Elevation of the Malar Fat Pad with a Percutaneous Technique（2）
TECHNIQUE
The senior author has used 2 separate techniques. The first involved a Superior subcutaneous Anchoring of the suspension sutures in the Temple via a subcutaneous polytef (Gore-Tex; Gore-Tex Inc, Flagstaff, Ariz) patch, as shown to him by Sasaki.15 The sutures and polytef patch were anchored through a needle hole. No incisions in the temple or nasolabial fold were made. This technique was successful, but the senior author modified it because of several patients' ability to palpate the subcutaneous polytef patch. This annoyed 2 patients enough to require a minor reoperation, with removal of the patch and replacement of the sutures.
Our current malar pad suspension technique, which requires a small incision in the temporal hairline, involves fixation of the sutures to deep temporal fascia. With this technique, the patient is brought to the operating room and markings are placed as noted in Figure 2. These markings delineate the insertional points of the suture, the projected travel pathway of the Keith needle, and the temple incision and anchoring point.
Figure 2. Markings.
While the surgeon is marking and injecting the patient, the assistant or scrub nurse is fashioning the double strand of sutures with a small polytef bolster. One end of a 4-0 polypropylene (Prolene) suture is passed through the eye of a Keith needle and stabilized with a hemostat. The suture is then passed through both ends of a 2 × 2-mm polytef bolster and passed through the eye of a second Keith needle and stabilized with a hemostat. Both ends of a 3-0 polyglactin 910 (Vicryl) or polyglycolic acid (Dexon) suture are then placed parallel to the 4-0 polypropylene sutures through the Keith needles and stabilized by the same hemostats (Figure 3).
Figure 3. Needle passage.
The patient's hair is then braided out of the way of the incision, and the patient is prepared and fully draped. Meticulous attention to surgical technique is imperative to avoid infection. The surgeon uses a standard scrub and full gowning. Use of a modified sterile technique with surgical gloving and draping of the head area produced 2 surgical infections that required a course of antibiotics to resolve.
A No. 15 blade is used to make a 2- to 3-cm incision in the temporal hairline at the end of the projected pathway of needle travel. An iris scissors is used to complete the dissection down to the deep temporal fascia. An elevator is used to dissect a pocket posteriorly and then anteriorly past the brow along the deep temporal fascia in the pathway of needle travel. Creation of this pocket is a modification of the procedure that both protects the facial nerve and allows more elevation of the malar pad.
The surgeon then makes a small stab incision with a No. 11 blade at the demarcated spots that are to be the needle insertion points. The suture loop that was previously constructed with a Keith needle at each end is placed on the table. The Keith needle attached to each suture end is then passed through the stab incision to move the suture loop into position (Figure 3).
The Keith needle is inserted almost to the level of the bone and angled upward toward the temple incision. The plane of dissection is a palpable one that ends up in the "Suprafibromuscular" plane3 in the cheek, ie, the Superficial fascial plane of the face, below the Malar fat pad and above the Zygomatic muscles. An Aufricht nasal elevator is then placed in the temple incision, and the Keith needle is advanced into the temple area under the elevator and retrieved and pulled through the incision.
A "sawing" motion with the 3-0 polyglactin 910 suture is used to create a "passageway tract" for the 4-0 polypropylene–bolstered suture loop, which remains outside the stab incision. A release of the "puckered" tissue is then observed. This is the critical point of the operation, in that if the tract that is created is too shallow, a pucker can result. If the sawing motion is continued for too long and the tract is placed too deep, the subsequent elevation of the malar fat pad that is obtained will be too little. If the tract does not result in a lack of a pucker or the desired elevation of the malar fat pad, the suture is then removed and another suture loop is placed.
The 3-0 polyglactin 910 suture is then removed.
The 4-0 polypropylene–bolstered suture loop is then maneuvered through the stab incision and seated within the tract (Figure 4). Tugging on the suture loop demonstrates a Lack of pucker and Upward movement of the malar fat pad. The second suture loop is then placed through the second stab incision in a similar manner. After both suture loops are placed into position, a French eye needle is used to anchor the sutures to the deep temporal fascia. The sutures are then tied down and the temple incision is closed.
Figure 4. Mobilization of the malar fat pad.
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