Malar suspension and meloplication performed with either the suture suspension technique or a procedure using a bioabsorbable suspension device (Coapt Endotine Midface ST 4.5, Coapt Technologies) offer a minimally invasive, safe and effective physiologic approach for restoring a natural, more youthful appearance to the midface, according to William Beeson, M.D.
Speaking at the 26th annual scientific meeting of the American Academy of Cosmetic Surgery, Dr. Beeson explained that the appearance of nasojugal lines, infraorbital hollowing, malar flattening, cheek ptosis and nasolabial folds develop as early signs of midface aging and are the result of anterior, lateral and downward descent of the malar fat pad.
As popularized by Gordon Sasaki, M.D., and Greg Keller, M.D., both the suture suspension technique and the Coapt Endotine approach are designed to reposition the descended midface cheek mass by about 3 mm to 5 mm and offer an anatomic solution to the underlying cause for the facial changes.
“The malar fat pad lies immediately superficial to the SMAS and is more adherent to the subcutaneuous tissue and dermis than it is to the SMAS. Therefore, it can be easily separated and moved. Furthermore, because the SMAS is contiguous with the zygomaticus major and minor muscles, the dissection and passage of needles in these procedures occurs in a safe zone,” says Dr. Beeson, clinical professor, departments of dermatology and otolaryngology — head and neck surgery, Indiana University School of Medicine, Indianapolis, and director, Beeson Aesthetic Surgery Institute, Carmel, Ind.
“These techniques for midface rejuvenation are quick outpatient procedures, and they are very effective for creating three-dimensional improvement that is esthetically pleasing, long-lasting and associated with high rates of patient satisfaction,” he explains.
Surgery vs. fillers
As the landscape of the aging midface represents a situation of hills and valleys, use of injectable fillers to elevate the valleys may be considered as another minimally invasive approach to midface rejuvenation. However, soft tissue augmentation with dermal fillers really only produces satisfactory results when the depth of the nasolabial fold is minimal, and even then it provides more of a pseudocorrection, Dr. Beeson says.
In more advanced cases of midface aging, a higher volume of filler material is required, increasing the cost of the procedure. Then the benefit only lasts about six months, and the filler material may even accelerate the aging process by stretching the skin in a viscoelastic effect.
Use of more permanent filler materials may cause alterations in the dermal and subdermal architecture that might compromise the results of future surgical correction by increasing the risk for asymmetry, Dr. Beeson adds.
Midface surgery summaries
The suture suspension technique uses two sets of permanent sutures with a small Goretex graft to create a hammock that lifts and pulls the malar fat pad in a superior lateral direction. The sutures are introduced through two dot skin incisions adjacent to the nasolabial line, and they are fixed to the superficial layer of the deep temporal fascia, securing the malar fat pad elevation.
The procedure can be completed in just seven to 10 minutes per side, is easily done under local anesthesia and is associated with little, if any, postoperative discomfort. There can be some transient dimpling at the site of needle introduction, as well as a mounded “chipmunk cheek” appearance that also resolves over time.
“Patients are generally highly satisfied with the results, but the surgery can also be easily reversed by clipping the suture through the temporal incision,” Dr. Beeson notes.
In the Endotine technique, the appliance is inserted via an intraoral approach with dissection similar to that performed for placement of a malar implant. The appliance is fixed into the superficial layer of the deep temporal fascia to provide mechanical fixation of the malar fat pad suspension. Its copolymer material is absorbed over time while biologic fixation takes over.
Relative to the suture suspension, the Endotine procedure takes a little longer, about 10 minutes to 15 minutes per side, but it enables better control of the midface elevation and projection. As it involves subperiosteal dissection, only select patients will tolerate surgery under local anesthesia only. In addition, the appliance is sometimes palpable until it is absorbed. However, increased cost is probably the major downside of this procedure, Dr. Beeson says.
Positive outcomes
Personal experience indicates these midface suspension procedures are associated with high rates of patient satisfaction, although that is somewhat of an interesting phenomenon considering that comparisons of before and after photographs do not reveal striking differences, Dr. Beeson says.
“The improved appearance is really a three-dimensional effect that can not be appreciated in a two-dimensional photo. Patients are generally happier with their results than I am, and these midface procedures are very popular as a result of referrals from satisfied patients,” he says.
Literature reports also document excellent outcomes, but indicate there is a learning curve such that better results are obtained in more experienced hands. Sasaki reports the largest series including almost 400 patients with follow-up to six years after suture suspension. His results show that 85 percent of patients rated their result as good or excellent, and complications were minimal with an early asymmetry (3.8 percent) and early dimpling (3.6 percent) being the most common events, and only a single case of track infection (0.3 percent).
Keller reported on 115 patients with one year of follow-up after suture suspension. Temporary asymmetry affected 6.8 percent of patients, there was a 1.7 percent infection rate and 1.7 percent of patients required revision surgery.
“In contrast, LaFerriere, who only reported six-month outcomes for about 50 patients, noted a 20 percent revision rate,” Dr. Beeson says.
Standalone or combined
Candidates for these minimally invasive procedures for midface rejuvenation include patients in their 30s without excessive facial skin laxity, as well as postrhytidectomy patients who have experienced new signs of aging associated with descent of the malar fat pad. In addition, the midface procedures can be combined with traditional or minimal undermining (eg. S-lift) facelift procedures where their use would enhance the overall aesthetic outcome as well as the longevity of the results.
“Repositioning of the malar fat pad is not effectively accomplished during a facelift procedure, and as noted by Yousef and others, dissection and repositioning of the SMAS during a facelift will not correct the nasolabial fold and may even deepen it,” Dr. Beeson says.
Disclosures: Dr. Beeson was previously a consultant to Coapt.
