- Email: [email protected]
Experience with Percutaneous Suspension of the Malar Fat Pad for Midface Rejuvenation
393
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 13 (2005) 393–399
Experience with Percutaneous Suspension of the Malar Fat Pad for Midface Rejuvenation Keith A. LaFerriere, & & &
MD, FACS,
Richard D. Castellano,
Anatomy of midface aging Patient selection Technique
Repositioning of the ptotic malar fat pad represents a key element of midface rejuvenation. Traditional face-lifting techniques have been minimally effective in correcting the midface changes commonly seen in aging. For this reason, multiple procedures have been developed specifically to address this problem, including deep plane dissections, subperiosteal and endoscopic midface-lifts, and transorbital approaches [1–8]. These techniques are relatively invasive, carry significant morbidity, require more advanced surgical training to accomplish, and often result in prolonged healing time. Many candidates, especially younger patients, desire procedures that have rapid recovery times with reduced risk and the absence of visible incisions; therefore, a minimally invasive technique producing a long lasting elevation of the malar fat pad would be a welcome addition to midface rejuvenation. Percutaneous suspension of the malar fat pad to reposition it in a more youthful position has the potential to fit this description.
Anatomy of midface aging With aging, the malar fat pad descends in an inferomedial direction so that its most inferior extent
& & &
MD*
Results Summary References
collects against the fixed fusion line of the melolabial crease, adding to the fullness of the melolabial fold and accentuating the melolabial line. The descent also contributes to the crescent-shaped hollow below the lower edge of the orbicularis oculi muscle, deepens the nasojugal groove, and makes the infrazygomatic cheek concavity more prominent. Sasaki and Cohen [9] performed cadaveric studies that indicated the greatest average depth of the malar fat pad was approximately 6 mm, whereas the thickness at the melolabial fold was 2.2 mm. The malar fat pat was found to be anatomically indistinguishable from the subcutaneous fat of the infraorbital cheek skin. Furthermore, the malar fat was described as a superficial structure less adherent to the superficial musculoaponeurotic system (SMAS) layer investing the zygomatic major and minor muscles. The anatomy of midface ptosis has also been well described by Lucarelli and coworkers [10]. They demonstrated that although attenuation of the orbitomalar, zygomatic, and masseteric cutaneous ligaments occurs, midface ptosis results mainly from the inferior migration of skin and subcutaneous fat with relative sparing of the deeper tissues. These findings support the concept of meloplication for midface rejuvenation.
Fremont Avenue Medical Building, 1965 S. Fremont, Suite 1990, Springfield, MO 65804, USA * Corresponding author. 7520 Brompton Street, #682, Houston, TX 77025. E-mail address: [email protected] (R.D. Castellano). 1064-7406/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2005.05.002
394
LaFerriere & Castellano
Patient selection This procedure is best suited for younger patients manifesting inferior descent of the malar fat pad with deepening of the melolabial fold as their main complaint. These patients do not exhibit the jowling and skin laxity that would be treated with a face-lift. The procedure can also be helpful in older patients who have significant midface ptosis when performed as an open procedure, allowing for a more conservative lower face-lift. The authors have found that male and female patients may benefit from melolabial plication. The procedure is effective when performed alone or in combination with a face-lift, forehead-lift, or blepharoplasty. Patients are counseled that a recovery period of 1 week is generally needed before normal social interaction can occur, and that a longer period may be needed if significant ecchymosis occurs. Although they are less ideal candidates, patients who have insufficient fat in the malar fat pad complex and patients with flat or hypoplastic malar eminences can still benefit from melolabial plication. This technique will not correct the deep crescent hollow at the lid/ cheek junction, and patients are educated accordingly on the need for blepharoplasty techniques with fat repositioning or fat grafting, or transorbital midface-lifting.
Technique The cutaneous markings on the face are positioned as shown in Fig. 1. An imaginary line extending
Fig. 1. The needle insertion sites are 1 cm from the alar-facial junction, spaced 1 cm apart from one another, and parallel to the melolabial fold. The path of the sutures continues 1 and 2 cm lateral to the lateral orbital rim.
Fig. 2. Preparation of sutures. The polygalactic acid suture allows for a sawing motion through the dermal remnants that impedes the seating of the e-PTFE pledget, thereby avoiding dimpling of the skin. The suture is anchored in the malar fat pad with the e-PTFE swatch. Temporally, an additional e-PTFE swatch is used to anchor the insertion and to assist in localization of the suture if revision is necessary.
from the columella through the alar base is extended onto the cheek, and a mark 1 cm lateral to the melolabial fold is inscribed. A second mark is made 1 cm inferior to the first and parallel to the melolabial fold. The path of the suspension sutures is perpendicular to the melolabial fold, and a second set of marks 1 cm and 2 cm away from the lateral orbital rim is made as a guide. A 3-cm temporal incision is outlined approximately 2 cm posterior to the hairline and centered on the path from the melolabial markings through those adjacent to the lateral orbital rim. The sutures are prepared [Fig. 2] by threading a 2-mm thick, 2 × 2 mm expanded polytetrafluoroethylene (e-PTFE) (Gore-Tex, Flagstaff, Arizona) swatch on a 3N02, CV-3 needle e-PTFE suture, and 6-cm Keith needles are threaded at both free ends. A 3-0 polygalactic acid suture (Vicryl; Ethicon, Cincinnati, Ohio) is then placed through the Keith needles, parallel to the e-PTFE suture, and the ends of both sutures and the e-PTFE swatch are secured with hemostats. The braided nature of the polygalactic acid suture allows for a sawing motion through the dermal remnants that impedes the seating of the e-PTFE pledget, thereby avoiding dimpling of the skin. The temporal incision is carried down to the superficial layer of the deep temporal fascia, and
Percutaneous Suspension of the Malar Fat Pad
Fig. 3. Sutures are placed superficial to the facial nerve inferiorly, superficial to the orbicularis oculi, and deep to the temporoparietal fascia containing the frontal branch of the facial nerve.
the dissection proceeds on this plane to the previously marked areas adjacent to the lateral orbital rim. Stab incisions are made along relaxed skin tension lines at the marks adjacent to the melolabial folds. One of the Keith needles with the attached e-PTFE and polygalactic acid sutures is inserted through the upper stab incision adjacent to the melolabial fold and carried down to the maxilla, retracted slightly, and directed superolaterally through the malar fat pad toward the medial mark at the lateral orbital area, surfacing between the orbicularis oculi muscle and skin. Care is taken to ensure that the needle has not engaged the dermis to avoid dimpling in the skin and that it is superficial to the orbicularis oculi muscle. An Aufrecht retractor is inserted in the temporal incision and directed toward the Keith needle lateral to the orbital rim. The Keith needle is then advanced on the undersurface of the Aufrecht retractor and
Fig. 4. Photographs of a 51-year-old woman (A,B) preoperatively and (C,D) 1 year postoperatively after meloplication only. Note the subtle improvement in the malar fullness in the frontal view and the malar projection on the right side as viewed from the left 45-degree view.
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retrieved through the temporal incision. The retractor is deep to and protects the frontal branch of the facial nerve, which lies in the superficial temporal fascia. The ends of the two sutures are secured with a hemostat. The path of the suture is safe, being superior to the parotid duct, through the malar fat pad with no important structures at risk, above the orbicularis oculi muscle, and deep to the frontal branch of the facial nerve [Fig. 3]. In identical fashion, the remaining Keith needle with the other end of the suture complex is passed through the same stab incision adjacent to the melolabial fold and delivered through the temporal incision. The e-PTFE swatch on the e-PTFE suture is withheld from entering the stab incision by the hemostat placed previously. From the temporal incision, the polygalactic acid suture is pulled through the stab incision and used to saw gently through the dermal attachments to prevent dimpling of the skin when the e-PTFE suture with the
e-PTFE swatch is seated. Care is taken to prevent excessive sawing of the polygalactic acid suture once the dermal attachments are freed so that the suture does not penetrate through the entire malar fat pad. One can discern when the polygalactic acid suture is seated in the malar fat by feeling an abrupt release of the dermis or by visualizing the effacement of the skin dimple. The polygalactic acid suture is withdrawn through the temporal incision, and the e-PTFE suture with the e-PTFE swatch is pulled through the stab incision and seated to allow for plication of the malar fat pad. This maneuver is repeated through the inferior stab incision adjacent to the melolabial fold, and the second plication suture is seated. Both e-PTFE sutures are then secured to the superficial layer of the deep temporal fascia at the level of the temporal incision using a French-eye needle. Each suture is then tied over an additional 4 × 4 mm swatch of
Fig. 5. Photographs of a 43-year-old woman (A, B) preoperatively and (C, D) 1 year after meloplication, full-face laser resurfacing, and endoscopic brow-lift.
Percutaneous Suspension of the Malar Fat Pad
2-mm e-PTFE after suitable elevation of the malar fat pad is achieved. This e-PTFE swatch is helpful in securing the e-PTFE suture and in locating the suture at a subsequent time if additional suspension or modification is desired. The average amount of malar fat pad elevation is 3 mm but can be more or less depending how much movement is desired. The result is a plication of the malar fat pad, not a repositioning of the entire skin and fat complex, thereby avoiding bunching of skin in the lateral orbital area. The temporal incisions are closed with surgical staples, and the opposite site is treated in identical fashion.
Results This technique has been performed on 64 patients (61 women and 3 men), with an average age of
48.1 years [Figs. 4–6]. Follow-up has ranged from 3 to 42 months (average, 28 months). Of the 64 patients, 17 underwent meloplication only, 26 had meloplication performed with a face-lift, and 21 had meloplication performed with other procedures (eg, laser resurfacing, forehead-lift, blepharoplasty). The results in the first 37 patients (O’Mara and LaFerriere, unpublished data, 2004) were evaluated by an anonymous patient questionnaire and a blinded study of preoperative and postoperative photographs by three independent physician observers. Patient satisfaction as measured by the questionnaires (46% return rate) was high. Most of the patients were not only satisfied with the procedure but would also recommend it to others. The physicians’ rating of the preoperative and postoperative photographs was less enthusiastic. Nevertheless, they rated the results as good. The complication rate in the early experience was sig-
Fig. 6. Photographs of a 55-year-old woman (A,B) preoperatively and (C,D) 1 year after meloplication, face-lift, and transconjunctival blepharoplasty with fat repositioning and full-face laser resurfacing.
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nificantly higher than that reported in previous studies. The authors performed six unilateral revisions for asymmetry, four within the first 2 months postoperatively, one 9 months postoperatively, one at 1 year, and a bilateral revision 2 years postoperatively, for a combined revision rate of 19%. Of the last 27 procedures performed, only 2 have been revised. With further experience, the authors realized that many of the asymmetries that were revised in the early postoperative period would have resolved with the passage of time without intervention. In the past year, only one of the melolabial plication procedures has been revised, and that was because of patient insistence despite the authors’ reassurance that the asymmetry would likely resolve in time. Two unilateral infections occurred secondary to extrusion of the e-PTFE swatch in the lateral orbital area. These infections occurred early in the series and were likely related to overly aggressive sawing with the Vicryl suture, which resulted in the e-PTFE swatch passing through the malar fat pad, migrating to a subdermal location, and causing an inflammatory reaction. One of these patients required scar revision, and the other healed without perceptible scarring. Additionally, a few patients experienced prolonged discomfort for up to 1 month postoperatively.
Summary Su [11] introduced percutaneous suture plication of the malar fat as a minimally invasive technique for elevating the malar fat pad and softening the melolabial fold. Sasaki and Cohen [9] then reported on 392 cases over 6 years in a retrospective study. When performed alone or in conjunction with a face-lift, an overall 1 to 3 mm of malar fat pad elevation was demonstrated. A 10.5% complication rate was noted in the form of early asymmetry (3.8%), early dimpling at the stab incision sites (3.6%), and visible scars at the stab incision sites (1.8%). Using e-PTFE suture and anchor grafts, 2-year outcomes described as ‘‘good’’ were present in 85% of patients. All asymmetries and dimpling were resolved at 3 months postoperatively. Additionally, a unilateral lip weakness occurred in one patient that resolved within 4 weeks, and a suture tract infection occurred in one patient. No parotid duct injuries were reported. Keller and coworkers [12] prospectively studied 118 patients over 12 months undergoing melolabial plication alone or in conjunction with a face-lift. These patients obtained 3 to 7 mm of elevation. Temporary asymmetry was seen in eight patients (6.8%), which was completely resolved in 3 months. Two patients (1.7%) sustained infection
postoperatively that was effectively treated with antibiotics. The original technique performed did not use stab incisions to bury the e-PTFE swatch. Owing to patients’ palpation of the swatch and the two (1.7%) patients who required revision surgery, the technique was modified to include the stab incision. All of the patients maintained their elevation at 1 year. The senior author (K.A.L) visited Dr. Keller in 2001, observed his technique, and began using it with minor modifications in selected cases. Based on these studies, the technique seems to be minimally invasive with a low complication rate and a high degree of success over a 1- and 2-year follow-up period. Currently, the literature is limited to the experience of Sasaki and Keller for long-term studies of melolabial plication. In the authors’ experience, this procedure is well tolerated by patients, with reasonably good results at 1- to 3-year follow-up. Analysis of postoperative outcomes for 5- and 10-year suspensions will be necessary to provide evidence of long-term results. Nonetheless, for appropriately selected patients, especially younger individuals without significant associated aging changes, this technique represents a valuable addition to the treatment of the aging midface. Unlike in many other cosmetic procedures, the results can easily be revised, or the fat resuspended after several years, with minimal morbidity.
References [1] Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: shortterm success but long-term failure. Plast Reconstr Surg 2002;110(3):940–51. [2] Hester TR, Codner MA, McCord MD, et al. Evolution of the technique. Plast Reconstr Surg 2000; 105(1):393–406. [3] Williams JV. Transblepharoplasty endoscopic subperiosteal midface lift. Plast Reconstr Surg 2002;110(7):1769–75. [4] Gunter JP, Hackney FL. A simplified transblepharoplasty subperiosteal cheek lift. Plast Reconstr Surg 1999;103(7):2029–35. [5] Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg 1995;22(2):295–311. [6] Quatella VC, Jacono AA. The extended centrolateral endoscopic midface lift. Facial Plast Surg 2003;19(2):199–207. [7] Williams EF, Vargus H, Dahiya R, et al. Midface rejuvenation via a minimal-incision brow-lift approach. Arch Facial Plast Surg 2003;5:470–8. [8] Williams JV. Transblepharoplasty endoscopic subperiosteal midface lift. Plast Reconstr Surg 2002;110(7):1769–75. [9] Sasaki GH, Cohen AT. Meloplication of the malar
Percutaneous Suspension of the Malar Fat Pad
fat pads by percutaneous cable-suture technique for midface rejuvenation: outcome study. Plast Reconstr Surg 2002;110:635–54. [10] Lucarelli MJ, Khwarg SI, Lemke BN, et al. The anatomy of midfacial ptosis. Ophthal Plast Reconstr Surg 2000;16(1):7–22.
[11] Su NN. Closed suspension mini-cheek lift to reduce the nasolabial fold: a preliminary report. Am J Cosmetic Surg 1995;12:31–4. [12] Keller GS, Namazie A, Blackwell K, et al. Elevation of the malar fat pad with a percutaneous technique. Arch Facial Plast Surg 2002;4:20–5.
399
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 13 (2005) 393–399
Experience with Percutaneous Suspension of the Malar Fat Pad for Midface Rejuvenation Keith A. LaFerriere, & & &
MD, FACS,
Richard D. Castellano,
Anatomy of midface aging Patient selection Technique
Repositioning of the ptotic malar fat pad represents a key element of midface rejuvenation. Traditional face-lifting techniques have been minimally effective in correcting the midface changes commonly seen in aging. For this reason, multiple procedures have been developed specifically to address this problem, including deep plane dissections, subperiosteal and endoscopic midface-lifts, and transorbital approaches [1–8]. These techniques are relatively invasive, carry significant morbidity, require more advanced surgical training to accomplish, and often result in prolonged healing time. Many candidates, especially younger patients, desire procedures that have rapid recovery times with reduced risk and the absence of visible incisions; therefore, a minimally invasive technique producing a long lasting elevation of the malar fat pad would be a welcome addition to midface rejuvenation. Percutaneous suspension of the malar fat pad to reposition it in a more youthful position has the potential to fit this description.
Anatomy of midface aging With aging, the malar fat pad descends in an inferomedial direction so that its most inferior extent
& & &
MD*
Results Summary References
collects against the fixed fusion line of the melolabial crease, adding to the fullness of the melolabial fold and accentuating the melolabial line. The descent also contributes to the crescent-shaped hollow below the lower edge of the orbicularis oculi muscle, deepens the nasojugal groove, and makes the infrazygomatic cheek concavity more prominent. Sasaki and Cohen [9] performed cadaveric studies that indicated the greatest average depth of the malar fat pad was approximately 6 mm, whereas the thickness at the melolabial fold was 2.2 mm. The malar fat pat was found to be anatomically indistinguishable from the subcutaneous fat of the infraorbital cheek skin. Furthermore, the malar fat was described as a superficial structure less adherent to the superficial musculoaponeurotic system (SMAS) layer investing the zygomatic major and minor muscles. The anatomy of midface ptosis has also been well described by Lucarelli and coworkers [10]. They demonstrated that although attenuation of the orbitomalar, zygomatic, and masseteric cutaneous ligaments occurs, midface ptosis results mainly from the inferior migration of skin and subcutaneous fat with relative sparing of the deeper tissues. These findings support the concept of meloplication for midface rejuvenation.
Fremont Avenue Medical Building, 1965 S. Fremont, Suite 1990, Springfield, MO 65804, USA * Corresponding author. 7520 Brompton Street, #682, Houston, TX 77025. E-mail address: [email protected] (R.D. Castellano). 1064-7406/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2005.05.002
394
LaFerriere & Castellano
Patient selection This procedure is best suited for younger patients manifesting inferior descent of the malar fat pad with deepening of the melolabial fold as their main complaint. These patients do not exhibit the jowling and skin laxity that would be treated with a face-lift. The procedure can also be helpful in older patients who have significant midface ptosis when performed as an open procedure, allowing for a more conservative lower face-lift. The authors have found that male and female patients may benefit from melolabial plication. The procedure is effective when performed alone or in combination with a face-lift, forehead-lift, or blepharoplasty. Patients are counseled that a recovery period of 1 week is generally needed before normal social interaction can occur, and that a longer period may be needed if significant ecchymosis occurs. Although they are less ideal candidates, patients who have insufficient fat in the malar fat pad complex and patients with flat or hypoplastic malar eminences can still benefit from melolabial plication. This technique will not correct the deep crescent hollow at the lid/ cheek junction, and patients are educated accordingly on the need for blepharoplasty techniques with fat repositioning or fat grafting, or transorbital midface-lifting.
Technique The cutaneous markings on the face are positioned as shown in Fig. 1. An imaginary line extending
Fig. 1. The needle insertion sites are 1 cm from the alar-facial junction, spaced 1 cm apart from one another, and parallel to the melolabial fold. The path of the sutures continues 1 and 2 cm lateral to the lateral orbital rim.
Fig. 2. Preparation of sutures. The polygalactic acid suture allows for a sawing motion through the dermal remnants that impedes the seating of the e-PTFE pledget, thereby avoiding dimpling of the skin. The suture is anchored in the malar fat pad with the e-PTFE swatch. Temporally, an additional e-PTFE swatch is used to anchor the insertion and to assist in localization of the suture if revision is necessary.
from the columella through the alar base is extended onto the cheek, and a mark 1 cm lateral to the melolabial fold is inscribed. A second mark is made 1 cm inferior to the first and parallel to the melolabial fold. The path of the suspension sutures is perpendicular to the melolabial fold, and a second set of marks 1 cm and 2 cm away from the lateral orbital rim is made as a guide. A 3-cm temporal incision is outlined approximately 2 cm posterior to the hairline and centered on the path from the melolabial markings through those adjacent to the lateral orbital rim. The sutures are prepared [Fig. 2] by threading a 2-mm thick, 2 × 2 mm expanded polytetrafluoroethylene (e-PTFE) (Gore-Tex, Flagstaff, Arizona) swatch on a 3N02, CV-3 needle e-PTFE suture, and 6-cm Keith needles are threaded at both free ends. A 3-0 polygalactic acid suture (Vicryl; Ethicon, Cincinnati, Ohio) is then placed through the Keith needles, parallel to the e-PTFE suture, and the ends of both sutures and the e-PTFE swatch are secured with hemostats. The braided nature of the polygalactic acid suture allows for a sawing motion through the dermal remnants that impedes the seating of the e-PTFE pledget, thereby avoiding dimpling of the skin. The temporal incision is carried down to the superficial layer of the deep temporal fascia, and
Percutaneous Suspension of the Malar Fat Pad
Fig. 3. Sutures are placed superficial to the facial nerve inferiorly, superficial to the orbicularis oculi, and deep to the temporoparietal fascia containing the frontal branch of the facial nerve.
the dissection proceeds on this plane to the previously marked areas adjacent to the lateral orbital rim. Stab incisions are made along relaxed skin tension lines at the marks adjacent to the melolabial folds. One of the Keith needles with the attached e-PTFE and polygalactic acid sutures is inserted through the upper stab incision adjacent to the melolabial fold and carried down to the maxilla, retracted slightly, and directed superolaterally through the malar fat pad toward the medial mark at the lateral orbital area, surfacing between the orbicularis oculi muscle and skin. Care is taken to ensure that the needle has not engaged the dermis to avoid dimpling in the skin and that it is superficial to the orbicularis oculi muscle. An Aufrecht retractor is inserted in the temporal incision and directed toward the Keith needle lateral to the orbital rim. The Keith needle is then advanced on the undersurface of the Aufrecht retractor and
Fig. 4. Photographs of a 51-year-old woman (A,B) preoperatively and (C,D) 1 year postoperatively after meloplication only. Note the subtle improvement in the malar fullness in the frontal view and the malar projection on the right side as viewed from the left 45-degree view.
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retrieved through the temporal incision. The retractor is deep to and protects the frontal branch of the facial nerve, which lies in the superficial temporal fascia. The ends of the two sutures are secured with a hemostat. The path of the suture is safe, being superior to the parotid duct, through the malar fat pad with no important structures at risk, above the orbicularis oculi muscle, and deep to the frontal branch of the facial nerve [Fig. 3]. In identical fashion, the remaining Keith needle with the other end of the suture complex is passed through the same stab incision adjacent to the melolabial fold and delivered through the temporal incision. The e-PTFE swatch on the e-PTFE suture is withheld from entering the stab incision by the hemostat placed previously. From the temporal incision, the polygalactic acid suture is pulled through the stab incision and used to saw gently through the dermal attachments to prevent dimpling of the skin when the e-PTFE suture with the
e-PTFE swatch is seated. Care is taken to prevent excessive sawing of the polygalactic acid suture once the dermal attachments are freed so that the suture does not penetrate through the entire malar fat pad. One can discern when the polygalactic acid suture is seated in the malar fat by feeling an abrupt release of the dermis or by visualizing the effacement of the skin dimple. The polygalactic acid suture is withdrawn through the temporal incision, and the e-PTFE suture with the e-PTFE swatch is pulled through the stab incision and seated to allow for plication of the malar fat pad. This maneuver is repeated through the inferior stab incision adjacent to the melolabial fold, and the second plication suture is seated. Both e-PTFE sutures are then secured to the superficial layer of the deep temporal fascia at the level of the temporal incision using a French-eye needle. Each suture is then tied over an additional 4 × 4 mm swatch of
Fig. 5. Photographs of a 43-year-old woman (A, B) preoperatively and (C, D) 1 year after meloplication, full-face laser resurfacing, and endoscopic brow-lift.
Percutaneous Suspension of the Malar Fat Pad
2-mm e-PTFE after suitable elevation of the malar fat pad is achieved. This e-PTFE swatch is helpful in securing the e-PTFE suture and in locating the suture at a subsequent time if additional suspension or modification is desired. The average amount of malar fat pad elevation is 3 mm but can be more or less depending how much movement is desired. The result is a plication of the malar fat pad, not a repositioning of the entire skin and fat complex, thereby avoiding bunching of skin in the lateral orbital area. The temporal incisions are closed with surgical staples, and the opposite site is treated in identical fashion.
Results This technique has been performed on 64 patients (61 women and 3 men), with an average age of
48.1 years [Figs. 4–6]. Follow-up has ranged from 3 to 42 months (average, 28 months). Of the 64 patients, 17 underwent meloplication only, 26 had meloplication performed with a face-lift, and 21 had meloplication performed with other procedures (eg, laser resurfacing, forehead-lift, blepharoplasty). The results in the first 37 patients (O’Mara and LaFerriere, unpublished data, 2004) were evaluated by an anonymous patient questionnaire and a blinded study of preoperative and postoperative photographs by three independent physician observers. Patient satisfaction as measured by the questionnaires (46% return rate) was high. Most of the patients were not only satisfied with the procedure but would also recommend it to others. The physicians’ rating of the preoperative and postoperative photographs was less enthusiastic. Nevertheless, they rated the results as good. The complication rate in the early experience was sig-
Fig. 6. Photographs of a 55-year-old woman (A,B) preoperatively and (C,D) 1 year after meloplication, face-lift, and transconjunctival blepharoplasty with fat repositioning and full-face laser resurfacing.
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nificantly higher than that reported in previous studies. The authors performed six unilateral revisions for asymmetry, four within the first 2 months postoperatively, one 9 months postoperatively, one at 1 year, and a bilateral revision 2 years postoperatively, for a combined revision rate of 19%. Of the last 27 procedures performed, only 2 have been revised. With further experience, the authors realized that many of the asymmetries that were revised in the early postoperative period would have resolved with the passage of time without intervention. In the past year, only one of the melolabial plication procedures has been revised, and that was because of patient insistence despite the authors’ reassurance that the asymmetry would likely resolve in time. Two unilateral infections occurred secondary to extrusion of the e-PTFE swatch in the lateral orbital area. These infections occurred early in the series and were likely related to overly aggressive sawing with the Vicryl suture, which resulted in the e-PTFE swatch passing through the malar fat pad, migrating to a subdermal location, and causing an inflammatory reaction. One of these patients required scar revision, and the other healed without perceptible scarring. Additionally, a few patients experienced prolonged discomfort for up to 1 month postoperatively.
Summary Su [11] introduced percutaneous suture plication of the malar fat as a minimally invasive technique for elevating the malar fat pad and softening the melolabial fold. Sasaki and Cohen [9] then reported on 392 cases over 6 years in a retrospective study. When performed alone or in conjunction with a face-lift, an overall 1 to 3 mm of malar fat pad elevation was demonstrated. A 10.5% complication rate was noted in the form of early asymmetry (3.8%), early dimpling at the stab incision sites (3.6%), and visible scars at the stab incision sites (1.8%). Using e-PTFE suture and anchor grafts, 2-year outcomes described as ‘‘good’’ were present in 85% of patients. All asymmetries and dimpling were resolved at 3 months postoperatively. Additionally, a unilateral lip weakness occurred in one patient that resolved within 4 weeks, and a suture tract infection occurred in one patient. No parotid duct injuries were reported. Keller and coworkers [12] prospectively studied 118 patients over 12 months undergoing melolabial plication alone or in conjunction with a face-lift. These patients obtained 3 to 7 mm of elevation. Temporary asymmetry was seen in eight patients (6.8%), which was completely resolved in 3 months. Two patients (1.7%) sustained infection
postoperatively that was effectively treated with antibiotics. The original technique performed did not use stab incisions to bury the e-PTFE swatch. Owing to patients’ palpation of the swatch and the two (1.7%) patients who required revision surgery, the technique was modified to include the stab incision. All of the patients maintained their elevation at 1 year. The senior author (K.A.L) visited Dr. Keller in 2001, observed his technique, and began using it with minor modifications in selected cases. Based on these studies, the technique seems to be minimally invasive with a low complication rate and a high degree of success over a 1- and 2-year follow-up period. Currently, the literature is limited to the experience of Sasaki and Keller for long-term studies of melolabial plication. In the authors’ experience, this procedure is well tolerated by patients, with reasonably good results at 1- to 3-year follow-up. Analysis of postoperative outcomes for 5- and 10-year suspensions will be necessary to provide evidence of long-term results. Nonetheless, for appropriately selected patients, especially younger individuals without significant associated aging changes, this technique represents a valuable addition to the treatment of the aging midface. Unlike in many other cosmetic procedures, the results can easily be revised, or the fat resuspended after several years, with minimal morbidity.
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Percutaneous Suspension of the Malar Fat Pad
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