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Plastic Surgery Associates of New York

Plastic Surgery Publications

The Extended Minimal Incision Approach to Midface Rejuvenation

Allison T. Pontius, MD, Edwin F. Williams III, MD, FACS

Article Outline

With age, the convex contour of a youthful face is lost as the malar fat pad descends in an inferomedial direction, leaving in its wake a hollowed appearance to the lower eyelids, a skeletonized infraorbital rim, a prominent nasojugal fold, deepening of the nasolabial fold, and a pronounced labiomandibular fold with jowling [Fig. 1]. Unfortunately, the changes seen with midfacial aging are not adequately addressed by traditional rhytidectomy alone.

Characteristic findings seen with aging include a hollowed appearance to the lower eyelids, a skeletonized infraorbital rim, a prominent nasojugal fold, deepening of the nasolabial fold, and a pronounced labiomandibular fold with jowling.

Over the past 15 years, multiple surgical techniques to address the midface have been introduced, including deep plane rhytidectomy [1], composite rhytidectomy [2], the transblepharoplasty subperiosteal midface-lift with [3] or without [4] formal canthoplasty, the transblepharoplasty endoscopic subperiosteal midface-lift [5], direct suspension of the malar fat pad with sutures [6,7], the transmalar subperiosteal midface-lift [8], and the percutaneous technique of malar fat pad elevation [9], among others [10-15]. The authors' current concept is to address the brow and midface as a single unit, providing comprehensive rejuvenation to the upper two thirds of the face. Additionally, in appropriate candidates, the brow/midface-lift is combined with a superficial musculoaponeurotic system (SMAS) rhytidectomy to provide complete facial rejuvenation. The key to a successful operation is to weigh the advantages of performing each technique against the limitations and potential risks of the procedures.

The operation is performed through a minimal incision brow-lift approach relying on tactile feedback (the "smart-hand" technique) without the use of endoscopic guidance. The midface dissection and elevation are performed under direct visualization through a temporoparietal incision with the use of appropriate retraction and headlight illumination. This technique has been performed in more than 650 patients over a 9-year period by the senior author (EFW) and has been found to be safe, reliable, and effective [16].

Potential sequelae or complications associated with midface lifting include temporary or permanent injury to the temporal, zygomatic, or buccal branches of the facial nerve, decreased sensation over the malar region, lateral canthal distortion, lower lid malposition, temporal wasting, incisional alopecia, and prolonged postoperative edema [17-19]. With judicious patient selection, attention to the appropriate surgical planes, and gentle handling of tissues, the incidence of these morbidities has decreased to reasonable levels.


Knowledge of the surgical anatomy of the temporal and midface region is essential to perform safe and effective brow and midface surgery. Dissection during the brow- and midface-lift occurs in multiple anatomic planes, and awareness of pertinent vital structures within these planes is crucial [Fig. 2].

Anatomy of the temporal region
Fig. 2. Anatomy of the temporal region.

The superficial temporal fascia is also referred to as the temporoparietal fascia (TPF) and is located deep to the subcutaneous fat of the temporal region. The TPF is continuous medially with the galea and continuous inferiorly with the SMAS of the lower face. The temporal branch of the facial nerve lies within the TPF. Immediately deep to the TPF is the true temporalis fascia. All dissection in this region takes place immediately superficial to the true temporalis fascia and deep to the TPF to avoid injury to the temporal branch of the facial nerve. The temporal branch of the facial nerve crosses the zygomatic arch halfway between the lateral canthus and the root of the auricular helix within the TPF. The true temporal fascia splits at the level of the supraorbital ridge to become the superficial layer of the deep temporal fascia and the deep layer of the deep temporal fascia, between which lies the superficial temporal fat pad. Once the supraorbital margin is traversed, the superficial fat pad is gently entered as dissection proceeds toward the zygomatic arch. The superficial layer of the deep temporal fascia attaches to the superior edge of the zygomatic arch laterally, and the deep layer of the deep temporal fascia attaches medially. Underneath the deep layer of the deep temporal fascia lies the deep temporal fat pad. Overzealous dissection causing injury to the deep temporal fat pad carries the risk of postoperative temporal wasting [20].

The malar fat pad is triangular, with its base at the nasolabial fold and its apex at the malar eminence. It is situated between the skin and the SMAS. It is loosely adherent to the SMAS and firmly attached to the skin. In detailed anatomic and histologic studies, Mendelson and coworkers [21,22] described the surgical anatomy of the midface and the ligamentous attachments of the lower lid and lateral canthus. Through an understanding of these attachments, one can see how gravitational forces acting on the midface against these fixed attachments create the typical findings seen in the aging midface [Fig. 3]. In youth, the midface is characterized by a malar fat pad seated over the zygomatic arch with its upper border covering the orbital part of the orbicularis oculi muscle and its inferior border located along the nasolabial fold [23]. With age, the malar fat pad descends over the SMAS in an inferomedial direction, causing an increase in the apparent length of the lower eyelid, a skeletonized infraorbital rim, and an increased prominence of the nasolabial and labiomandibular folds [Fig. 4A,B]. Correction of this deformity requires resuspension of the malar fat pad in a cephalic direction.

The aging malar fat pad
Fig. 3. The aging malar fat pad sags inferomedially, creating a hollow infraorbital rim and pronounced nasolabial fold. (Adapted from Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg 1993;91:463-74; with permission.)

The descent of the malar fat pad The youthful infraorbital area
Fig. 4. (A) The descent of the malar fat pad and the orbicularis oculi muscle causes an increase in the apparent length of the lower eyelid. (B) The youthful infraorbital area (a) is narrow with an immediate transition to the cheek mound, whereas the aged infraorbital region (b) displays pseudoherniation of the orbital fat pads, skeletonization of the infraorbital rim, and a ptotic midface. (Adapted from Hamra SR. Arcus marginalis release and orbital fat preservation in midface rejuvination. Plast Reconstr Surg 1995;96:356; with permission.)


The authors believe that any patient undergoing a brow-lift procedure should be considered as a candidate for a concomitant midface-lift. The lateral brow region and the midface age in concert, and correction of one while overlooking the other will lead to less than optimal rejuvenation for the patient. The procedures are performed through the same incisions with minimal additional morbidity. This success is especially true in younger patients (40 to 50 years old) who have evidence of lateral brow and midface descent but may not yet be candidates for a traditional rhytidectomy. In patients with significant aging in the lower face and neck, the extended midface-lift can be performed with a concurrent rhytidectomy. Additionally, the extended midface-lift can be performed in conjunction with resurfacing procedures without risk to the vascularity of the overlying flap given the subperiosteal plane of dissection.

Surgical technique

The patient is administered anesthesia via intravenous sedation or general anesthesia [24]. Five standard endoscopic brow-lift incisions are marked out with a surgical marking pen. One is situated in the midline; two are located lateral to the midline in the paramedian position (approximately at the lateral canthus) just posterior to the hairline; and two additional longer incisions are located more temporally, also camouflaged by the hairline and extending over a 4-cm distance above the helical crus and over the temporalis muscle and fascia. The supraorbital notches are palpated and marked with a surgical marking pen on each side. One percent lidocaine with 1:100,000 epinephrine is infiltrated into the described incision sites and along the entire orbital rim, zygomatic arch, and midface bilaterally [Fig. 5].

Local anesthesia infiltrated
Fig. 5. Local anesthesia is infiltrated into the incision sites and along the entire orbital rim, zygomatic arch, and midface bilaterally.

If a transconjunctival lower lid blepharoplasty is entertained, this procedure should be performed before brow and midfacial suspension. After midfacial elevation, the lower lid becomes extremely taut, restricting ease of transconjunctival entry into the lid. Conversely, an upper lid blepharoplasty should be deferred until the brow and midface are appropriately elevated so that an accurate assessment of residual cutaneous redundancy can be made. At the outset of the brow-lift, the patient is inclined approximately 30 degrees in a semi-sitting position. This upward position facilitates ease of bone tunneling and visualization of the midface using the headlight and retractor. The midline brow incision is made with a No. 15 Bard-Parker blade down through the periosteum. Monopolar electrocautery is used to achieve hemostasis along the cut edges of the wound, with care taken not to apply excessive cautery to the exposed hair follicles. The cautery device is also used to ensure that the periosteum is completely incised. A small sharp flat periosteal elevator is used to dissect subperiosteally for a distance of a few centimeters circumferentially around the incision site. Posterior elevation is limited to approximately 4 to 5 cm because more extensive dissection toward the occiput provides limited additional benefit in transposition of the brow upward. A larger sharp flat periosteal elevator that reduces the risk of injury to the periosteum is then introduced to elevate the central pocket down to the orbital rim to release the arcus marginalis, but no aggressive dissection of the glabellar musculature is undertaken.

After the surgical maneuvers have been completed through the midline brow incision, the same technique of subperiosteal dissection is performed via the two paramedian ports. Again, the sharp flat periosteal elevator is used to carry out blind dissection down to the arcus marginalis for proper periosteal release at the orbital rim. The elevator is handled in an upward gentle lifting motion when the tip approaches a 1- to 2-cm distance above the supraorbital notch to avoid any paresthesias or neuropraxias that may ensue from violating the supraorbital neurovascular bundle. With proper wound retraction using wide double-pronged hooks, a hand drill (Stryker Corp., Kalamazoo, Michigan) outfitted with a 1.5-mm wide by 6-mm long drill bit is used to enter the outer calvarial table at 30 degrees (to the horizontal) and joined with an opposing entry of the drill to form a bone tunnel through which the brow-fixating suture may be passed at the end of the procedure [Fig. 6]. The 6-mm recessed drill bit permits ease of bone tunnel creation while minimizing inadvertent entry through the full thickness of the skull when used at a 30-degree angle. Additionally, the 1.5-mm wide drill bit accommodates the caliber to the needle. The bone tunnel should be made in the posterior aspect of the incision because suspension of the brow upward will cover the bone tunnel if the tunnel is created too anteriorly relative to the incision. An expanded polytetrafluoroethylene CV-3 needle (Gore-Tex; WL Gore and Associates, Flagstaff, Arizona) is passed through the tunnel to ensure easy passage of the needle at the end of the procedure.

Creating a bone tunnel
Fig. 6. A hand-held drill is used to create a bone tunnel through which the brow-fixating suture may be passed at the end of the procedure.

The longer lateral temporoparietal incisions are then addressed [Fig. 7]. Dissection is carried down through the TPF so that a proper tissue plane can be achieved between the TPF and the true temporalis fascia to avoid injury to the temporal branch of the facial nerve. The incision should be situated approximately 1 cm behind the hairline to lie over the temporalis muscle and not more posteriorly to avoid transection of the superficial temporal artery and to minimize the long trajectory of dissection needed to reach the midface. Initial dissection is performed with a large blunt elevator over the true temporalis fascia. The larger flat periosteal elevator is then used to break the conjoined tendon of the temporalis muscle that divides the central and lateral pockets. It is imperative to aim the elevator superiorly to ensure that the entire length of the conjoined tendon is freed. Aiming up toward the right paramedian incision and passing the instrument through that incision ensures that complete release of the tendon is accomplished.

The temporoparietal incision
Fig. 7. The temporoparietal incision is approximately 4 cm long and placed 1 cm behind the hairline to lie over the temporalis muscle.

Under direct vision with a headlight and Converse retractor, dissection is taken downward to the orbital rim with the small sharp periosteal elevator, looking carefully for the presence of the sentinel vein. If the vein lies in the direct path between the upper and midface, it can be skeletonized and cauterized with a bipolar device and transected with scissors to permit entry into the midface. Injudicious cautery of the sentinel vein, especially if the bipolar cautery tips are aimed superficially, may jeopardize the temporal branch of the facial nerve. The arcus marginalis is released from the superolateral orbital rim near the lateral canthus with the periosteal elevator. The assistant places a finger along the lateral margin of the orbital rim to limit the surgeon's dissection and to avoid excessive release of periosteum from the lateral canthus. This 1-cm cuff of periosteum around the lateral canthus, the lateral orbital thickening [22], is retained to avoid undesirable lateral-canthal elevation.

Under direct view, the large sharp periosteal elevator is guided downward to enter the superficial temporal fat pad gently and to release the periosteal attachments overlying the zygomatic arch. This technique allows direct access to the midfacial structures. Next, an angled periosteal elevator is used to continue dissection inferiorly over the malar eminence to release the zygomaticus major and minor muscular attachments and the malar fat pad from the underlying zygomatic and maxillary bone. The dissection proceeds inferiorly over the masseter muscle until all midfacial structures are adequately released [Fig. 8]. A CV-3 suture is passed through the temporalis fascia and muscle just anteroinferior to the temporoparietal incision and then passed through the malar fat pad with a long needle driver. The suture is pulled superiorly to test whether sufficient release of the midfacial tissues has been achieved. If not, further dissection is performed medially and inferiorly until appropriate release of the midface is observed. The paramedian suture on the same side is tied down before the suture in the malar fat pad is fastened superiorly to the temporalis fascia. The paramedian suture is fixated first to relieve any tension on the suture that elevates the midface and to permit better brow positioning by suspending the most superior suture initially. A CV-3 suture is used to secure the overlying frontalis muscle through the bone tunnel in the paramedian incision. A generous bite of frontalis muscle needs to be taken to achieve a secure and adequate suspension.

Extent of undermining
Fig. 8. Extent of undermining.

After the paramedian suspension has been completed and the incision closed, the surgeon should return to the lateral temporal incision to suspend the already distally placed suture through the malar fat pad to the proximal temporalis muscle and fascia at the incision site. The vector of suspension should be essentially vertically oriented (with approximately 15 degrees of posterior angulation), and the suture through the malar fat pad should be situated more laterally over the malar prominence-both of which minimize untoward distortion of the lateral canthus [Figs. 9 and 10]. Next, the TPF just anterior to the temporoparietal incision is sutured to the temporalis muscle and fascia with the CV-3 suture to pull the overlying brow and soft tissue superolaterally. This suture placement is undertaken twice. All incisions are closed with surgical clips. Bacitracin ointment is applied to the external incisions, and a pressure dressing is fashioned into place. The preoperative and 2-year postoperative photographs of a patient undergoing an extended midface-lift are demonstrated in Fig. 11A to F.

The suture is placed
Fig. 9. A suture is placed in the ptotic malar fat pad and zygomaticus major muscle.

Midface structures elevated
Fig. 10. After securing the suture to the temporalis fascia, the descended midface structures are elevated to a more youthful position.

Postoperative care

The patient is seen on postoperative day 1, and the wounds are inspected and cleaned with peroxide. A lighter dressing is applied that the patient will remove on the following day. The patient returns on postoperative day 6, and the surgical staples are removed at that time.


Problems associated with rejuvenation of the upper and midface can be minimized with meticulous attention to proper tissue handling and the proper plane of dissection. Asymmetry in brow elevation may be noted by the patient postoperatively. This appearance is most commonly secondary to an unnoticed preoperative asymmetry. It is critical in the preoperative assessment that any pre-existing brow or facial asymmetries are pointed out to the patient, because it may not be possible to correct the underlying asymmetry completely with surgery.

Most concerning to the patient and surgeon is the postoperative development of a motor or sensory nerve deficit. The most common causes for this outcome include excessive retraction on the temporoparietal flap, dissection in an improper plane in the temporoparietal region (temporal branch injury) or midfacial region (zygomatic or buccal branch injury), injudicious use of bipolar cautery in the region of the cephalic vessel [25], and injury during the midface dissection. Additionally, aggressive midfacial dissection medially toward the nasolabial sulcus has been associated with a greater likelihood of buccal branch paresis. In more than 650 procedures, the senior author has encountered nine cases of temporal branch and one case of buccal branch neuropraxias, all of which completely resolved within a 6-month period. One additional case of temporal branch palsy has failed to resolve in 12 months and is now considered permanent. Additionally, one case of permanent unilateral cranial nerve V2 (infraorbital nerve) paresthesia has been encountered [16]. Management includes expectant care with frequent visits to provide reassurance during the postoperative course. If indicated, ocular lubrication may be performed.

Incisional alopecia and unfavorable scars on the scalp can be minimized by proper handling of tissues and attention to avoiding transection of the hair follicles by beveling the knife blade according to the direction of hair growth. For the three medial incisions, the knife blade should be perpendicular to the scalp. For the two temporal incisions, it should be beveled posteroanteriorly. Additionally, excessive monopolar cautery should be minimized at the wound edges, and undue tension on wound closure should be avoided. After modification of the brow suspension technique from a screw suspension to a bone tunnel technique, no further evidence of incisional alopecia or unfavorable scarring has been seen. A possible explanation is that the screw held the brow suspended by the skin rather than the frontalis muscle, causing compression alopecia.


Although multiple procedures have been developed over the years to rejuvenate the midface, there is no perfect procedure that is without its own set of limitations. One of the limitations of the minimal incision brow-lift approach to the midface, as in the majority of midface techniques, is the modest improvement seen in the region of the nasolabial fold. The senior author critically reviewed a random group of 100 patients who underwent the procedure (with 6 to 50 months of follow-up) by assessing midface elevation in three facial zones judged by three independent evaluators. Zone I represented the malar/infraorbital complex; zone II, the nasolabial fold; and zone III, the jawline [Fig. 12]. The zones were rated on a scale from 0 to 2 (0, no improvement; 1, mild improvement; and 2, marked improvement). The evaluators found that most patients (70%) had marked improvement in zone I (30% with mild improvement and 0% with no improvement), 30% had marked improvement in zone III (50% with mild improvement and 20% with no improvement), and 4% had marked improvement in zone II, the nasolabial fold (60% with mild improvement and 36% with no improvement) [16]. These findings correlate with conclusions drawn by Hamra [26] after critically reviewing his long-term results (minimum 10-year follow-up) in patients undergoing a deep plane face-lift. He found that the results of malar fat repositioning at 1 to 2 years postoperatively were successful. Nevertheless, the long-term results showed a failure of the early improvement, manifested by a recurrence of the nasolabial folds. He concluded that only direct excision of the nasolabial folds provides permanent correction.

Fig. 12. The three facial zones. Zone I represents the malar/infraorbital complex; zone II, the nasolabial fold; and zone III, the jawline.


The minimal incision brow-lift approach provides rejuvenation to the upper two thirds of the face by effectively targeting midface soft tissue descent and lateral brow ptosis. These procedures can be performed alone or in conjunction with traditional rhytidectomy to provide comprehensive facial rejuvenation. Complications can be minimized by careful attention to the relevant anatomy of the region, adherence to dissection in proper tissue planes, and careful handling of tissues. The major limitation of the procedure is the steep learning curve and the difficulty in providing long-term correction of the nasolabial fold. Nevertheless, consistent use of this technique in appropriately selected patients will provide the surgeon and patient with significant benefits and a low risk of complications.


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