MIDI Facelift

The Scar Solution Natural Scar Removal

The Scar Solution

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Dimitrije E. Panfilov



Looking tired is reason enough for many 35-45-year-olds to ask a plastic surgeon for prophylactic rejuvenation. They want to achieve good and long-lasting effects with harmonious features, small scars, and -as they are still very active in their professional and private lives - a quick recovery is very important for them. We have developed a modification of the short-scar facelift with solid deep support. We call it the MIDI facelift. MIDI stands for Minimal-Invasive, Deep-Intensive.

The technical details are as follows. Two half Z-plasties are performed at each end of modest skin excision, supraauriculary and retroauriculary, to avoid uneven suture edges. By doing so we achieve very unobtrusive scarring. For solid superficial mus-

culo-aponeurotic system (SMAS) tension, the procedures suggested in Chap. 36 are suggested. Depending on preoperative cheek fullness, we perform SMAS plication, simple SMAS flaps, snail SMAS flap, or tricuspidal SMAS flap.

By applying tumescent local anaesthesia with adrenaline and fibrin glue at the end of the procedure, we can avoid the drainage, so 96% of our patients were outpatients. The satisfaction of our patients was high (88%) and no major complications have occurred. Only three out of 200 patients had to undergo revi-sionary surgery.

The way that people of about 60 years of age participate in public life has changed radically during the last century. In the past they used to withdraw almost completely from public life. Nowadays they are still fully active, mainly on a private level, but also professionally - consuming the fruits of their life's efforts.

Prophylactic Facelift
Fig. 50.2. Markings of incisions, presumed excision, vectors of traction, and superficial nerve branches

Rejuvenation not only creates the mythological illusion of eternal life, it has also become a very important factor for the quality of life.

The outcomes of facelifts dramatically improved over the last few decades. Many details of anatomical understanding (four levels of acting, volume preservation and replacement, endoscopy, various traction vectors, restoration of different mimic units) have replaced simple skin traction - with its unpleasant operated look - with harmonious rejuvenation and stable effects.

It is a general observation that more and more younger people are coming to our offices asking for aesthetic surgery. This phenomenon is also occurring in the field of rejuvenation surgery. Our patients say: "Why should I wait until I am old and ugly before I do something? Now when I am fully active in life I want to benefit from my attractive appearance. If I look tired, people will not believe I have enough energy and fun for life."

Fig. 50.3. Steps of retroauricular skin advancement and resection
Fig. 50.4. The steps of the minimal-invasive, deep-intensive (MIDI) facelift
One Week After Facelift
Fig. 50.5. The youngest patient was 34 years of age. At this age we cannot rejuvenate somebody much, but can beautify and enhance. a Before b and after MIDI facelift and lip augmentation
Fig. 50.6. A 40-year-old patient a before b and 1 year later
Year Old Edgy
  1. 50.8. a Presumed skin excision and edgy contour of malar region "edgee line". b Four weeks after surgery. Note very fine scarring and the harmonious contour of malar region ("ogee line")
  2. 50.7. Our oldest female patient, 51 years of age, a before b 3 months after MIDI facelift
  3. 50.8. a Presumed skin excision and edgy contour of malar region "edgee line". b Four weeks after surgery. Note very fine scarring and the harmonious contour of malar region ("ogee line")


Materials and Methods

For our patients around 40 years old, we are looking for procedures that require less effort and may be performed on an outpatient basis, have fewer complications, smaller scars, shorter recovery, and stable or prolonged effects. The special request of these patients, as they are fully integrated in active lives, is for short recoveries. Another request of our patients is that they remain themselves. They do not want to change their facial expressions, but simply to achieve more freshness, harmony, and youth, and to get rid of features that look tired and pessimistic. The change should not be obvious to everybody.

First, the skin drawings are made. These include incision lines, dotted lines of presumed excision, vectors of traction for the cheeks and neck skin, markings of superficial nerve branches, and midline marking of the throat for symmetry control. All drawings have to be made when the patient is upright.

The skin flap release is by tunnelling with a lipo-suction cannula but without suction, or with the spreading-scissor technique - closed scissors are advanced blindly under the skin and then opened. Hereby, we stay in the proper layer and we can stretch the nerve branches without cutting them. By dividing the skin flap from the underlying tissue, we release McGregor's malar ligament and other connecting tissue septa up to the front cheek and platysma margin. The perforator vessels should be preserved at this level to keep the skin flap safe.

The incisions have to divide the half Z-plasty markings, beginning in the supraauricular region and ending in the retroauricular region, as shown in Fig. 50.3. Depending on whether a patient has full cheeks or hollow cheeks, we treat the deep SMAS-pla-tysma layer that has to undergo solid traction.

We first used liposuction of the submental area only occasionally and noticed that it improved skin retraction. We eventually decided to do it regularly, even if there is no fat to be removed, and we continue to do so.

It is very important to harmonize the skin and deep layers after we have played with the different vectors at the key point, 2-5 cm lateral of the lip commissures. If we neglect to release this adhesion, we will create a case of the "sofa button" phenomenon, with the unpleasant stigma of an operated look.

To make the skin anchorage sutures, the skin flap is first stretched to its maximum point, then released 2-3 mm. There is the motto in aesthetic surgery: What ever you do, do not overdo.

The supraauricular and retroauricular anchorage sutures are made first. The skin flap is then cut in the direction of the ear lobe. There has to be no tension on the ear lobe. We then size the skin that will be sutured retrotragally and put the third anchorage suture upwards of the tragus.

After the anchorage sutures have been placed, fibrin glue is applied to the skin that is pulled upwards for 3 min. This is good prevention of swelling and bruising, so our facelift patients rarely need drainage anymore. Intradermal sutures complete the wound closure.

We check the midline to test the symmetry. After the right side has been lifted, the midline deviates to the right. When the left side has been completed, it returns into midposition again. The patient wears a head net bandage for 1 day. The patient can be dismissed from the clinic the same evening or late afternoon. The patient can be picked up or driven by taxi but cannot drive or use a bus or train alone. The next day we remove the bandage. After 6 days, the intradermal sutures are removed. The anchorage sutures are removed after 10 days.

50.3 Results

We have treated 200 patients in 4 years with the MIDI facelift method. The satisfaction rate among the patients is promising: high 88%, moderate 11%, low 1%. We could not observe any major complications; nerve lesions 0%, skin necrosis 0%. Only in two cases of consecutive bleeding and one case of a postoperative salivary cyst did a patient have to undergo surgical revision (Table 50.1).

The latter did not have to be done: the revision of salivary cysts is not necessary. Table 50.2 shows the adjuvant procedures performed. Figures 50.9-50.11 show some results.

There are some aging patients who do not want to undergo "real" operation. For them we offer alternatively the following procedures: autologous fat augmentation of facial structures like folds, cheeks, malar prominence, lips, and the possibility of combining it with a handlift.

Seventy-five percent of our patients were between 35 and 45 years of age. If they were older than 50 (women) and platysma bands had already developed, the MIDI facelift was not recommended. Rather, the full facelift, with extended retroauricular skin resection and platysmoraphy, was indicated.

With patients younger than 35, we employed the mini lift that only uses preauricular incisions. In the 19 male patients (9.5% of the total) who underwent MIDI facelifts, we observed that the higher upper age limit was 58 years.

The MIDI facelift is a one-stage operation with short scars, short recovery, and short operative time

Table 50.1. Complications in 200 minimal-

invasive, deep-in-

tensive (MIDI) facelifts


2 consecutive bleedings unilateral


1 postoperative salivary cyst


12 postoperative unilateral swellings


8 cases of prolonged wound healing


2 hypertrophic retroauricular scars


Table 50.2. Among 200 MIDI facelifts, these additional surgeries were done on request


8 endoforehead lifts


35 blepharoplasties


9 rhinoplasties


18 partial peels (forehead or lips)


23 lip augmentations


42 double-chin liposuction


3 chin implants


Facelift With Tricuspidal Smas Flap
Fig. 50.9. A 38-year old actress a before and b 2 weeks after MIDI facelift and lower blepharoplasty
Bicht Fat Pad
Fig. 50.10. A 45-year old patient a before and b 6 months after volumetric MIDI facelift, with cheek and lip enlargement by autologous fat
Plastic Surgery Markings

Fig. 50.11. a Before surgery. b Dermographic markings and c 6 weeks after MIDI facelift, upper and lower blepharoplasty, auto-logous fat transfer, and reductive rhinoplasty of a 50-year-old patient

(90 min on average), which allows outpatient treatment and combination with other aesthetic procedures.

Modern rejuvenation procedures combine different methods, creating better and longer-lasting results and with less aggressive surgery than the singular methods. Less aggressive surgery has fewer complications, which translates into great safety for both the patient and the surgeon.

The MIDI facelift is easily taught and easily learned (prerequisites are anatomical knowledge and opera tive skills). It shows no major complications and serves to the satisfaction of the patient. In four words we can say it is easy, simple, effective, safe.


Please see the general bibliography at the end of this book.

51 Skin Resection Rhytidoplasty

Ulrich K. Kesselring



The last 50 years has been a period of intense diversification of facial rejuvenation surgery. Face-lifting procedures have been developed further, becoming more extensive in all dimensions as the mechanisms generating the visible signs of aging became better understood.

Parallel to the trend that favored more invasive and often more traumatizing techniques that promised better and longer-lasting results, there were always tendencies where one would try to achieve with a light, precise and well-aimed surgical gesture a favorable result in a given situation.

If one agrees that in the face and neck unsightly signs of aging are mainly due to skin alteration and associated soft-tissue shifts, there are a series of smaller procedures available if one accepts a fine inconspicuous scar in a visible area.

A good understanding of the vectors implied in repositioning surgery of the face helps to determine the required tissue shift.


Temporo-canthal Rhitydectomy

After repeated facelift procedures implying vertical soft-tissue repositioning and diagonal skin traction, a more vertical skin shift including the subjacent soft tissue becomes necessary in most cases. Such an upward advancement brings redundant skin to the in-frapalpebral area as well as to the malar and temporal area. Incisions at the border of the hair-bearing area can take care of the skin abundance in the latter region. As a lower blepharoplasty will then also be required, it makes sense to use what we call the tempo-ro-canthal incision [1], which starts at the inner canthus and goes all the way to the fossa supratragica (Fig. 51.1). From there, the incision can be carried downwards behind or in front of the tragus, depending on the convictions of the surgeon. We favor the retrotragal incision that does not leave a telltale scar

Fig. 51.1. The temporo-canthal incision makes sense since in most cases a lower blepharoplasty has to be performed

in a prominent area. To avoid an unsightly yawning of the meatus acusticus, the small flap eventually covering the tragus will have to be thoroughly defatted and shaped generously in order to avoid forward traction (Figs 51.2, 51.3).

Another important point is the design of the horizontal incision. Beyond the orbital rim, the incision should be directed upwards, following one of the upper crow's-feet folds, thus reaching the hair-bearing area in a lazy curve. From there, the incision follows the scalp border to the preauricular area (Fig. 51.4).

Pinching the skin over the zygomatic arch, one can get a rough idea of how much skin can be removed there. Having already drawn the upper incision line, the estimated amount of removable skin can now be marked below this line (Fig. 51.5). The estimated resection line can now be drawn, starting at the inner canthus and delimiting a slender triangle of which the long sides have a similar curved pattern. The maximum width is situated just before the hairline and usually measures between 20 and 30 mm.

Fig. 51.2. The defattening of the small "peninsula flap" which will cover the tragus is essential. It will allow the skin to smoothly adhere and reproduce the cartilaginous structure
Fig. 51.3. If required, the removed fat can be grafted into the tear troughs or the lips

Fig. 51.4. After following one of the crow's-feet folds, the tem-poro-canthal incision curves down in front of the hair-bearing area to reach the fossa supratragica

This resection pattern minimizes the risk of creating an ectropion. To be even more on the safe side, the orbicularis oculi muscle can be attached in the lateral canthal region to the orbital rim periosteum with an absorbable 5/0 suture (Fig. 51.6).

Once the initial incisions have been made, the surgeon will decide how to intervene on the subjacent structures. All options are possible and all planes easily accessible (Fig. 51.7).

The advantage of this and other, related incision patterns resides in the fact that the skin shift vector points in the right direction and we can achieve a considerable tissue lifting and tightening effect down to the mandibula-neck angle without displacing the scalp (Fig. 51.8).

Fig. 51.6. The orbicularis oculi muscle, which is attached to Fig. 51.7. As this incision gives a generous access and view of our skin/muscle flap, will be attached to the orbital rim perio- the deeper layers, any technique can be used at that level steum with one suture


The Difficult Neck

A crucial telltale area that can be addressed separately also is the neck area, if there is a significant redundancy of skin and platysma with or without excessive fat tissue.

This symptomatology is usually dealt with during a comprehensive facelift, combined with a minimal incision submental procedure. There are, however, patients who do not wish to undergo such extensive surgery, e.g., the typical male patient who just wants to be able to close his collar button to wear a tie rather than to hide his turkey gobbler neck behind a John Wayne neckerchief.

For these cases we use a midline multiple w skin resection [2], which gives excellent access to the subjacent structures (Fig. 51.9) that can now be surgically modified and rearranged as necessary. It is also a nice approach to do a first-time Connell [3] or a Feldman [4] procedure with an anatomical view of the layers involved. Precise skin approximation and suturing are imperative and make all the difference in the final appearance of the scar (Fig. 51.10). In an aged, atrophic skin, one or two simple Z-plasties instead of a long W-closure may be a valid alternative (Fig. 51.11).

This operation is not suitable for patients with drooping jowls as the forward repositioning of the neck skin can accentuate that problem.


Drooping Lip Commissures

Downward drawn mouth angles give the face a bitter, disapproving expression. The multifactor etiology includes lower-lip retraction through soft-tissue loss, cheek ptosis and chronic mimic activity.

The problem has been addressed in various ways, surgically, with fillers or with Botox. Austin and Weston [5] reported a simple skin resection above the commissures (Fig. 51.12). We added to this technique the subtotal transection of the m. depressor anguli oris, folding its stump upon itself and keeping this pad in place with a 6/0 absorbable suture (Fig. 51.13). With this procedure we reposition the angles of the mouth cranially, we weaken significantly the active downward pull and we fill the subangular depression with our pad.

The scar, which lies some 10 mm along the upper vermilion border and reaches 10 mm into the adjacent cheek skin, is very inconspicuous and always well accepted by the patients (Fig. 51.14).


  1. Kesselring, UK: Die temporo-canthale inzision beim Facelift. Congress of the German Plastic Surgeons, Düsseldorf 1989.
  2. Kesselring, UK: Direct Approach to the Difficult Anterior Neck Region. ISAPS course, Tokyo 1991.
  3. Connell, BF, Shamoun, IM: The significance of digastric muscle contouring for rejuvenation of the submental area. Plast Reconstr Surg 99: 1586, 1979.
  4. Feldmann, JJ: Corset platysmaplasty. Plast Reconstr Surg 85: 333, 1990
  5. Austin, H, Weston, G: Rejuvenation of the Aging Mouth. Clin Plast Surg 19:511, 1992.
Fig. 51.9. The vertical multiple w skin resection in the neck gives excellent access to the subjacent structures
Fig. 51.10. Precise skin approximation is essential to produce an inconspicuous scar
Kesselring Plastic SurgeryKesselring Plastic SurgeryKesselring Plastic SurgeryRight Commisure Depressor
Fig. 51.13. Under direct view the muscle is transected cranially and the stump folded and sutured upon itself. The resulting pad efficiently fills the infraangular "bitterness troughs"

Fig. 51.12. The lozenge skin resection along the upper vermilion border reaches beyond the commissure and gives access to the depressor muscle

Fig. 51.14. Case: 51.14 67 year old patient, pre-op and 14 months after lip commissure plasty

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  • Elvira Dellucci
    How old should the average 45year old look?
    4 years ago

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