This document provides an overview of different surgical techniques for rejuvenating the mid-face, including the SMAS division mid-face lift and SOOF lift blepharoplasty. The SMAS division mid-face lift is effective at reducing nasolabial folds and restoring youthful contours by releasing and elevating the malar fat pad. The SOOF lift blepharoplasty improves tear trough deformities while also aiding in mid-face rejuvenation. Both procedures have minimal scarring but require skill to perform safely. Fillers can also be used for mild aging but surgery is generally best for more significant cases.

1. Rejuvenation of the mid-face
Author: M. Sean Freeman, MD, FACS
Introduction
Rejuvenation of the mid-face is more commonly asked for now than in the
past. This is in part due to younger patients seeking facial rejuvenation and
in part due to increased awareness among consumers that targeted
rejuvenation is possible. Patients in general are searching for techniques that
can provide renewal with as little downtime as possible. Patients are more
conscious of the length of time that they will need to take off work to
recuperate and are seeking procedures were the healing period is minimized.
Along this same vein, patients are similarly interested in procedures that
provide natural looking results with minimal visible incisions. Fortunately
for the interested patient and the trained facial plastic surgeon there are good
techniques available that can accomplish these goals in the midface.
The intent of this chapter is to provide the author's bias as it relates to
rejuvenation of the midface and to briefly review other treatment options.
Having expertise and the availability of an endoscope is an aid in performing
the midface lifts described below. As the surgeon gains experience with
these techniques or in the hands of an experienced surgeon in mid-face
surgery, it is not an instrument that I find absolutely necessary in order to
accomplish these procedures.
There are other approaches to the mid-face other than the techniques that the
author has a preference for, which have need of mentioning. The first is the
endoscopic subperiosteal midface lift as popularized by Ramirez and others
1, 2
. This approach is an interesting procedure from a theoretical viewpoint
but in the author's point of view has limited applications 3
. The reason for
this can be found by reviewing the anatomy of the fold. From a review of
mid-face anatomy we find that there are fascio-fiber connections between
the dermis and the underlying superficial muscles of facial expression,
which allows these muscles to animate the nasolabial fold. Over time the
effects of gravity and repeated animation result in the malar fat pad rotating
in a medial - inferior direction that results in a deepening of the nasolabial
fold. Therefore by repositioning the muscles of facial expression along with
the malar wad together by a subperiosteal approach little to no improvement
in the fold can be anticipated since there is no relative change in the position
of the malar wad with respect to the underlying facial muscles. This is what

2. is needed to expect a positive effect on the depth of the nasolabial fold.
Another major strike against this approach, other than the fact that it doesn’t
work well, is the prolonged healing that is necessitated with the use of this
procedure. Interested readers are referred to the bibliography for further
reading.
Another approach that has recently gained popularity in the lay press is the
technique that has been called a “lunchtime” lift 4
. This technique attempts
to lift the ptotic malar wad without much more than a temporal incision and
craftily placed transcutaneous mid-face sutures rescued from the mid-face
and secured to the deep temporal fascia via a bluntly advanced trocar. This
approach would seem to excellently fit the requirements of limited healing
and invisible incisions. The results obtained may be another consideration.
There is no attempt to release the zygomatic cutaneous ligaments; this step
in the authors experience is necessary to get significant long-term elevation
of the malar wad. The other concern with this approach relates to the suture
placement necessitated by the technique. By approaching the depressed
malar wad with sutures placed thru the skin it would be difficult to position
said sutures deep enough within the malar wad to obtain elevation without
risking dimpling of the skin. Indeed this is one of the more difficult tasks
when suture fixating this wad from underneath, as will be described later.
Perhaps this approach will prove itself to be useful enough over time to be
considered as an alternative.
Elevating the malar wad from a deeper approach has been labeled by the
author as the “SMAS division mid-face lift”; this procedure is a
modification of the technique originally described by the author as the
“endoscopic malar pad lift” 5,6
. The endoscopic malar pad lift was modified
to allow lifting of the mid-face with a less visible incision. The SMAS
division mid-face lift circumvents many of the disadvantages of the
subperiosteal mid-face lift and in general is more effective. This technique
can also be used in conjunction with a subperiosteal brow lift and/or a
facelift.
Finally there is an approach to the midface that is designed mainly for
improving tear trough deformity but is also beneficial in helping the mid-
face. This technique was initially described in the literature by the author
and has been coined a “SOOF lift blepharoplasty” 7,8
. There have been many
techniques described in the literature to improve tear trough deformity, also
known as naso-jugular deformities 9,10
. As is typically the case when there
exists several different techniques to improve the same problem, none of
these approaches has stood the test of time and become the favored. The
SOOF lift blepharoplasty has been used by the author since December of
2

3. 1998 and has proven to be safe, reliable and yield good to excellent results.
This approach to the lower lid has become the main approach for lower lid
rejuvenation in my practice and aids in mid-face rejuvenation.
The discussion that follows concentrates on surgical approaches to mid-face
rejuvenation. I would be remiss in not mentioning that there are certainly
other techniques available to aid in mid-face rejuvenation that are relatively
simply, fairly effective and accomplish the goal of speedy healing. I am
referring to fillers that can be injected or surgically implanted to the
nasolabial fold. This is an approach to the problem of deepening of the
nasolabial fold that is often used by the author but is in general applied to
patients with mild signs of mid-face aging. The interested reader is referred
to the many available articles that review the fillers available and the
appropriate associated techniques11, 12
. Certainly the use of fillers is the most
common approach to selective management of early mid-face aging.
The surgical approaches described below assume the patient has adequate
supporting skeletal structures. Should a patient present with a complaint of
aging of the mid-face and the facial plastic surgeon notes that the patient has
mid-face atrophy and/or deficient development of the malar eminence, then
the treatment should be directed to malar, sub-malar or combined
augmentation (fig. 1). A well-trained and experienced facial plastic surgeon
should have no trouble discerning which patients fit into this category.
Advantages/Disadvantages
SMAS Division Mid-face Lift
The main benefit of this approach is its proficiency in decreasing the depth
of the nasolabial fold while at the same time restoring a youthful mid-face
contour. The technique used is also very adaptable in that it can be
performed as a sole procedure or easily incorporated into an endoscopic
brow lift or a routine facelift. When this lift is performed by itself, the
incision is located in the temporal hair and extended minimally into the
preauricular skin. When this procedure is done with an endoscopic brow lift,
the lateral brow lift incision is extended minimally into the preauricular area.
The reason for extending the incision minimally into the preauricular area is
that the surgeon will find that he or she will be dealing with a standing cone
due to the tissue excess that is generated following mid-face elevation. In
addition, a SMAS division mid-face lift is routinely performed during a
face-lift, with or without a brow lift.
The efficacy of this approach as it relates to the nasolabial fold can be
understood if we look at the regional anatomy involved in the dynamics of
3

4. midface laxity. The gradual deepening of the nasolabial fold occurs over
time by the combination of repeated pulling on the dermis by the fascio-fiber
connections between the dermis and the underlying muscles of facial
expression and by the inferior to medial rotation of the malar wad 5,13
(fig 2).
The net effect of releasing and elevating the malar wad is to reposition this
wad of fibro-fatty tissue along a posterior to superior vector in addition to
providing a pull on the epidermis lateral to the fold. The outcome is an
improvement in the depth of the nasolabial fold as well as the contour of the
malar area.
The main disadvantage of this approach is that it takes a surgeon with an
adequate working knowledge of the special anatomy in this area of the face
to accomplish the procedure safely. An endoscope allows the surgeon to
more easily identify the correct plane of dissection and its use is encouraged
with the beginning surgeon. Swelling typically lasts to the point were it is a
concern for the patient for approximately 7-10 days. In addition, surplus
lower lid skin can result which will at times oblige removal using a pinch
technique or improvement via resurfacing.
As with any endoscopic procedure, adequate didactic and cadaver training
are required. There is risk of injury to the buccal branch of the facial nerve,
which lies below the zygomaticus major muscle. In addition, suture fixation
must be done properly to obtain a satisfactory result and to avoid indention
of the epidermis.
SOOF Lift Blepharoplasty
The main advantage of this approach is that it allows the physician to safely
improve a nasojugal deformity in a predictable fashion. In addition the
physician carries out a lower lid blepharoplasty via a transconjunctival
approach. Should the facial plastic surgeon follow the authors’ advice and
remove orbital fat from only the lateral fat compartment, then their patients
will retain orbital volume and not develop enophthalmos from over
aggressive orbital fat removal. Finally by lifting the SOOF, there is
improvement in midface laxity.
The main disadvantage is that the patient can expect swelling of the
infraorbital area to last slightly longer than the swelling from a routine
transconjunctival blepharoplasty.
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5. Indications/Contraindications
SMAS Division Mid-face Lift
The SMAS division mid-face lift is in general applicable to any patient who
desires improvement in significant mid-face aging. The procedure can be
used either by itself or in conjunction with a subperiosteal endoscopic brow
lift. Patients’ intent on a face-lift should have a SMAS division mid-face lift
incorporated into their procedure. The SMAS division mid-face lift is
contraindicated in patients who are noted on exam to have little to no malar
fat pad. In the authors experience these patients are ectomorphic to the point
that they have little mid-face fat ptosis for the simple reason that they have a
paucity of fat in general. Most of these patients do well with traditional
SMAS plication techniques or mid-face fillers.
Patients who have had previous aesthetic surgery in the mid-face can safely
have this procedure.
SOOF Lift Blepharoplasty
Perhaps it is more appropriate to discuss which patients do not fall into the
category as being candidates for this approach. Although it has been my
experience that the majority of patients benefit from this technique, there are
categories of patients that would benefit from a different procedure.
Occasionally a patient will present in there twenties to thirties with early
onset of pseudo-herniation of the lower lids. This small group of patients
typically does well with conventional transconjunctival lower lid
blepharoplasty with aggressive fat excision from each
orbital compartment (fig 3).
Rarely there is the patient who presents later in life for surgical correction
but who developed pseudo-herniation their twenties to thirties; they do not
seek a surgical correction until later on when they also have skin laxity and a
nasojugal deformity. In this group of patients an aggressive
transconjunctival lower lid blepharoplasty is recommended with fat excision
from each orbital compartment along with and a SOOF lift and concomitant
CO2 resurfacing.
There is another group of patients that have little to no pseudo-herniation,
but mainly complain of wrinkling of the lower lid skin. In this group of
5

6. patients CO2 resurfacing or aggressive chemical peeling is the recommended
approach (fig 4).
There is a smaller subset of this group that has persistent redundancy of the
orbicularis oculi muscle that will require pinch excision, typically as a
secondary procedure after laser resurfacing (fig 5).
Lastly, there are patients that have significant laxity of the lower lid skin and
muscle, festooning, a degree of pseudo-herniation and typically laxity of the
lower lid. This small group of patients requires a transcutaneous skin flap
past the area of the festooning along with a separate muscle flap, sparing the
pretarsal component. A lateral canthoplasty is then added with suturing of
the muscle flap to the periosteum of the lateral orbital rim utilizing a lateral
superior vector and finally removal of excess skin. The fat pads in this group
are usually trimmed and the SOOF lifted (fig 6). This technique has been
described in the literature as an extended blepharoplasty 14
.
The rest of the patients are a candidate for the SOOF lift blepharoplasty. The
average patient presents in there forties to fifties with a depression along the
medial portion of the lower lid in association with the normal aging process
(fig 7). Most will have a degree of skin laxity and occasionally orbicularis
oculi hypertrophy. The SOOF lift blepharoplasty with minimal fat excision
has become the dominant approach for rejuvenation of the lower lid in the
authors practice and can be safely performed in conjunction with laser
resurfacing, facelift surgery and/or endoscopic forehead or mid-face surgery.
Procedure
SMAS Division Mid-face Lift
When performed as a sole procedure an incision is made posterior to the
temporal hairline immediately above the anterior superior attachment of the
auricle (fig 8). Dissection is carried down past the superficial temporal
fascia to the deep temporal fascia. To protect hair follicles, dissection is
carried out on top of the deep temporal fascia towards the malar eminence;
once the surgeon is beyond the hair, the dissection is in a subcutaneous plane
over the zygomatic arch. Following this plane will protect the frontal branch
of the facial nerve which at this level is beneath the SMAS and superficial to
the periosteum of the arch. Dissection is continued in this plane up to the
malar eminence.
At this level the SMAS is split and the surgeon identifies the attachment of
the zygomaticus major and minor to the malar eminence (fig 9). The
endoscope is a useful aid in identifying the zygomaticus muscle. Recall the
6

7. spatial anatomy in this area, the orbicularis oculi overlies the zygomaticus
major muscle and the buccal branch of the facial nerve will be coming in
underneath the zygomaticus major muscle, typically in the mid-part of the
muscle (Fig 10). The SMAS invests the superficial muscles of facial
expression but also invests the malar wad so in essence it is at this point that
the facial plastic surgeon is splitting the SMAS. The attachment of the
zygomaticus muscle is dissected to the point that one can insert a finger
superficial to the muscle and its investing fascia. Confirmation can be
obtained that one is indeed looking at the zygomaticus by observing
contraction of the muscle when the patient smiles.
Using a combination of finger dissection and endoscopic controlled blunt
dissection a pocket is created between the underlying zygomaticus muscle
and its investing SMAS fascia and the overlying SMAS fascia, fat and skin.
The direction of the dissection is parallel to the zygomaticus or toward the
commissura labiorum. The depth of the dissection proceeds from deep on
top of the SMAS investment of the zygomaticus muscle to superficial and
the dissection ends at the level of the nasolabial fold.
At this point the fibro-fatty malar pad is identified just medial to the
dissection pocket. The surgeon must then release the zygomatic-cutaneous
ligament just superior and lateral to the malar wad. The author feels that this
step is crucial to obtaining significant long lasting mid-face rejuvenation (fig
11).
A 3-0 permanent braided suture is used to secure the malar wad in a
superior-lateral direction using a figure of 8 stitch. The suture is secured to
the deep temporal fascia. The placement of this suture is key to successful
surgery and the beginning surgeon may have to place this suture several
times before obtaining the desired result. A suture secured in a superficial
plane may produce an indention of the epidermis whereas a suture fixated at
the level of or thru some of the fibers of the zygomaticus may actually
deepen the fold while at the same time elevating the commissura of the lips.
It is not infrequent to have to repeatedly suture fixate the malar wad before
an adequate lift is obtained. With experience this lift becomes routine and
the fixation step becomes less problematic.
When this procedure is done with an endoscopic browplasty, the fixation
suture is also secured to the deep temporal fascia. The dissection is the same
as that described above. The only point to be made is that the endoscopic
dissection of the forehead should precede the mid-face dissection. Mid-face
dissection and suture fixation should go before lateral suspension of the
forehead.
7

8. SOOF Lift Blepharoplasty
The first step is to make a routine incision for a transconjunctival
blepharoplasty. It is important to make this incision approximately three to
four millimeters below the caudal margin of the tarsal thickening. Making
this incision too close to the sulcus could increase the possibility of a
contraction scar from the incision to the arcus marginalis. The conjunctival
flap is then raised leaving the fibers of the orbital septum posterior so as to
keep the nasal, medial, and lateral orbital fat pockets
contained (fig 12).
At this point the surgeon needs to decide if the patient requires excision of
fat. Excising fat in the average patient should be avoided in the nasal and
mid fat pockets. Over zealous excision of orbital fat tends to make a
patient’s lower lids appear artificially concave 15,16
. There are exceptions,
patients that presents with familial pseudo-herniation in their twenties to
thirties and have significant positive vector have an excess of orbital fat and
do better with aggressive excision of fat from each compartment.
When the orbital septum is left intact it can be cauterized with a bipolar to
contain the fat in the nasal and medial compartments. Bipolar cauterization
of the orbital septum stimulates thickening and strengthening of the septum
by inducing a layer of scar tissue formation 17
.
The lateral fat pocket seems to fall into a separate category. Failure to excise
fat from this pocket in the average patient will result in fullness of the lateral
lower lid post operatively in a significant percentage of patients (personal
experience). Therefore, fat is routinely removed from the lateral pocket. The
reason for this is that the orbital septum over this area of the lid is more
tenuous and should there be any excess pressure on the septum post
operatively, it is here that it will fail. Think of this area of the septum as a
pressure relief valve, excess pressure (fat) that is detected following bipolar
cauterization of the mid and nasal areas of the septum is released by
judicious removal of fat from the lateral compartment. This concept works
since there are in reality not three fat compartments to the lower lid; all of
the fat within the orbital cone commingles posterior to the orbital septum 18
.
Therefore removing a small amount of fat from the lateral compartment in
reality redistributes pressure throughout the orbit behind the
orbital septum.
The next step is to make an incision just above the arcus marginalis down to
the periosteum along the medial half of the infra-orbital rim. The incision is
made down to the periosteum but not through this layer. Dissection is then
8

9. carried out on top of the periosteum past the inferior margin of the tear
trough deformity (Fig. 13). Following the initial development of the
dissection plane with a small scissors a good portion of this dissection is
performed bluntly using Q-tips. The SOOF is then identified. Typically, the
SOOF will be found on the inside portion of the elevated flap or wrapping
around the levator anguli oris. A horizontal mattress suspension suture from
the SOOF to the arcus marginalis of the infra-orbital rim is performed along
the width of the deformity (Fig. 14 a-d). The author prefers a 4-0 braided
suture for this step. Enough tension must be applied to raise the SOOF to the
level of the rim. Attention must be paid to the vector applied at the level of
the rim to prevent inadvertent tearing of the periosteum.
Once the SOOF has been successfully repositioned, a buried single
absorbable suture is used to repair the conjunctival incision. This stitch
should be placed lateral to the cornea. Any bothersome bleeding encountered
during the surgery should be controlled with a bipolar cautery, preferably a
bipolar that is insulated. Using a unipolar cautery may inadvertently injure
the inferior orbital nerve, the overlying skin, or the orbit.
Discussion
There have been many papers written concerning the correct way to
approach rejuvenation of the midface. The techniques presented within this
article address the midface from different directions and depths. The deepest
approach of the three is the subperiosteal lift, which is not covered in detail.
The reason for this is that the author feels that subperiosteal midface-lifts
should in general be replaced by SMAS division mid-face lifts due to the
contention that the latter procedure to improves the nasolabial fold more
completely and has a lower morbidity. There are, however, some patients
who remain candidates for this approach. I would consider this approach as
an option for a cosmetic patient who was a heavy smoker, had a severe
redundancy of their lower eyelid skin and complained of a down turned
corner of the mouth; as long as they understood that their nasolabial fold
would not be significantly improved over time.
The SMAS division mid-face lift is an approach that certainly improves the
depth of the nasolabial fold while restoring a youthful cheek contour. The
percentage of patients that present with a complaint solely of mid-face laxity
is low. Most patients have other concerns in addition to their midface.
However the number of patients presenting with concerns specific to the
mid-face seems to be increasing. This may have something to do with
9

10. increased patient awareness that mid-face rejuvenation is a possibility or
may more simply be due to aging baby boomers. Regardless of the
experience of the individual facial plastic surgeon in regards to this specific
request, it is important for any facial aesthetic surgical expert to be familiar
with the anatomy in this area and become comfortable with mid-face
rejuvenation techniques. The reason for this is that it is the authors’ belief
that most patients undergoing a facelift should also have a SMAS division
mid-face lift (fig 15).
The versatility of the SMAS division mid-face lift has been an advantage
and will allow the physician to offer rejuvenation of the mid-face solely or
in conjunction with a brow lift (fig 16). When done alone, swelling lateral
to the orbit can be occasionally a concern for two – four weeks. However
most patients are satisfied with the improvement after seven to fourteen
days. The amount of swelling has been relatively well accepted.
There haven’t been any cases of post operative facial nerve paralysis noted
in the over three hundred cases of mid-face rejuvenation performed over the
past five years including all patients who have had mid-face rejuvenation
using a SMAS division approach. As was reported in an earlier publication
there were initially two cases of mild mid-face dyskinesis, both of which
cleared in less than six week6
. These cases were felt to be due to excessive
pressure exerted on the zygomaticus muscle and/or to violation of the SMAS
sheath of the muscle during the initial dissection.
The addition of the SOOF lift blepharoplasty to the authors’ surgical
armamentarium has improved the results in the midface. This technique
certainly would not replace a SMAS division mid-face lift for primary mid-
face rejuvenation. However, since developing this technique and gaining
experience, more patients have been identified who benefit from both
approaches. Indeed, even when this technique is performed by itself, a
modest improvement in the midface can be anticipated (Fig 17).
Utilization of the transconjunctival approach to accomplish a SOOF lift
blepharoplasty minimizes the risk of scleral show and virtually eliminates
the risk of ectropion. A transconjunctival approach allows the facial plastic
surgeon to adequately address the weakening of the orbital septum that
occurs over time resulting in pseudoherniation of orbital fat. In the majority
of patients that do not have early onset of pseudoherniation associated with a
positive vector and a definite family history, using the approach advocated
by the author of judicious removal of orbital fat from the lateral
compartment only while tightening the orbital septum using a bipolar
cautery, will allow resolution of a patients pseudoherniation without giving
the patients a hollow/sunken appearance. Unfortunately, sole dependence on
10

11. classical transconjunctival blepharoplasty with aggressive fat removal from
all three areas of the lower lid often leaves patients with a somewhat
hollowed-out appearance and surgical enophthalmos. Adding a SOOF lift to
these patients simply improves the result even more by addressing the
associated nasojugal deformity and improving the transition from the lower
lid to the mid-face.
Surgeons who adopt this approach to the lower lid will need to be
comfortable with addressing the overlying skin and muscle of the lower lid
as a separate distinct entity requiring management. Many patients will
require no additional treatment other than the SOOF lift blepharoplasty.
Other patients will desire improvement in even mild lower lid and cheek
rhytids. This problem can be adequately overcome in the average patient by
performing simultaneous laser resurfacing of the lower lids or aggressive
chemical peeling. Patients that have persistent lower lid rhytids due to the
orbicularis oculi muscle should be corrected using a pinch excision. This is a
safer way of managing this problem than utilizing a skin muscle flap. Done
correctly the risk of postoperative drooping of the lower lid should be
minimal. The only downside to using this approach is that the incision is not
hidden quite as well. The authors’ personal experience has been that this is
rarely a cause of concern for the patient. For those patients that feel their
incision is too visible, light CO2 resurfacing has sufficed to mitigate their
concerns.
Perhaps the main question that remains unanswered in reference to the
SOOF lift blepharoplasy technique as originally published by the author
relates to cauterizing the orbital septum and expecting this approach alone to
contain the nasal and medial fat pockets. The concept of cauterization of the
orbital septum is not new having initially been reported by Cook 17
. The
approach advocated in that article was to cauterize the orbital septum in
basically all patients without fat removal. Unfortunately, over time there was
recurrence of patients pseudo-herniation in a percentage of patients and the
technique was not universally accepted. I believe the reason the approach
advocated by Cook was not more widely employed whereas the SOOF lift
blepharoplasty appears to be more predictable is tri-fold. First, there is the
issue of patient selection. As discussed, in the case of pseudo-herniation
noted in patients twenties to thirties there exists a relative overabundance of
orbital fat and excision is warranted. Indeed failure to excise fat will result
in a recurrence of pseudo-herniation, so treatment of patients in this category
with techniques that ignored fat excision resulted in patient failures. Second,
for patients with middle age or late onset of pseudo-herniation treated with
bipolar cauterization of the orbital septum utilizing the SOOF lift
11

12. blepharoplasty technique, it is recommended that a small amount of fat be
removed from the lateral fat pocket. This step was omitted in previous
approaches. Removing orbital fat from the lateral pocket may relieve some
pressure on the orbital septum since, as was discussed earlier, all three fat
pockets are connected. Finally, by lifting the SOOF pad and filling in the
nasojugal depression, a small degree of fullness in the medial and nasal
compartments may be less noticeable since there is no longer a depression to
accentuate the fullness.
CONCLUSION
There are several techniques available to the facial plastic surgeon to affect a
positive change in reference to the midface. Using an endoscope to assist in
these procedures is advantageous. The author has found that the
subperiosteal lift is not as good at improving the aging midface as
procedures that attempt to lift the malar wad and or the SOOF pad. The
SOOF lift blepharoplasty is the newest procedure to be added to the facial
plastic surgeons armamentarium and has been useful in improving this
challenging area.
12