As our concept of facial rejuvenation has evolved, the midface has become an area of interest to oculoplastic surgeons. The midface is involved in the extended eyelid complex and also is affected by descent of the facial tissues during the aging process of the body. Drooping of facial skin and deepening of the nasolabial sulcus are characteristic features of midface descent. Several surgical methods that achieve vertical elevation are available to address this problem1. Today, the surgical techniques are shaped by an improvement in inert suture materials and interest for less invasive surgeries by the public. Herein, we describe and report the results of a simple and effective treatment for midface descent which is less invasive than the traditional deeper plane facelift surgeries. The purpose of the current paper is to describe two years follow up of 35 patients with mid-face descent of various causes who were operated using suture mid-face cable suspension at the division of orbito-facial surgery, Jules Stein Eye Institute.

We reviewed the charts of 35 patients who underwent suture facelift surgery and at least 2 years of follow up after the operation. In this series, the procedure was performed either as primary surgery or as an adjunct to other oculoplastic procedures such as upper and lower blepharoplasty, endoscopic brow lift and neck liposuction.

All patients were assessed using pre- and post-operative full face photographs. Digital images were taken and recorded in the electronic medical record of the oculoplastic registry at the Jules Stein Eye Institute at each postoperative visit. Images were reviewed by two independent observers.

Facial symmetry and a satisfactory midface lift were obtained in all patients with this procedure (Figures 6, 7). Local soft tissue reaction in the stab wound sites were observed in 2 patients immediately after the operation probably due to the Gore- tex. This reaction subsided quickly with the use of a tapered dose of oral steroids (Methylprednisolone dose package).

Facelift surgery is a part of facial rejuvenation. The main goal of surgery for facelift is to achieve a vertical elevation. It is in constant evolution, but is somewhat limited since the aging changes in the lower face are not completely addressed by current surgical techniques23.

A combination of gravity and loss of elasticity and tone causes facial aging4. The sagging of the malar fat pad over the nasolabial folds contributes to a deeper appearance of these folds with time. Especially in patients at around the 40 year-age group, other signs of facial aging are not yet prominent. As classic techniques of facelift result in only modest improvement of deep nasolabial folds, in these cases a less invasive technique directly addressing the problem would be the procedure of choice. Suture midface suspension is especially helpful for the patient who is primarily concerned with midface descent.

Facelift surgery has some potential complications. Probably the most important one is damage to the facial nerve causing partial or complete facial palsy. Parotid duct injury may also occur. Flap necrosis and compromised wound healing causing scar tissue on the face are also important complications especially for smokers and vegetarian patients. Using an inert suture material to suspend the malar tissues above the nasolabial sulcus solves the problem in a simple and less complicated way. Softening of the nasolabial fold and lifting the malar fat pad can be achieved by these sutures.

On the other hand, suture midface suspension does not address all components of facial aging, such as fat atrophy. There is also a question of how long it lasts. The limitations of this technique should be explained to the patient before surgery.

A similar technique was previously described by Keller and associates5 who evaluated 118 patients undergoing percuatneous malar fat pad elevation; at 3 months, all but two patients had a significant elevation of the malar fat pad of 3–7 mm. This procedure was associated with very little morbidity.

Suture midface suspension has the following advantages over deep plane facelifts: minimally invasive technique, performed under local anesthesia and relatively short procedure. However this technique has the following potential disadvantages: since there is no periosteal release and undermining the potential for significant and lasting elevation and repositioning of the malar mound may be limited; it is a blind procedure; hence it may carry the risk for neurovascular damage and finally stab incisions are done in visible, prominent areas. In addition skin irregularities (dimpling and bouncing) may appear at fixation points and sutures passed under the thin skin of the lateral canthal area may be palpable by the patients. Fixation to deep fascial plains such as deep temporalis fascia and passing the sutures at the SMAS levels may prevent these possible complications.

Our follow-up showed a reasonable cheek elevation and patient satisfaction. The results were more dramatic with moderate nasolabial folds and less dramatic in older patients with heavy nasolabial folds. This is as a result of inadequate suspension of the fat pad superiorly. We found this technique to be a useful adjunctive procedure in young patients who were undergoing surgery for facial rejuvenation and also in older patients who had previously undergone facelift surgeries. Further studies are warranties to evaluate the long term effect of suture midface suspension.