One of the earliest signs of aging is the sagging that occurs in the midface. This can begin to develop in women as early as their thirties and steadily progresses as they advance into middle age. The slow descent of the midface results in a number of aesthetic issues because of its central location in the face and its association to many surrounding structures.

The most common complaints are of a gradual hollowing around the lower eyelid, the development of folds from the nose to the corner of the mouth and a droop at he corner of the mouth. Beyond adding to the apparent age of a person, these changes can give the appearance of fatigue and poor rest. Until recently addressing this early but important component of the aging process required extensive midface lift procedures which often resulted in weeks of swelling and recovery. Because of this serious trade off, the area was often ignored and allowed to deteriorate while patients addressed other more easily remediable areas such as their eyes or neckline.

Mid-Facial Aging

The critical anatomical element that is responsible for the effects of midfacial aging is the fat pad that rests in the cheek called the malar fat pad. In our youth this fat pad sits along the "cheekbone" segment of the face under the eyes. They provide fullness to the eyes and cheek and a youthful contour to the face. As time progresses, gravity begins to pull this fat pad down. As it descends it causes a fold to develop between the nose and the corner of the mouth. This fold is called the nasolabial fold. While the descending fat makes this fold more prominent it leaves a deficit in its original location under the eye. This region becomes hollowed and often appears to have dark circles because of the shadowing of light in the area.

Mid-Face Lifts

Traditional methods to lift up this fat pad involved incisions around the hairline and ear along with extensive surgery to traverse the face to reach this fat pad. Sutures are then placed in the fat pad as it is pulled back up to its original location. While effective in replacing the fat pad to its original position these techniques required a tremendous amount of surgical dissection through regions of the face which had nothing to do with the aging effects of the malar fat pad descent. Important branches of the facial nerve which move the face can be placed at risk trying to reach the cheek fat pad with the traditional lifting approach.

These problems led to the search for a more effective way to address the malar fat pad descent. In the late 1990's in Los Angeles a group of ophthalmologists and facial plastic surgeon developed a suture-based technique that allowed a simple resolution of this problem in a minimally invasive fashion. This technique was called the Percutaneous Midface Lift (PML) or cheeklift for short.

Percutaneous Mid-Face Lift or "Cheeklift"

The basic premise of this procedure is quite simple and elegant. Instead of traversing though the face to get to the cheek fat pad to place a suture, what if the suture was placed from the front and the fat pad were suspended by passing the thread via a specially designed needle through a small incision in the hair. In essence, as long as the suture is anchored in the malar fat pad, the final effect of the suspension is identical to the tradition methods of lifting all the skin to find the fat pad. The technique is shown in figure 1.

The development of this technique has revolutionized management of the midface. The PML can be done with local anesthesia with light sedation. The procedure is an outpatient procedure which only takes about 40 minutes to complete and patients are generally fully recovered within a week. The risks to the facial nerve and other structures are avoided by eliminating all the surgical dissection. And finally, unlike any other face-lifting procedure, the results are adjustable or reversible if necessary. Simply opening up the small hairline incision the suture can be adjusted or released to achieve the desired modification.

Dr Alam was involved in the development of this procedure when he was a clinical instructor in the division of facial plastic surgery at the UCLA medial school. He was involved in the largest published clinical series on this technique and written and spoken on the topic to plastic surgeon throughout the country.

Am I a Candidate For The Cheeklift?

This technique is ideal for addressing aging tin the midface but is only useful for this indication. Jowling, sagging along the neckline as well as heaviness in the brow and upper eyelids are not addressed by the PML. They must be managed by separate techniques. These can be done along with the cheeklift to achieve a balanced final result. When done in isolation the midface lift is perfect for the person who has developed some prominence of their nasolabial fold, hollowing in their eyes but is otherwise still not ready for the time, recovery and investment involved in a facelift. It is a minimally invasive and far less expensive procedure than the traditional facelift with much less recovery time.

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