"Staying out of the eyelid, except for minimal amounts of work, mainly just to support the lid but staying out of the mid-lamella compartment, tends to reduce the risk of having the lid retract when doing a midface lift," says Malcolm D. Paul, M.D., F.A.C.S. He is associate professor of clinical surgery in the plastic surgery division at the University of California, Irvine, and president-elect of the California Society of Plastic Surgeons.
In keeping with this philosophy, Dr. Paul's approach, called the trans-temporal trans-buccal approach, involves two incisions — one behind the hairline and one inside the mouth."It's a subperiosteal approach on top of the bone," he says. "From that approach, the entire midface is lifted and supported with cable sutures from inside the mouth to the deep temporal fascia. At the same time, we usually work on the lower eyelid to rejuvenate it."
Dr. Paul and his colleagues employ minor skin pinches to more aggressive maneuvers designed to recontour the lower lid by using the orbicularis oculi muscle as a pedicle flap, elevated and sutured to the deep temporal fascia or to the periosteum of the orbital rim.
"Sometimes we do some work on the fat compartments," he adds. "Often, the lateral fat compartment has to be reduced. However, sometimes we don't have to do much of anything on the lower eyelid, depending on the age of the patient, because if someone's 40 or 45, there may be very little bulging fat" in that area.
In contrast, some patients have very prominent lower-lid fat pads. In such cases, solutions include partially resecting the fat or redraping it over the orbital rim. The latter technique is particularly useful for patients seeking to improve the contour of their lid-cheek junction.
"With these procedures come certain possible complications such as lower lid malposition, which is usually temporary and responds to massage, but occasionally requires a secondary procedure such as a canthopexy or canthoplasty," Dr. Paul says. "But, by adequately supporting the lower lid at the time of the midface lift, the risk of complications, and the need for additional procedures is reduced. Sometimes just raising the midface flap and advancing it will push the lower lid up higher toward the iris to raise the lid. Sometimes you have to do that maneuver as well as opening the eyelid laterally and doing a canthoplasty where the tarsus is tightened up against the orbital rim, usually in addition to a muscle flap, which is also used to support the lid."
Some patients, however, suffer from pre-existing lid malposition resulting from prior surgery.
"That can often be improved by elevating the midface because it will push the lid back up," he says. "But, sometimes, it requires maneuvers on the lid itself."
Other complications that can result from dissecting in the midface area include sensory and motor deficits.
"There's a sensory nerve that sometimes is divided when that whole flap is moved. Patients usually don't complain about it. If you really question them, they'd report some numbness. But it's not something that really bothers them," Dr. Paul says.
More troubling, though, is any muscle weakness, either in closing the eyelid — due to denervation of the orbicularis oculi muscle — or from temporary neuropraxias of the nerves that innervate the elevators to the upper lip.
"The problems are very few and very infrequent. And I've never had a problem that didn't resolve over time, usually within six weeks," he says.
Dr. Paul attributes his success to the fact that, through years of experience in performing midface procedures, he's learned proper methods of dissection to avoid stretching or placing sutures in nerves.