Midfacial Rejuvenation (eBook)

Morris E. Hartstein, MD, FACS Clinical Associate ProfessorSaint Louis University School of MedicineDepartment Ophthalmology and Division of Plastic Surgery  St. Louis, MO 63105andChief, Ophthalmic Plastic and Reconstructive SurgeryAssaf Harofeh Medical CenterZerifin, Israelmhartstein@earthlink.net Allan E. Wulc, MD, FACS Clinical Associate ProfessorScheie Eye InstituteUniversity of Pennsylvania; andDrexel University Dept. of Ophthalmology and Otolaryngology PA 19462email: awulc@aol.comDavid EE Holck, MDAssistant Clinical ProfessorUniversity of Texas Health Science Center at San Antonio San Antonio, TX 78258dh_holck@grandecom.net 

Midfacial Rejuvenation 3
Foreword 5
Preface 7
Acknowledgments 9
Contents 11
Contributors 13
1: Anatomy of the Midface 17
Introduction 17
Definition and Contour 17
Osteology 18
Musculature 20
Ocular Components 20
Lip Elevators 20
Muscles Around the Mouth 21
Muscles of the Nose 21
Muscles of Mastication 21
Connective Tissues 22
Subcutaneous Tissues of Midface 22
Malar Fat Pad 22
Superficial Musculoaponeurotic System 22
Loose Areolar Tissue and Retaining Ligaments 23
Orbitomalar Ligament 23
Zygomatico-Cutaneous Ligament 24
Masseteric Cutaneous Ligaments 24
Fat Pads 24
Suborbicularis Oculi Fat Pad 24
Sub-SMAS Fat Pad 25
Buccal Fat Pad 26
Innervation 26
Vasculature 27
Arterial Supply 27
Venous Drainage 28
Lymphatics 29
Nasal Cavity and Paranasal Sinuses 29
Conclusion 29
References 30
2: The Anatomic Basis of Midfacial Aging 31
Morphology 32
Periorbital Tissues 32
Midface Skeleton 34
Dentition 35
Musculature 35
Adipose Tissue 35
Superficial Muscular Aponeurotic System 37
Ligaments 37
Skin 38
The Volumetric Theory of Facial Aging 38
The Gravitational Theory of Facial Aging 39
Conclusions 42
References 42
3: Evaluation of the Lower Eyelids and Midface 45
Introduction 45
History 46
Examination 47
Standardized Photography 52
Surgical Decisions 53
Preoperative Discussion/Informed Consent/Post-consultative Follow-Up 54
Conclusion 54
References 54
4: The Transtemporal Subperiosteal Approach for Midface Lifting 55
Surgical Technique 56
Discussion 60
References 62
5: Cheek–Midface Lift 64
Preparation for Surgery 64
Surgical Technique 65
Dissection of Cheek Periosteum 66
Tarsal Strip Procedure 68
Repositioning of the Nasal and Central Lower Eyelid Fat Pads 69
Conjunctival Closure 69
Formation of the Orbicularis Flap 70
Skin Dissection 71
Skin Closure 71
Completion of Fat Repositioning 72
Modification of Cheek Midface Lift in the Treatment of Lower Eyelid Retraction and Cicatricial Ectropion 72
Preparation Before Surgery (with the Implementation of a Hard-Palate Graft) 72
Obtaining the Hard-Palate Graft 73
Sizing of the Allogeneic Dermal Matrix Grafts 73
Suturing the Hard-Palate Graft to Lower Eyelid Retractors and Tarsus 73
Suturing the Tarsys to Lower Eyelid Retractors and Tarsus 74
Mouth Care 75
Postoperative Care 75
Complications 75
Results 76
References 79
6: Preperiosteal Midface Lift/Transtemporal Approach 80
Introduction 80
Rationale 80
Relevant Surgical Anatomy 81
Temporal Fossa 81
Bony Structures of the Midface 82
Soft-Tissue Layers 83
Midface SMAS and Fat Compartments 83
Retaining Ligaments 84
Prezygomatic Space 85
Indications and Techniques 86
Surgical Techniques 86
Anesthesia 86
Endoscopic Instrumentation 87
Surgical Markings 88
Endoscopic Brow Dissection 88
Endoscopic Midface Dissection 89
Midface Suspension 90
Perioculoplasty (Lateral Sling Elevation of the Orbicularis) 90
Malarplasty 91
Brow Suspension 92
Adjunctive Procedures 92
Post-operative Course and Management of Complications 92
Results 93
Conclusion 93
References 95
7: Transeyelid Supraperiosteal (Preperiosteal) Midface Lifting 97
Introduction 97
Techniques of Midface Lifting 98
Surgical Technique 99
Conclusions 100
References 101
8: Midface Lifting with Expanded Polytetrafluoroethylene Orbital Rim Implants 102
Introduction 102
Anatomic Considerations 103
The ePTFE Orbital Rim Implant 105
Procedure 105
Recovery 112
Case Histories 113
Case 1 113
Case 2 113
Complications 114
Conclusions 115
References 116
9: Aesthetic Cheek Implants 118
Introduction 118
Types of Implants 119
Metal Implants 119
Silicone Implants 119
Polymethylmethacrylate Polymer 120
Expanded Polytetrafluoroethylene 120
Polyethylene Implants 120
Polyamide Mesh 120
Facial Analysis 121
Surgical Approaches 121
Transoral Technique in Detail 123
Complications 125
Conclusions 127
References 127
10: Minimally Invasive Midface Elevation Using a Percutaneous Suspension Suture Sling Technique 129
Introduction 129
Release of the Midface 129
Elevation of the Midface Using a Percutaneous Suture Sling Technique 131
Results 137
Complications 141
Infection 141
Exposure 141
Overcorrection 141
Conclusions 141
References 141
11: Fat Grafting: A Volumetric Approach to Midfacial Rejuvenation 142
Introduction 142
How the Midface Ages 143
Preoperative Considerations 143
The Evolution of Aging Through Old Photographs and Facial Shape 144
Fat Transfer as Part of a Larger Rejuvenative Strategy 144
Establishing Patient Expectations Preoperatively 145
Technique 146
Preoperative Planning 146
Anesthesia 147
Harvesting 147
Processing 149
Injection 150
Inferior Orbital Rim 150
Anterior Cheek 151
Lateral Cheek 152
Buccal Area 152
Anterior Chin and Prejowl Sulcus 152
Nasolabial Groove 152
Postoperative Care 153
Management of Complications 153
Conclusions 153
References 154
12: Synthetic Fillers 155
Introduction 155
Fillers for Midface Rejuvenation 156
How to Choose a Filler 156
CaHA (Radiesse) 156
Hyaluronic Acid 157
Restylane 157
Perlane 157
Juvederm 157
Prevelle Silk 158
Hydrelle 158
Puragen 158
Poly- l -Lactic Acid 158
Sculptra 158
Polymethylmethacrylate 159
ArteFill 159
Liquid Injectable Silicone 159
Adatosil 5000, Silikon 1000 159
Technique 160
Pain Control 160
Cold Application 160
Topical Anesthetics 160
Nerve Blocks 160
Lidocaine Solution Mixed into Filler 160
General Considerations 160
Technique for Fillers by Site 162
Tear Trough 162
Lateral Orbit and Brow 163
Malar and Submalar Cheek 164
Zygoma and Preauricular Area 165
Temporal Fossa 165
Perialar Cheek and Nasolabial Fold 166
Nose 167
Lips 167
Mandible and Chin 169
Conclusion 171
References 174
13: Midface Lifting for the Repair of Lower Lid Retraction 176
Anatomy and Approach to the Patient 177
Procedure: General Observations 179
Surgical Approach 179
Conclusion 184
References 186
14: Rhytidectomy and Transtemporal Subperiosteal Midface Lifting 187
Technique 188
References 194
15: Lower Eyelid Blepharoplasty with Fat Repositioning 195
Introduction 195
Anatomy 196
Evolution of Surgical Approaches to the Lower Eyelid 197
Surgical Approach 197
Adjunctive Therapies 200
Complications 200
Conclusions 201
References 202
16: Canthal Surgery 203
Anatomy 203
General Considerations 204
Surgical Techniques 205
Surgical Technique 205
Canthoplasty–Lateral Tarsal Strip 205
Canthopexy 206
Orbicularis Hitch 206
Complications 209
Conclusion 210
References 211
17: The “Ogee” of the Midface: Aesthetic and Technical Considerations 212
Introduction 212
The Ideal Contour of the Midface 212
Patient Selection 213
Indications 214
Technique 214
Lower Eyelid Blepharoplasty 220
Fat Grafting 221
Drains, Closure, Taping, and Dressing 222
Summary 222
References 225
18: The Trans-oral Vertical Midface Lift 226
Preparation for Surgery 226
Surgical Technique 227
Exposure 227
Drilling the Bone Tunnel 228
Passing the Fixation Suture 230
Engaging and Suspending the Malar Fat Pad 230
Closure 232
Post-operative Care 232
Post-operative Complications and Results 233
Alternative Techniques of Fixation 235
Conclusions 235
References 235
19: Festoons 236
Conclusion 239
References 240
20: Complications of Midfacelifting 241
General Complications 242
Aesthetic Complications 247
Conclusion 248
References 248
Index 250