Does the Technique Achieve the Set Goals

Virenque [45] mentioned in 1925 that there is an anterior mobile area of facial expression and a posterior more stable parotid-masticatory region and recommended oblique supero-lateral sutures for stabilization of the anterior region. In 1959 Aufricht [1] used a plication of the subcutaneous tissues. In my opinion the vector should be a deep plane vertical upward rotation; however, with only a minor posterior displacement at the skin level. It should be a vertical lifting and not a major posterior "pull", which produces a "high-speed look".

The vertical lifting elevates and stabilizes the anterior mobile area of facial expression, i.e. the lateral two thirds of the brow and infrabrow segment, the lateral canthal region and lateral two thirds of the orbicularis muscle, which are laterally rotated upward around the fixed point of insertion of the lateral canthal ligament at Whitnall's tuberculum.

Thus, the patient regains the looks of his/her youth by displacing the ptotic tissues to where they were located. The distance from the eyelid rim to lateral brow increases by lifting the brow, thus giving the eye a "clearer" appearance. The height of the lower eyelid decreases as does the depth of the naso-palpebro-ma-lar sulcus. The aspect of the lateral canthal region substantially improves by a moderate elevation with correction of crow's-feet. However, an additional can-thoplasty or canthopexy is required whenever the slant of the palpebral fissure should be considerably improved. Lower eyelid bags, and a "skeletonized" appearance [8], are corrected. The oblique malar or "social" profile, as also seen in a frontal view, improve by the increased soft tissue malar volume, without the need of a malar implant, as long as there is not a real bony hipoplasia. The ptotic cheeks are elevated so that the flat midface contour becomes full and round in a lateral or oblique projection with the increased volume of youth (Little's "ogee curve" [31]).

This volumetric goal is achieved without changing the volume by plication but only by elevating the ptotic tissues to the location they had in youth (Figs. 41.13, 41.14). The naso-labial fold is decreased owing to the fact that there is no overhanging of ptotic midface fat tissue.

Flat Midface
  1. 41.13. Result 2 months after vertical periocular and midface as well as cervico-facial rhytidectomy, blepha-roplasty and rhinoplasty. Notice the improvement of the upper eyelid, partially covered by the ptosis of the brow and infrabrow segment; the decrease in height of the lower eyelid; the recovery of midface fullness, achieved by elevation of the ptotic midface tissues
  2. 41.13. Result 2 months after vertical periocular and midface as well as cervico-facial rhytidectomy, blepha-roplasty and rhinoplasty. Notice the improvement of the upper eyelid, partially covered by the ptosis of the brow and infrabrow segment; the decrease in height of the lower eyelid; the recovery of midface fullness, achieved by elevation of the ptotic midface tissues
Flat Midfacial Area
Fig. 41.14. The lateral profile before and 8 years after surgery: the vertical height of the lower eyelid is still improved, as is the fullness of the midface, characteristic of youth

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