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Panel puts different perspective on midface procedures

Boca Raton, Fla. — There are many challenges in performing midface corrective procedures.

But the most unique challenge for the cosmetic surgeon is that there are so many midface procedures — yet no one set solution that will meet the needs of every patient.

That was the central message a panel of facial plastic surgeons delivered at the American Academy of Facial Plastic and Reconstructive Surgery spring meeting, here. The panel was moderated by Mark Glasgold, M.D., and included Edwin Williams, M.D., Corey Maas, M.D., and Thomas Tzikas, M.D.

"There are lots of operations for the midface, but no one 'good' operation," Dr. Glasgold says. He heads the Glasgold Group for Plastic Surgery in Highland Park, N.J. "Different operations address different needs or complaints that the patient may have."

Primary complaint

Dr. Glasgold, who defines the midface area as running from the lateral canthus of the eye to the corner of the mouth, says that the primary complaint of his mostly female patient population is nasolabial folds — and adds that more often than not, there are other problems that the patient doesn't see.

"I'd say that nine out of 10 times, patients want to get their 'smile lines' removed," he says. "It's important to remember, however, that when a patient looks in a mirror, all he or she sees is a straight-on frontal view, which may reveal nasolabial folds but not other potential problems. The world looks at you not only from a straight-on perspective, but from three-quarters and side views and every other conceivable angle, and that these perspectives usually reveal other problems in addition to smile lines.

"Doctors need to educate their patients about this when they consult with them, both with three-way mirrors and facial photos from various angles, so that the patient can see problems that weren't evident before, because they see themselves only from the one perspective," Dr. Glasgold adds.

In addition to the nasolabial-fold problems that come with age, Dr. Glasgold notes frequently accompanying conditions that a patient might not notice.

"Besides smile lines," he says, "the hallmarks of facial aging are separation between the corner of the eyelid and the cheek, creating a hollow, and in the malar region area, lines running parallel to the nasolabial folds that result in a double contour in the cheeks."

Dr. Glasgold also notes lower orbital hollowing, nasojugal grooves, malar volume loss — where cheeks become concave from the convex — buccal hollowing, malar fat-pad ptosis and early jowls as being hallmarks.

Dr. Glasgold's panel focused on the three most popular midface techniques, noting that they've proved to have the best benefit-to-problem ratio: percutaneous cheek lift, autologous fat transfer and the endoscopic subperiosteal technique. They also discussed the limitations of three other procedures that don't have as high a benefit-to-problem ratio: the extended subciliary, orbital fat transposition and alloplastic implant procedures.

"One problem with the fat-transposition technique, where fat is taken from eye 'bags' to fill in the orbital hollow, is that there's often not enough fat volume that can be recruited to effectively fill the hollows," Dr. Glasgold says. "The extended subciliary technique often results in lower-lid malposition, and for that reason it's not a preferred procedure."

He adds that the alloplastic implant procedure, which is intended to augment the cheek, often has the unsatisfactory result of increasing hollowing in the area.


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