The aging human face undergoes several changes which may be addressed with cosmetic treatments. Most notably, the soft tissue (skin, fat and muscle) of the face deflates over time and sags downward as the fibrous attachments between the skin and deeper structures weaken. While the lower face lift and neck lift treat the sagging tissue of the jawline, jowls, and neck, these procedures do not significantly improve the area of the midface. For certain individuals with predominantly mid-facial aging changes, a distinct mid-face lift is necessary to create facial rejuvenation. In other patients, both the midface and lower face together must be corrected in order to create a balanced, youthful appearance.
Generally, the midface refers to the area beneath the eyes and cheek bone, to the side of the nose, and above the smile lines. The soft tissue in the midface contains a thick fat pad, called the malar fat pad. In youth, this fat pad is suspended high in the face, creating an appearance of volume and youthfulness. The fullness in the midface and cheek bones together provides volume in the upper face. This contributes to an overall triangular shape of the youthful face in which fullness higher in the face tapers into a narrower shape toward the bottom of the face (mouth and chin).
The midface soft tissue is overall loosely connected to the underlying facial skeleton. This is different from some other areas of the face in which the skin is tightly connected to the deeper structures of the face. The laxity of the connections of the midface allow it to descend earlier and to a greater degree than in some other areas of the face. This leads to deepening of the nasolabial folds (lip-cheek smile lines or “parenthesis lines”) as the midface tissue descends and hangs over the lip skin below the fold (which does not descend significantly).
Because the midface is also continuous with the skin and soft tissue of the lower eyelids, midface aging changes also impact the appearance of the eyes. Specifically, as the midface descends, the tissue pulls downward on the lower lid soft tissue creating hollowing, deepening of the tear trough, and dark circles under the eyes caused by shadows in the areas of volume deficiency.
The goal of the midface lift is to restore the position and volume of the midface into a more youthful appearance. This involves dissection of the midfacial soft tissue off of the facial bone and suspension of the soft tissue upward. There are variations of the procedure, mainly involving the location of the fixation, i.e., the point above the midface onto which the soft tissue is anchored. These variations are briefly explained below.
This approach may be used when a standard facelift is also being performed. In this procedure the midface soft tissue is accessed through a standard vertical facelift incision just in front of the ear. The dissection is extended further toward the center of the face and higher toward the eye in order to free the midface from its attachments to the bone. Through this approach, the undersurface of the midface is pulled with stitches in a diagonal direction (upward and toward the ear) and secured to connective tissue around the temple or in front of the ear. The advantage of this approach is that a separate incision is not necessary for the midface when it is being performed in the same setting as a standard facelift. The disadvantage is that the pull is in more of a diagonal direction, rather than a true upward direction. This can create some elevation of the corners of the eyes, though the distortion typically resolves over a few weeks after surgery.
This approach involves placement of an incision within the lower eyelid. It is most commonly performed when a lower blepharoplasty is also being performed in the same surgery. The incision allows direct access to the orbital rim of bone below the eye. The midface soft tissue can also be dissected free from the bone through the eyelid incision. An additional incision inside the mouth at the underside of the upper lip can also be used to access further elevation of the midface tissue from below. The undersurface of the midface is stitched to small screws placed into the orbital bone rim below the eye to create the desired elevation. Skin and soft tissue may bunch up under the eye as a result of the procedure. For this reason, a concurrent lower blepharoplasty can help in smoothing out the contour. Because this approach can elevate the midface in a true vertical direction, it creates a true “reversal” of the downward descent of the aging midface. The main disadvantage is that there a greater risk of a downward pull on the lower eyelids, which can create a visible change to the shape of the eye.
This is the most common approach used to elevate the midface when a concurrent brow or forehead lift is being performed. The forehead incision is extended to the hair bearing scalp of the temple and the soft tissue of the midface is accessed through downward dissection. Dissection around the cheek bone must be limited to the area close to the corner of eye in order to avoid the branch of the facial nerve that controls motion of the forehead muscles. Again, an incision inside the mouth can be used to aid in the elevation of the midface off of the bone. The midface soft tissue is then secured by suture from its undersurface upward and outward to the fascia of the temple.
The procedures described create rejuvenation of the midface predominantly by elevating the soft tissue into a higher position. If there is adequate thickness and volume of the midface tissue, the elevation alone will be sufficient to create the youthful appearance to the face. However, if there is significant deflation of the midface as well as descent, additional volume may need to be placed into the midface in addition to elevation. This can be accomplished through fat transfer, which can be done at the time of surgery. It may also be accomplished through the placement of commercially available dermal fillers.
Like other facial rejuvenation procedures, the midface lift can result in bleeding, hematoma (abnormal blood collection), or infection. Temporary elevation of the outer corners of the eyes can be bothersome for patients, but will resolve over the course of weeks following surgery. Prolonged swelling is another complication, though also temporary in nature. In some cases, particularly when the midfacial tissue is heavy, recurrence of descent and aged appearance of the midface may occur after surgery.