Midface lift and cheek

What it is

The midface is the cheek between the lower eyelid and the corner of the mouth (PMID 11786834). A standard SMAS facelift treats the jawline and neck well, but it usually leaves some midface changes behind: a lowered cheek, hollows under the eye and deep folds from nose to mouth (PMID 9811022, PMID 11786834). A midface lift frees the cheek tissue and fixes it higher over the cheekbone (PMID 9811022).

The cheek ages in more than one way. The border between lid and cheek stays in place for decades and shows more as the tissue around it changes (PMID 17898614). The deep fat of the inner cheek deflates, which makes the cheek look dropped and the nasolabial fold deeper (PMID 18520902). The upper jaw recedes under the eye socket with age (PMID 17486402). What was once called the malar fat is several separate compartments (PMID 17519724). Lifting repositions tissue, and anatomists suggest pairing it with restored fat and bone volume for a longer-lasting fold correction (PMID 37130080).

Where it came from

In 1992 Hamra argued that the platysma, cheek fat and orbicularis eye muscle sag together, and that conventional lifts separate the skin from them. His composite rhytidectomy lifted all three with the skin as one flap (PMID 1615067). In 1993 Owsley freed the malar fat pad, the cheek fat that slides toward the nasolabial fold, and stitched it higher on the cheekbone (PMID 8438018).

In 1995 Aiache described the SOOF as a contributor to lower lid deformity (PMID 7809265), and Hamra began keeping lower lid fat and moving it over the bony rim, because removing it can leave a hollow, operated look (PMID 7624408).

In 1998 Anderson used an endoscope to release the midface under the periosteum and hang it from the temple (PMID 9811022). Other surgeons reached the same plane through a lower eyelid incision (PMID 10627009, PMID 10359270). Ramirez avoided the eyelid altogether, using the temple and the inside of the upper lip, because eyelid approaches had brought more complications (PMID 11786834).

Complications of eyelid-route lifts led to new rules. Patipa built four principles from repairing complications referred to him (PMID 15060363), and Hester identified which patients were at high risk of a pulled-down lid (PMID 19319073). Owsley changed his dissection to leave the malar septum intact and cut bruising and swelling (PMID 12142695). Mendelson mapped the gliding space over the cheekbone, a plane that can be reached from the temple, lower lid or cheek (PMID 12172155).

Recent work fixes the cheek more firmly and studies why results fade. Surgeons now anchor the lift inside the eye socket or through small holes in its rim (PMID 36342769, PMID 42009921). Cadaver testing in 2023 showed that the skin carries the pull of a composite cheek lift, which the authors link to early return of the nasolabial fold (PMID 37130080).

Who it suits

• A long lower eyelid with a double contour. The lift shortens the lid and smooths the step between lid and cheek (PMID 22936382).
• A lowered cheek and hollows under the eye. These improve most; the nasolabial fold and jowl improve less (PMID 12825160, PMID 12352817).
• Eyes where standard eyelid surgery fails. These include a cheek that sits behind the eye, an outer eye corner that slants down, men with large bags, and repeat lower lid surgery (PMID 36342769).
• A lower lid pulled down by earlier blepharoplasty. A midface lift through the inside of the lid, with a graft from the palate, raises the lid (PMID 35321816).
• Asian patients. A vertical lift through one lower lid incision and two small temple incisions improved the cheek more than the lower face (PMID 32079870).
• Higher risk. Deep-set eyes, a loose lower lid and previous lower lid surgery raise the risk of a pulled-down lid (PMID 19319073).

Some patients do as well without a lift. Lower blepharoplasty with fat moved over the rim improved the lid-cheek contour as much as a temple lift (PMID 31298695), and surgeons match the operation to the mix of fat bulge, loose skin, cheek descent and volume loss (PMID 34579833).

How it is done

Through the temple

• An endoscope is passed through small incisions in the temple hair; the cheek is released under the periosteum and hung from the deep temple fascia (PMID 9811022, PMID 12825160).
• Ramirez adds an incision inside the upper lip, moves the lower lid fat over the rim and repositions the buccal fat pad to add cheek volume (PMID 11786834).
• The temporal facelift combines a vertical deep-plane midface lift with tightening of the outer eye corner and a brow lift (PMID 39641911).
• A dual-plane version works through the temple and the mouth, with hidden incisions (PMID 39009872).

Through the lower eyelid

• A lower blepharoplasty incision reaches the cheek under the periosteum (PMID 10627009); Gunter's version drops the routine tightening of the outer eye corner (PMID 10359270).
• The triple-layer lift moves the orbital fat, the SOOF and the skin-muscle layer separately, under local anesthesia (PMID 24938687).
• The medial limited lift keeps the release small, stays to the outer side of the nerve that gives the cheek feeling, and fixes the tissue through holes drilled in the rim of the eye socket (PMID 42009921).
• The intraorbital fixation lift anchors the cheek inside the eye socket (PMID 36342769). The V3 lift hangs it along three lines, through the inner and outer eye corners and along the lower edge of the cheek fat (PMID 42798641).
• A SOOF lift raises the fat under the eye muscle and can be combined with moving the lower lid fat (PMID 41823632, PMID 34579833).

In the fat layer

• Owsley's malar fat pad lift frees the pad above the cheek muscles and stitches it higher (PMID 8438018).
• Finger-assisted malar elevation frees the pad with a finger sweep in a plane with few blood vessels (PMID 16932185).
• A percutaneous method lifts the pad through the skin without wide dissection (PMID 11843672).

Adding volume

• Fat grafted to the tear trough through the endoscope during a midface lift (PMID 40341978).
• Small fat grafts to the tear trough and over the rim of the eye socket, which made open surgery on the eyelid fat almost always unnecessary for Hester's group (PMID 19319073).

Anatomy that keeps it safe

• A natural gliding space over the cheekbone allows the tissue to move; the nerve branches to the eye muscle run in its walls and roof and do not cross it (PMID 12172155).
• Releasing the ligament attachments around the outer eye socket frees the cheek fat with less risk to the facial nerve than lateral facelift approaches (PMID 15156975).
• Facial nerve danger zones lie over the front of the cheekbone arch and just above and below the outer eye corner (PMID 32652025).

Results and how long they last

• The cheek and the hollow under the eye improve most, then the nasolabial fold, then the jowl (PMID 12825160).
• After a temple lift combined with blepharoplasty through the inside of the lid, the lower lid was 2.5 mm shorter on average at a year, and no patient needed revision (PMID 22936382).
• Tear trough volume rose after a midface lift whether the eyelid fat was removed, moved or left alone (PMID 36719989). Fat grafted to the tear trough during the lift was stable at a year (PMID 40341978).
• After the V3 lift, about 9 in 10 patients rated themselves much or very much improved at a year (PMID 42798641).
• With intraorbital fixation, the cheek did not drop again in any first-time patient (PMID 36342769).
• About 3 in 100 malar fat pad lifts needed a second lift (PMID 12800899). The second lift came a little over 3 years after the first, on average (PMID 12800899).
• The nasolabial fold can return early, because in a composite lift the skin carries the pull and the skin stretches (PMID 37130080).
• Repair of a lid pulled down by earlier surgery held steady over years of follow-up (PMID 35321816).

Risks and how surgeons lower them

• A pulled-down lower lid. Eyelid approaches carry this risk, and it is higher with deep-set eyes, a loose lid or earlier lid surgery (PMID 19319073). Surgeons lower it by not dissecting between the eye muscle and the septum, and by tightening a loose lid during the lift (PMID 19319073).
• Rules for the eyelid route. Patipa keeps the bond between the eye muscle and the septum, reattaches a loose outer eye corner, treats eyelid fat from inside the lid and fixes the cheek with a stitch at the rim of the eye socket (PMID 15060363).
• Firm fixation. With the cheek anchored inside the eye socket, no first-time patient developed a turned-out or permanently pulled-down lid (PMID 36342769).
• Touch-ups. After the triple-layer lift, about 15 in 100 patients had a complication (PMID 24938687). About 9 in 100 needed a short procedure under local anesthesia to fix it (PMID 24938687). A lid-tightening tuck at the same operation lowers the risk in patients prone to a pulled-down lid (PMID 24938687).
• Facial nerve weakness. After the temporal facelift, about 6 in 100 patients had temporary weakness of the forehead on one side (PMID 39641911). It resolved on its own in about 3 months on average (PMID 39641911). Temporary weakness of lip muscles was rare after Ramirez's endoscopic lift (PMID 11786834).
• Swelling of the eye surface. Temporary swelling of the white of the eye followed about 7 in 100 V3 lifts, with no permanent lid turning or nerve injury (PMID 42798641).
• Other effects. Numbness, bruising, infection and minor asymmetry after the dual-plane lift (PMID 39009872); dimples that faded within 5 months after the temporal facelift (PMID 39641911); persistent eye irritation after repeat malar fat pad lifts (PMID 12800899).
• Fat-layer lifts. Finger-assisted malar elevation had minor complications in about 2 in 100 patients (PMID 16932185).

Recovery

• After Owsley's refined malar fat pad lift, patients returned to usual activities and work in 10 to 21 days (PMID 12142695).
• After Ramirez's endoscopic lift through the temple and mouth, patients returned to work at about 2 weeks, with less swelling than after open or eyelid-route lifts (PMID 11786834).
• After the temporal facelift, swelling is managed with taping, lymphatic massage and, when it is heavy, steroid injections (PMID 39641911).
• After a SOOF lift, results settled between 3 and 6 months (PMID 41823632).
• After repair of a pulled-down lid, lid position kept changing for a year, then held (PMID 35321816).

With a facelift

• In Ramirez's practice, a midface lift is more often part of a full facial rejuvenation than done alone (PMID 11786834).
• The endoscopic midface lift combines with a facelift, neck lift, temple lift and laser resurfacing (PMID 9811022).
• In the composite facelift, the cheek fat and eye muscle move with the platysma in one flap, and the lower lid fat is moved over the rim in every case (PMID 1615067, PMID 7624408).
• Most repeat malar fat pad lifts were done with a SMAS facelift, and many with neck tightening (PMID 12800899).
• To make nasolabial fold correction last, the 2023 cadaver study proposes reshaping the deep cheek fat and restoring fat and bone volume (PMID 37130080).
• Fat can be grafted to the tear trough during the midface lift as part of a full facial rejuvenation (PMID 40341978).

Questions to ask a surgeon

• Will you reach my cheek through the temple, the lower eyelid, the mouth or the facelift incision? (PMID 11786834)
• Do my eyes or lower lids put me at higher risk of a pulled-down lid? (PMID 19319073)
• How will you support my lower eyelid during and after the lift? (PMID 15060363)
• How will you hold my cheek in its new position? (PMID 36342769)
• Would lower blepharoplasty with fat repositioning give me the same result? (PMID 31298695)
• How long will the change in my nasolabial fold last? (PMID 37130080)
• When can I go back to work, and how long will the swelling last? (PMID 12142695)
• Have your patients had temporary forehead weakness, and how long did it last? (PMID 39641911)

Open questions

• Whether the midface descends or deflates: photographs show a stable lid-cheek junction (PMID 17898614), MRI shows the cheek fat redistributed (PMID 15793457), and loss of deep fat and bone are described (PMID 18520902, PMID 17486402).
• Lift or blepharoplasty: one comparison found equal contour gain from a temple lift and lower blepharoplasty with fat repositioning (PMID 31298695).
• Eyelid safety by approach: risk factors (PMID 19319073), fixation methods (PMID 36342769, PMID 42009921) and eye corner support (PMID 15060363) differ from surgeon to surgeon.
• How long the nasolabial fold correction lasts (PMID 37130080, PMID 12800899).
• Most evidence comes from single-surgeon series rated by the surgeon, often with short follow-up (PMID 24938687, PMID 12352817).

Terms

• Midface: the cheek area between the lower eyelid and the corner of the mouth (PMID 11786834).
• Malar fat pad: cheek fat over the cheekbone that sags toward the nasolabial fold (PMID 8438018).
• SOOF: suborbicularis oculi fat, a fat layer under the eye muscle over the cheekbone (PMID 7809265).
• Prezygomatic space: a natural gliding space over the cheekbone used as a surgical plane (PMID 12172155).
• Orbicularis retaining ligament: ligament that forms the upper border of the prezygomatic space (PMID 12172155).
• Lid-cheek junction: the line where thin eyelid skin meets thicker cheek skin (PMID 17898614).
• Subperiosteal: under the membrane covering the bone (PMID 10627009).
• Transtemporal lift: a midface lift done through small incisions in the temple hair, often with an endoscope (PMID 22936382).
• Transblepharoplasty lift: a midface lift done through a lower eyelid incision (PMID 10359270).
• Canthopexy / canthoplasty: tightening or reattaching the outer eye corner to support the lower lid (PMID 15060363).
• Arcus marginalis release: freeing the orbital rim attachment so lower lid fat can be moved over the rim (PMID 7624408).
• Pseudoptosis: apparent sagging caused by volume loss (PMID 18520902).
• Ectropion: a lower lid that turns outward (PMID 36342769).
• Chemosis: swelling of the clear membrane over the white of the eye (PMID 42798641).

Papers