History

Surgery of the deep layer tissues of the face and neck is now established as a permanent part of facelift operations. There is no clear consensus as to how to treat the midface and its related nasolabial fold. Skoog introduced tightening of the midface superficial fascia and platysma muscle in the late 1960s, and Mitz and Peyronie verified the anatomy of the superficial musculoaponeurotic system (SMAS) in 1976. Surgery of the midface developed subsequent to descriptions of the retaining ligaments of the cheek, as the focus of facial rejuvenation extended to correction of the nasolabial fold. Masseteric-cutaneous and lateral zygomatic-cutaneous ligament release allowed lifting of the SMAS to correct the lower face below the zygoma. However, approaches to the prezygomatic SMAS developed in an effort to gain harmony of the upper and lower parts of the face. In this effort two different approaches are in use:

In the deep plane facelift the plane of the dissection for the lateral segment of the face is in the sub-SMAS plane, but more anterior the plane changes to become more superficial overlying the zygomatic muscles, therefore the cheek fat remains adherent to the skin flap. The composite facelift technique (this technique later modified by Hamra with the zygoorbicular dissection) continues the sub-SMAS dissection beneath the central part of the malar fat including the prezygomatic SMAS and the orbicularis oculi muscle and its fascia. Mendelson has noted that this prezygomatic space is a surgically safe space that can be entered through the lower eyelid or laterally through a space between the temporal and the zygomatic branches of the seventh nerve as is performed in the FAME (finger assisted malar elevation) technique.

Physical evaluation

Anatomy

The midcheek can be understood as part of the midface and refers to a part of the cheek medial to a line extending from the frontal process of the zygoma to the oral commissure and from the lower lid above to the nasolabial fold below. It is composed of two functionally distinct parts including the prezygomatic part over the body of the zygoma and maxilla and infrazygomatic part below, as described by Mendelson (Ch. 6). A major determinant of the shape of the midface is the underlying skeleton as it connects the orbital and oral cavities and provides a bony platform for their skeletal attachments and retaining ligaments of each muscle. The aging changes that appear in the midcheek largely reflect the effect of laxity and ptosis of the soft tissues relative to the underlying skeleton. This affects the upper face by revealing the anatomy of the orbit, with exposure of the bony orbital rim inferiorly, palpebromalar groove laterally, and nasojugal groove medially. The displaced soft tissue accentuates the nasolabial fold and reveals lower lid fat bulges. With soft tissue descent, laxity of the structures of the prezygomatic space including the orbital retaining ligament at its uppermost aspect and its roof (pars orbitale of the orbicularis oculi) are resisted by the zygomatic-cutaneous ligaments below. When visibly enlarged this area forms the clinical entity known as the malar mounds, also termed malar bags and malar crescent. It should be noted that the presence of the malar septum was described by Pessa and Garza and Pessa et al. to explain the clinical appearance of a black eye, and explain the anatomic basis of malar mounds and malar edema. Malar mounds should be distinguished from the malar fat pad. The anatomical terminology regarding this area can be somewhat confusing, as the malar fat pad is also simply known as malar fat.

Specifically, the malar fat pad is a term used to describe the subcutaneous fat of the medial cheek that exaggerates the nasolabial fold. The malar fat pad is a localized thickness of the subcutaneous panniculus adiposus (Fig. 7.1). The malar fat pad is of maximum thickness centrally in youth with a well-defined border at the nasolabial crease and less discrete border in the upper face as it blends imperceptibly into the lower lid with a gradual decrease in thickness over the prominence of the orbital rim and zygoma. The malar fat has upper, middle and lower components. The fullness of the nasolabial fold is in large part caused by the medial and inferior migration of the soft tissue medial to the zygomaticus major muscle (primarily the malar fat pad). It is triangular in shape with its base along the nasolabial crease, and its apex overlies the body of the zygoma. The malar fat pad firmly attaches to skin. It is easily separated from underlying fascia, and the malar fat pad moves forward and down perpendicular to the nasolabial crease during the aging process.

Fig. 7.1 Malar fat pad is a localized increase thickness of the panniculus adiposis.

The prezygomatic space overlies the body of the zygoma and the origins of the lip elevator muscles. It extends to the posterior border of the body of the zygoma and can be accessed from the lower temporal region and lower lid. The floor is a thick layer of preperiosteal fat with an overlying thin membrane which covers the origins of the muscle bellies of the lip elevators. The upper border of the space is formed by the orbicularis retaining ligament, which separates the preseptal from the prezygomatic space and becomes confluent at the inferolateral orbital rim with the broad lateral orbital thickening that overlies the frontal process of the zygoma. The zygomatic-cutaneous neurovascular pedicle is the only structure crossing this space as Mendelson has previously elucidated. The roof of the space is the orbicularis oculi and its investing fascia, which is contiguous with the temporoparietal fascia laterally. The inferior wall of the prezygomatic space is lined by a continuation of the preperiosteal membrane and the most cephalad of the zygomatic-cutaneous ligaments as they extend between the origins of the lip elevator muscles through the subcutaneous fat to the dermis. With blunt dissection in this space, as in the FAME procedure, the smooth surface of this membrane remains intact and preperiosteal fat remains attached to the underlying facial bones. Mendelson has noted that the prezygomatic space can be entered from (1) the lower eyelid; (2) the temporal area; (3) laterally passing between the seventh nerve branches as performed with the FAME procedure to enter the prezygomatic space (Fig. 7.2).

Fig. 7.2 Mendelson’s description of the prezygomatic space and the three access routes, lower lid, temporal and lateral.

Reproduced with permission from Mendelson BC, Muzaffar AR, Adams WP, Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002;110:885–896.

Technical steps

The senior author (SJA) began using the FAME technique in the early 1990s as a procedure in conjunction with a standard SMAS/platysma facelift to improve the midface and nasolabial fold. The FAME technique (finger assisted malar elevation) is a composite technique designed to elevate skin, lateral orbicularis oculi muscle, and reposition the malar fat pad. This technique is used in combination with skin undermining and a SMAS/platysma flap to correct the remainder of the laxity in facial and cervical areas. The description given here is as performed for approximately 14 years. Recent modifications since February 2006 will be described below.

In the temporal area the skin is undermined sharply for approximately half the distance between the ear and lateral canthus. The right index finger is rotated medially and inferiorly so as to separate the orbicularis oculi muscle from the temporal fascia; the lateral canthus is easily reached (Fig. 7.3).

Fig. 7.3 The right index finger is advanced across the temporal area separating the orbicularis oculi muscle from the temporal fascia.

Next, the facial and cervical skin flap undermining, as indicated for the individual, is completed. In the midface skin undermining is carried medially to approximate the course of the zygomaticus major muscle. In the lower face, when indicated by skin redundancy, undermining may be carried medially to the labiomandibular fold. The mandibular ligament is divided in most patients. Any anterior platysma procedures are completed. Complete submandibular and submental skin undermining and anterior platysma procedures are frequently indicated. Necessary anterior platysma procedures are performed prior to lateral platysma and cheek work.

Attention is now returned to the lateral canthus. With the index finger pulp surface down under the orbicularis oculi muscle pressure is exerted downward, inferiorly, and medially across the malar prominence (Fig. 7.4A&B). The orbicularis oculi muscle and the malar fat pad separate rather easily from the underlying fascia overlying the preperiosteal fat thus entering the prezygomatic space (Fig. 7.4C). The entire malar fat pad in undermined with the index finger going to near the nasal alar attachment (Fig. 7.4D). The index finger is turned over with the pulp surface up in order to permit leverage for complete mobilization of the malar fat pad. Bimanual palpation with one index finger in the “deep plane” helps evaluate malar fat pad thickness and mobility (Fig. 7.5).

Fig. 7.4 A, The index finger is passed under the lateral orbicularis oculi muscle. B, The index finger is turned to pass under the orbicularis oculi muscle and to enter the prezygomatic space. C, The index finger is advanced into the prezygomatic space under the orbicularis muscle and the malar fat pad. D, The index finger is advanced to the base of the prezygomatic space.

Fig. 7.5 Bimanual palpation determines the thickness of the malar fat pad and mobility.

At this point the levels of dissection have been established (1) subcutaneously and (2) underneath the malar fat pad and orbicularis oculi (in the deep plane and a composite flap). The subcutaneous soft tissue bridge separates the two planes at the lower quarter of the malar prominence. Redraping of the composite flap in a cephaloposterior direction with the emphasis on the vertical vector will demonstrate repositioning of the malar fat pad to its earlier location over the malar prominence. If more mobility is needed for repositioning of the malar fat pad, the subcutaneous bridge is dissected until the desired mobility of the composite flap is achieved.

Next, attention is directed to developing a SMAS/platysma flap. The lateral border of the platysma muscle is incised at the anterior border of the sternocleidomastiod muscle and carried from the angle of the mandible inferiorly 7–8 cm below the angle of the mandible. Subplatysmal dissection is carried medially for 4–7 cm, depending on the amount of platysma mobility needed for the individual patient. The zygomatic arch is palpated with fingertips to determine its exact location, and an incision is made through the SMAS along the lower border of the zygomatic arch extending from approximately 5 mm anterior to the base of the tragus to approximately 1 cm from the subcutaneous bridge separating the deep plane and subcutaneous plane.

A SMAS flap is developed going inferiorly to join the subplatysmal dissection and going medially anterior to the parotid gland until the desired flap mobility is obtained. The SMAS platysma flap and, when indicated, anterior platysma procedures give independent control for lower facial and cervical contouring. The SMAS/platysma flap is elevated and rotated in the cephaloposterior direction with the vectors of lifting and repositioning according to the anatomy of the patient and the desired facial contouring.

Excess SMAS is then resected along the horizontal SMAS incision line and sutured to the incised SMAS edge. In the preauricular area the SMAS is then cut vertically creating a small SMAS flap, which is positioned behind the ear and sutured to the sternocleidomastoidmastoid fascia to help with jawline contouring. The lateral platysma is sutured to the sternocleidomastoid muscle fascia. Final jawline fat contouring is carried out by open suction lipectomy or sharp dissection.

The description of the technique above is as performed by the senior author for approximately 15 years. Most cases were performed without malar fat pad fixation to the zygoma. However, in some patients the malar fat was sutured to the periosteum of the zygoma to help maintain the vertical vector. In February 2006 the senior author modified the technique by extending the SMAS flap through the subcutaneous bridge between the deep plane and the subcutaneous plane. It is now an extended SMAS flap joining the FAME composite deep plane flap, thereby giving more mobility to the malar soft tissue (Fig. 7.6A&B). The SMAS flap is not excised but sutured to the temporal fascia (high lamella fixation) in order to maximize the vertical vector of the midface repositioning (Fig. 7.7A). The elevated malar fat pad is sutured to the periosteum of the zygoma in a vertical vector (Fig. 7.7B). In patients with a thin or poor quality SMAS, the FAME technique can be performed with plication of the SMAS. Likewise, a smasectomy can be performed with the FAME in patients where it is desirable to excise facial fat.

Fig. 7.6 A, Extended SMAS flap showing dissection medial to the zygomaticus major and joining the FAME dissection. B, Intraoperative photograph showing zygomaticus major muscle and gauze in the prezygomatic space.

Fig. 7.7 A, Vertical vector elevation of extended SMAS flap and malar fat pad. B, Flap sutured to temporal fascia and zygoma at lateral canthus. Excess preauricular SMAS flap transposed and sutured to sternocleidomastoid fascia.

Redraping of the skin flap in the cephaloposterior direction repositions the malar fat pad and orbicularis oculi muscle. In general, the maximum vertical vector possible is desired in order to return the malar soft tissue onto the malar prominence. An incision is made beneath the temporal hairline so as not to narrow or elevate the sideburn. A Burrow’s triangle is excised so as to place only minimal tension on the elevated and rotated skin flap. Excess tension will only result in scar migration and add nothing to the lift. In the vast majority of patients, an incision along the anterior hairline is avoided entirely. When a small “dog ear” is present at the end of the transverse incision under the hairline, a small anterior hairline incision (5 to 7 mm) will eliminate the “dog ear” and permit restoration of the sideburn shape and position. The remainder of the skin flap is trimmed and sutured in a routine fashion. The FAME procedure can be performed with a short scar facelift technique or conventional scar technique, where the posterior scar is curved in the mastoid hair so as to be as almost imperceptible. Pre- and postoperative views of patients who have undergone a facelift with the FAME technique are shown (Figures 7.C1–C5).

Fig. 7.C1 A 58-year-old-patient following facialplasty with FAME technique, extended SMAS/platysma flap, endoscopic browlift and lower lid blepharoplasty. Postoperative photographs show lower and midface repositioning and lateral orbicularis tightening.

Fig. 7.C2 A 59-year-old patient 10 months postoperative facialplasty with FAME technique, extended SMAS, laternal platysma dissection, high lamella fixation, chin implant, 4-lid blepharoplasty, erbium laser resurfacing lower lids and rhinoplasty. Postoperative photographs show repositioning of mid and lower facial soft tissue and lateral orbicularis tightening.

Fig. 7.C3 A 58-year-old patient 1 year postoperative facialplasty with FAME technique, SMAS/platysma flap procedure and 4-lid blepharoplasty. Postoperative photographs show repositioning of thick, heavy midface and lateral orbicularis tightening.

Fig. 7.C4 A 55-year-old patient 2 years postoperative facialplasty with FAME technique, SMAS/platysma flap procedure, 4-lid blepharoplasty and chin implant. Postoperative photographs show mid and lower face correction and lateral orbicularis oculi tightening.

Postoperative care

Standard postoperative facelift care is used. A facelift dressing is placed in the operating room and removed the first day after surgery. Treatment of hypertension and maintenance of blood pressure is stressed especially in the perioperative period, and drains are usually removed on the first postoperative day. The following information is typical of that given to our facelift patients.

Complications

Possible complications are those of a standard facelift. Serious complications from facelift surgery are extremely rare. As with any surgical procedure, complications and risks can often be minimized if the operation is performed by an experienced surgeon who has performed many facelifts. Complications of any facelift include bleeding (hematoma), infection, prominent or widened scars, alopecia, or nerve damage. Sequelae specific to the FAME facelift that patients should be advised of is the possibility of midface edema that resolves usually over the first 2 to 3 months. However, all facelift techniques have some edema that resolves over this amount of time.