This document discusses techniques for midface rejuvenation during facelift surgery. It describes how the midface and lower eyelids are important for a youthful appearance. It recommends a "SOOF lift blepharoplasty" procedure to address hollowness under the eyes and migration of orbital fat. For inadequate volume at the malar eminence, it suggests malar augmentation with implants or fat injections. It also describes a "malar pad lift" to address ptosis of the malar pad and inferior migration of midface fat. The goal is to restore adequate skeletal and soft tissue support at the malar eminence and infraorbital rim.

1. How to improve the
midface during
rytidectomy

2. M. Sean Freeman MD, FACS
Charlotte, NC

3. The lower lid and mid-face are both important in obtaining the inverse
triangle of a youthful face

4. Midface Rejuvenation
• Adequate skeletal and soft tissue envelope must be present at the
level of the malar eminence and infraorbital rim for a youthful
look
– Cause of hollow look under eye, migration of SOOF
– Answer “SOOF lift blepharoplasty”
– Cause of soft tissue inadequacy of the rest of midface
– Ptosis of malar pad
– Shallow malar eminence
– Mid-face fat atrophy
– Combination of the above

5. SOOF lift blepharoplasty
15 year retrospective
• Highlights of procedure
– Transconjunctival approach with incision through the capsulopalpebral fascia
– Tighten the orbital septum over the nasal and mid fat pockets and remove fat
from the lateral fat pocket only
– We do not grow fat as we age!!!
– Extraperiosteal dissection inferior to the arcus marginalis
– SOOF released and elevated to arcus marginalis
– Closure of capsulopalpebral fascia and conjunctival mucosa
– Light CO2 laser of lower lid skin

6. Previous subciliary approach with
aggressive fat removal

7. SOOF lift blepharoplasty
15 year retrospective
• I’ve performed over 750 of these procedures
• Operative failures since 2001
– One patient
– Recurrence of pseudoherniation of orbital fat due to misdiagnosis
– Patient had congenital pseudoherniation which requires more aggressive fat removal
– No patients with scleral show or frank ectropion
– No loss of eradication of nasojugal depression to date
• Operative failures prior to 2001
– Trichiasis(~5)
– Lack of reconstituting the capsulopalpebral fascia/inferior tarsal muscle

8. SOOF lift blepharoplasty
15 year retrospective
• Why does this procedure work so well with so few risks?????
– Restoring the lower eyelid anatomy to it’s youthful position

13. Midface Rejuvenation
• Adequate skeletal and soft tissue envelope must be present at the
level of the malar eminence and infraorbital rim for a youthful
look
– Cause of hollow look under eye, migration of SOOF
– Answer “SOOF lift blepharoplasty”
– Inadequate 3D volume at the malar eminence
– Shallow malar eminence / Midface fat atrophy
– Answer; Malar augmentation
– Main risks/infection, poor implant placement
– Alternative; Fat injections
– Main risks/inability to quantify, clumping, poor longevity
– Ptosis of malar pad

14. Inadequate 3D volume at the malar eminence

15. Midface fat atrophy

16. Midface Rejuvenation
• Adequate skeletal and soft tissue envelope must be present at the
level of the malar eminence and infraorbital rim for a youthful
look
– Cause of hollow look under eye, migration of SOOF
– Answer “SOOF lift blepharoplasty”
– Inadequate 3D volume at the malar eminence
– Mid-face fat atrophy
– Shallow malar eminence
– Ptosis of malar pad
– Midface lift/ “Malar pad lift”
– Main risks/ infection, tethering of lift (release during surgery-McGregor’s patch)

17. Midface Rejuvenation
•Importance of SMAS in relation to aging
–Fascio-fiber connections between the
superficial muscles of facial expression, the
SMAS and the dermis at the level of the
nasolabial fold trap the migration of the
malar fat pad over time thus deepening this
fold
–Over time, midface fibro-fatty tissue is
displaced above the level of the SMAS and
then trapped by the SMAS connections at
the nasolabial fold

19. Midface rejuvenation
Subperiosteal approach for the midface
 The periosteum does not relax with time
 Pulling up on the periosteum in the midface
lifts the superficial muscles of facial expression
which will result in pulling in of the fascio-
fiber connections between these muscles and
the nasolabial fold
 Net effect on the depth of the fold is negligible

20. What is the best plane in the midface?
 Between the investing SMAS of the superficial
muscles of facial expression and the overlying
malar fat pad
 Allows repositioning of the malar fat pad
 Allows release of the zygomatic cutaneous ligament
Midface rejuvenation

28. Midface Rejuvenation
Management of regional fat
ptosis
• Know how to deal with inferior
migration of the SOOF. Learn
how to do a “SOOF lift
blepharoplasty”!
• Learn how to deal with inferior to
medial migration of the malar
wad via a malar pad lift.
Management of inadequate 3D
volume of the cheek
• Should this be due to inadequate
bone structure consider a cheek
implant
• Should this be due to midface fat
atrophy consider cheek implants
or fillers such as fat injections