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Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting
G Model
JORMAS 68 1–6 J Stomatol Oral Maxillofac Surg xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
1 2 3 4 5 6 7 8
Original Article
Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting Q1 H.
Chatel, B. Hersant *, R. Bosc, S. La Padula, J.P. Meningaud
Department of Plastic, Reconstructive and Maxillo-facial Surgery, Henri-Mondor Hospital, 51, avenue du Mare´chal-de-Lattre-de-Tassigny, 94010 Cre´teil, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 February 2017 Accepted 26 June 2017
Objective: The aim of this study was to describe a technique for midface rejuvenation combining lower blepharoplasty, midcheek lift and autologous fat transfer. Methods: All patients who underwent a midface rejuvenation procedure performed by the same surgeon and using a classic subciliary blepharoplasty surgical approach were identified. The technique combined three distinct procedures: lower blepharoplasty with use of a transposition flap of orbital adipose tissue in the medial and central compartment to reduce the subpalpebral bags and attenuate the palpebrojugual sulcus; midcheek lift in the preperiosteal plane with trans-osseous fixation exerting traction on the soft tissues of the cheek along several vectors; autologous fat transfer to offset the loss of volume in the target area. Results: Between January 2011 and December 2015, 14 patients were operated with the described technique. Long-term results were good and stable over time. Two complications in the form of ectropion were observed in the series but resolved with daily massages. Conclusions: The combination of lower blepharoplasty, midcheek lift and autologous fat transfer appear to enable treatment of midface ageing. The results were satisfactory and durable, and the procedure was well tolerated. The procedures could be combined with others for the treatment of the upper and lower face during the same surgical procedure.
C 2017 Elsevier Masson SAS. All rights reserved.
Keywords: Aesthetic Blepharoplasty Midface Lifting Aging Lipofilling
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1. Introduction
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Midfacial ageing manifests clinically as bags under the eyes, accentuation of the ‘‘valley of tears’’ with marked palpebrojugal sulci and ptosis of the soft tissues of the cheeks [1–3]. Subpalpebral bags are generally considered, by the surgeon as an excess of periorbital fat, and treated with adipose tissue exeresis. Dark circles are caused by structural ageing, which, over time, result in a change in fat distribution in the various adipose compartments surrounding the eyeball. In that context, rejuvenation surgery should aim to restore the adipose tissue distribution. Since the early 1980s, several fat transposition techniques have been reported by Loeb [4], and then by Hamra [5,6] and Eder [7], and by Goldberg [8]. Although each technique has its own specificities, the unanimous consensus is that it is necessary to distribute the adipose tissue so to smooth the contrasts between the various periorbital contours induced by fat migration.
* Corresponding author. E-mail address: [email protected] (B. Hersant).
The other aspects of midface ageing should be treated concomitantly. While the most widespread midcheek lift technique is subperiosteal [8–10], a preperiosteal approach in nonvascular dissection plane is possible. The recent anatomical descriptions of facial soft tissues have allowed better understanding dissection [13,14]. The advantages of the technique are under study [15]. The technique provides excellent results with high patient satisfaction rates and limited complications. Combining lower blepharoplasty, midcheek lift and autologous fat graft may constitute the key to treatment [16–19] in the overall management of midface ageing. The aim of this study was to describe the technique and report on a series of midface rejuvenation results obtained by combining the above procedures.
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2. Material and methods
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All patients having undergone a midface lift rejuvenation procedure in our department between January 2011 and December 2015 were identified.
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http://dx.doi.org/10.1016/j.jormas.2017.06.014 C 2017 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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JORMAS 68 1–6 H. Chatel et al. / J Stomatol Oral Maxillofac Surg xxx (2017) xxx–xxx
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2.1. Surgical technique
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The procedures were performed under general anesthesia with orotracheal intubation using a preformed median oral tube. In all cases, 5 mL of lidocaine and epinephrine were infiltrated into the inferior orbital rim. The surgical approach was the classic subciliary incision route for lower blepharoplasty.
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2.1.1. Lower blepharoplasty with fat grafting Procedures began with a subciliary incision exceeding the outer canthus by 5 mm in a ‘‘crow’s foot’’ wrinkle. Dissection, using Stevens’ scissors, happened between the orbicular muscle, in the anterior plane, and the posterior tarsal plane, throughout the length of the lower eyelid at the subciliary level. Extension of the skin and the orbicular muscle incision was performed using scissors, throughout the necessary length and stopping 3 mm beyond the lacrimal point. The lower orbicular muscle was displaced downward to expose its insertion on the inferior orbital rim. The arcus marginalis was detached, using a periosteal elevator, from medial to lateral, avoiding disinsertion of the lateral third to preserve satisfactory muscle function. A subperiosteal pocket was formed aiming at subsequently hosting the transposition flap. The periorbital fat was accessed using a septum incision. Any excess (evidenced by light pressure on the eyeball) could be resected at this stage. A periosteal elevator was used to detach the periorbital fat from the periosteum of the orbit floor. An adipose flap with a superior pedicle of the correct dimensions was dissected. It was necessary to release the anterior third of the orbit floor to prevent tension and the risk of ectropion. Meticulous hemostasis was performed to preserve the flap vascularization and prevent the risk of orbital hematoma. The adipose transposition flap was used to offset the adipose deficit at the posterior face of the orbicular muscle (Fig. 1).
Fig. 1. Dissection of a fat flap during lower blepharoplasty.
2.1.2. Preperiosteal midcheek lift The surgical approach was the previously described using subciliary incision. The procedure was performed after the inferior blepharoplasty procedure. Depending on the number of traction vectors to be exerted, one or several trepanations were made on the edge of the inferior orbital rim (beginning at the junction between the medial third and intermediate third). Discision was made in the deep preperiosteal plane toward the nasolabial fold. The exact direction depended on the traction vector(s) required. Thus, there was no risk of damaging the infraorbital nerve at its point of emergence or the angular vein. The scissors were positioned vertically. A non-resorbable suspended the soft tissues using a specific needle (double-beveled hollow straight needle through which the suture runs). This enabled the surgeon to pass the needle through the cutaneous plane without the suture coming out and to impart a second direction to the suture thanks to the fact that both ends of the needle were beveled (Fig. 2). The suture was thus run through the trepanation hole in the margin (1-mm drill) and then into the previously-dissected preperiosteal deep space, before partially exiting the needle at the point of reflection in the nasolabial fold. A second direction was then imparted to the suture, returning it toward the orbital rim in a more superficial plane and exiting under the orbicular muscle. It was important not to snag the deep dermis to prevent pad formation. It was also important not to snag the orbicular muscle and to pass beneath it to avoid compromising eyelid dynamics. The knot was fixed with a degree of traction suitable for the desired result. The knot was then slid, buried and flattened against the orbital floor to prevent it bulging under the palpebral skin. The inferior blepharoplasty procedure was then completed. The pediculate adipose flap was sutured with a U 5/0 resorbable suture running to the inferior margin of the posterior part of the orbicular muscle (the positioning of the suture was determined preoperatively with the patient in the vertical position). Cutaneous resection was then performed as required by the excess. The subciliary incision was closed by intradermal running suturie with Nylon 5/0.
Fig. 2. Use of a traction suture for a midcheek lift (submusculus orbicularis oris fat).
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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2.1.3. Autologous fat grafting The adipose tissue was obtained as described by Coleman and in compliance with the latest recommendations [21]. The adipose tissue obtained was combined with platelet-rich plasma (PRP) with a 5:1 ratio. According to the latest recommendations, that method of preparation enhanced lipofilling yield [22]. The incisions were made at the nasolabial folds using a needle bevel. Subcutaneous re-injection was made using a 2-mm multiperforated Coleman cannula. The fat was injected into the nasolabial folds and over the cheek bones (injection elsewhere was possible if necessary). The amount of adipose tissue injected depended on the desired result.
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2.2. Postoperative care
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The patient had to apply vitamin A ointment on the scars after having dabbed them with regular saline daily for seven days. The sutures were removed after eight days. In the absence of any complication, daily massaging of the scars was authorized for at least one month to improve scar flexibility. Patients had to be seen for postoperative follow-up at least after one, three, six, 12 and 24 months. Patient satisfaction was evaluated at one year after surgery by another senior surgeon of the department.
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3. Results
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Among the 51 patients who underwent midface rejuvenation, 14 (one man and 13 women) underwent a procedure combining a preperiosteal centrofacial lift, blepharoplasty with fat transposition
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Table 1 Patients characteristics. Demographic data Age, mean, year (SD) BMI, mean, kg/m2 (SD) Gender (%) Male Female Current smoker (%) Surgical data Total number of procedures Time since procedure, mean, month (SD) Procedure duration, mean, minute (range) Type of procedure Primary (%) Secondary or tertiary (%) Associated procedures Neck lift (%) Forehead lift (%) Upper blepharoplasty (%) Rhinoplasty (%) Cervicoplasty (%) Upper lip dermabrasion (%) Genioplasty (%) Complications (%) Immediate revision surgery Secondary revision surgery Hospital stay length, day, mean (SD)
66 22.5 1 (7) 13 (93) 2 (14.3) 14 32.5 ( 14.9) 258 (150–340) 14 (100) 0 13 (92.9) 10 (71.4) 14 (100) 0 9 (64.3) 4 (28.6) 2 (14.3) 3 (21.4) 0 2 (14.3) 1.15 ( 0.38)
and an autologous fat graft. All patients underwent primary rejuvenation procedures; none underwent a secondary or tertiary procedure. Other facial esthetic procedures were often combined (Table 1), such as upper blepharoplasty, neck and forehead lift,
Fig. 3. (Left) Preoperative frontal and right profile views of a 69-year-old patient who underwent midface rejuvenation surgery. (Right) One-year postoperative outcome.
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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cervicoplasty, and genioplasty [20]. Patient mean age was 64 years old. Two patients were current smokers, which does not constitute a contraindication for the procedure. The mean total duration of the facial rejuvenation procedure was 258 minutes (range: 150–340 minutes). The midface part of the procedure lasted 90 minutes. The mean time since the procedure was 32.5 months (range: 10–63 months). The amount of fat injected varied in our series, ranged from 15 to 26 cm3 for a full face rejuvenation. The average length of hospitalization was one day. In all cases, the procedure combined preperiosteal midcheek lift, lower blepharoplasty with fat transposition and autologous fat graft enabled treatment of each of the components of midface ageing with effective and lasting results (Figs. 3–5). Incorrect lower ciliary positioning and ectropion are potential complications of the procedure. In our series, there were two cases of ectropion, which required repeated massages and resolved within 3 months. One case of prolonged chemosis (more than three weeks) was observed, and spontaneously regressive at two months after vitamin A ointment application. No hematoma or infection was observed.
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4. Discussion
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Midface ageing is the result of four components: bags under the eyes; looseness of the skin; volume loss; soft tissue ptosis [23,24]. Combining several procedures in a single operation allows treatment of those aspects of ageing. The techniques have
progressed over time and become less invasive and more effective [25]. This study reports a series of 14 patients who underwent lower blepharoplasty, preperiosteal midcheek lift and fat graft for facial rejuvenation. Lower blepharoplasty with fat conservation and transposition is an interesting procedure in the treatment of facial ageing. In young subjects, the subcutaneous fat is fine and regular, and the deep fat located under the orbicular muscle form a thick cushion, protecting the muscle from the orbital margin when it contracts. Every day, the orbicular muscle is solicited several tens of thousands of times while blinking, smiling or in case of dazzling. According to the Face Recurve1 concept [24], there is a progressive transfer of fat on either side of the arciform periorbital insertion of the orbicular muscle due to the increase in resting tone of the facial expression muscles. Repeated contractions over time transpose the adipose tissue from a submuscular deep location toward a subcutaneous superficial location [27]. Skin ageing results due to wrinkling and changes in the contours. The surgical procedure is a refinement of the processes already reported in the literature: use of a pad of fat from the medial orbital compartment, as described by Loeb [4], and disinsertion of the arcus marginalis from the orbital margin and suturing it posttransposition, as described by Hamra [28]. The disinsertion is partial and limited to the amplitude of the observed hollow under the eye, as suggested by Goldberg et al. [29], in order to maximize preservation of muscle function.
Fig. 4. (Left) Preoperative frontal and right profile views of a 73-year-old patient who underwent midface rejuvenation surgery. (Right) One-year postoperative outcome.
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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Fig. 5. (Left) Preoperative frontal and right profile views of a 64-year-old patient who underwent midface rejuvenation surgery. (Right) One-year postoperative outcome.
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The subciliary incision approach is preferred in order to enable concomitant removal of excess cutaneous tissue at this level [30]. In the event of blepharoplasty alone, without any cutaneous excess, a transconjunctival surgical procedure may be used to enable immediate access to and dissection of the periorbital fat in the medial and central compartments. The arcus marginalis is then partially disinserted from the orbital rim and the transposition fat pad is maintained at the posterior part of the orbicular muscle in a malar subperiosteal pocket by a transcutaneous suture. The procedure may then be performed under local anesthesia. Midcheek lifting is the key stage in midface rejuvenation procedures. The anatomy of the area is now well known [31] and two surgical approaches have been widely described. The subperiosteal route is conventionally used due to its simplicity and the quality of the results [9,32]. However, the postoperative course may sometimes involve a high complication rate. The preperiosteal route is an alternative with numerous advantages. The anatomical sliding plane enables dissection with little bleeding and without trauma. It allows a short convalescence times with few edema and ecchymosis result and low complication rates [33]. The preperiosteal approach enables the traction exerted on the jugal soft tissues to be increased. Since the periosteum is an inextensible anatomical structure, its integration in the context of subperiosteal dissection results in limited movements of the jugal soft tissues and only allows a single traction vector.
Our experience has shown that up to three traction vectors may be used when the periosteum is not included in the sliding plane by preperiosteal dissection. To obtain lasting results, we prefer to fix the jugal soft tissues by fixation through the bone of the orbital rim [36] rather than by a simple periosteal suture. Some complications such as ectropion were observed in our series. The underlying mechanism is indirect traction on the tarsus, via the septum, which is known to occur with the procedure [37]. The combined procedures led to lasting good results in our series of patients. While this study addresses midface rejuvenation, other procedures may be combined with those described for a holistic approach to the treatment of facial ageing [38].
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5. Conclusion
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Combining lower blepharoplasty with fat transposition, midcheek lift and autologous adipose tissue transfer constitutes a technique enabling restoration of a physiological status very like that observed in young subjects through the treatment of several components of facial ageing. The good and lasting nature of the results make the procedure a very valuable option for facial rejuvenation. These techniques may be performed alone or in combination with other facial rejuvenation procedures.
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Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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Patient consent
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All patients provided their written consent to the use of their photographs.
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Disclosure of interest
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The authors declare that they have no competing interest.
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[11,12,26,34,35].
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Acknowledgements
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All the authors gave their contribution to write the paper. Sophie Pegorier helped us for the English language.
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References
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[1] Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 2007;120:1367–76. [2] Mendelson B, Wong C-H. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg 2012;36:753–60. [3] Stevens HPJD, Willemsen JCN, Durani P, Rasteiro D, Omoruyi OJ. Triple-layer midface lifting: long-term follow-up of an effective approach to aesthetic surgery of the lower eyelid and the midface. Aesthetic Plast Surg 2014;38:632–40. [4] Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 1981;8:757–76. [5] Hamra ST. Repositioning the orbicularis oculi muscle in the composite rhytidectomy. Plast Reconstr Surg 1992;90:14–22. [6] Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995;96:354–62. [7] Eder H. Importance of fat conservation in lower blepharoplasty. Aesthetic Plast Surg 1997;21:168–74. [8] Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000;105:743–9. [9] Hoenig JF, Knutti D, de la Fuente A. Vertical subperiosteal midface lift for treatment of malar festoons. Aesthetic Plast Surg 2011;35:522–9. [10] Bonnefon A. [Subperiosteal midface lifting]. Ann Chir Plast Esthet 2006;51:170–7. [11] Hester TR, Codner MA, McCord CD, Nahai F, Giannopoulos A. Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience. Plast Reconstr Surg 2000;105:393–406. [12] Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 2002;109:329–41. [13] Wong C-H, Hsieh MKH, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg 2012;129:1392–402.
[14] Wong C-H, Mendelson B. Facial soft tissue spaces and retaining ligaments of the midcheek: defining the premaxillary space. Plast Reconstr Surg 2013;132:49–56. [15] Wong C-H, Mendelson B. Midcheek lift using facial soft tissue spaces of the midcheek. Plast Reconstr Surg 2015;136:1155–65. [16] Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg 1998;102:1646–57. [17] Le Louarn C. The concentric malar lift: malar and lower eyelid rejuvenation. Aesthetic Plast Surg 2004;28:359–73. [18] Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg 2008;121:241–50. [19] Schiller JD. Lysis of the orbicularis retaining ligament and orbicularis oculi insertion: a powerful modality for lower eyelid and cheek rejuvenation. Plast Reconstr Surg 2012;129:692–700. [20] Le Louarn C. [Midface region: functional anatomy, ageing process, indications and concentric malar lift]. Ann Chir Plast Esthet 2009;54:411–20. [21] Coleman SR, Katzel EB. Fat grafting for facial filling and regeneration. Clin Plast Surg 2015;42:289–300. [22] Li F, Guo W, Li K, Yu M, Tang W, Wang H, et al. Improved fat graft survival by different volume fractions of platelet-rich plasma and adipose-derived stem cells. Aesthetic Surg J Am Soc Aesthetic Plast Surg 2015;35:319–33. [23] Pontius AT, Williams EF. The evolution of midface rejuvenation: combining the midface lift and fat transfer. Arch Facial Plast Surg 2006;8:300–5. [24] Botti G, Botti C. Midface lift: our current approaches. Handchir Mikrochir Plast Chir Organ Deutschsprachigen Arbeitsgemeinschaft Fu¨r Handchir Organ Deutschsprachigen Arbeitsgemeinschaft Fu¨r Mikrochir Peripher Nerven Gefa¨sse Organ Ver Dtsch. Plast Chir 2014;46:224–33. [25] Sclafani AP, Dibelius G. Transpalpebral midface lift. Facial Plast Surg Clin N Am 2015;23:209–19. [26] Le Louarn C, Buthiau D, Buis J. The face recurve concept: medical and surgical applications. Aesthetic Plast Surg 2007;31:219–31. [27] Le Louarn C. [Muscular aging and its involvement in facial aging: the Face Recurve concept]. Ann Dermatol Venereol 2009;136:67–72. [28] Hamra ST. The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg 2004;113:2124–41. [29] Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg 1999;15:225–9. [30] Yin VT, Chou E, Nakra T. The transeyelid midface lift. Clin Plast Surg 2015;42:95–101. [31] Doumit G, Gharb BB, Rampazzo A, McBride J, Papay F, Zins J, et al. Surgical anatomy relevant to the transpalpebral subperiosteal elevation of the midface. Aesthetic Surg J Am Soc Aesthetic Plast Surg 2015;35:353–8. [32] Patrocinio LG, Patrocinio TG, Patrocinio JA. Subperiosteal midface lift. Facial Plast Surg 2013;29:206–13. [33] Gordon NA, Adam SI. Deep plane face lifting for midface rejuvenation. Clin Plast Surg 2015;42:129–42. [34] Ho¨nig JF, Knutti D, Hasse FM. Centro-lateral subperiosteal vertical midface lift. Q3 GMS Interdiscip Plast Reconstr Surg DGPW 2014;3–4. [35] Engle RD, Pollei TR, Williams EF. Endoscopic midfacial rejuvenation. Facial Plast Surg Clin N Am 2015;23:201–8. [36] Pascali M, Botti C, Cervelli V, Botti G. Midface rejuvenation: a critical evaluation of a 7-year experience. Plast Reconstr Surg 2015;135:1305–16. [37] Schwarcz RM, Kotlus B. Complications of lower blepharoplasty and midface lifting. Clin Plast Surg 2015;42:63–71. [38] Park DM. Total facelift: forehead lift, midface lift, and neck lift. Arch Plast Surg 2015;42:111–25.
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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JORMAS 68 1–6 J Stomatol Oral Maxillofac Surg xxx (2017) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
1 2 3 4 5 6 7 8
Original Article
Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting Q1 H.
Chatel, B. Hersant *, R. Bosc, S. La Padula, J.P. Meningaud
Department of Plastic, Reconstructive and Maxillo-facial Surgery, Henri-Mondor Hospital, 51, avenue du Mare´chal-de-Lattre-de-Tassigny, 94010 Cre´teil, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 February 2017 Accepted 26 June 2017
Objective: The aim of this study was to describe a technique for midface rejuvenation combining lower blepharoplasty, midcheek lift and autologous fat transfer. Methods: All patients who underwent a midface rejuvenation procedure performed by the same surgeon and using a classic subciliary blepharoplasty surgical approach were identified. The technique combined three distinct procedures: lower blepharoplasty with use of a transposition flap of orbital adipose tissue in the medial and central compartment to reduce the subpalpebral bags and attenuate the palpebrojugual sulcus; midcheek lift in the preperiosteal plane with trans-osseous fixation exerting traction on the soft tissues of the cheek along several vectors; autologous fat transfer to offset the loss of volume in the target area. Results: Between January 2011 and December 2015, 14 patients were operated with the described technique. Long-term results were good and stable over time. Two complications in the form of ectropion were observed in the series but resolved with daily massages. Conclusions: The combination of lower blepharoplasty, midcheek lift and autologous fat transfer appear to enable treatment of midface ageing. The results were satisfactory and durable, and the procedure was well tolerated. The procedures could be combined with others for the treatment of the upper and lower face during the same surgical procedure.
C 2017 Elsevier Masson SAS. All rights reserved.
Keywords: Aesthetic Blepharoplasty Midface Lifting Aging Lipofilling
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1. Introduction
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Midfacial ageing manifests clinically as bags under the eyes, accentuation of the ‘‘valley of tears’’ with marked palpebrojugal sulci and ptosis of the soft tissues of the cheeks [1–3]. Subpalpebral bags are generally considered, by the surgeon as an excess of periorbital fat, and treated with adipose tissue exeresis. Dark circles are caused by structural ageing, which, over time, result in a change in fat distribution in the various adipose compartments surrounding the eyeball. In that context, rejuvenation surgery should aim to restore the adipose tissue distribution. Since the early 1980s, several fat transposition techniques have been reported by Loeb [4], and then by Hamra [5,6] and Eder [7], and by Goldberg [8]. Although each technique has its own specificities, the unanimous consensus is that it is necessary to distribute the adipose tissue so to smooth the contrasts between the various periorbital contours induced by fat migration.
* Corresponding author. E-mail address: [email protected] (B. Hersant).
The other aspects of midface ageing should be treated concomitantly. While the most widespread midcheek lift technique is subperiosteal [8–10], a preperiosteal approach in nonvascular dissection plane is possible. The recent anatomical descriptions of facial soft tissues have allowed better understanding dissection [13,14]. The advantages of the technique are under study [15]. The technique provides excellent results with high patient satisfaction rates and limited complications. Combining lower blepharoplasty, midcheek lift and autologous fat graft may constitute the key to treatment [16–19] in the overall management of midface ageing. The aim of this study was to describe the technique and report on a series of midface rejuvenation results obtained by combining the above procedures.
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2. Material and methods
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All patients having undergone a midface lift rejuvenation procedure in our department between January 2011 and December 2015 were identified.
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http://dx.doi.org/10.1016/j.jormas.2017.06.014 C 2017 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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2.1. Surgical technique
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The procedures were performed under general anesthesia with orotracheal intubation using a preformed median oral tube. In all cases, 5 mL of lidocaine and epinephrine were infiltrated into the inferior orbital rim. The surgical approach was the classic subciliary incision route for lower blepharoplasty.
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2.1.1. Lower blepharoplasty with fat grafting Procedures began with a subciliary incision exceeding the outer canthus by 5 mm in a ‘‘crow’s foot’’ wrinkle. Dissection, using Stevens’ scissors, happened between the orbicular muscle, in the anterior plane, and the posterior tarsal plane, throughout the length of the lower eyelid at the subciliary level. Extension of the skin and the orbicular muscle incision was performed using scissors, throughout the necessary length and stopping 3 mm beyond the lacrimal point. The lower orbicular muscle was displaced downward to expose its insertion on the inferior orbital rim. The arcus marginalis was detached, using a periosteal elevator, from medial to lateral, avoiding disinsertion of the lateral third to preserve satisfactory muscle function. A subperiosteal pocket was formed aiming at subsequently hosting the transposition flap. The periorbital fat was accessed using a septum incision. Any excess (evidenced by light pressure on the eyeball) could be resected at this stage. A periosteal elevator was used to detach the periorbital fat from the periosteum of the orbit floor. An adipose flap with a superior pedicle of the correct dimensions was dissected. It was necessary to release the anterior third of the orbit floor to prevent tension and the risk of ectropion. Meticulous hemostasis was performed to preserve the flap vascularization and prevent the risk of orbital hematoma. The adipose transposition flap was used to offset the adipose deficit at the posterior face of the orbicular muscle (Fig. 1).
Fig. 1. Dissection of a fat flap during lower blepharoplasty.
2.1.2. Preperiosteal midcheek lift The surgical approach was the previously described using subciliary incision. The procedure was performed after the inferior blepharoplasty procedure. Depending on the number of traction vectors to be exerted, one or several trepanations were made on the edge of the inferior orbital rim (beginning at the junction between the medial third and intermediate third). Discision was made in the deep preperiosteal plane toward the nasolabial fold. The exact direction depended on the traction vector(s) required. Thus, there was no risk of damaging the infraorbital nerve at its point of emergence or the angular vein. The scissors were positioned vertically. A non-resorbable suspended the soft tissues using a specific needle (double-beveled hollow straight needle through which the suture runs). This enabled the surgeon to pass the needle through the cutaneous plane without the suture coming out and to impart a second direction to the suture thanks to the fact that both ends of the needle were beveled (Fig. 2). The suture was thus run through the trepanation hole in the margin (1-mm drill) and then into the previously-dissected preperiosteal deep space, before partially exiting the needle at the point of reflection in the nasolabial fold. A second direction was then imparted to the suture, returning it toward the orbital rim in a more superficial plane and exiting under the orbicular muscle. It was important not to snag the deep dermis to prevent pad formation. It was also important not to snag the orbicular muscle and to pass beneath it to avoid compromising eyelid dynamics. The knot was fixed with a degree of traction suitable for the desired result. The knot was then slid, buried and flattened against the orbital floor to prevent it bulging under the palpebral skin. The inferior blepharoplasty procedure was then completed. The pediculate adipose flap was sutured with a U 5/0 resorbable suture running to the inferior margin of the posterior part of the orbicular muscle (the positioning of the suture was determined preoperatively with the patient in the vertical position). Cutaneous resection was then performed as required by the excess. The subciliary incision was closed by intradermal running suturie with Nylon 5/0.
Fig. 2. Use of a traction suture for a midcheek lift (submusculus orbicularis oris fat).
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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2.1.3. Autologous fat grafting The adipose tissue was obtained as described by Coleman and in compliance with the latest recommendations [21]. The adipose tissue obtained was combined with platelet-rich plasma (PRP) with a 5:1 ratio. According to the latest recommendations, that method of preparation enhanced lipofilling yield [22]. The incisions were made at the nasolabial folds using a needle bevel. Subcutaneous re-injection was made using a 2-mm multiperforated Coleman cannula. The fat was injected into the nasolabial folds and over the cheek bones (injection elsewhere was possible if necessary). The amount of adipose tissue injected depended on the desired result.
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2.2. Postoperative care
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The patient had to apply vitamin A ointment on the scars after having dabbed them with regular saline daily for seven days. The sutures were removed after eight days. In the absence of any complication, daily massaging of the scars was authorized for at least one month to improve scar flexibility. Patients had to be seen for postoperative follow-up at least after one, three, six, 12 and 24 months. Patient satisfaction was evaluated at one year after surgery by another senior surgeon of the department.
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3. Results
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Among the 51 patients who underwent midface rejuvenation, 14 (one man and 13 women) underwent a procedure combining a preperiosteal centrofacial lift, blepharoplasty with fat transposition
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Table 1 Patients characteristics. Demographic data Age, mean, year (SD) BMI, mean, kg/m2 (SD) Gender (%) Male Female Current smoker (%) Surgical data Total number of procedures Time since procedure, mean, month (SD) Procedure duration, mean, minute (range) Type of procedure Primary (%) Secondary or tertiary (%) Associated procedures Neck lift (%) Forehead lift (%) Upper blepharoplasty (%) Rhinoplasty (%) Cervicoplasty (%) Upper lip dermabrasion (%) Genioplasty (%) Complications (%) Immediate revision surgery Secondary revision surgery Hospital stay length, day, mean (SD)
66 22.5 1 (7) 13 (93) 2 (14.3) 14 32.5 ( 14.9) 258 (150–340) 14 (100) 0 13 (92.9) 10 (71.4) 14 (100) 0 9 (64.3) 4 (28.6) 2 (14.3) 3 (21.4) 0 2 (14.3) 1.15 ( 0.38)
and an autologous fat graft. All patients underwent primary rejuvenation procedures; none underwent a secondary or tertiary procedure. Other facial esthetic procedures were often combined (Table 1), such as upper blepharoplasty, neck and forehead lift,
Fig. 3. (Left) Preoperative frontal and right profile views of a 69-year-old patient who underwent midface rejuvenation surgery. (Right) One-year postoperative outcome.
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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cervicoplasty, and genioplasty [20]. Patient mean age was 64 years old. Two patients were current smokers, which does not constitute a contraindication for the procedure. The mean total duration of the facial rejuvenation procedure was 258 minutes (range: 150–340 minutes). The midface part of the procedure lasted 90 minutes. The mean time since the procedure was 32.5 months (range: 10–63 months). The amount of fat injected varied in our series, ranged from 15 to 26 cm3 for a full face rejuvenation. The average length of hospitalization was one day. In all cases, the procedure combined preperiosteal midcheek lift, lower blepharoplasty with fat transposition and autologous fat graft enabled treatment of each of the components of midface ageing with effective and lasting results (Figs. 3–5). Incorrect lower ciliary positioning and ectropion are potential complications of the procedure. In our series, there were two cases of ectropion, which required repeated massages and resolved within 3 months. One case of prolonged chemosis (more than three weeks) was observed, and spontaneously regressive at two months after vitamin A ointment application. No hematoma or infection was observed.
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4. Discussion
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Midface ageing is the result of four components: bags under the eyes; looseness of the skin; volume loss; soft tissue ptosis [23,24]. Combining several procedures in a single operation allows treatment of those aspects of ageing. The techniques have
progressed over time and become less invasive and more effective [25]. This study reports a series of 14 patients who underwent lower blepharoplasty, preperiosteal midcheek lift and fat graft for facial rejuvenation. Lower blepharoplasty with fat conservation and transposition is an interesting procedure in the treatment of facial ageing. In young subjects, the subcutaneous fat is fine and regular, and the deep fat located under the orbicular muscle form a thick cushion, protecting the muscle from the orbital margin when it contracts. Every day, the orbicular muscle is solicited several tens of thousands of times while blinking, smiling or in case of dazzling. According to the Face Recurve1 concept [24], there is a progressive transfer of fat on either side of the arciform periorbital insertion of the orbicular muscle due to the increase in resting tone of the facial expression muscles. Repeated contractions over time transpose the adipose tissue from a submuscular deep location toward a subcutaneous superficial location [27]. Skin ageing results due to wrinkling and changes in the contours. The surgical procedure is a refinement of the processes already reported in the literature: use of a pad of fat from the medial orbital compartment, as described by Loeb [4], and disinsertion of the arcus marginalis from the orbital margin and suturing it posttransposition, as described by Hamra [28]. The disinsertion is partial and limited to the amplitude of the observed hollow under the eye, as suggested by Goldberg et al. [29], in order to maximize preservation of muscle function.
Fig. 4. (Left) Preoperative frontal and right profile views of a 73-year-old patient who underwent midface rejuvenation surgery. (Right) One-year postoperative outcome.
Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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Fig. 5. (Left) Preoperative frontal and right profile views of a 64-year-old patient who underwent midface rejuvenation surgery. (Right) One-year postoperative outcome.
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The subciliary incision approach is preferred in order to enable concomitant removal of excess cutaneous tissue at this level [30]. In the event of blepharoplasty alone, without any cutaneous excess, a transconjunctival surgical procedure may be used to enable immediate access to and dissection of the periorbital fat in the medial and central compartments. The arcus marginalis is then partially disinserted from the orbital rim and the transposition fat pad is maintained at the posterior part of the orbicular muscle in a malar subperiosteal pocket by a transcutaneous suture. The procedure may then be performed under local anesthesia. Midcheek lifting is the key stage in midface rejuvenation procedures. The anatomy of the area is now well known [31] and two surgical approaches have been widely described. The subperiosteal route is conventionally used due to its simplicity and the quality of the results [9,32]. However, the postoperative course may sometimes involve a high complication rate. The preperiosteal route is an alternative with numerous advantages. The anatomical sliding plane enables dissection with little bleeding and without trauma. It allows a short convalescence times with few edema and ecchymosis result and low complication rates [33]. The preperiosteal approach enables the traction exerted on the jugal soft tissues to be increased. Since the periosteum is an inextensible anatomical structure, its integration in the context of subperiosteal dissection results in limited movements of the jugal soft tissues and only allows a single traction vector.
Our experience has shown that up to three traction vectors may be used when the periosteum is not included in the sliding plane by preperiosteal dissection. To obtain lasting results, we prefer to fix the jugal soft tissues by fixation through the bone of the orbital rim [36] rather than by a simple periosteal suture. Some complications such as ectropion were observed in our series. The underlying mechanism is indirect traction on the tarsus, via the septum, which is known to occur with the procedure [37]. The combined procedures led to lasting good results in our series of patients. While this study addresses midface rejuvenation, other procedures may be combined with those described for a holistic approach to the treatment of facial ageing [38].
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5. Conclusion
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Combining lower blepharoplasty with fat transposition, midcheek lift and autologous adipose tissue transfer constitutes a technique enabling restoration of a physiological status very like that observed in young subjects through the treatment of several components of facial ageing. The good and lasting nature of the results make the procedure a very valuable option for facial rejuvenation. These techniques may be performed alone or in combination with other facial rejuvenation procedures.
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Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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Patient consent
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All patients provided their written consent to the use of their photographs.
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Disclosure of interest
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The authors declare that they have no competing interest.
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[11,12,26,34,35].
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Acknowledgements
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All the authors gave their contribution to write the paper. Sophie Pegorier helped us for the English language.
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References
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Please cite this article in press as: Chatel H, et al. Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/ 10.1016/j.jormas.2017.06.014
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