Endoscopically Assisted Triple-Suture Midface Lift: A Refined Cable-Suture Technique

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Superior repositioning of ptotic malar fat pads in an aging face is considered a key element in midface rejuvenation [2, 4, 5]. Several surgical techniques have been developed to achieve this goal, but many remain technically challenging or are associated with increased patient morbidity [6, 7]. The unique anatomy of the malar fat pad, loosely attached to the superficial musculoaponeurotic system (SMAS), makes elevation of the malar fat pads via traditional methods of SMAS rhytidectomy less than optimal [1, 2]. The principle of transcutaneous suspension of malar fat pads with cable sutures was introduced in 2002 [7]. The cable-suture technique can provide both restoration of volume and optimal repositioning of fat pads. Based on this, we developed the endoscopically assisted triple-suture midface lift (‘‘3S’’ midface lift) technique to enhance the midface lift through three sets of suspension sutures, all anchored to the deep temporal fascia: (set 1) transcutaneous suspension cable suture around the nasolabial fold, (set 2) suspension suture on the apex of the malar fat pad, and (set 3) temporal scalp dermal suspension suture. Preoperative markings are drawn with the patient sitting. The nasolabial crease is marked, and a point is marked on the midpoint along a line 5 mm lateral and parallel to the nasolabial crease. This is where a stab incision will be made for the insertion of a cable suture. The vector along which the cable suture will be pulled is perpendicular to the nasolabial crease. Another point 20 mm below the lateral canthus is marked, indicating where the suspension suture on the apex of malar fat pad will be placed. This point is similar to Tonnard’s point [8, 9] The temporal scalp incision is about 20 mm behind the hairline. This procedure can be performed with the patient under local or general anesthesia depending on what other accompanying procedures are being performed simultaneously. The temporal incision can be extended caudally to join the preauricular incision of open rhytidectomy or be a standard temporal working port for an endoscopic forehead lift. The dissection is performed with the help of a 3-mm 30 endoscope on the plane between the superficial and deep temporal fascia. The dissection is carried gradually into the midface between the suborbicularis oculi fat and the orbicularis oculi muscle [3]. After the midface is entered, further dissection is performed bluntly into the cheek region. Figure 1 shows the extent of the dissection. The cable suture is inserted through the stab wound lateral to the nasolabial crease using the method described by Sasaki and Cohen [7]. The thread of the cable suture is passed through to the temporal incision. Under direct vision by the endoscope, a hemostat is inserted to grasp the apex of the malar fat pad at the previously marked point below the lateral canthus. After confirmation of adequate malar fat pad movement, a 4-0 Prolene suture is passed through and also brought out through the temporal incision. Both the cable suture and the malar fat pad suture are anchored to the deep temporal fascia and tied with maximal tension. The medial edge of the temporal scalp wound then is deepithelialized to a width of about 3 mm. The deepithelialized portion is anchored to the deep temporal C.-C. Yu R. Tsai T.-C. Tung (&) Celebrity Cosmetic Center, 3F-1, 243, Sec. 1, Fu-Hsing S. Rd, Taipei City 10666, Taiwan e-mail: tung@celebritycosmetic.com