Overview of Midface Lift
As we get older, our face naturally starts to change. Things like the fat pads in our cheeks shrinking, our smile lines getting deeper, our skin becoming less stretchy, and our lower cheeks sagging can all happen as part of the ageing process. However, there are many different ways to rejuvenate or refresh the look of our face.
Non-surgical options include treatments like botox, skin fillers, skin resurfacing using lasers, dermabrasion (which is a type of skin smoothening treatment), chemical peels, and advanced procedures that use cold therapy (cryotherapy) or radio waves (radiofrequency energy). On the other hand, there are surgical treatments that can be done to refresh the look of the face including moving fat from one area to another, lifting the eyebrows, eyelid surgery, neck and face lifts, and lifts specifically for the middle of the face.
Operations to lift the middle of the face, or “midface lifts,” can be done in a couple of different ways. One way is to do it during a deep plane facelift, which involves lifting and tightening the deeper layers of the face. Another method is through a minimal access cranial suspension facelift, a less invasive procedure that uses small incisions. This lift can also be done with careful cuts along the lower eyelid or in the hair on the temple and near the mouth. It’s important that the method that is chosen suits the individual’s aims for their facial rejuvenation.
Anatomy and Physiology of Midface Lift
In order to have a successful facelift surgery, it’s crucial for the surgeon to understand the different layers of face tissues. These layers include the skin, the layer of fat under the skin, the superficial muscular aponeurotic system (SMAS) which roughly refers to the muscles and connective tissue layer under the fat, the parotidomasseteric fascia, and the parotid gland – which is a salivary gland thats located in front of the ears. These layers go from the surface of your face (skin) to deeper parts (parotid gland). Moreover, the SMAS connects with other facial muscles responsible for your facial expressions, such as smiling.
As part of the detailed structure of the face, the SMAS changes into the temporoparietal fascia (TPF, another layer of connective tissue) above the zygomatic arch (part of cheekbone), and integrates with the platysma (muscle overlapping the jawline) below. Crucially, the facial nerve, which controls facial muscle movement, runs beneath the SMAS layer and other adjoining tissue layers. This means that during a facelift, the surgeon needs to operate on the surface of the SMAS layer to avoid accidentally harming these nerves.
Having a successful facelift surgery is a combination of preventing mishaps and achieving the desired looks aspired by the patients. For midface lifts, usually the main goals are to smooth out nasolabial folds (deep lines running from either side of the nose to the corners of the mouth), and restoring youthful cheek volumes. These folds develop due to facial muscles being close to skin without a layer of fat in between, similar to the natural structure in the upper eyelid. An effective midface rejuvenation aim to reposition and refill the volume in the cheek fat pads just above the underlying facial muscles. This approach not only smoothens out nasolabial folds, but also targets facial fat loss linked to aging, rather than just filling nasolabial folds with substances like hyaluronic acid or fat.
The distribution of fat in the face and how it contributes to facial aging is important. For example, moving fat pads back to their original youthful positions may require identifying and dividing some ligaments under the dermis (the thick layer of skin beneath the outermost layer), like the zygomatic retaining ligaments and the mandibular retaining ligaments. This is a careful approach to rejuvenate the midface providing natural and comprehensive results.
Why do People Need Midface Lift
A facelift for the middle of your face, also known as a midface lift, is often needed because of sagging cheek fat, which leads to deep wrinkles known as nasolabial folds and loss of face fat at the same time. This impacts the lower eyelids leading to the formation of ‘bags’ called festoons, as a result of overgrown eyelid muscle.
In such cases, a midface lift can be helpful, which is usually done along with eyelid surgery and a technique called lateral canthopexy to prevent eyelids from turning outward after surgery. This type of lift can also work well with lower face or neck lifts in situations where there are sagging jowls or loose skin, particularly after substantial weight loss.
While some people consider midface lifting as a secondary option after unsuccessful treatments using dermal fillers or fat transfers, others see combining volume boosts as a good addition to the surgical lift of the midface. This dual approach can help to achieve the best results for mid-face rejuvenation.
When a Person Should Avoid Midface Lift
Midface lifting, a type of cosmetic surgery, usually doesn’t bring about significant physical changes after the surgery. However, certain pre-existing health conditions could make this operation more complex. These can include:
1. People with bleeding disorders or those who can’t stop their blood thinning medication may face a higher risk of a condition known as postoperative hematoma. This is when blood collects under the skin after surgery, leading to extended periods of bruising, swelling, potential infection, and less than ideal scarring.
2. People with diabetes may need to temporarily pause their diabetes medication, particularly a type called sulfonylureas and inhibitors of the sodium-glucose cotransporter-2, before they can have the surgery.
3. Those who are prone to poor scarring or healing problems might not be the best candidates for this surgery. Risk factors include having diabetes, weakened immune system, smoking for a long time or recently, having had facial radiation therapy, and autoimmune or collagen vascular diseases which affect your body’s ability to heal.
4. Lastly, patients who have a greater chance of heart or lung problems during anesthesia should get their health issues under control before considering elective cosmetic surgery.
Equipment used for Midface Lift
Before the operation, the doctor uses a special pen to mark the areas of the face where changes are going to be made, such as the tear troughs (the hollow area that runs from the inner eye down along the upper cheek) and the nasolabial folds (the lines that run from the nose to the corners of the mouth). Even if you’re asleep under general anesthesia, it’s helpful to get an injection of local anesthetic or a special solution. This helps lessen the need for anesthetic drugs, aid blood clotting, and manage pain after surgery. One way to reduce bleeding during surgery is by adding a drug called tranexamic acid into the solution that’s injected.
Before the surgery, your skin is cleaned with Betadine (a type of antiseptic) or isopropyl alcohol. Isopropyl alcohol is preferred at times because it doesn’t hide the natural color and texture of your skin, and there’s no need to wipe it off after it’s used. However, it’s important to prevent it from getting into your eyes as it can cause severe damage.
The doctor makes cuts in the skin and removes any extra skin during the operation using a particular type of scalpel called a #15 blade scalpel. The special tools used for this type of facial surgery may include certain types of scissors like Gorney-Freeman or Goldman-Fox, a retractor with a light (a tool used to hold back tissues so the surgical area is better visible), skin hooks, suction, different types of clamps, tools for holding and using sutures, and a device for stopping bleeding by using heat (electrocautery). Sutures (or stitches) play a key role, and the doctor often uses heavier and thicker ones to lift saggy soft tissues, and thinner ones to close the skin.
There may be times when the facelift procedure is extended to include a midface lift, requiring the use of additional tools like a 30° Hopkins rod telescope, camera, optical dissector sheath, and different types of surgical spatulas called Freer and Daniel elevators. In a midface lift, absorbable implants (pieces of specially designed material that the body can gradually break down and eliminate) are commonly used, requiring one implant per side of the face.
After surgery, your face will be covered with a thick bandage made of sponges and gauze. Ice packs are recommended to limit any bruising or swollen areas, and in some cases, small tubes might be inserted to help drain any blood or fluid that builds up.
Who is needed to perform Midface Lift?
When a surgery is performed, the doctor doing the operation isn’t alone. They are usually joined by a group of healthcare professionals to make sure everything goes smoothly. This team could include a person in charge of anesthesia (the medication that keeps you from feeling pain during surgery), a nurse who helps during the operation, and a professional who is specialized in doing technical things during surgery, like handling the surgical instruments.
In certain situations, an extra surgical helper like another nurse or doctor-in-training, might be there too. Once the surgery is over, the nurses play a very important role in making sure you are comfortable and following your post-surgery care plan. This can range from giving you medications, taking out stitches or staples, restricting certain activities, and taking care of your surgical cut.
Nurses also have the critical job of watching out for and tackling any problems that might come up while you are recovering from the surgery. In simpler terms, these medical professionals work together to make your surgical experience safe and comfortable.
Preparing for Midface Lift
Success of facial rejuvenation, or facelift, surgery depends on a team of professionals working together. This team approach not only makes the operation go smoothly but also enhances patients’ satisfaction. Prior to the surgery, patients should be well informed about what to expect during recovery. It’s also important for the patient and healthcare team to have a clear understanding of the patient’s desired outcome. Discussing proper pain management and limiting activities for 4 weeks after surgery is important for ideal healing.
There might also be a discussion about other treatments that could complement the surgery, such as improvements to the skin surface, treatments to relax facial muscles (botulinum toxin), fillers that plump up the skin, or other treatments that don’t require surgery. Certain natural supplements, like Arnica montana, may be suggested to reduce bruising.
When giving consent for the surgery, it’s critical for patients to discuss their goals and review them just before the surgery begins. This ensures that the surgical team is specific about what will be done during the operation. The team should note any areas of particular interest on the face, as well as any areas of weakness or numbness. Taking photographs of the patient before the surgery can also be helpful. This is because the patient’s appearance can change when lying down compared to standing up, and the pictures can help guide the surgical team.
Before starting the surgery, everyone on the team should understand what equipment is needed and what steps will be taken. This helps avoid delays during the operation.
During the procedure, the person giving the anesthesia (pain relief) may also give steroids to reduce swelling and feeling sick after surgery. They might also give antibiotics to prevent infection. The anesthetic used might be an injection rather than a gas, to avoid complications. It’s important to monitor the patient’s heart rate and other vital signs to avoid risks after surgery. Communicating with the anesthesia provider is key in controlling blood pressure and preventing bleeding during and after surgery. A medicine called tranexamic acid might be given to control bleeding. The usual dose is 1 g at the start of the surgery, with an extra 1 g dose given at the end or 4 hours later.
How is Midface Lift performed
There are various techniques to lift the midface, an area of the face that includes the cheekbones and the region immediately below. All of these methods involve a procedure called rhytidectomy, more familiar to us as a facelift, and aim to help enhance your facial contours and reduce signs of aging.
In one method, the surgeon makes an incision in your hairline region, extending it to behind your ear. Men get another incision near their sideburns, while women get theirs near the ear. The doctor then creates a flap of skin and takes it up towards the cheekbones. A section of the face, just below the cheekbones, is separated from the muscle beneath it. After finishing the rest of the procedure, your surgeon will then lift the cheek area upwards and secure it to prevent sagging. Ice packs could be useful in limiting swelling or puffiness. This procedure achieves a rejuvenated but still natural look.
A different technique, called the Minimal Access Cranial Suspension Facelift, uses a smaller incision and focuses on lifting the layer below the skin that includes the cheek fat pad. Your surgeon uses specialized sutures to raise and secure this fat to a region just outside the eye. If needed, they could use these sutures to tighten other portions of the face, improving jaw-line definition.
If your problem areas are majorly around the eye, the surgeon may opt for a Subciliary Midface Lift. An incision is made near the eyelash line and the skin around it is separated from the cheek fat and underlying muscle. Further specialized techniques would involve manipulating these structures to provide a youthful and fresh look.
In the case of the Implant-Assisted Endoscopic Midface Lift, absorbable implants are used to anchor the cheek fat to the cheekbone. This procedure may be coupled with an endoscopic brow lift, as the areas addressed overlap to some extent.
Post-surgery, a tight dressing will be applied to your head for a 24-hour period. Once the dressing is removed, ice should be applied intermittently to reduce swelling. If any drains were placed during surgery, they will be removed the next day. The doctor will also check the strength and sensation of your facial nerves. You will have follow-up appointments for suture removal, wound checks, and to assess your satisfaction with the results. Photographs will be taken to document the healing process.
Possible Complications of Midface Lift
Getting facial cosmetic surgery doesn’t always meet expectations, this is what is meant by patient dissatisfaction. This is actually the most common problem related to such procedures. This highlights the importance of detailed discussions before surgery, ensuring patients have realistic expectations, and selecting appropriate candidates for the procedure.
Men might face a slightly higher risk of developing a complication known as hematomas, which are pockets of blood that collect outside blood vessels. This is because they have more blood supply needed for facial hair growth. Hematomas usually appear within a day after the surgery.
Down the line, as the body heals, seromas (pockets filled with clear bodily fluids) or sialoceles (cysts filled with saliva) may develop. The treatment for seromas involves draining fluid using a needle, while sialoceles might benefit from injections of botulinum toxin into the parotid gland, which produces saliva.
It’s rare, but permanent facial nerve injury can happen in less than 1% of patients, while temporary weakness can affect up to 2.6% of patients.
There are other complications to be aware of. These include infections at the surgical site, a deformity known as pixie ear, poor scarring, and hair loss. Skin death can also occur if the skin is pulled too tight when being stitched up or if the skin flap is thinned too much during surgery. If the approach to the surgery involves making an incision below the lower eyelashes, a condition known as ectropion (where the eyelid turns outward) can develop if too much pressure or energy is applied.
People may also experience what is called a “first bite syndrome”, which is a rare side effect of face lifting surgery.
Lastly, it’s important to note that patients who have a history of depression may experience a depressive episode post-surgery. Research by Goin and his colleagues suggested that over 50% of female patients who undergo a face lift will experience depression after the surgery.
What Else Should I Know About Midface Lift?
Midface lifting is a type of surgery that aims to give your face a younger appearance. It does this by moving the soft tissues in your cheeks (malar soft tissues) to a position that more closely resembles how they were positioned in your youth. This can help reduce lines near your nose and mouth (nasolabial folds) and make the area around your mouth and cheeks look smoother.
This surgery can be done on its own or alongside other facial rejuvenation procedures like endoscopic brow lifting (a procedure to raise the eyebrows), blepharoplasty (surgery on the eyelids), and cervicofacial rhytidectomy (surgery to remove loose skin and tighten muscles in the face and neck). This allows the surgeon to take a more comprehensive approach, addressing multiple areas of the face at once for a more cohesive rejuvenation effect.
