Understanding of malar fat pad crucial to middle face facelift success

The key to an effective and long-lasting midface facelift is understanding how to safely reposition the malar fat pad. "The most important advance in facial rejuvenation in the past 25 years has been our understanding of the mid-face," says Luis Vasconez, M.D., professor, division of plastic and reconstructive surgery, University of Alabama, Birmingham. Key to this understanding is the so-called malar fat pad, which he says is a misnomer: "It is not fat, but fibroadipose tissue."

Objectives of midface facelifting include elevating the corners of the mouth, restoring the prominence of the cheek (particularly along the zygoma), improving the nasojugal folds and elevating the jowls, Dr. Vasconez says.

"People talk about vectors," he adds. "But I would suggest paying attention to only one vector — the movement of the deep structures, as well as the skin, vertically. That way, you will avoid the stigma of the facelift that gives the patient a windswept appearance."

The malar fat pad is a superficial structure distinct from the superficial musculoaponeurotic system (SMAS), he says. "If one gets to the lateral edge of the malar fat pad, pulling on this structure vertically gives fullness to the cheek and elevates the corner of the mouth. If one is not elevating the corner of the mouth, one has not grasped the malar fat pad.

"I approach the malar fat pad from the lateral aspect and suture it to the deep temporalis fascia at a distance," Dr. Vasconez says. Suturing in this location is not absolutely necessary. "One could instead anchor the suture to the zygomatic arch, but I prefer to anchor it to the deep temporalis fascia because this does not put any pressure on the frontal branch of the facial nerve."

Moreover, he says suturing to the deep temporal fascia "holds quite well. In fact, we use the 3-0 nylon suture, which research has shown will break before it pulls out of the malar fat pad (de la Torre JI, Martin SA, Vásconez LO. Aesthet Surg J. 2002;22(5):446-450)."

The SMAS starts along the platysma and continues to the orbicularis muscle, says Dr. Vasconez. Accordingly, one can conceive of it as a unique layer that extends all the way across the midface, he says. "The SMAS layer does have some bony attachments, which are usually on the zygomatic arch and along the horizontal ramus of the mandible," he says.

Complications such as asymmetries, where one cheek may appear more prominent than the other, can occur. According to Dr. Vasconez, this asymmetry cannot be avoided, but fortunately, the aesthetic aspect of the asymmetry is not that much of a problem.

"Due to the fact that most of us are born with existing asymmetries in one half of the face as compared to the other, this 'new' asymmetry may even go unnoticed. However, as a rule, presurgical existing asymmetries should always be pointed out to the patient to avoid any unwanted surprises post-op," Dr. Vasconez says.

One can also perform a midface facelift through a lower eyelid incision subperiosteally. According to Dr. Vasconez, this approach is also an effective method in elevating the mid-face. It has been found necessary to perform a canthotomy, however, dividing the canthus laterally on each side of the face, he says.

"It is easy to restore the canthus; however, it is very difficult to get symmetry when one does both or restores both," Dr. Vasconez says. "For this reason, the subperiosteal approach through the lower lid has been supplanted by a subperiosteal approach through the upper lid without cutting the canthus. Though considered a safe approach, the subperiosteal approach ... is not as popular in elevating the midface."