbinot P. Midface
Lift through Lower Lid Blepharoplasty
Incision. Clin Surg. 2016; 1: 1254.
Abstract
Background: Today's concept of facial rejuvenation emphasizes a harmonious natural look without the visible signs of surgery. Various techniques have achieved elevation of the midface in the
pursuit of the anatomical repositioning of tissue congruent with youth. An open approach via the
transcutaneous blepharoplasty incision allows for direct fixation of tissues along the periosteum of
the inferior orbital rim, respecting the vertical vectors and reshaping the face by restoring volume
to the midface.
Methods: Between 2004 and 2011, 298 patients, (237 females and 61 males) underwent a midface
lift through subcilliary incisions of lower eyelid blepharoplasty, either with or without simultaneous
endobrow lift, upper lid blepharoplasty, and/or lipofilling. In order to assess patient satisfaction,
a telephone questionnaire was administered to 80 of the 298 total patients. To develop a more
objective assessment of the results, 42 patients’ photographs were randomly selected to measure
and to quantify the improvement in the elevation of the midface.
Results: The majority of the interviewed patients (89%) were satisfied with their physical appearance
and happy (77%) with the results one year post-op. Sixteen patients (20%) referred transitory minor
complications as edema, chemosis and alterations of eyelid shape. No patients had to undergo
surgical revision related to these complaints. Analysis of the measurements showed a positive
correlation between patient satisfaction and quantifiable improvement. There was a reduction of
the distance from the pupil to the nasojugal fold postoperatively compared to preoperative values,
with p< 0. 001.
Conclusion: The open subciliary supraperiosteal midface lift is an effective, low morbidity technique
yielding high patient satisfaction.
Keywords: Midface lift; Lower lid blepharoplasty; Rejuvenation
Introduction
Today's concept of facial rejuvenation emphasizes harmonious natural looking without the
stigma of surgery. Several techniques have thus far effected elevation of the midface through
various approaches to anatomical repositioning of tissues. Currently, however, to achieve the signs
of midface aging with a more natural result is entirely related to vectors and volume. Improved
understanding of the facial aging process has led to the concept of repositioning volume as a threedimensional
tissue structure mobilized upward in a vertical direction [1]. Based on this concept,
procedures for facial rejuvenation are in constantly evaluation. Techniques development began with
Hinderer [2-6], a pioneer in anatomical description of periorbital region, and more specifically, the
nasojugal groove. He described open surgical techniques for repositioning tissues in this region, via
lower blepharoplasty incision.
Since 1991, in addition to the periorbital region, attention also turned to the midface, especially
with the work of Isse [7,8] and Ramirez [9]. And also Graf [10], suggested endoscopic repositioning
of mid facial tissues. New surgical principles were introduced, such as preservation and repositioning
of the periorbital fat [11], treatment for muscles of glabellar region [12,13], and repositioning of
orbicular is muscle and suborbicular is oculi fat (SOOF) [14-16]. The open approach discussed
here, through lower blepharoplasty incision, allows direct fixation of tissues along inferior orbital
rim periosteum, respecting vertical vectors, so the upper nasolabial fold and lid-cheek junction are
directly improved [17].
In order to obtain the desired lower eyelid tonicity and to
maintain a natural and youthful aesthetic of eyelid shape, a lateral
canthopexy is performed. Two common and troubling complications
of blepharoplasty, scleral show and ectropion, are greatly decreased
as a result of the midface direct fixation and the lateral muscular
canthopexy [18,19].
Figure 1
Figure 2
Figure 2
Steps of surgery. a) Sub cilliary incision showing skin flap due to a supramuscular undermining.
b) Four stitches for midface suspension,
c) Lateral cantophexy with orbicularis muscle,
d) Conservative resection of skin of the lower eyelid.
Figure 3
Figure 4
Figure 5
Figure 5
Caudal and supraperiosteal undermining along inferior orbital rim, toward the midface, under the orbicularis muscle and suborbicularis oculi fat pad (SOOF).
Patients and Method
All patients in this study underwent treatment of the midface
through a subciliary incision; the same incision used for lower
blepharoplasty and was treated by the senior author during 2004-
2016. Inclusion criteria were age homogeneity, signs of aging in
periorbital and midface regions, showing inferior orbital rim, with
clear presence and accessible nasojugal groove.
Follow up at least until one year postop of all patients was made
to achieve a more objective understanding of patient satisfaction.
Postoperative care was more frequent at first months and patients
were followed each month after third post op month.
One hundred patients’ photographs were randomly selected
and evaluated using Image J Software. In each photograph, one line
(the distance - MPN) from the pupil to the pre- and post-operative
nasojugal fold was measured (Figure 1). After obtaining this distance,
a statistical analysis was performed, of the median, average, minimum
and maximum values for the standard deviation. The Jarque-Bera test
was used to establish the norm, with p< 0.05.
Surgical Technique
Patient underwent local anesthesia and sedation (160 ml of 0.9%
saline solution, 20 ml of lidocaine 2%, 20 ml of 0.5% Marcaine and 1
ml of 1:200.000 epinephrine). From this solution, 20-30 ml was used
in total for the upper and lower eyelids. A subciliary incision is made
and continued laterally into a crow's feet line. A skin flap is developed
1.5 centimeters inferiorly. Undermining is performed through the
orbicularis oculi muscle, while maintaining the pre-tarsal strip of the
orbicular is muscle (3-4 mm). Maintaining this muscle portion intact
is important for lower eyelid closure and support (Figure 2). Care
must be taken to not damage the buccal branch from the zygomatic
nerve innervating the orbicular is oculi muscle to avoid postoperative
hypotonicity of the lower lid [20]. Orbital septum is also maintained
intact (Figure 3). Mild third elevation will hide a mild to moderate
amount of infraorbital fat protuberance. If periorbital fat is grossly
herniating, electro-coagulation of the septum will reduce the fat pads
into the orbital cone [21-23] (Figure 4). In patients with moderate to
severe infraorbital fat protuberance fat excision is not performed but
rather perform orbital septum electrocoagulationto shrinking and
move back the fat pad preventing the occurrence of enophtalmos.
Caudal and supraperiosteal undermining along the inferior
orbital rim, toward the midface, under the orbicular is muscle and
suborbicularis oculi fat pad (SOOF) is done (Figure 5), releasing
orbital retaining ligament following the inferior orbital rim (Figure
6), avoiding going to medial to preserve the angular artery and the
buccal branch from the zygomatic nerve. An immediate lifting of
the lateral canthus is observed (Figure 7). Inferior and lateral to the
infraorbital nerve, the pre-zygomatic space described by Mendelson
[24] is undermined until nasolabial fold.
Detached midface tissue is vertically suspended with prolene
4.0 and fixed to the periosteum of lower orbital rim in four points;
first, medial to the infra-orbital nerve, setting the lowest portion of
the orbicularis, and second, central portion of the orbital rim (pupil
line), lateral to the infra-orbital nerve, then third, to the inferolateral
orbital rim, thus suspending and fixing the SOOF, and finally, fourth,
securing the orbicularis muscle to the lateral orbital rim at the level
of the pupil (Figure 8). Four stitches (prolene 4-0) are used initiating
0,5 cm from lacrimal punctum until lateral part or inferior orbital rim
(from medial part to lateral part of inferior orbital rim suspending
midface soft tissue taking care of with angularis artery), aiming to
transpose this descended tissue, to fill up the tear trough deformity
and to obtain an effective and long-term result in midface suspension.
Lateral canthus support (prophylactic canthopexy) is a routine
component of the procedure, used to obtain the desired lower eyelid
tonicity and to maintain an aesthetic, natural eyelid shape. Associated
complication rate is acceptable [19]. Dissection is carried out through
the upper blepharoplasty incision. A submuscular tunnel is created
toward the lateral portion of the inferior preseptal orbicularis muscle.
Through the tunnel, the orbicularis muscle of lower lid is clamped
and pulled up vertically and medially, anchored to the periosteum of
the inferior border of the superior orbital rim (Figure 9).
Conservative resection of lower eyelid skin is performed after
assessing static and dynamic tissue surplus (mouth opening) (Figure
10). Intradermal sutures are made (Figure 11). Dissected areas are
taped over, to minimize tissue edema and to maintain suspension
(Figure 12).
Figure 6
Figure 7
Figure 7
Excessive skin showing midface suspension after SOOF undermining and orbital retaining ligament releasing. No depression at infraorbital rim after retaining ligament releasing.
Figure 8
Figure 9
Figure 9
Lateral canthus support (prophylactic canthopexy) used to obtain the desired lower eyelid tonicity and to maintain an aesthetic, natural eyelid shape. a) Submuscular tunnel. b) Orbicularis muscle clamped and pulled up. c,d) Muscular fixation to periosteum. e) Final aspect, with natural eyelid shape.
Figure 10
Figure 11
Results
457 patients underwent surgery between 2004-2016, 373(81.6%)
women and 84(18.4%) men, between 36 and 79 years-old, mean age
51 years old. Seventy five percent of these patients underwent to
primary surgery and 25% had had previous blepharoplasties.
Three hundred thirteen patients (68.4%) were reached for
interview and could be evaluated postoperatively, with average
of 42 months after surgery. Two hundred sixty three (84%) were
women. From the survey, twenty-eight patients (9%) referred minor
complications as edema, chemosis and eyelid shape change. The other
patients could not be found at the time of the interview.
Retouch surgeries happened between 4 to 12 months after first
procedure (average of 8 months) and they were made in nine patients.
They were related to a unilateral new canthopexy for symmetrization
(5 patients), removal of excessive skin (2), fatpad excess removal
(1) and removal of a thin muscular strip (1). Minor complications
were transitory and disappeared at least in three months, after local
massage. These patients had a closer follow-up and were found to
answer the questionnaire.
Regarding the patients interviewed, 84% (264/313) thought
that blepharoplasty enhanced their physical appearance and judged
as an excellent result. 21 patients were happy with the results one
year after the surgery. Only 9 percent (28/313) were not completely
satisfied with the result and minor complications were observed, all
related to bruises on the skin 21 days after the surgery. No ectropion
was observed. Ninety-one percent (285/313) of the patients stated
that relatives thought they had a much younger appearance postoperatively.
The most commonly mentioned improvements were in
the sub palpebral pouches and in the palpebromalar groove (85% and
71% respectively, among those reporting good results). Ninety-three
percent of patients liked their new appearance after the surgery, and
their mean time of self-assessed rejuvenation was 6 years. Figures 13
and 14 show the results obtained with the technique described herein.
In the analysis of the photographs of 100 patients, randomly
selected, the distance from the pupil to the nasojugal fold (MPN)
measurement of the preoperatively and postoperatively are
compared. Among these patients, the photographs were taken at
one-year post-op. Analysis of pre and postoperative times were
compared considering “t” Student test for independent samples.
Confidence interval of 95%, considering both eyes of each patient,
was considered by Hotelling T2 statistic. There was a reduction of
MPN postoperatively compared to preoperative values, with p=0.002
(Table 1 and Graphic 1).
Figure 12
Figure 13
Figure 13
Patient male, 53 years old, pre- and 5 year post-operative views, showing the results obtained with the technique described.
Figure 14
Figure 14
Patient female, 68 years old, pre- and 3 year post-operative views, showing the results obtained with the technique described.
Graphic 1
Graphic 1
Mean and standard deviation of all cases, compared into two times (pre and post operative) in both eyes. Measures from pupil to nasojugal fold were made in unit/pix.
Table 1
Table 1
In this table, mean and standard deviation of all cases are compared into two times (pre and post operative) in both eyes. Measures from pupil to nasojugal fold were made in unit/pix.
Discussion
Harmonious facial appearance is determined by a balanced
relationship between all facial features. With advancing age,
that balances between bone, muscle, fat and skin is often lost as
progressive changes occur in their volume, shape, position, texture
and consistency [25-26].
Yousif [27] studied changes of the midface area, observing that
with age, the cheek mass appears to descend. With this descent, there
is a depression in the infraorbital area, giving a hollow, gaunt look that
varies in depth and shape. Descent of cheek mass away from lower
eyelids and a subsequent soft-tissue deficit creates visual elongation of
the lower lids, extending them beyond inferior orbital rim.
The four most important features of midface aging, as summarized
by Hester et al. [28], are: (1) descent of malar fat pad, with loss of
malar prominence; (2) deepening of tear trough (nasojugal fold); (3)
exaggeration of nasolabial fold; and (4) gradual ptosis of cheek skin
below the inferior orbital rim, with descent of attenuated lower eyelid
skin, creating a skeletonized appearance, with infraorbital hollowness.
The nasojugal groove, an area of continuing discussion for its
difficulty in treating harmoniously, is an extremely common and
consistently deforming characteristic of lower orbital region. It is
this groove that creates a transition of color and shading, visible in
lower periorbital region. The nasojugal groove begins at the medial
aspect of the lower eyelid and is created by the descent of midfacial
structures away from lower eyelids and becomes gradually prominent
with aging. The bulging of descended orbital fat and the prominence
of the orbital rim after descent of the malar fat pad all contribute to
increase nasojugal groove [29,30]. Malcolm Paul [1] described tear
trough deformity as a groove located at orbital rim base. Volume loss
allows the surface anatomy to appear as a triangular confluence of
inferomedial part of orbicularis oculi muscle, alae nasi levator muscle,
and upper lip levator muscle. Increased understanding of facial aging
processes introduces the concept of volume repositioning as the
upward, vertical mobilization of a three-dimensional tissue structure.
Based on this concept, the surgical procedures for facial rejuvenation
evolved [1,31].
In 1974, Skoog [32] introduced the deep lateral approach to
the midface, and was followed by other similar techniques [33-
35]. In 1979, Tessier [36] published his "mask lift," a sub periosteal
forehead lift congruous with a vertical sub periosteal approach to the
midface. Tessier's [36] principles are still used today and have also
been followed in other similar techniques [37]. In 1985, Hinderer
[6] published a vertical preperiosteal (sub-SMAS) approach to the
midface and periocular frame of eyelids. Hester [15] proposed the
“centrofacial” approach for correction of facial aging, which required
a full blepharoplasty incision and a canthopexy to support midface
suspension. Open techniques created complications, such as lower
eyelid malposition and ectropion. In order to minimize postoperative
complications, lateral canthopexy and alternative approaches such as
the transconjuntival approach were employed [38,39].
Isse [8] first published the endoscopic supraperiosteal approach
to rejuvenation of the mid-third face. Isse [7] and Hinderer [6] have
addressed approach choice between open, endoscopic, or combined.
Ramirez [9] initially proposed the midface is best approached by
means of a combination of a temporal slit incision and an upper oral
sulcus incision, with no eyelid access used. Hester explained that
the lower lid suspensory mechanism is exposed to the weight of the
cheek; a strong lateral canthus support is necessary in the form of
canthopexy or canthoplasty. Long-term evaluation of the technique
revealed a 19% incidence of ectropion [18]. As a result, the original
authors now mainly favor a supraperiosteal midface lift with a
temporal approach [17]. In our series, there was no ectropion. The
orbicularis retaining ligament, when it is released, can maintain lower
lid position and shape [31,40].
Rohrich et al. [20] described an important technique with
five steps to treat the lower lid detaching retaining ligaments and
blending the eyelid-cheek junction. Their technique brought us
the new concept for the modern blepharoplasty associated to a
prophylactic canthopexy, but do not suspend effectively the midface.
The supraperiosteal midface lift has been indicated for treatment of
sagging tissue in malar-orbital area. The goals of the procedure are to
adequately correct the eyelid frame, laterally and superiorly rotate the
orbicularis oculi muscle and external canthus region, decrease "crow's
feet," attenuate nasolabial folds, and suspend submalar fat pads and
cheeks, thus elevating and minimizing the nasojugal groove [41,43].
An open approach via transcutaneous blepharoplasty incision allows
direct fixation of tissue along periosteum of the inferior orbital rim,
respecting vertical vectors and reshaping the face by restoring volume
to the midface. Periosteum is a hard and inelastic tissue, which makes
difficult to elevate midface tissues. For this reason, supraperiosteal
undermining is chosen in this technique. Besides that, intact
periosteum is a support for SOOF fixation. Nerve or vascular lesions
were not identified in our casuistry. Pre zygomatic space described by
Mendelson is undermined and it is an avascular plane. All retaining
ligaments are totally released in supraperiosteal plane.
For effective correction of mid-facial tissues ptosis and raising
the nasojugal groove, it is extremely important to correct any tissue
displacement as well as perform an efficient method of suspension and
fixation of tissues (muscle and orbicularis SOOF). The open subcilliary
supraperiosteal technique advocates the release of the orbicularis to
the fullest extent of inferior orbital rim, preserving some of its medial
portion, with detachment performed supraperiosteally at the inferior
orbital rim and at the maxillary region at the pre-zygomatic space to
the nasolabial fold (Figure 1).
Routine lateral preseptal muscular canthopexy with the midface
direct fixation decreases scleral show and ectropion, the most
common complications of blepharoplasty [44].
The open subcilliary technique allows the vector of suspension of
the check to be strictly vertical, rather than lateral or superolateral.
This achieves a direct, significant lifting of the upper nasolabial fold
and accomplishes an anatomical correction of the downward descent
of the cheek complex that occurs over time.
Blepharoplasty techniques aim in the majority treat nasojugal fold.
Besides that, our objective is to elevate midface. With undermining in
pre-zygomatic space, soft tissues from midface are repositioned, filling
depression areas created by aging process. Sutures for suspension and
fixation at the periosteum are a contributing factor for a long-last
result.
Conclusion
The open subcilliary supraperiosteal midface lift is an effective, low morbidity technique yielding high patient satisfaction and offering long lasting results for rejuvenation of the periorbital and midface region.
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