What the research shows
Why the midface falls. The fat pads of the cheek move down with age, deepening the groove under the eye and the fold beside the nose (Ugradar 2023). Part of the lost fullness is fat that has fallen rather than disappeared: a vertical deep plane lift restored measurable cheek volume that lasted at least a year (Jacono 2015).
Lifting under the bone covering. Psillakis lifted the soft tissue of the cheek, eye socket and nose off the bone (the subperiosteal plane) to restore its relation to the skeleton; some patients had temporary forehead paralysis (Psillakis 1988). Ramirez changed the temple dissection and anchoring and saw no nerve injuries, where the earlier methods had injured it in one in nine to one in five of his first patients (Ramirez 1991). In a later series, complications occurred in about 1 patient in 20, mostly temporary (Heinrichs 1998). Done through brow incisions, the lift improved the cheek most, the jawline somewhat and the fold beside the nose least (Williams 2003); with endoscopic fixation devices, lifts were more even and left no skin dimples (Saltz 2012).
Lifting with the facelift. Raising the cheek fat pad vertically during a facelift reshaped the cheekbone, softened the fold and refreshed the lower lid, with only temporary nerve problems (De Cordier 2002). Keeping skin and SMAS joined in the cheek doubled the measured midface lift compared with separating them (Mani 2016), and deep plane lifts improved the cheek and neck about twice as much as SMAS plication in blinded ratings (Adamson 2007). The direction of pull matters: anchoring toward the temple lifted the cheekbone best, and anchoring to the eye rim best filled the groove under the eye (Pascali 2015).
The fold beside the nose. Hamra, who first moved the cheek fat in a deep plane lift, followed his patients for years: the fold improved at one to two years and then returned, while the jawline and forehead results lasted (Hamra 2002). Freeing the deep cheek fat and tightening the main smile muscle softened the fold more than a standard deep plane lift (Kim 2024).
Lift and fill. In a randomized trial, patients with prominent eyes who had fat added to a midface lift were more satisfied and needed fewer later procedures than those lifted alone (Barone 2021).
The lower eyelid. A vertical midface lift repaired a pulled-down lower lid in nearly every patient (Pascali 2017). Done through the lower lid, a midface lift can itself pull the lid down; one practice that repairs these problems set four rules to prevent them, including reattaching a loose outer corner (Patipa 2004).
Where surgeons disagree
- Does the fold correction last. One surgeon reported lasting results from lifting the cheek fat (De Cordier 2002); the surgeon who introduced fat repositioning found the fold returned and concluded only direct excision corrects it permanently (Hamra 2002).
- Lift or fill. A vertical deep plane lift may make fat grafting unnecessary in some patients (Jacono 2015); the randomized trial favored adding fat (Barone 2021).
- Surgery or injections. Surveyed surgeons now favor fillers and fat transfer over surgery for the midface, and among operations prefer the deep plane lift to the subperiosteal lift (Shehan 2023).
What is new
- A cheek lift that moves the whole front of the face upward through a wide skin dissection, reported over a decade, had complications in about 1 patient in 14, mostly hematoma and skin loss (Bellity 2025).
- A temple-based lift combines midface lift, outer eye corner support and brow lift; temporary forehead weakness occurred in about 1 patient in 18 and resolved within three months (Şirinoglu 2025).
- Deep plane lifts that also free the deep cheek fat target the fold directly (Kim 2024).
What is still unknown
- Exactly how the midface ages; studies of its anatomy vary in quality and conflict (Ugradar 2023).
- Which technique is best; trial data are scarce and surgeons rely on small studies (Shehan 2023).
- How long thread lifts last; barbed sutures gave moderate improvement up to about 16 months (Kaminer 2008).
Key papers
- Psillakis 1988: the subperiosteal facelift.
- Ramirez 1991: changes that made the subperiosteal lift safer for the nerve.
- Hamra 2002: the fold beside the nose returned in the long term.
- De Cordier 2002: vertical lift of the cheek fat pad.
- Williams 2003: which parts of the face a midface lift improves.
- Adamson 2007: deep plane against SMAS plication in the midface.
- Jacono 2015: a vertical deep plane lift restores cheek volume.
- Mani 2016: keeping skin and SMAS together lifts the midface more.
- Barone 2021: adding fat to a midface lift raised satisfaction.