Your face usually portrays the first visible signs of aging and your midface is an essential component of an attractive face. The triangular area formed between the two corners of your eye and the corner of your mouth makes up the mid face. With the aging process, the fatty tissue that normally drapes over the cheekbones can begin to drop resulting in less prominent cheekbones and a droopy fold of skin and fat between your nose and cheek known as the nasolabial fold. The tear trough, or the area between your lower lid and your cheek, becomes more prominent with aging, causing more apparent and prominent lower eyelid bags. In addition to sagging of the skin and fat of the midface, volume deficiencies from your cheeks occur with aging due to the loss of cheek fat and muscle.
As individuals age, the bony skeleton and soft tissues of the face lose volume producing a slightly wider orbital aperture and less anterior projection. This decreases the overall projection of the cheek and diminishes bony support for the overlying soft tissue structures. The preseptal orbicularis oculi muscle loses tone, resulting in herniation of the intraorbital fat. Ptosis of midfacial adiposity exposes the inferior orbital rim. Further descent of cheek fat and separation from the suborbicularis oculi fat (SOOF) can be heralded by a faint diagonal groove in the infraorbital area parallel to the nasolabial crease. Furthermore, descent of the Bichat fat pad over the upper mandible can increase lower facial jowling. Individuals in their early 30s may have descent of the malar fat pad; this may lead to the formation of infraorbital dark circles and deepening of the nasolabial and nasojugal (tear trough) creases. These changes occur earlier in the presence of poor bony support and midface retrusion.
A Cheek Lift, also referred to a Midface Lift, is a cosmetic surgery procedure to improve the appearance of your face by tightening the facial skin. It is performed to lift sagging cheeks and it can also reduce the wrinkles and crease lines around your nasal and eye regions. It has become a popular cosmetic surgery choice and most patients requesting evaluation for a Cheek Lift feel that their facial features no longer reflect their youthful spirit.
The three main reasons patients choose a Cheek Lift include:
To Treat Sagging Skin–Facial skin tends to loose its elasticity and tone with age, resulting in the formation of crease lines between the nose base and corners of your mouth. This can give a tired appearance to your face or even make it appear you have large jowls. Genetics, sun exposure, smoking, and other factors can result in drooping cheeks and this is one reason people choose to have a mid face lift or cheek lift. A Cheek Lift will add more definition to your cheek area by reshaping the cheek contours. Wrinkles also appear in your face, as you grow older, especially around your lower eyelids, mouth, and nose. A Cheek Lift can be performed to correct sagging skin by repositioning the cheekbone in an upward direction so that a youthful appearance is achieved. The skin also appears smooth because wrinkles are removed.
Medical/Genetic Reasons–Thyroid eye disease, ectropion, and lower eyelid retraction are some of the medical reasons to choose Cheek Lift surgery. Thyroid eye disease causes inflammation of soft tissues like fat tissues and muscles around the eyes giving a protruding appearance to the eyes, which may hinder vision in severe cases. Ectropion is a condition where the lower eyelid turns out exposing the inner surface of the eyes. The genetic make-up of a person and facial features are related. Some people have sunken eyes, which give an aged and unpleasant appearance, and this can be corrected when the skin of the lower eyelid region is rearranged and resurfaced to get rid of the sunken eye appearance. All of these genetic and medical conditions can be rectified or improved by means of a Cheek Lift surgery.
Improve Facial Features–A Cheek Lift is often performed to treat conditions associated with aging. It may be done in conjunction with other cosmetic procedures to achieve a more harmonious facial appearance.
History of Cheek Lifts
Ancient Egyptians and Romans recorded techniques for giving the face a more youthful appearance, but contemporary Facelift techniques have developed over the course of the last century. The first face-lift is attributed to Eugen Hollander who performed the surgery in Germany in 1901. Facelifts were rare for several reasons and one was that cosmetic surgery was usually considered an unnecessary risk before the discovery of antibiotics. Infection was inevitable and the consequences were dire at that time. Secondly, doctors during that era closely guarded their secrets, as they believed riches would soon follow the doctor who discovered the secret to regaining youth.
The first popular face-lift technique emerged in the 1920s and didn’t change for nearly fifty years. This face-lift technique was eventually replaced, as the results over time were less than optimal. A man by the name of Skoog advanced face-lift surgery in 1974 by changing the suture technique. Near the same time, new understanding for the facial tissue that underlies the skin gave rise to a new face lift technique called the SMAS face lift, which is named after the structures beneath the face it addresses. This face-lift technique was steadily refined until the next jump in the 1990s.
In the 1990s, the deep plane and composite rhytidectomy techniques appeared and showed promise of surpassing the SMAS technique. In the first cheek lifts performed in the mid-1990s, an extended open subperiosteal facelift was performed and the intermediate temporal fascia was used to anchor the mid face. To better elevate the cheek, the suspension point was changed to the suborbicularis oculi fat (SOOF). These techniques usually were performed through a full blepharoplasty incision, but this resulted in an unacceptable level of eyelid retraction. Because the procedure was performed on the side of the face, the middle of the face was virtually ignored. Over time, sagging occurred in the middle of the face, causing an unnatural result.
The access incision then was modified to a crow’s foot incision, spreading the orbicularis oculi at the site of the incision without disrupting the muscle. The orbital septum was not violated and the infraorbital fat only was resected in patients with obvious proptosis (5% of patients). With these modifications, no permanent ectropion or eyelid malposition was observed. Having eliminated the need to perform any periocular incision, the periosteum was raised over the entire anterior malar area and the anterior two thirds of the zygomatic arch. Tunnels were then made over the zygomatic arch and independent suture suspension of the SOOF, inferior malar soft tissues, and Bichat fat pad was performed.
Over the past 20 years, several techniques have been described to specifically address the mid face, since this area is not addressed with standard cervicofacial rhytidectomy. As well, technology advanced the procedures performed in concert with a face-lift. Both endoscopic techniques and CO2 lasers pushed innovation in both limiting incisions and refining the incision lines afterward. As face-lifts have improved over time, social acceptance continues to improve, increasing demand and further improving face-lift techniques
A Cheek Lift is a cosmetic surgical procedure performed to rejuvenate the lower eyelid and mid-face or cheek area of the face. The goal is to blend the lower eyelid and the cheek and to raise the position of the cheek into a natural and youthful position. A number of Cheek Lift or Midface Lift procedures may be performed to solve a single problem either alone or in combination with other procedures.
Dr. Brent Moelleken, M.D., F.A.C.S. is a Plastic and Reconstructive surgeon with private practice offices in Beverly Hills and Santa Barbara, California. Dr. Moelleken has several innovated and trademarked procedures including USIC® and LUSIC® Ultrashort incision Cheeklift procedures. Dr. Moelleken pioneered the USIC® (Ultrashort incision Cheeklift) and LUSIC® (LiveFill® Ultrashort incision Cheeklift), superficial, fast recovery, fat restoration techniques for lifting and rejuvenating the lower eyelids and cheek region. The superficial Cheek Lift produces a cleaner; more rested appearance below the eyes than conventional lower eyelid surgery and avoids some of the changes in eye shape associated with lower eyelid surgery involving an incision below the eyelid. His technique was published in Plastic and Reconstructive Surgery and he has demonstrated his technique on numerous local, national, and international television segments.
The superficial Cheek Lift is a new technique. It involves raising up the midface underneath your eye and no plastic or implants are used. The unique feature of this operation is that the cheek pad is tied with invisible stitches to the very tough tissue beside your eye, which means it does not rely on the very weak lower eyelid. The recovery time is about the same as for the lower eyes and most patients are back to their normal routine in a week or less. The superficial Cheek Lift uses an incision hidden just below your lower eyelashes and all the remaining stitches are buried under the skin.
The superficial Cheek Lift elevates your cheek pads and rejuvenates your lower eyes. This differs from a conventional facelift, which only pulls tissues to the side. The midfacial area and lower eyelids cannot be rejuvenated through a conventional facelift incision. A windswept, unnatural “too tight” appearance may result if that is attempted. When performed at the same time as a facelift, the superficial Cheek Lift avoids this by elevating your cheeks, rather than by pulling them to the side. The result is a more natural rejuvenation.
In Dr. Moelleken’s practice, a Cheek Lift is effective at smoothing your lower eyelids at the level of your cheeks, for the slight elevation of your cheeks, and to reduce the hollowness below your lower eyelids (especially the LUSIC Cheeklift with LiveFill®). Many people think of a Cheek Lift as an alternative to a Facelift but it is not. It is a new procedure designed to make your lower eyelids and midface look better and less hollow. It is also very valuable in correcting the appearance of the lower eyelids if they have had conventional subciliary eyelid surgery and have pulled down, rounded, or changed in appearance. Cheek Lifts typically do nothing for the jowls and not much for the nasolabial folds.
Some doctors try to perform aggressive lifts on the midface but in Dr. Moelleken’s opinion, he feels that is a mistake. Revision of aggressively performed Cheek Lifts is usually impossible so Midface lifts should be subtle. Radically performed cheeklifts from inside the mouth/temple incision approach can cause a greatly increased intermalar distance between the cheek pads, giving the face an odd cat-like appearance. Aggressive elevation of the cheeks can cause bunching of the tissue beside the eye, necessitating aggressive lateral brow elevation.
Cheek Lifts performed through the lower eyelid at the subperiosteal level also has potential hazards with contraction of the orbital septum and pulling down of the lower eyelid (ectropion). The lower eyelid tissue is very delicate and prone to problems so extraordinary care must be taken when operating on the midface. It is arguably the most difficult area in plastic surgery and not an operation an occasional surgeon should attempt. Facelifts and Mini-Facelifts address the bottom two thirds of the face and the neck, not the area below the eyes. For the patient desiring a subtle reduction in hollowness below the lower eyelids, a subtle correction of midfacial descent, or correction back to an almond eye shape in patients who have had conventional lower eyelid surgery before, a Cheek Lift can be just the right thing.
There are many types of Cheek Lifts. Technically, any Cheek Lift is a midface procedure because it deals with the tissues below the eyes into the cheek area. Subperiosteal is one Cheek Lift method, performed through a lower eyelid incision that is falling out of favor with physicians because of the chance of pulling down the lower eyelid, or ectropion, even in highly skilled hands.
Basically, Cheek Lifts fall into several categories including:
Lower Eyelid Procedures: Full and minimal incision versions give the best results for the lower eyelid. Highest risk for lower eyelid problems unless they avoid the orbital septum through the USIC, Ultrashort Incision Cheek Lift. The directions of pull tends to be straight up and this can be subperiosteal (more risky) or suborbicularis (less risky).
Through the Mouth/Temple: Direction of pull tends to be up and out. Often combined with Endotine device, this does little for the lower eyelid.
Fixation Devices Primarily Endotine Fixation Devices: this can be performed through incisions to the side of the eye (often visible) and the temple, which can result in hair loss. Direction of pull tends to be straight up for side of the eye and up and out for temple approach.
Combined Brow lift/Cheeklift Technique: Usually performed through the mouth and the temple, often with fixation device. A combination of the above procedures, the direction is pull up and out.
Through the Facelift: If deep tissue restructuring is done, not conventional SMAS procedure, cheek tissue can be elevated. There are many methods of this as well such as subcutaneous vs. deep (i.e. Owsley, Hamra). This aspect of the surgery cannot be performed any other way other than through facelift incisions.
Dr. Moelleken offers two new versions of the Cheek Lift: the USIC and the LUSIC, Cheek Lifts with Ultrashort incisions that either use LiveFill® (when hollowness is present) or not (USIC), depending on the clinical situation. Cheeklifts are among the most difficult procedures to perform, so it is my opinion that surgeons should have a special interest in this field before regularly undertaking such cases. Every Cheek Lift is tailored to the patient’s needs and anatomy.
In medical terms, the superficial subciliary cheek lift is an aesthetic operation to rejuvenate the infraorbital region and midface. It smoothes and rejuvenates the nasojugal groove, the nasolabial fold, and the cheek pad with a direct pull upward. This technique is a technically straightforward procedure that does not involve dissection at a subperiosteal level, endoscopic equipment, a formal canthotomy, or drill fixation. It does not produce superior displacement of the lateral canthus. The entire operation is performed through an extended subciliary incision. Fixation is accomplished to the intermediate temporal fascia just lateral to the lateral orbital rim. No reliance is placed on the lower eyelid for tightening the midface region. The superficial subciliary cheek lift can be performed as a separate operation or in conjunction with a facelift. It is an aesthetic procedure that is an adjunct to a subciliary lower blepharoplasty when rejuvenation of the upper midface and nasojugal area is also required.
Dr. Moelleken uses LiveFill® for augmenting the cheek area because it is soft tissue and the recovery is very quick. It is normally easy to remove a cheek implant, depending on the material that the cheek implant was made of. Usually it is removed through an incision in the mouth unless the cheek implant was literally made like cement and it has fused to the bone. Dr. Moelleken has treated patients with cheek implants that are impinging on the nerve or causing numbness and pain. In this case, he removes the implant and replaces it with LiveFill®, which is a soft filling material that is not hard.
Usually there is no issue with an existing cheek implant however Dr. Moelleken often places LiveFill® to blunt the appearance of the cheek implant. This will soften the face during the Cheek Lift, especially if the cheek implant has become visible or it may become visible. Dr. Moelleken also assesses for the placement and appearance of the cheek implant such as if there is excessive submalar projection causing a prematurely aged appearance or if the implant is the right size and shape. In most cases, he can work around the implant.
As with any surgery, there are risks and you must be in good health to undergo any elective surgery. Fortunately, the risks of the LUSIC® superficial Cheek Lift are low if you follow all of the guidelines presented during your consultation with Dr. Moelleken. The Cheek Lift is typically performed under a “light” general anesthetic however depending on the situation; it can also be performed under local anesthesia or IV sedation. This technique provides excellent operating conditions while affording maximal patient comfort and safety. In Dr. Moelleken’s practice, a board certified anesthesiologist who remains in attendance throughout your operation to monitor your progress administers all anesthetics.
If you are a smoker, it is imperative that you quit all Nicotine products at least two weeks prior and two weeks after your surgery as this would impede your healing process greatly. You will also be advised not to take aspirin or aspirin-containing products two weeks prior to surgery and for two weeks after your surgery as these can cause excessive bleeding. Post-operatively, you will be encouraged to return to your normal routine (with clearance from Dr. Moelleken) soon after surgery, with frequent periods of resting. You will experience a minimal to moderate amount of pain and medication is available to control any discomfort experienced while in an after-care facility or at home. Each patient heals differently so this varies depending on your situation. Thin skin color steri-strip tapes will be applied to your incisions. The scars left by this procedure are generally predictable and although they fade with time, they are permanent. As with any facial surgery, you should avoid bending forward as this will create a strain on the incisions that are healing. You should avoid sun exposure to incision site following your surgery, as this may result in a hyperpigmented scar.