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1. Figures for correction of midface area
Fig 1: Younger patient with lack of skeletal support for the midface.
Fig 2: Same patient from fig 1 after malar augmentation and transconjunctival
blepharoplasty with SOOF pad lift.
Fig 3: Patient is sixth decade with ptosis of soft tissue envelope of midface
Fig 4: Same patient from fig 3 after SOOF pad lift with a minituck and a
transconjunctival blepharoplasty with a SOOF pad lift.
Fig 5: Mother and daughter showing the changes that occur with age. Daughter has
adequate midface skeletal support and midface soft tissue structures have not become
ptotic; nor has she any facial fat atrophy. Mother shows midface soft tissue ptosis marked
by sagging of the malar pad and SOOF pad with elongation of the lower lid and double
convex deformity; she also has a degree of fat atrophy noted in the submalar area.
Fig 6: Older patient with midface soft tissue ptosis and lack of skeletal support with
submalar atrophy. He underwent a SOOF pad lift with a facelift and malar augmentation
as well as an endoscopic browlift.
Fig 7: Older patient with generalized fat atrophy of the face.
Fig 8: Artists depiction of malar fat pad overlying the orbicularis oculi, SOOF pad and
zygomaticus muscles.
Fig 9: Intra-operative picture of fine clamp releasing the frontozygomatic ligament.
Fig 10: Artists rendition of the malar fat pad being ensnared at the level of the nasolabial
fold by the fascial fiber connections between the superficial muscles of facial expression
and the dermis.
Fig 11: Marking on skeleton showing the subzygomatic fossa which is the location of the
lateral attachment of the zygomaticus muscles. Medially they attach to dermis.
Fig 12: Infraorbital foramen which provides the exit point for the infraorbital nerve.
Avoidance of this nerve is important during midface surgery.
Fig 13: Patient being measured for malar implant.
Fig 14: Implant is positioned on the patient in the position felt to be ideal by the
physician. The pocket area is marked. It is important that both sides be marked
symmetrically. Any areas that need trimming are marked and trimmed.

2. Fig 15: The length of the incision need only be as long as the width of the implant folded
along its longitudinal axis. Incision is through mucosa only. Be sure to make the incision
cephalad enough to give you a cuff of mucosa to sew with during closure.
Fig 16: A fine clamp is used to divide the vertical fibers of the levator labii superioris and
the levator anguli oris muscles aiming for the inferior-medial aspect of the dissection
pocket for the implant. At that point a small curved retractor is inserted and the periosteal
dissection is begun.
Fig 17: A precise pocket has been made for the implant.
Fig 18: The implant is folded in half along its long axis and inserted into the precise
pocket. The physician should check the implant after insertion to make sure the pocket
isn’t too small or too large. Should the pocket be too small the implant will curl and not
look natural post-operatively. Should the pocket be too big the surgeon should consider
screw fixation.
Fig 19: Close the periosteum along the inferior-medial edge of the pocket to hold the
implant in place and seal it from infection. A layered closure of the mucosa follows with
an absorbable braided suture.
Fig 20: Markings made on patient in the upright position for insertion and end points for
trocar. Note that two threads are used for each area. Picture of trocar exiting midface
point medially.
Fig 21: Two barbed threads can be seen exiting from the midface. The patient is then put
in an upright position and the midface tissue massaged superiorly-laterally in the
direction of the barbs until the surgeon is satisfied with the lift obtained. Note the
immediate post-op improvement is impressive.
Fig 22: Curvilinear incision made around ear extending into the tragus inferiorly and the
temporal hair superiorly.
Fig 23: Anterior extent of subcutaneous dissection is made up to the level of the malar
eminence and subzygomatic fossa.
Fig 24: View is via an endoscope within the temporal pocket made for an endoscopic
browlift being performed in this case along with a midface lift. Note the lateral orbital
rim with periosteum elevated inferiorly down to the level of Whitnall’s tubercle. The
deep temporal fascia is below and the superficial temporal fascia, fat pad and frontal
branch of the facial n. is above. There is no advantage to releasing this bridge of tissue
from the zygoma and arch inferiorly, thus risking injury to the frontal branch.
Fig 25: Artists rendition of dividing the SMAS at the level of the subzygomatic fossa to
find the lateral attachment of the zygomaticus muscles. Intraoperative picture of the
lateral attachment of zygomaticus muscle.

3. Fig 26: Tunnel over the zygomaticus muscles is complete.
Fig 27: View of frontozygomatic ligament being released. This step is key to obtaining
motion of the midface.
Fig 28: Figure of eight suture used to elevate the malar fat pad to the periosteum of the
zygomatic arch.
Fig 29: Preoperative photo of a patient with significant orbicularis oculi redundancy
along with ptosis of the midface fat pads.
Fig 30: Lower lid everted around a blunt edged retractor such as a vein retractor.
Fig 31: Making the incision too close to the tarsal strip may cause the lower lashes to
invert slightly after surgery.
Fig 32: The first picture shows the view of the orbital fat pockets following splitting of
the orbital septum down to the level of the arcus marginalis. In the second picture we see
the arcus marginalis along the infraorbital rim. Note that the orbital septum has been
scarified with a bipolar cautery to thicken this layer with the intent of containing the
orbital fat posteriorly. The final picture shows a cadaver dissection showing the arcus,
SOOF pad and the levator anguli oris.
Fig 33: Fat being removed from the lateral fat pocket in the normal fashion.
Fig 34: Artists depiction of the plane of dissection down to the SOOF pad. The SOOF
pad is easy to find on top of the periosteum a variable distance below the arcus. The
SOOF pad can at time be found below the levator anguli oris and at times below and
around the edges of this muscle.
Fig 35: Artists portrayal of the SOOF pad before and after suture elevation to the arcus
marginalis. The other three pictures show the SOOF pad as it looks in its ptotic state
below the level of the infraorbital rim, how the fat can be elevated with a suture and the
final look after suture elevation of the SOOF pad to the arcus marginalis.
Fig 36: Typical patient before and after a SOOF lift blepharoplasty. This patient did not
have a malar pad lift. Her other procedures include a short flap facelift (which I have
trademarked as a “Signature Lift”), an endoscopic browlift and a rhinoplasty. Note the
improvement in the midface by lifting the SOOF pad only via a transconjunctival
approach.
Fig 37: Before and after views of the SOOF pad being elevated during an open or
subciliary approach, as is used in patients with significant orbicularis oculi redundancy.

4. Fig 38: Pictures of a facial skeleton with submalar and combined malar/submalar
implants.
Fig 39: Three sets of patients with combined malar/submalar atrophy who underwent
rejuvenation including the use of malar/submalar augmentation. The first patient had
generalized facial wasting and had undergone previous poly-L-lactic acid injections
without much improvement as well as fat injections. He had an endoscopic browlift as
well as a minituck and midface implant. The second patient complained of midface aging
among other concerns and had an endoscopic browlift, rhinoplasty, SOOF lift
blepharoplasty as well as a midface implant. The last patient had a facelift elsewhere but
was not happy with the results. She had a revision of her facelift with a midface implant.
Results are all over six months.
Fig 40: A syringe of calcium hydroxylapatite is connected to 0.3 cc of 1% lidocaine via a
luer lock to luer lock connector. This is mixed before injection to minimize pain.
Fig 41: Injection technique for using calcium hydroxylapatite via a trans-mucosal
approach to help midface fat atrophy.
Fig 42: Photos of a series of patients injected with calcium hydroxylapatite for midface
aging. Note improvement if the nasolabial folds, hollow appearance under the eyes and
malar area.
Fig 43: Photos of well known celebrities with beautiful midface structure showing the
inverse triangle of youth.
Fig 44: Mother and daughter demonstrating how the midface changes over time. Note the
elongation of the lower lid associated with a double convex deformity, the ptosis of the
malar fat pad and thinning of midface fat.
Fig 45: Younger patient with a weak malar bone and early aging who benefited from
malar augmentation. She also had a sort flap facelift (“Signature Lift”), and a lip lift.
Fig 46: Before and after photos of a series of patients before and after midface surgery
including lifting of the malar fat pad and lifting of the SOOF pad demonstrating how in
these patients who do not present with significant infirmity of midface fat or the malar
skeleton that addressing the soft tissue ptosis by using the techniques presented in this
chapter provides excellent midface rejuvenation.
Fig 47: The first patient in this series had a facelift by another physician and was
disappointed with the results. She was pleased following a midface implant. The second
patient demonstrates sagging of the facial skin envelope with little midface fat. She had a
minituck without lifting of the nonexistent malar fat pad, a transconjunctival SOOF pad
lift and a combined malar/submalar augmentation. She also had an endoscopic lateral
browlift.