"Via a lower-lid blepharoplasty incision," Dr. Patipa says, "I go down to the descended midface and elevate the descended malar fat pad. I use three points of fixation. One is tightening of the lateral canthal tendon (see related story p. 66). The second is a suture that simulates the orbitomalar ligament, which is a suture that's placed at the junction of the inferior lateral orbital rim, and when I pull the midface up, that suture holds the midface in an elevated position. Third, I place three sutures that pull the orbicularis up to the lateral orbital rim periosteum. And with those three sutures, I'm able to elevate the descended malar fat pad and reposition the eyelid and midface back to where they used to be prior to their descent."
Dr. Patipa is an ocular plastic surgeon and practices at Oculoplastic and Orbital Consultants, West Palm Beach, Fla.Elevating the malar fat pad includes dissecting skin 6 to 8 mm down and making an incision in the orbicularis oculi muscle lateral to the lateral canthal angle down to the lateral orbital rim. Then, Dr. Patipa makes a preperiosteal dissection inferiorly to below and around the zygomaticofacial nerve and vascular complex. From this point, one can elevate the malar fat pad and back-cut tissues to mobilize it (Plast Reconstr Surg. 113: 1459, 2004.).
Lateral canthal tendon When it comes to tightening the lateral canthal tendon, he believes methods to suspend the lateral retinaculum work well for patients with minimal or no laxity of the lateral canthal tendon.
However, for the vast majority of patients who suffer from midface descent and lateral canthal tendon laxity, he advises returning this tendon to its normal anatomic insertion. Once the lateral canthal tendon (and, with a 5-0 Vicryl suture, the lower eyelid) has been tightened, it's possible to elevate the midface by pulling up on it via the lateral orbicularis oculi muscle.
The foregoing approach cuts complications by design.
Dr. Patipa explains, "it's a direct access via a lower-lid blepharoplasty operation, so it's just a couple of additional steps above and beyond the cosmetic lower-lid operation that let the midface be elevated in conjunction with the blepharoplasty. I emphasize that there are many different procedures available for elevating a midface. And you have to customize the procedure based on your surgical armamentarium and what the patient needs."
Procedures ranging from conventional facelifts to endoscopic browlifts all lend themselves to different approaches to midface lifts.
"Based on what the patient needs," he says, "you implement the procedure that best applies to giving them the best cosmetic result." About the only situations in which Dr. Patipa won't perform the surgery are when it's not needed or when patients desire facelifts as well, which he does not perform.
Drawbacks, advantages As for the procedure's drawbacks, he says, "There are always potential risks. You just have to weigh the risk-reward ratio and decide what's right for the patient."
The greatest advantage of the transblepharoplasty midface lift is its direct, straightforward nature. As such, it helps minimize risks including swelling, chemosis and undercorrection that can plague midface procedures.
In a series of 65 transblepharoplasty midface rejuvenation elevations recently reported by Dr. Patipa (Plast Reconstr Surg. 113: 1459, 2004.), 50 were performed on patients who had undergone previous eyelid and/or facial cosmetic surgery. Twenty-four patients in the series reported dissatisfaction with results of their previous cosmetic surgeries. Their complaints included sad-looking and round eyes, as well as dry eyes and ocular irritation. As part of their surgery, all patients received lateral canthal tendon tightening. Only two patients reported residual laxity of this tendon, which Dr. Patipa attributes most likely to postoperative edema suture stretching. It should be noted, however, that both of these patients experienced many previous cosmetic surgeries and secondary reoperations prior to reaching him.