- Email: [email protected]
Management of the Midface
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FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 213–220
Management of the Midface Vito C. Quatela, -
-
a,
MD
*, Daniel R. Olney,
Midfacial anatomy and the orbital complex Fascial layers of the midface Sensory and motor nerves in the midface Patient selection and preoperative evaluation
Traditional techniques for facial rejuvenation have preferentially focused on rejuvenation of the lower face. Before the 1990s, treatment of the aging face was synonymous with a lower facelift and blepharoplasty, regardless of individual patient’s anatomy. Often, the upper and midface were inadequately addressed resulting in suboptimal facial harmony. The contribution of the upper two thirds of the face to the stigmata of aging has since become well established. Deepening of the nasolabial fold owing to descent of the malar fat pad was recognized early as a signature feature of the aged face. Hamra’s deep plane rhytidectomy, first reported in 1990, was the first technique that showed dramatic improvement of the midface [1]. This procedure involves blunt finger dissection in the infraorbital region to separate the thick subcutaneous cheek fat from the zygomaticus major and orbicularis oculi muscles and lateral advancement of the midface flap, resulting in dramatic improvement of the nasolabial fold. More recently, the effects of malar descent on the orbital complex has become recognized as a central feature of the aging process. The vertical elongation of the lower eyelids, with bony exposure of the infraorbital rim and the subsequent creation of a double contour irregularity are key changes that modern surgical procedures must address to
-
b
MD
Operative technique Discussion Summary References
achieve ever more optimal results. Consequently, the last 15 years have seen many advances in face lift techniques focused on the midface [2]. Along with the deep plane rhytidectomy, other methods for midface lifting have been developed, including the lower-eyelid approach to midface lifting and the midface sling. Recently, retained barbed suture techniques have received much attention in their ability to suspend the midface with minimal downtime. All these techniques, however, have inherent disadvantages. One concern with the deep-plane rhytidectomy is the vector of pull, which is more lateral and not superolateral; thus, the degree of malar fat pad elevation is suboptimal. The lower eyelid approach has problems with adequate fixation and its inability to address redundant temple skin once the midface is elevated. The newer techniques such as the midface sling and barbed suture suspension carry many doubts about longevity of results. The advent of endoscopic techniques in the early 1990s first used by Core and coauthors [3] and Liang and Narayanan [4] proved that all the components of the aging face could now be addressed with ever-increasing patient satisfaction and safety. Smaller incisions, decreased risk of alopecia, and equivalent or better results to traditional techniques
a
The Lindsay House Center for Plastic Surgery, 973 East Avenue, Suite 100, Rochester, NY 14607-2216, USA Private Practice, Iowa City, IA 52245, USA * Corresponding author. E-mail address: [email protected] (V.C. Quatela). b
1064-7406/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2006.05.005
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have made the endoscopic treatment of the brow and midface a powerful tool for modern facial plastic surgeons. The advantage of our technique for endoscopic midface lifting is its release of the entire central and lateral midface, which allows for a complete resuspension with a more natural vector of pull. It has proven to achieve reliable and consistent results when performed properly and does so with an outstanding record of both safety and patient satisfaction.
Midfacial anatomy and the orbital complex Understanding the midface anatomy and anatomy of adjacent regions like the forehead and orbital complex is critical for harmonious results to be realized. This is especially true when endoscopic techniques are used, because they necessitate an understanding of anatomic relationships from a different and more thorough perspective. The midface is defined arbitrarily as the area between the level of the midhorizontal orbit and the mandibular margin; typical aging changes in this area are well understood [5]. The cheek tissue descends inferiorly away from the lower eyelids, and the lack of tissue in the infraorbital area gives a hollowed out appearance. Pseudoherniation of fat in the lower eyelid complex results in a doubleconvexity deformity with the convexity of the orbital fat and descended suborbicularis oculi fat (SOOF)/malar fat pad complex separated by the infraorbital rim (Fig. 1). Removal of pseudoherniated fat with different blepharoplasty techniques alone only serves to further accentuate the hollowed eye appearance. In addition, when the eyelids are addressed with traditional blepharoplasty techniques, the lower lid is at risk for ectropion and scleral show because already it has decreased tension owing to the forces of aging. Often, lateral canthopexy or lid tightening procedures are needed to avoid disappointing or even disastrous results. One advantage
Fig. 1. Typical changes in the orbital complex with midfacial ptosis. Note the double contour deformity.
to performing an endoscopic midface lift is correction of this eyelid malposition. The malar prominence descends inferomedially with aging to deepen the nasolabial crease and expose the lateral orbital rim. It is composed of a subcutaneous malar fat pad with underlying orbicularis oculi muscle. Deep to this fat is the SOOF, which is intimately associated with the periosteum of the infraorbital rim and maxilla and the insertions of the zygomaticus major and minor muscles. With the descent of the midface structures, in particular the malar fat pad, the corners of the mouth sag and create a frown or drawn appearance (Fig. 2).
Fascial layers of the midface Understanding the multiple fascial layers that the endoscopic surgeon must traverse is crucial to safe dissection because the frontal branch of the facial nerve is particularly vulnerable. Many surgeons have been reluctant to embrace this technique because of this risk. When properly performed, however, the frontal branch can be protected confidently. The most superficial layer encountered is referred to as the superficial temporalis fascia or temporoparietal fascia (TPF). This is a fascial extension above the zygoma of the superficial musculoaponeurotic system (SMAS). The frontal branch of the facial nerve lies within this fascia. Similarly, the temporal artery and vein course in this fascial layer superiorly toward the temporal line. The TPF joins medially and is contiguous with the galea of the scalp. Deep to the TPF the deep temporalis
Fig. 2. Transtemporal approach to midface complex. Shaded area indicates degree of dissection. (From Quatela VC, Jacano AA. The extended centrolateral endoscopic midface lift. Facial Plastic Surg 2003; 19(2):199–208; with permission.)
Management of the Midface
fascia or true temporalis fascia is a single fascial layer but splits into two sheets of fascia at the level of the superior orbital margin. The intermediate temporalis fascia attaches to the lateral aspect of the zygomatic arch, and the deep temporalis fascia attaches to the medial aspect. Between these two fascial planes lies the intermediate temporal fat pad. Deep to the deep temporal fascia is the deep temporal fat pad. Dissection deep to the deep temporal fascia risks violation of the deep temporal fat pad and resultant fat atrophy with the appearance of temporal wasting (Fig. 3).
Sensory and motor nerves in the midface The facial nerve supplies all the muscles of facial expression including muscles as far medial as the corrugator supercilii and procerus. The temporal branch of the facial nerve crosses the zygomatic arch halfway between the lateral canthus and the root of the auricular helix within the TPF. Sabini and coauthors [6] uncovered a more accurate means of identifying the precise location the frontal branch of the facial nerve during endoscopic dissection. A series of bridging vessels, including one larger sentinel vein, are encountered between the deep temporal fascia and the TPF during the dissection in the temporal region. These bridging vessels were shown to point to the frontal branch of the nerve as it coursed through the TPF (Fig. 4). Motor nerve supply to the muscles of the midface comes from the zygomatic and buccal branches of the facial nerve traveling along the deep surface of the muscles. Sensory innervation to the midface is supplied by the second division of the trigeminal nerve,
Fig. 3. Coronal section of temporal anatomy focusing on fascial layers. (From Quatela VC, Choe KS. Endobrow-midface lift. Facial Plast Surg 2004 Aug;20(3): 199–206; with permission.)
Fig. 4. Endoscopic view of the sentinel vein and bridging veins. These accurately localize the location of the frontal branch of the facial nerve.
the infraorbital nerve, which exits the infraorbital foramen, and the zygomaticotemporal branch of the trigeminal nerve that exits through the body of the zygoma. The zygomaticotemporal nerve supplies the lateral temple region of the scalp and is encountered in a midfacial dissection, although it is visualized rarely. Transection of this nerve, although not desirable, rarely is clinically significant because sensation to the lateral brow in all but the rarest of cases will return.
Patient selection and preoperative evaluation Careful selection of the appropriate patients is central to preoperative planning. This evaluation should start with a thorough history and physical examination. The ideal candidate is in good mental and physical health without uncontrolled systemic diseases. Preoperative screening for conditions that could adversely affect patient’s surgical experience is mandatory. Patient education is an effective tool for reducing anxiety and establishing realistic postoperative goals and should begin even before the initial consultation. Midface lifting warrants careful consideration of a variety of factors that determine the clinical appearance of the upper two thirds of the face. Crucial components of the preoperative evaluation include degrees of temporal and midface ptosis, orbital rim exposure, descent of the SOOF, and severity of pseudoherniated orbital fat manifesting itself with the double-contour deformity. The depth of the nasolabial folds should also be determined. Other minor factors would include lower face laxity and lateral jowling. It is important to note that laxity in the neck is not addressed by midface resuspension; therefore, patients with significant laxity below the mandible should be considered for additional procedures. The need for other ancillary procedures
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such as blepharoplasty and skin resurfacing should also be recognized. A patient who is a candidate for endoscopic midface rejuvenation surgery deserves special mention. This procedure induces a longer period of postoperative edema secondary to subperiosteal dissection—generally 4 to 6 weeks. These patients require more intense and close monitoring to guide them through the normal healing process [7]. Furthermore, patients with ptotic midface tissues but with adequate soft tissue padding tend to achieve better aesthetic outcomes than those who lack soft tissue bulk and appear ‘‘bony.’’
Operative technique Our technique for endoscopic midface lifting uses the same hairline incisions for endoscopic forehead lifting. In describing the endoscopic midface lift, it is necessary to review the endoscopic forehead lift dissection because it ‘‘sets the stage’’ to approach the midface. Multiple planes of dissection must be traversed, and a thorough understanding of the anatomy of the fascial planes in the temporal/zygomatic region, as described previously, is a prerequisite to avoid injury to the frontal branch of the facial nerve. The patient is examined preoperatively upright, and the brow position is assessed. The amount of desired medial brow elevation is measured; in most patients with mild to moderate brow ptosis 2 to 4 mm of brow elevation is required to bring the medial aspect of the brow to the level of the supraorbital rim. The patient is then marked while awake. Pitanguy’s line, (representing the superficial topography of the frontal branch of the facial nerve), the supraorbital notch, and vertical and horizontal glabellar infrowning are marked bilaterally. The temporal line is marked into the hairline while having the patient clench his or her teeth. Two incisions are then marked on each side. The lateral incision starts approximately 1 cm behind the hairline at the superior aspect of the temporalis muscle. Starting anterior at the previously marked temporal line, it continues for 3 cm inferolaterally; care must be taken that this marking is 1.5 to 2 cm inferior to the superior temporal line or suspension sutures placed into the deep temporal fascia will be difficult to place. The medial incisions begin a few millimeters behind the hairline centered over the lateral limbus and extend posteriorly for 2 cm. The incision lines and supraorbital, infraorbital, and zygomaticofacial nerves are injected with 10 mL of 2% lidocaine with 1:100,000 epinephrine mixed equal parts with 0.25% bupivacaine with 1:200,000 epinephrine. The remainder of the forehead and midface is injected with 40 mL of
0.5% lidocaine with 1:200,000; the temporal region is injected just superficial to the deep temporal fascia, the forehead subperiosteal, and the midface along the face of the maxilla, infraorbital rim, zygoma, and the anterior aspect of the zygomatic arch subperiosteally. After waiting adequate time for vasoconstriction, the lateral incision is made with a #10 blade, taking care to bevel it parallel to the hair follicles, which is important to achieve maximal scar camouflage because transecting the hair follicles results in a few millimeters of permanent alopecia. Approximately 5% of patients will experience telogen effluvium, which can result in 1 cm of alopecia around the incisions; by performing the lateral excisions exactingly, the surgeon can counsel the patient confidently that the hair will return after 3 to 9 months. The incision is carried down through the superficial temporal fascia to the deep temporal fascia. A double hood is used to retract the skin superior to the incision, and an Endoforehead T Dissector (Snowden Pencer, Tucker, GA) is used to elevate the superficial temporal fascia and overlying tissue off the deep temporal fascia to the temporal line. The countertraction of the skin hook and the Endoforehead T Dissector used at an angle of 45º helps define the proper plane. The dissection continues superiorly in a subperiosteal plane after dissection through the tenacious fascia of the temporal line and ends at the level of the occiput. This ensures that the elevated forehead and lateral temporal tissues will redrape and not bunch anteriorly once suspended. Inferior to the incision, dissection on top of the deep temporal fascia is performed blindly for 2 to 3 cm. A fiberoptically lighted Aufrecht retractor is used for better direct visualization more inferiorly as dissection in this region approaches the frontal branch of the facial nerve. Again, dissection on top of the deep temporal fascia anteriorly requires lysis of the fascia at the temporal line, and subperiosteal dissection is continued to the supraorbital rim. Using a down-biting Endoforehead A/M Dissector (Snowden Pencer), the arcus marginalis often can be released from lateral to within 1 cm of the superficial marking made for the supraorbital neurovascular bundle. Bimanual dissection often is helpful, and the hand placed on the surface of the skin helps prevent injury to the orbit with inferior dissection. Laterally, the conjoint tendon is dissected bluntly with the Endoforehead T Dissector. If this fascial condensation is not released adequately elevation of the lateral brow will be incomplete during suspension. The medial incision is then made with a #10 blade down to the frontal bone, and an Endoforehead Curved Dissector (Snowden Pencer, Tucker,
Management of the Midface
GA), is used to elevate a small 1 cm circumferential subperiosteal pocket. Before any more of the forehead flap is elevated, screw holes are drilled with a hand drill with a preset stop of 4 mm to prevent deeper penetration past the calvarium. This technique allows exact measurement of the amount of brow elevation from the preoperative brow position. The suspension translates into the amount of medial brow elevation, as the forehead flap between the two medial incisions moves as a sheet superiorly and translates primarily to the mid- and medial brow. We use temporary fixation with stainless steel screws that are removed 1 week after surgery. Elevation of the medial endoscopic incisions of 8 mm results in maintenance of the preoperative medial brow height. Therefore, if medial brow elevation of 2 to 4 mm is desired, the screw holes should be placed 10 to 12 mm from the anterior edge of the incision, respectively. The remaining subperiosteal dissection of the forehead pocket is performed blindly using an Endoforehead Curved Dissector to within 1 cm of the supraorbital notch marked before surgery. A down-biting subperiosteal dissector is used to blindly elevate medial to the bundle, over the glabella, and onto the radix of the nose. The endoscope is then passed through the medial incision and the supraorbital neurovascular bundle is dissected subperiosteally under direct visualization with a small pick. A temporary transcutaneous suture placed in the medial brow and lifted by an assistant can help open the pocket of the dissection. An up-biting Endoforehead Spreader (Snowden Pencer), is used to complete the arcus marginalis and conjoint tendon release under endoscopic visualization. The corrugator supercilii and procerus muscles are resected and cauterized; this will eliminate the vertical and horizontal glabellar furrow. If brow asymmetries are present preoperatively, unilateral orbicularis oculi myotomies may be performed. A Colorado tip cautery is used for the myotomies on the side that is more ptotic to allow for greater release and greater elevation during suspension; during this step it is important to always be aware of the frontal branch of the facial nerve using Pitanguy’s line as a guide. With inferior temporal dissection, the surgeon must take extra care in the region of Pitanguy’s line. Multiple bridging veins penetrate the plane of dissection perpendicularly in the region of the frontal branch of the facial nerve. These veins have been shown to be located within 2 mm of the frontal branch of the facial nerve in cadaver dissection study. When these bridging veins are encountered, they are freed 360º, and then with traction the deep aspect of the vessel overlying the
deep temporal fascia is cauterized with a bipolar cautery. This technique prevents thermal conduction to the superficial temporal fascia and elevated flap that contains the frontal branch. An additional measure of caution is necessary in the temporal region because forceful dissection may result in penetration through the deep temporal fascia. Penetration through this layer will expose the infratemporal fat pad, and even minimal trauma can result in reduction of its volume with temporal wasting postoperatively. Further inferior dissection approaches the zygomatic arch. The deep temporal fascia splits at the level of the supraorbital ridge to form an intermediate temporal fascia and deep temporal fascia with the intermediate temporal fat pad located in between them (Fig. 5). It is safe to dissect within the intermediate fat pad; however, we prefer to elevate the intermediate fat pad up and dissect on top of the deep temporal fascia. We believe that elevating all these tissues helps provide an additional cuff of tissue to insulate the frontal branch from thermal or mechanical trauma. A lateral 1-cm cuff of tissue is preserved at the lateral canthus to prevent permanent distortion postoperatively. The periosteum over the entire superior aspect of the zygomatic arch is exposed, and it is incised at the anterior aspect of the arch with the #4 dissector. The zygomaticofacial foramen often is encountered and the neurovascular structures kept intact as this an important landmark for later suspension of the midface. Subperiosteal dissection continues posteriorly at the superior edge of the zygomatic arch to within 1 cm of the external auditory canal. Using a down-biting Endoforehead A/M Dissector,
Fig. 5. Coronal section of transtemporal approach through the fascial layers.
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the periosteum over the zygomatic arch is released. This subperiosteal dissection is continued medial over the infraorbital rim to the nose in a blind fashion. Bimanual dissection is required with the dissector passed between the index finger that protects the globe and the thumb positioned over the infraorbital nerve (this landmark can be palpated through the skin). The down-biting dissector is then passed subperiosteally starting at the body of the zygoma directed toward the pyriform aperture, inferior to the infraorbital nerve. This accomplishes dissection over the face of the maxilla and with a superior sweeping motion releases all tissue inferior the infraorbital nerve. Care should be taken here not direct the dissector through the buccal mucosa. With the lighted Aufrecht retractor, the tendinous attachments at the lateral aspect of the maxilla are lysed with the down-biting dissector, and the masseteric tendon just inferior to the inferior aspect of the zygomatic arch is cut with a downward motion. The flap is dissected inferiorly below the masseteric aponeurosis just on top of the belly of the masseter to approximately 1 cm superior to the gonial angle. The medial subperiosteal midface dissection pocket and lateral submasseteric aponeurosis pocket are connected with a sweeping finger dissection from the medial to lateral pocket breaking the last few fascial attachments at the lateral aspect of the maxilla. This dissection has accomplished a complete release of the midface as well as the tissues laterally to the external auditory canal and inferiorly to the level of the gonial angle. This ensures free mobility of the midface, malar fat, and SOOF. The midface is suspended. Using an 0-vicryl on a UR-6 needle (Ethicon) a bite of the released periosteum just lateral to the zygomaticofacial foramen is taken. This is tacked back to the deep temporal fascia at a vector superior and slightly lateral. With proper midface dissection, the angle of the mandible is marked preoperatively, the skin overlying the angle of the mandible is elevated 1 to 1.5 cm. The second suspension suture is placed superior to Pitanguy’s line in the flap and back to the deep temporal fascia. Three more suspension sutures are placed at the anterior skin edge through the superficial temporal fascia suspending it to the deep temporal fascia posterosuperiorly in the region of the temporal line. These three sutures are the reason the placement of the lateral incision is so important, because placement of the incision too high will prevent the ability to suspend the excess skin of the temporal region that bunches after elevation of the midface. With the midface lift, even if a full endoscopic forehead lift is not performed, a lateral temporal lift with release of the arcus marginalis and conjoint tendon is required to prevent bunching of skin in the lateral temporal region.
The forehead elevation is performed. Two 14 4 mm removable screws are placed into the previously drilled holes, the incision is retracted posteriorly until its leading edge rests against the screw, and a staple is placed just behind the screw. This most anterior staple sits behind the screws and prevents the forehead flap from gravitating inferiorly. The lateral temporal incisions are closed with interrupted vertical mattress 5-0 nylon sutures.
Discussion The senior author (V.C.Q.) has now performed more than 800 endobrow-midface cases and has experienced minimal morbidity. It has proven a safe and reliable method to rejuvenate the upper two thirds of the face with less than 1% revision surgery rate. Many surgeons have been reluctant to embrace this technique owing to a perceived high risk-tobenefit ratio. Of paramount concern is the risk of injury to the facial nerve. The senior author’s experience has been reviewed, and the temporary neuropraxia occurred in only 1% of cases. Shortterm complications included hematoma, infection, prolonged edema (greater than 6 to 8 weeks), transient alopecia, engorgement of temple veins, and dry eyes all were also less than 1%. Although not a true complication, initial masticatory tenderness at the temple is expected 100% of the time because of the placement of sutures to the deep temporal fascia. This usually resolves within a week. There can be significant periorbital edema and chemosis postoperatively, especially when combined with a blepharoplasty. Prolonged chemosis beyond an initial 2-week period occurred in 25% of the cases, but complete resolution can be expected by 6 to 8 weeks. Ectropion does not occur with endoscopic midface lifts because the lower eyelid tension is actually increased. We have proven the force required to displace the lower lid from the globe is actually doubled when an endoscopic midface lift is performed [8]. A slight canthal distortion is almost always present, but circumferential massaging will generally return the lateral canthus to its baseline position within several weeks. Patients who underwent this procedure earlier in the development of this technique had greater distortion at the lateral canthus. Although we currently leave a 1 cm cuff of tissue around the lateral canthal tendon, the senior author has performed a more aggressive dissection closer to the canthal tendon. This dissection resulted in a slight upward misplacement of the lateral canthus with the midface suspension. Less aggressive dissection technique at the lateral canthal tendon has made this problem quite temporary and tolerable.
Management of the Midface
Fig. 6. (A, B) Postoperative results from an endoscopic midface lift.
Slight skin bunching in the temple region from the tacking sutures is common; however, this too resolves within several weeks. Patients are generally presentable in 2 weeks and return to normal activity and work in 3 weeks. Routine examination of pre- and postoperative photos has been performed focusing on degree of improvement of four areas: infraorbital hollowing, midface tissue ptosis, depth of nasolabial folds, and degree of jowling. We found the greatest overall improvement is the extent of midface ptosis and infraorbital hallowing followed by improvement in the nasolabial region. Improvement in jowling was common but less significant than the improvement of the midface structures. We feel that this dramatic improvement is owing to multiple factors. With wide and complete release of the central and lateral midfacial structures, the en bloc suspension of the SOOF and malar fat pad is thoroughly
accomplished. Unlike other midfacial techniques, the endoscopic midface achieves pull in two vectors; directing the repositioning of tissues both superiorly and laterally. The superior vector repositions the SOOF and malar fat pad over the bony infraorbital rim and malar/zygomatic complex, whereas the lateral pull effaces the nasolabial fold. This more accurately reverses the forces of aging displayed on the ptotic midface. Lastly, although this technique is not designed primarily to eliminate jowling at the mandible, it has been noted that elevation of 1 to 1.5 cm of skin overlying the mandible is typical.
Summary Management of the midface in facial rejuvenation surgery has evolved rapidly over the last 15 years. Our application of the endoscope coupled with
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a trans-temporal approach to a complete resuspension of the midfacial soft tissue complex has proven a powerful, relatively aggressive technique that we believe will stand the test of time. With a firm understanding of surgical anatomy and an appreciation for aesthetic ideals and meticulous patient evaluation and selection, the facial plastic surgeon may safely offer the patient excellent long-term results without the typical morbidities associated with other traditional forehead and midface lifting techniques (Fig. 6A, B).
References [1] Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 1990;86:53. [2] Larson DL. An historical glimpse of the evolution of rhytidectomy. Clin Plast Surg 1995;22:207.
[3] Core GB, Vasconez LO, Askren C, et al. Coronal facelift with endoscopic techniques. Plast Surg For 1992;15:227. [4] Liang M, Narayanan K. Endoscopic ablation of the frontalis and corrugator muscles: a clinical study. Plast Surg For 1992;15:58. [5] Keller G, editor. Endoscopic facial plastic surgery. St. Louis (MO): Mosby; 1997. [6] Sabini P, Wayne I, Quatela VC. Anatomic guides to precisely localize the frontal branch of the facial nerve. Arch Facial Plast Surg 2003;5: 150–2. [7] Williams EF, Vargas H, Dahiya R, et al. Midfacial rejuvenation via minimal-incision brow-lift approach. Arch Facial Plast Surg 2003;5:470–8. [8] Villano ME, Leake DS, Jacano AD, et al. Effects of endoscopic forehead/midface-lift on lower eyelid tension. Arch Facial Plastic Surg 2005;7: 227–30.
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 14 (2006) 213–220
Management of the Midface Vito C. Quatela, -
-
a,
MD
*, Daniel R. Olney,
Midfacial anatomy and the orbital complex Fascial layers of the midface Sensory and motor nerves in the midface Patient selection and preoperative evaluation
Traditional techniques for facial rejuvenation have preferentially focused on rejuvenation of the lower face. Before the 1990s, treatment of the aging face was synonymous with a lower facelift and blepharoplasty, regardless of individual patient’s anatomy. Often, the upper and midface were inadequately addressed resulting in suboptimal facial harmony. The contribution of the upper two thirds of the face to the stigmata of aging has since become well established. Deepening of the nasolabial fold owing to descent of the malar fat pad was recognized early as a signature feature of the aged face. Hamra’s deep plane rhytidectomy, first reported in 1990, was the first technique that showed dramatic improvement of the midface [1]. This procedure involves blunt finger dissection in the infraorbital region to separate the thick subcutaneous cheek fat from the zygomaticus major and orbicularis oculi muscles and lateral advancement of the midface flap, resulting in dramatic improvement of the nasolabial fold. More recently, the effects of malar descent on the orbital complex has become recognized as a central feature of the aging process. The vertical elongation of the lower eyelids, with bony exposure of the infraorbital rim and the subsequent creation of a double contour irregularity are key changes that modern surgical procedures must address to
-
b
MD
Operative technique Discussion Summary References
achieve ever more optimal results. Consequently, the last 15 years have seen many advances in face lift techniques focused on the midface [2]. Along with the deep plane rhytidectomy, other methods for midface lifting have been developed, including the lower-eyelid approach to midface lifting and the midface sling. Recently, retained barbed suture techniques have received much attention in their ability to suspend the midface with minimal downtime. All these techniques, however, have inherent disadvantages. One concern with the deep-plane rhytidectomy is the vector of pull, which is more lateral and not superolateral; thus, the degree of malar fat pad elevation is suboptimal. The lower eyelid approach has problems with adequate fixation and its inability to address redundant temple skin once the midface is elevated. The newer techniques such as the midface sling and barbed suture suspension carry many doubts about longevity of results. The advent of endoscopic techniques in the early 1990s first used by Core and coauthors [3] and Liang and Narayanan [4] proved that all the components of the aging face could now be addressed with ever-increasing patient satisfaction and safety. Smaller incisions, decreased risk of alopecia, and equivalent or better results to traditional techniques
a
The Lindsay House Center for Plastic Surgery, 973 East Avenue, Suite 100, Rochester, NY 14607-2216, USA Private Practice, Iowa City, IA 52245, USA * Corresponding author. E-mail address: [email protected] (V.C. Quatela). b
1064-7406/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2006.05.005
214
Quatela & Olney
have made the endoscopic treatment of the brow and midface a powerful tool for modern facial plastic surgeons. The advantage of our technique for endoscopic midface lifting is its release of the entire central and lateral midface, which allows for a complete resuspension with a more natural vector of pull. It has proven to achieve reliable and consistent results when performed properly and does so with an outstanding record of both safety and patient satisfaction.
Midfacial anatomy and the orbital complex Understanding the midface anatomy and anatomy of adjacent regions like the forehead and orbital complex is critical for harmonious results to be realized. This is especially true when endoscopic techniques are used, because they necessitate an understanding of anatomic relationships from a different and more thorough perspective. The midface is defined arbitrarily as the area between the level of the midhorizontal orbit and the mandibular margin; typical aging changes in this area are well understood [5]. The cheek tissue descends inferiorly away from the lower eyelids, and the lack of tissue in the infraorbital area gives a hollowed out appearance. Pseudoherniation of fat in the lower eyelid complex results in a doubleconvexity deformity with the convexity of the orbital fat and descended suborbicularis oculi fat (SOOF)/malar fat pad complex separated by the infraorbital rim (Fig. 1). Removal of pseudoherniated fat with different blepharoplasty techniques alone only serves to further accentuate the hollowed eye appearance. In addition, when the eyelids are addressed with traditional blepharoplasty techniques, the lower lid is at risk for ectropion and scleral show because already it has decreased tension owing to the forces of aging. Often, lateral canthopexy or lid tightening procedures are needed to avoid disappointing or even disastrous results. One advantage
Fig. 1. Typical changes in the orbital complex with midfacial ptosis. Note the double contour deformity.
to performing an endoscopic midface lift is correction of this eyelid malposition. The malar prominence descends inferomedially with aging to deepen the nasolabial crease and expose the lateral orbital rim. It is composed of a subcutaneous malar fat pad with underlying orbicularis oculi muscle. Deep to this fat is the SOOF, which is intimately associated with the periosteum of the infraorbital rim and maxilla and the insertions of the zygomaticus major and minor muscles. With the descent of the midface structures, in particular the malar fat pad, the corners of the mouth sag and create a frown or drawn appearance (Fig. 2).
Fascial layers of the midface Understanding the multiple fascial layers that the endoscopic surgeon must traverse is crucial to safe dissection because the frontal branch of the facial nerve is particularly vulnerable. Many surgeons have been reluctant to embrace this technique because of this risk. When properly performed, however, the frontal branch can be protected confidently. The most superficial layer encountered is referred to as the superficial temporalis fascia or temporoparietal fascia (TPF). This is a fascial extension above the zygoma of the superficial musculoaponeurotic system (SMAS). The frontal branch of the facial nerve lies within this fascia. Similarly, the temporal artery and vein course in this fascial layer superiorly toward the temporal line. The TPF joins medially and is contiguous with the galea of the scalp. Deep to the TPF the deep temporalis
Fig. 2. Transtemporal approach to midface complex. Shaded area indicates degree of dissection. (From Quatela VC, Jacano AA. The extended centrolateral endoscopic midface lift. Facial Plastic Surg 2003; 19(2):199–208; with permission.)
Management of the Midface
fascia or true temporalis fascia is a single fascial layer but splits into two sheets of fascia at the level of the superior orbital margin. The intermediate temporalis fascia attaches to the lateral aspect of the zygomatic arch, and the deep temporalis fascia attaches to the medial aspect. Between these two fascial planes lies the intermediate temporal fat pad. Deep to the deep temporal fascia is the deep temporal fat pad. Dissection deep to the deep temporal fascia risks violation of the deep temporal fat pad and resultant fat atrophy with the appearance of temporal wasting (Fig. 3).
Sensory and motor nerves in the midface The facial nerve supplies all the muscles of facial expression including muscles as far medial as the corrugator supercilii and procerus. The temporal branch of the facial nerve crosses the zygomatic arch halfway between the lateral canthus and the root of the auricular helix within the TPF. Sabini and coauthors [6] uncovered a more accurate means of identifying the precise location the frontal branch of the facial nerve during endoscopic dissection. A series of bridging vessels, including one larger sentinel vein, are encountered between the deep temporal fascia and the TPF during the dissection in the temporal region. These bridging vessels were shown to point to the frontal branch of the nerve as it coursed through the TPF (Fig. 4). Motor nerve supply to the muscles of the midface comes from the zygomatic and buccal branches of the facial nerve traveling along the deep surface of the muscles. Sensory innervation to the midface is supplied by the second division of the trigeminal nerve,
Fig. 3. Coronal section of temporal anatomy focusing on fascial layers. (From Quatela VC, Choe KS. Endobrow-midface lift. Facial Plast Surg 2004 Aug;20(3): 199–206; with permission.)
Fig. 4. Endoscopic view of the sentinel vein and bridging veins. These accurately localize the location of the frontal branch of the facial nerve.
the infraorbital nerve, which exits the infraorbital foramen, and the zygomaticotemporal branch of the trigeminal nerve that exits through the body of the zygoma. The zygomaticotemporal nerve supplies the lateral temple region of the scalp and is encountered in a midfacial dissection, although it is visualized rarely. Transection of this nerve, although not desirable, rarely is clinically significant because sensation to the lateral brow in all but the rarest of cases will return.
Patient selection and preoperative evaluation Careful selection of the appropriate patients is central to preoperative planning. This evaluation should start with a thorough history and physical examination. The ideal candidate is in good mental and physical health without uncontrolled systemic diseases. Preoperative screening for conditions that could adversely affect patient’s surgical experience is mandatory. Patient education is an effective tool for reducing anxiety and establishing realistic postoperative goals and should begin even before the initial consultation. Midface lifting warrants careful consideration of a variety of factors that determine the clinical appearance of the upper two thirds of the face. Crucial components of the preoperative evaluation include degrees of temporal and midface ptosis, orbital rim exposure, descent of the SOOF, and severity of pseudoherniated orbital fat manifesting itself with the double-contour deformity. The depth of the nasolabial folds should also be determined. Other minor factors would include lower face laxity and lateral jowling. It is important to note that laxity in the neck is not addressed by midface resuspension; therefore, patients with significant laxity below the mandible should be considered for additional procedures. The need for other ancillary procedures
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such as blepharoplasty and skin resurfacing should also be recognized. A patient who is a candidate for endoscopic midface rejuvenation surgery deserves special mention. This procedure induces a longer period of postoperative edema secondary to subperiosteal dissection—generally 4 to 6 weeks. These patients require more intense and close monitoring to guide them through the normal healing process [7]. Furthermore, patients with ptotic midface tissues but with adequate soft tissue padding tend to achieve better aesthetic outcomes than those who lack soft tissue bulk and appear ‘‘bony.’’
Operative technique Our technique for endoscopic midface lifting uses the same hairline incisions for endoscopic forehead lifting. In describing the endoscopic midface lift, it is necessary to review the endoscopic forehead lift dissection because it ‘‘sets the stage’’ to approach the midface. Multiple planes of dissection must be traversed, and a thorough understanding of the anatomy of the fascial planes in the temporal/zygomatic region, as described previously, is a prerequisite to avoid injury to the frontal branch of the facial nerve. The patient is examined preoperatively upright, and the brow position is assessed. The amount of desired medial brow elevation is measured; in most patients with mild to moderate brow ptosis 2 to 4 mm of brow elevation is required to bring the medial aspect of the brow to the level of the supraorbital rim. The patient is then marked while awake. Pitanguy’s line, (representing the superficial topography of the frontal branch of the facial nerve), the supraorbital notch, and vertical and horizontal glabellar infrowning are marked bilaterally. The temporal line is marked into the hairline while having the patient clench his or her teeth. Two incisions are then marked on each side. The lateral incision starts approximately 1 cm behind the hairline at the superior aspect of the temporalis muscle. Starting anterior at the previously marked temporal line, it continues for 3 cm inferolaterally; care must be taken that this marking is 1.5 to 2 cm inferior to the superior temporal line or suspension sutures placed into the deep temporal fascia will be difficult to place. The medial incisions begin a few millimeters behind the hairline centered over the lateral limbus and extend posteriorly for 2 cm. The incision lines and supraorbital, infraorbital, and zygomaticofacial nerves are injected with 10 mL of 2% lidocaine with 1:100,000 epinephrine mixed equal parts with 0.25% bupivacaine with 1:200,000 epinephrine. The remainder of the forehead and midface is injected with 40 mL of
0.5% lidocaine with 1:200,000; the temporal region is injected just superficial to the deep temporal fascia, the forehead subperiosteal, and the midface along the face of the maxilla, infraorbital rim, zygoma, and the anterior aspect of the zygomatic arch subperiosteally. After waiting adequate time for vasoconstriction, the lateral incision is made with a #10 blade, taking care to bevel it parallel to the hair follicles, which is important to achieve maximal scar camouflage because transecting the hair follicles results in a few millimeters of permanent alopecia. Approximately 5% of patients will experience telogen effluvium, which can result in 1 cm of alopecia around the incisions; by performing the lateral excisions exactingly, the surgeon can counsel the patient confidently that the hair will return after 3 to 9 months. The incision is carried down through the superficial temporal fascia to the deep temporal fascia. A double hood is used to retract the skin superior to the incision, and an Endoforehead T Dissector (Snowden Pencer, Tucker, GA) is used to elevate the superficial temporal fascia and overlying tissue off the deep temporal fascia to the temporal line. The countertraction of the skin hook and the Endoforehead T Dissector used at an angle of 45º helps define the proper plane. The dissection continues superiorly in a subperiosteal plane after dissection through the tenacious fascia of the temporal line and ends at the level of the occiput. This ensures that the elevated forehead and lateral temporal tissues will redrape and not bunch anteriorly once suspended. Inferior to the incision, dissection on top of the deep temporal fascia is performed blindly for 2 to 3 cm. A fiberoptically lighted Aufrecht retractor is used for better direct visualization more inferiorly as dissection in this region approaches the frontal branch of the facial nerve. Again, dissection on top of the deep temporal fascia anteriorly requires lysis of the fascia at the temporal line, and subperiosteal dissection is continued to the supraorbital rim. Using a down-biting Endoforehead A/M Dissector (Snowden Pencer), the arcus marginalis often can be released from lateral to within 1 cm of the superficial marking made for the supraorbital neurovascular bundle. Bimanual dissection often is helpful, and the hand placed on the surface of the skin helps prevent injury to the orbit with inferior dissection. Laterally, the conjoint tendon is dissected bluntly with the Endoforehead T Dissector. If this fascial condensation is not released adequately elevation of the lateral brow will be incomplete during suspension. The medial incision is then made with a #10 blade down to the frontal bone, and an Endoforehead Curved Dissector (Snowden Pencer, Tucker,
Management of the Midface
GA), is used to elevate a small 1 cm circumferential subperiosteal pocket. Before any more of the forehead flap is elevated, screw holes are drilled with a hand drill with a preset stop of 4 mm to prevent deeper penetration past the calvarium. This technique allows exact measurement of the amount of brow elevation from the preoperative brow position. The suspension translates into the amount of medial brow elevation, as the forehead flap between the two medial incisions moves as a sheet superiorly and translates primarily to the mid- and medial brow. We use temporary fixation with stainless steel screws that are removed 1 week after surgery. Elevation of the medial endoscopic incisions of 8 mm results in maintenance of the preoperative medial brow height. Therefore, if medial brow elevation of 2 to 4 mm is desired, the screw holes should be placed 10 to 12 mm from the anterior edge of the incision, respectively. The remaining subperiosteal dissection of the forehead pocket is performed blindly using an Endoforehead Curved Dissector to within 1 cm of the supraorbital notch marked before surgery. A down-biting subperiosteal dissector is used to blindly elevate medial to the bundle, over the glabella, and onto the radix of the nose. The endoscope is then passed through the medial incision and the supraorbital neurovascular bundle is dissected subperiosteally under direct visualization with a small pick. A temporary transcutaneous suture placed in the medial brow and lifted by an assistant can help open the pocket of the dissection. An up-biting Endoforehead Spreader (Snowden Pencer), is used to complete the arcus marginalis and conjoint tendon release under endoscopic visualization. The corrugator supercilii and procerus muscles are resected and cauterized; this will eliminate the vertical and horizontal glabellar furrow. If brow asymmetries are present preoperatively, unilateral orbicularis oculi myotomies may be performed. A Colorado tip cautery is used for the myotomies on the side that is more ptotic to allow for greater release and greater elevation during suspension; during this step it is important to always be aware of the frontal branch of the facial nerve using Pitanguy’s line as a guide. With inferior temporal dissection, the surgeon must take extra care in the region of Pitanguy’s line. Multiple bridging veins penetrate the plane of dissection perpendicularly in the region of the frontal branch of the facial nerve. These veins have been shown to be located within 2 mm of the frontal branch of the facial nerve in cadaver dissection study. When these bridging veins are encountered, they are freed 360º, and then with traction the deep aspect of the vessel overlying the
deep temporal fascia is cauterized with a bipolar cautery. This technique prevents thermal conduction to the superficial temporal fascia and elevated flap that contains the frontal branch. An additional measure of caution is necessary in the temporal region because forceful dissection may result in penetration through the deep temporal fascia. Penetration through this layer will expose the infratemporal fat pad, and even minimal trauma can result in reduction of its volume with temporal wasting postoperatively. Further inferior dissection approaches the zygomatic arch. The deep temporal fascia splits at the level of the supraorbital ridge to form an intermediate temporal fascia and deep temporal fascia with the intermediate temporal fat pad located in between them (Fig. 5). It is safe to dissect within the intermediate fat pad; however, we prefer to elevate the intermediate fat pad up and dissect on top of the deep temporal fascia. We believe that elevating all these tissues helps provide an additional cuff of tissue to insulate the frontal branch from thermal or mechanical trauma. A lateral 1-cm cuff of tissue is preserved at the lateral canthus to prevent permanent distortion postoperatively. The periosteum over the entire superior aspect of the zygomatic arch is exposed, and it is incised at the anterior aspect of the arch with the #4 dissector. The zygomaticofacial foramen often is encountered and the neurovascular structures kept intact as this an important landmark for later suspension of the midface. Subperiosteal dissection continues posteriorly at the superior edge of the zygomatic arch to within 1 cm of the external auditory canal. Using a down-biting Endoforehead A/M Dissector,
Fig. 5. Coronal section of transtemporal approach through the fascial layers.
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the periosteum over the zygomatic arch is released. This subperiosteal dissection is continued medial over the infraorbital rim to the nose in a blind fashion. Bimanual dissection is required with the dissector passed between the index finger that protects the globe and the thumb positioned over the infraorbital nerve (this landmark can be palpated through the skin). The down-biting dissector is then passed subperiosteally starting at the body of the zygoma directed toward the pyriform aperture, inferior to the infraorbital nerve. This accomplishes dissection over the face of the maxilla and with a superior sweeping motion releases all tissue inferior the infraorbital nerve. Care should be taken here not direct the dissector through the buccal mucosa. With the lighted Aufrecht retractor, the tendinous attachments at the lateral aspect of the maxilla are lysed with the down-biting dissector, and the masseteric tendon just inferior to the inferior aspect of the zygomatic arch is cut with a downward motion. The flap is dissected inferiorly below the masseteric aponeurosis just on top of the belly of the masseter to approximately 1 cm superior to the gonial angle. The medial subperiosteal midface dissection pocket and lateral submasseteric aponeurosis pocket are connected with a sweeping finger dissection from the medial to lateral pocket breaking the last few fascial attachments at the lateral aspect of the maxilla. This dissection has accomplished a complete release of the midface as well as the tissues laterally to the external auditory canal and inferiorly to the level of the gonial angle. This ensures free mobility of the midface, malar fat, and SOOF. The midface is suspended. Using an 0-vicryl on a UR-6 needle (Ethicon) a bite of the released periosteum just lateral to the zygomaticofacial foramen is taken. This is tacked back to the deep temporal fascia at a vector superior and slightly lateral. With proper midface dissection, the angle of the mandible is marked preoperatively, the skin overlying the angle of the mandible is elevated 1 to 1.5 cm. The second suspension suture is placed superior to Pitanguy’s line in the flap and back to the deep temporal fascia. Three more suspension sutures are placed at the anterior skin edge through the superficial temporal fascia suspending it to the deep temporal fascia posterosuperiorly in the region of the temporal line. These three sutures are the reason the placement of the lateral incision is so important, because placement of the incision too high will prevent the ability to suspend the excess skin of the temporal region that bunches after elevation of the midface. With the midface lift, even if a full endoscopic forehead lift is not performed, a lateral temporal lift with release of the arcus marginalis and conjoint tendon is required to prevent bunching of skin in the lateral temporal region.
The forehead elevation is performed. Two 14 4 mm removable screws are placed into the previously drilled holes, the incision is retracted posteriorly until its leading edge rests against the screw, and a staple is placed just behind the screw. This most anterior staple sits behind the screws and prevents the forehead flap from gravitating inferiorly. The lateral temporal incisions are closed with interrupted vertical mattress 5-0 nylon sutures.
Discussion The senior author (V.C.Q.) has now performed more than 800 endobrow-midface cases and has experienced minimal morbidity. It has proven a safe and reliable method to rejuvenate the upper two thirds of the face with less than 1% revision surgery rate. Many surgeons have been reluctant to embrace this technique owing to a perceived high risk-tobenefit ratio. Of paramount concern is the risk of injury to the facial nerve. The senior author’s experience has been reviewed, and the temporary neuropraxia occurred in only 1% of cases. Shortterm complications included hematoma, infection, prolonged edema (greater than 6 to 8 weeks), transient alopecia, engorgement of temple veins, and dry eyes all were also less than 1%. Although not a true complication, initial masticatory tenderness at the temple is expected 100% of the time because of the placement of sutures to the deep temporal fascia. This usually resolves within a week. There can be significant periorbital edema and chemosis postoperatively, especially when combined with a blepharoplasty. Prolonged chemosis beyond an initial 2-week period occurred in 25% of the cases, but complete resolution can be expected by 6 to 8 weeks. Ectropion does not occur with endoscopic midface lifts because the lower eyelid tension is actually increased. We have proven the force required to displace the lower lid from the globe is actually doubled when an endoscopic midface lift is performed [8]. A slight canthal distortion is almost always present, but circumferential massaging will generally return the lateral canthus to its baseline position within several weeks. Patients who underwent this procedure earlier in the development of this technique had greater distortion at the lateral canthus. Although we currently leave a 1 cm cuff of tissue around the lateral canthal tendon, the senior author has performed a more aggressive dissection closer to the canthal tendon. This dissection resulted in a slight upward misplacement of the lateral canthus with the midface suspension. Less aggressive dissection technique at the lateral canthal tendon has made this problem quite temporary and tolerable.
Management of the Midface
Fig. 6. (A, B) Postoperative results from an endoscopic midface lift.
Slight skin bunching in the temple region from the tacking sutures is common; however, this too resolves within several weeks. Patients are generally presentable in 2 weeks and return to normal activity and work in 3 weeks. Routine examination of pre- and postoperative photos has been performed focusing on degree of improvement of four areas: infraorbital hollowing, midface tissue ptosis, depth of nasolabial folds, and degree of jowling. We found the greatest overall improvement is the extent of midface ptosis and infraorbital hallowing followed by improvement in the nasolabial region. Improvement in jowling was common but less significant than the improvement of the midface structures. We feel that this dramatic improvement is owing to multiple factors. With wide and complete release of the central and lateral midfacial structures, the en bloc suspension of the SOOF and malar fat pad is thoroughly
accomplished. Unlike other midfacial techniques, the endoscopic midface achieves pull in two vectors; directing the repositioning of tissues both superiorly and laterally. The superior vector repositions the SOOF and malar fat pad over the bony infraorbital rim and malar/zygomatic complex, whereas the lateral pull effaces the nasolabial fold. This more accurately reverses the forces of aging displayed on the ptotic midface. Lastly, although this technique is not designed primarily to eliminate jowling at the mandible, it has been noted that elevation of 1 to 1.5 cm of skin overlying the mandible is typical.
Summary Management of the midface in facial rejuvenation surgery has evolved rapidly over the last 15 years. Our application of the endoscope coupled with
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a trans-temporal approach to a complete resuspension of the midfacial soft tissue complex has proven a powerful, relatively aggressive technique that we believe will stand the test of time. With a firm understanding of surgical anatomy and an appreciation for aesthetic ideals and meticulous patient evaluation and selection, the facial plastic surgeon may safely offer the patient excellent long-term results without the typical morbidities associated with other traditional forehead and midface lifting techniques (Fig. 6A, B).
References [1] Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 1990;86:53. [2] Larson DL. An historical glimpse of the evolution of rhytidectomy. Clin Plast Surg 1995;22:207.
[3] Core GB, Vasconez LO, Askren C, et al. Coronal facelift with endoscopic techniques. Plast Surg For 1992;15:227. [4] Liang M, Narayanan K. Endoscopic ablation of the frontalis and corrugator muscles: a clinical study. Plast Surg For 1992;15:58. [5] Keller G, editor. Endoscopic facial plastic surgery. St. Louis (MO): Mosby; 1997. [6] Sabini P, Wayne I, Quatela VC. Anatomic guides to precisely localize the frontal branch of the facial nerve. Arch Facial Plast Surg 2003;5: 150–2. [7] Williams EF, Vargas H, Dahiya R, et al. Midfacial rejuvenation via minimal-incision brow-lift approach. Arch Facial Plast Surg 2003;5:470–8. [8] Villano ME, Leake DS, Jacano AD, et al. Effects of endoscopic forehead/midface-lift on lower eyelid tension. Arch Facial Plastic Surg 2005;7: 227–30.