Dr. Niamtu

Rancho Mirage, Calif. - Failure to address the midface when performing facial rejuvenation can lead to imbalance and patient dissatisfaction, said oral/maxillofacial and cosmetic facial surgeon Joseph Niamtu at the Annual Scientific Meeting of the American Academy of Cosmetic Surgery.

He described his own simplified technique for minimally invasive midface lift with optional simultaneous augmentation of the nasolabial folds, stressing that when performing facial rejuvenation, at any level, it is important to consider what you're doing in the context of the entire face.

Dr. Niamtu said that the midface-lifting technique that he currently uses requires minimal incisions, which are hidden. This procedure causes no negative effect on lower eyelid position, and can actually optimize conditions for a problematic lower lid, he said, adding that the procedure is easily performed in an ambulatory environment.

Specifically, it requires incisions both intraorally as well as in the temporal tuft. With experience, he said the procedure can eventually be performed in approximately 15 minutes per side.

The initial 2-cm temporal incision, located in a similar location to that used for an endoscopic brow lift, is first marked and then completed in the temporal tuft, perpendicular to the alar-canthal line, down to the level of the superficial layer of the deep temporal fascia.

Once the temporal incision is made, a dissection is performed with a No. 9 periosteal elevator in a line that intersects the lateral orbital rim and frontozygomatic suture.

When the lateral orbital rim is encountered, the elevator is rotated and used to burrow under the periosteal layer. This dissection plane proceeds from the deep layer of the superficial temporal fascia to the subperiosteal layer, thereby avoiding damage to the frontal branch of the facial nerve, as these are technically both "safe" dissection planes.

After entering the subperiosteal layer, the dissection is directed from above, over the malar eminence, completing the temporal dissection. Attention is then directed to the mouth. A gingival vestibular incision is made 5 mm above the attached gingiva, in the area of the cuspid tooth, to the first molar. Subperiosteal dissection is then performed to the inferior orbital rim, lateral nasal rim, and over the zygoma to the junction of the zygomatic arch.

"Caution is used here to avoid damage to the infraorbital nerve," he said. "This dissection joins the pocket created by the previous temporal dissection, thus creating a tunnel from the temple to the oral cavity."

The malar fat pad is readily visible and is sandwiched between the periosteum, muscle, and oral mucosa. Once identified, it is secured with a double-throw from a 2-0 PDS suture that will be passed up through the dissection tunnel.

"The position where the malar fat pad is secured with this suture relates to the final vector of the lift," Dr. Niamtu said. "By securing the fat pad in the region of the canine tooth, a more superior lift is produced. However, securing the fat pad in the region of the first molar produces a more superior lateral augmentation."

According to Dr. Niamtu, the ability to adjust the vector of the mid-facial augmentation is the main advantage of this technique. He said this allows variability and customization of the cosmetic result and is the perfect midface "implant."

Dr. Niamtu generally recommends securing the fat pad in the first molar area. After the suture is threaded, the position can be redirected on the fat pad to adjust to the desired level of augmentation.

"In some instances I will use two sutures: one in the cuspid region and one in the first molar region for a maximum augmentation," he said.

The next step is to pass the suture back through the incision tunnel. A thin tonsil clamp or a passing awl is positioned and passed from the temporal incision to the intra-oral area. The needle is cut off the suture and both suture tails are secured with the clamp or awl. The suture tails are then pulled back through the temporal incision, placed under tension, and the elevation of the midface is immediately apparent.

Patient pre-op (left) and post-op (right) after undergoing a simplified mid-face lifting technique that requires minimal incisions, which are hidden.

"The more tension placed on the suture tails, the more the midface is elevated," he said. "The level of augmentation may appear excessive, as the patient is in a recumbent position; however, post-operatively this is rarely the case."

Attachments designed to last

Dr. Niamtu secures the sutures with maximum fat pad elevation. Once he is satisfied with the vector of the lift, Dr. Niamtu threads a passing needle on the suture end and secures it to the superficial layer of the deep temporalis fascia, now under tension, to maintain the elevated midface. When the surgical site heals, the repositioned periosteum and soft tissues will reattach for a lasting augmentation.

In consideration of further mid-facial rejuvenation, Dr. Niamtu frequently addresses the nasolabial folds with Gore-Tex implants or fat transfer, and, in certain cases CO2 laser resurfacing.

"There is one caveat," Dr. Niamtu said. "Due to the extreme amount of elevation achieved, sometimes the intra-oral incision is gaping under the tension, with seemingly insufficient tissue to close the incision. If this should occur, simply dissecting the tethered mucosa from the deeper tissue will enable primary closure of the wound."

Dr. Niamtu said that if concomitant lower eyelid surgery is planned, the midface lift should be performed first because elevating the midface can change the lower eyelid esthetics.

Due to subperiosteal dissection, swelling can persist from one to three weeks. Most patients will experience a temporary paresthesia in the distribution of the infraorbital nerve. Dr. Niamtu said that he has not seen permanent numbness from this procedure, as this nerve can be easily seen and avoided during surgery.

"Because of the release of the periosteum, and subsequently the origin of the lip elevators, a temporary dysfunction may be seen upon smiling or puckering," he said. "In my experience, this improves over a several week period. This doesn't usually present as a problem if the patient is properly forewarned."

Dr. Niamtu said that he has seen two cases of intraoral wound dehiscence, both in smokers. This was treated by wound hygiene, using peroxide and antibiotic oral rinses. In both cases healing was uneventful.

He said that another possible option for midface rejuvenation involves the use of facial implants, but some patients are uncomfortable with thought of a foreign substance in their face.

"The minimally invasive rejuvenation procedure is easier to accept for some patients than the use of facial implants," he said. "The procedure consists of a repositioning of the patient's own tissue by elevating the malar fat pad. This procedure is not appropriate, however, for individuals who have a very thin, wasted or atrophic midface. In these cases there's no fat pad to lift. This is not a procedure for patients who are very gaunt, without adequate midface tissue."

Dr. Niamtu is currently doing a study on a cohort of 20 consecutive midface lift patients and, as this group approaches the two-year postoperative point, he said the level of augmentation and patient and operator satisfaction remain high.