The midface-cheek area spans the face from the eyes to the corners of the mouth. With age, the cheekbones' skin and underlying tissues begin to recede from lack of tone and natural thinning. The less-supple cheek grows more vulnerable to gravity, which pulls its skin and soft tissue toward the mouth. This condition, in turn, often deepens the tear troughs between the lower eyelid and the cheek into slight cavities, where "bags" of drooping skin and darker circles can develop.
At the lower edges of the midface are naso-labial lines, which form between the outside corners of the bottom of the nose, near the nostrils, and the corners of the mouth. These lines grow deeper and more pronounced with sagging cheek tissue and years of broad smiles.
A midface-cheek lift is a common cosmetic procedure in which the surgeon elevates that area through an incision behind the temporal hairline or at the lower eyelid. Surgery to this area can create a youthful, rejuvenated appearance. Often a dermal filler – a bio-friendly substance – is injected in concert with the surgical procedure to help support the cheek's new position, soften lines, and increase volume in cavities under the eyes.
Who seeks this surgery?
People who consider a midface-cheek lift for cosmetic reasons typically are 40 or older, and have faces with heavy lines or sagging skin. Many women in that age range and younger simply want the appearance of higher cheekbones. Often the procedure is done in tandem with a blepharoplasty, eyelid surgery, as the lower eyelid joins with the cheek. People who want to transform their “tired” eyes commonly seek an appearance in which their cheek volume is increased and/or cheek position is raised.
Eye expertise distinguishes oculoplastic surgeons
Ophthalmologists and oculoplastic surgeons draw on expertise gained from treating patients' eyes and surrounding musculature and tissues, including the tear drain and orbit. They are adept at recognizing how small surgical changes can significantly improve a person's appearance and expression. They understand subtleties of the facial areas' convergence zones, skin tension, and fat deposits. They know how to achieve desired results without overcorrecting – which can make a face appear unnaturally taut or give a person a look of perpetual surprise.
Based on an initial exam, the physician will identify the extent to which the cheek area can be raised (and still maintain natural alignment with other facial structures), and communicate his recommendations to the patient. Based on the patient's perceptions and desires, the surgeon will decide which of two surgical approaches described below will appropriately raise the cheek mound. The physician might recommend against cosmetic surgery if the person has underlying health issues such as diabetes or some other condition that inhibits their ability to heal. Patients with heart/lung disorders often cannot undergo anesthesia. As well, patients who use blood thinners or smoke might not be good candidates for elective surgery.
See Procedural Details for the surgical approaches and the use of dermal fillers and Botox®.
Augmentation with dermal filler
Surgeons can augment that midface-cheek region with injections of body-friendly filler material. Synthetically manufactured hyaluronic acid, marketed under brands such as Juvederm and Restylane, is chemically identical to the naturally occurring substance in the body.
Small volumes of the gel-like material are strategically injected into the skin’s underlying tissue to create volume and help support skin.
Injection treatments can increase volume at the tear trough, where the cheek meets the lower eyelid. This can restore the cheek's soft curve at that spot and artistically camouflage dark circles or bags of skin that have emerged. The injected materials also can reduce or soften the naso-labial lines between the nose and mouth by supporting the cheek from below.
For any site, multiple injections are typical to ensure that the material is distributed evenly into the skin's underlying tissue. The volume of injected material is small, and varies among patients and among injection sites. For instance, 0.5 cc would be sufficient for the area under the eye. Sometimes a superficial injection is more beneficial, sometimes the material must be dispersed relatively deep, near the patient's bone.
Deftly applied treatments with these fillers can restore fullness in areas that have lost volume (under the lower eyelids, along jaw lines) soften deep lines on the forehead and around the eyes and mouth, and support the elevation of droopy jowls and neck skin.
The effect of filler material is temporary. The body metabolizes the material over a period of six months to two years; their longevity varies among patients and depends somewhat on the anatomic site of injection. For instance, materials injected around the naso-labial lines and mouth would be metabolized faster than materials injected around the cheeks and eyes. Periodic augmentation treatments would be necessary to maintain the positive effects.
Injections alone are more common among people in their 30s and 40s, who are more often intent on building volume and raising the cheek position. People in the 50s and 60s often more intent on reducing heavy lines and sagging skin, and are better served by a combination of filler and surgery to elevate the midface-cheek area.
Botox does not involve surgery, but is identified here for comparison’s sake. Unlike the filler material described above, Botox relaxes muscles in the face, so a person's expressions are not as animated or severe, and skin will not be as creased and wrinkled as it normally would be. Botox often is used on the forehead and around the eyes, along the jaw line and, sometimes, in the neck. It is rarely used on the cheek. The effects of a Botox injection are temporary, and would require re-injection every three to six months to maintain the physical effect.
Endoscopic midface lift
In this surgical procedure, a small incision is made approximately 20 mm behind the hairline, above the temple on either side of the face. From these incision sites, the surgeon works under the skin relatively deeply, almost at bone level, manipulating instruments and a lighted telescope. The surgeon clasps tissue below the cheek and draws it up, re-suspending the cheek mound by suturing the periosteum tissue to the deep temporalis fascia, the fibrous sheath that covers a layer of muscle in the temple area.
As a result, the cheek mound at rest is at a more youthful position. Its exact positioning depends on the patient's desires and what is anatomically possible to achieve a natural result. Women typically want their cheeks at a higher position than men. Some patients simply want to stabilize their cheeks at their current height so their naso-labial lines don't become more prominent, or slightly raise the cheek so it better supports the lower eyelids, in concert with a blepharoplasty procedure.
The procedure is performed in an operating room, with the patient asleep under general anesthesia. It takes about two hours to complete both sides of the face. Patients can expect the procedure’s benefits to last six to 12 years.
SOOF (sub-orbicularis oculi fat) lift
A less aggressive procedure to the cheek is a SOOF lift. Its outcome is more subtle, and might be more desirable for a younger patient, perhaps his/her 20s or 30s, who does not need a dramatic cheek lift.
The surgeon makes an incision in one of two places – either on the skin at the bottom edge of the lower eyelid or inside the lower eyelid. The fat under the eye is repositioned and, as with the endoscopic midface lift, the cheek mound and underlying tissue are elevated and sutured in place at a higher position on the face.
The SOOF lift can be performed in an operating room or in a clinical procedure area, with the patient in sedation-induced twilight sleep or, sometimes, awake with local anesthesia to numb the area. It takes about two hours to complete both sides of the face. Patients can expect the procedure’s benefits to last six to 12 years.
Intravenous sedation and/or general anesthesia will be given to you before surgery. Your doctor will recommend the best choice for you.
In the days before surgery, the patient will start a regimen of antibiotics to guard against infection. Antibiotics are continued after surgery, and analgesics are prescribed to relieve pain.
People who are unhappy with the effect of aging or trauma’s effects on their cheeks and between their eyes and mouths foreheads, or who desire a more youthful or otherwise refreshed appearance are candidates for midface-cheek lift surgery. Patients should be physically healthy, have realistic goals for surgery, and fully comprehend the procedure’s limitations.
Women and men don't necessarily benefit equally from the same approach. For example, the endoscopic midface lift’s incisions behind the hairline wouldn’t be appropriate for a balding patient. Potential for scarring also could influence surgery decisions. Patients who are diabetic or who smoke sometimes don't heal well; those factors could influence the decision, as well. Patients who smoke might be required to stop the habit months in advance of surgery.
Anecdotally, most patients are highly satisfied with the results of a midface-cheek lift. The effects of a surgical lift have far greater longevity (10 to 12 years) than an injection of dermal filler (six months to two years).
Education is very important to patient satisfaction. During the evaluation, the surgeon and patient must clearly identify the goals to determine whether they are achievable, and set expectations appropriately. Patients who have reasonable expectations about what the surgery or dermal filler can deliver are much more likely to be satisfied with the outcome.
The dermal filler injections are of hypoallergenic gel, so typically they carry no risk, though medical literature has identified rare incidences of a patient’s negative reaction. The main reaction to an injection is bruising at the puncture site.
As with any surgery, the endoscopic midface lift and SOOF lift pose risk of infection and bleeding. Other risks include the following:
- Heavy scarring
- Dryness, itching or hair loss at the incision site
- Slow healing
- Under-correction or over-correction, compared with goals (With gel injections, if over-correction is noted, an enzyme can be applied immediately to turn the gel to water.)
- Paralysis to part of the face, due to nerve damage (rare)
The injections are done on an outpatient basis. Most patients who receive dermal filler injections don’t need to take time off from work. Cold compresses might improve the patient's comfort and help diminish bruising.
Patients who undergo the endoscopic midface lift or SOOF lift should plan to be away from work for about a week – longer if work involves manual labor. Additionally, for two weeks patients should refrain from physical activity that might jar loose the sutures holding cheek tissue in place. Bruising will last for one to two weeks, typically, but swelling can be managed with regular application of cold compresses. Patients are cautioned to keep incision sites for the first couple of days after surgery, and to touch their face minimally and, when doing so, gently.
Patients who undergo the endoscopic midface lift or SOOF lift must apply antibiotic ointment to the incision site for several days after the procedure; commonly the ointment gets into the eyes and blurs vision for SOOF lift patients. Patients also must take oral antibiotics to minimize the chances of infection postoperatively. Patients typically receive a prescription for pain medication that they can fill to help manage postoperative pain.