Rejuvenation of the aging face has well established methods for correcting the upper (browlift) and lower face (lower facelift/necklift) that produces consistent and satisfying results. But the face does not age in just individual subunits and the midface has similar aging issues that are uniquely different. Sagging cheeks, lower eyelid hollowness and lines and folds under the eyes present challenges for successful rejuvenation.

The development of midface rejuvenation techniques has historically lagged behind that of the upper and lower face. Only in the past decade has the concept of midface lifting emerged. The vector of the midface lift is different than that of a facelift being more vertical than oblique in orientation and more closely resembles the direction of a browlift. But it has been associated with significantly more complications and dissatisfaction than either browlifts or facelifts.

The factors that contribute to midface rejuvenation complications are several fold. First, most midface lifting techniques go through the lower eyelid and require resuspension after the tissues are lifted. This places the lower eyelid at risk for sagging or ectropion due to the tension placed on it and the very delicate suspension system of the lower eyelid which is easily disrupted. Secondly, where to attach the lifted cheek tissues to is limited and adequate bony support may be lacking.

As a result of this midface conundrum, a wide variety of open and endoscopic midface lifting techniques has developed. There is no consistent midface rejuvenation technique and this has lead to a lot of confusion on the part of both surgeons and patients alike.

To aid surgeons in midface analysis and in the selection of the most successful rejuvenation strategy, a paper on this topic published in the March 2013 issue of the journal of Facial Plastic and Reconstructive Surgery. A retrospective review was done on 150 patients who had midface rejuvenation procedures done by a single surgeon. The procedures included cheek implants, fat injections, limited and full midface lifts and facelifts. The vast majority were women (93%) with an average age of 51 years as would be expected. About one-third of patients had more than one treatment for their midface aging. Patient dissatisfaction in this study was 14%. Fat grafting alone had the highest rate of dissatisfaction of all treatments. The rate of patient dissatisfaction was associated with malar hypoplasia (skeletal deficiency) and loss of skin elasticity.

What makes midface rejuvenation unique from a facelift is that the degree of skeletal support is significant. No matter how well the cheke tissues are lifted, failure to achieve an aesthetically pleasing or a sustained result is doomed if the cheek bone does not have adequate projection to support it. The use of cheek volumizing through implants is needed in such cases. When the cheek skin has poor elasticity, pulling up alone again is inadequate and adding skeletal support needs to be considered.

Dr. Barry Eppley

Indianapolis, Indiana

The midface is the most difficult part of the face in which to reverse the effects of aging. While the upper face (forehead) can be very successfully treated by different forms of a browlift and the lower face (neck and jowl) with facelift variations, improving sagging cheeks poses different challenges. The presences of the eyes and the bony orbit prevents a straightforward upward vector for soft tissue re-suspension and easy incisional access.

While the cheek tissues sag and falls vertically, any method of soft tissue re-suspension must be in an oblique and not vertical vector because of the eye above it. In addition, the lower eyelid and its rather delicate suspension system holds it uptightly against the eye. While eyelid incisions are commonly used for midface lifts, they definitely pose risks for lower eyelid sag problems if any tension is placed upon them or they are not meticulously put back together.

This is why the endoscopic approach for midface lifts can often be the best and safest approach. Through a combination of a temporal hairline incision and a mucosal incision inside the mouth, an uncomplicated dissection can be done in the subperiosteal plane. Such an approach avoids the problems associated with eyelid incisions and potential postoperative ectropion. Dissection between these two points is joined over the body of the zygoma. The wide connection between the temporal and intraoral pockets allows for tissues to be lifted for a volumetric change at the zygomaticomaxillary point.

One complement to a midface lift is cheek or malar augmentation. There are two approaches, synthetic or a natural source of cheek augmentation. Before suspension, a small cheek implant can be used to add further volume at the height of the existing cheekbone. It would be important to screw this implant into position given the wide open tunnel from the endoscopic dissection. The other option that I have used in some cases would be to use the buccal fat pad as the implant. By mobilizing it from its submalar location, it can be draped up over the cheek by an additional suture passed up to the temporal region.

In the world of facelifting, emphasis has been finally placed on rejuvenating the midface and improving the eyelid-cheek interface. Unlike other areas of facial rejuvenation, however, there are real risks from problems caused by incisions to do the procedure. This makes doing a midface lift using non-eyelid incisions appealing if possible. A lower blepharoplasty can be done with the midface lift and often some skin removal may be necessary as the cheek tissues are pushed upward.

Dr. Barry Eppley

Indianapolis, Indiana

Lifting of aging and sagging facial tissues is often perceived as a facelift. In reality, a traditional facelift only affects the lower third of the face…the neck and jowls. That leaves out the two other major facial areas which can be lifted, the forehead (brows) and cheeks. Browlifts are well known and very effective facial rejuvenation procedures whose numerous techniques and methods are well established. Browlifts are often done in combination with a facelift. The cheek area, while aging as much as the brows and the neck, does not have a simple  and consistently effective  surgical lifting procedure.

Cheek lifts, also known as midface lifts, are intended to lift sagging tissues that were once on top of the cheeks. When the soft tissue falls off of the bony cheek due to loosening of its ligamentous attachments to the skin, it creates what are known as malar festoons. These are bags or bunching of tissue that often creates a ‘double bubble’ look to the midface. Or the midface can look like wax melting off of candle. Most people think that a facelift or a browlift will somehow correct this cheek sagging but it will not.

Midface lifts are relatively new compared to facelifts and numerous techniques have been used. The fundamental midface lift approach can be ascertained based on the vector of pull and incisional access. The traditional midface lifts is done through a lower eyelid incision and pull the cheek tissues directly upward. When using this technique, I will fix the cheek tissues to a cranial fixation point directly above a vertical line up from the cheek. This is a very powerful method for lifting sagging cheek tissues but involves manipulation around and through the eyelid. The eyelid is very unforgiving and numerous complications can result. Eyelid deformities, particularly ectropion, is not rare with this type of midface lift. This cheek lift requires absolute precision and is very unforgiving of any slight technical deviation.

An alternative and less problematic approach is that of the temporal cheek lift. The incision is right at the junction of the  preauricular and temporal hairline. By placing it here, the hairline will not be shifted upward and the delicate lateral eyelid area is completely avoided. Skin flaps elevated for about an inch or inch and a half downward so that its pull lifts the cheek tissues. This is then combined with the use of barbed sutures or threads which are inserted underneath the skin flaps. They are directly toward the sagging cheeks and then tied together to further lift the cheeks. The combination of the skin pull and the barbed sutures creates a very nice cheek tuck-up. The excess raised skin, now lying over the incision is trimmed and closed.

This temporal cheek tuck-up has numerous advantages including ease of execution, lack of any problems in the eye area, and very minimal recovery. It can be performed in the office under local anesthesia. Its disadvantage is that it is not as powerful as the cranially-directed midface lift so patient selection and expectations are critical. I have found it useful for those patients with more mild forms of cheek sagging, after a facelift procedure, and when a conventional midface lift needs further improvement.      

Dr. Barry Eppley

Indianapolis, Indiana

Recent internet blogs purport that Sarah Palin has had some plastic surgery done recently. Using some apparent inside information, it is stated that she had a ‘nasolabial fold lift, cheek implants, midface lift, eyebrows fixed and a sideburn graft.’ A series of photographs are shown which are supposed to support these contentions.

Normally, I wouldn’t waste valuable computer time on a topic that, while interesting to some, doesn’t add any facts to those truly interested in what plastic surgery has to offer. And there are lots of tabloids, websites and even TV shows that analyze celebrities and what they may have had done. But there is some educational value in assessing some of this content to separate procedures that do exist from those that don’t.  And when and why they are used.

I will preface these comments by saying that I have no knowledge of whether Sarah Palin had plastic surgery or not. Nor it is this a negative commentary on those that purport that she did. Nor am I a supporter or detractor of hers.

A ‘nasolabial fold lift’ is a misstated procedure. The deepening of one’s cheek-lip groove, also known as the nasolabial fold, is a function of one’s cheek tissues beginning to sag downward against upper lip tissues which do not sag with age. A deep or prominent nasolabial fold can be softened with injectable fillers and this simple office procedure is one of the main uses of filler products.

Cheek implants are used to highlight cheek and midfacial prominences and are often overdone  and easy to spot. But Sarah Palin is about the last person who would need them. She has the congenital benefit of a naturally strong facial bone structure with high cheek bones. This is one of the main reasons for her facial attractiveness.

Midface lifts are designed to lift sagging cheek tissues. They can be done open or from an endoscopic approach. As previously mentioned and for reasons similar to that of cheek implants, there is nothing in Sarah Palin’s photos that would remotely suggest she would benefit from such a procedure. An open midface lift involves incisions across the lower eyelid and sometimes inside the mouth. When properly used, it is a very effective procedure but it can cause problems of prolonged swelling and potential lower eyelid problems. An endoscopic midface lift is different as it is done from incisions up in the scalp and is used when the midface sagging is less severe. She may have had this done but the benefits of doing so, and the results obtained if done, are certainly suspect.

The ‘eyebrows fixed’ procedure could very well mean that an endoscopic browlift was done. This is a very frequently used procedure done from behind the frontal hairline. It can lift sagging or flat eyebrows and create more of an eyebrow arch and open up the eyes. But injectable Botox can create in some patients very much of the same result.  While the pictures later in the year of Sarah Palin show higher arched eyebrows, that photo was taken from a different angle and the facial expression is not the same. More on photos later.

The alleged ‘sideburn graft’ procedure does not exist. There would be no reason to graft a sideburn and skin grafts are never used in any form of facial plastic surgery. What they undoubtably mean is that the sideburn has been altered. This would be due to a form of a facelift known as a limited or mini-facelift, also called a Lifestyle Lift by some. This simple tuck-up procedure uses an incision from inside the ear, around the earlobe below, and up into the hairline above. The one side view photo does show a very straight back part of her sideburn (preauricular tuft of hair) which is a likely sign that it is from an incision. There is also a lump in front of her ear, which is certainly unnatural, and could be a small residual fluid collection or swelling from the procedure. This  ‘mini-facelift’ is a common little jowl tuck-up method that is best used when only  a small amount of jowling (early facial aging) is present. This would be believeable from my perspective on her as, at best, she would only need such a limited procedure.

A comment on photographs.  One thing that plastic surgeons are acutely aware of is the influence of photographs on how the face can look.  You can take a patient, change the lighting and angle, and one can look like they have had some procedure that has changed their appearance. It is for this reason that the sentinel journal of plastic surgery, Plastic and Reconstructive Surgery, has specific photographic standards so that the results of procedures can be accurately judged. Many commercial cosmetic products and devices take advantage of these photographic nuances to promote sales.

Did Sarah Palin have plastic surgery? Maybe… but the procedures would not be as many or of the magnitude that have been suggested. She may have taken advantage of some of today’s minimally-invasive techniques such as an endoscopic browlift and a tuck-up facelift. The recovery from these would be very quick, less than 7 to 10 days, until one is able to be back in front of the public again.  

Dr. Barry Eppley

Indianapolis, Indiana

The earliest signs of facial aging often appear in the midface area, a triangle defined by the inner and outer corners of the eye and the corner of the mouth. There may be loose lower eyelid skin and bulging fat bags. The line of demarcation between the lower eyelid and the cheek (lid/cheek junction) begins to drift lower. In addition, the cheek tissues slowly fall downward, making the nasolabial fold more prominent. The aging midface area can look a little like wax melting off a candle.

Traditional plastic surgical procedures are ineffective in correcting these midface problems, even when a lower blepharoplasty and facelift are done at the same time.. The classic lower eyelid tuck could remove excess skin and fat bags, but could do nothing with the fallen cheek tissues. The traditional facelift, or neck-jowl lift, offers virtually no changes in the cheek, nose, and upper lip area despite that many patients believe that it will.

As a result, the midface lift (not a facelift) procedure has emerged to correct this historically unreacheable aging area. The midface lift is done through an incision immediately below the lashes of the lower eyelid and extends slightly out from the outer corner of the eye in a crease line. By dissecting down to the cheek bone, the fallen cheek tissues are separated from the bone, lifted vertically, and put back up in a higher position on the cheek bone. Excess lower eyelid skin and fat can also be removed if necessary after the cheek tissue is repositioned. (which is almost always needed) The eyelid incisions are closed with dissolving sutures under the lashline and very small sutures out into the crease skin.

One of the keys to a good and stable midface lift is where to secure the cheek tissues which are lifted up by sutures. Here is a point of plastic surgery debate and different surgeons have their own methods. In my Indianapolis plastic surgery practice, I prefer to use a high cranial suspension point which is immediately vertical to the direction of upward pull. This requires a small incision in the scalp above the temporal area.

Midface lifts result in a smoother lower eyelid, a fuller cheek bone prominence, and a less deep nasolabial fold. Many patients will look like they have had a small cheek implant placed. Such changes created a less tired look and a face that has a more youthful and full appearance. Remember that this operation is not a facelift, it will not improve the neck or jowl area. It may frequently be done at the same time as a facelift to create a more complete facial rejuvenation.

A midface lift is often done with upper and lower eyelid tucks (blepharoplasty) at the same time, or even a facelift. As a result, the eye and cheek area will get fairly swollen and bruised after and the corners of the eye will feel tight. One will not look fairly reasonable in most cases until about 7 to 10 days after surgery. (non-operated look) One should be capable of returning to sedentary-type work – perhaps with some camouflage makeup – within a week after surgery. More vigorous activites must usually await three to four weeks until one is ready.

 Dr. Barry Eppley

Indianapolis, Indiana