Elevation of the Malar Fat Pad With a Percutaneous Technique（1）
Gregory S. Keller, MD; Ali Namazie, MD; Keith Blackwell, MD; Jeffrey Rawnsley, MD; Sajjad Khan, MD
Arch Facial Plast Surg. 2002;4(1):20-25. doi:.
Original Article | January 2002
（http://archfaci.jamanetwork.com/article.aspx?articleid=479899）
ABSTRACT
Objective To describe a simplified method of malar fat pad elevation to rejuvenate the midface, nasolabial folds, labiomental folds, infraorbital hollows, and jowls via a percutaneous approach.
Patients and Design One hundred eighteen patients were evaluated over a 12-month period in a prospective fashion by the operating surgeon. Preoperative and postoperative photographs were used for comparison.
Setting Private practice.
Main Outcome Measures Elevation of the malar fat pad by a measured amount.
Results At 3 months, all patients had a significant elevation of the malar fat pad (3-7 mm), with the exception of 2 early patients who underwent revision surgery, with satisfactory results.
Conclusions A simplified method of malar fat pad elevation is described. This method allows for elevation of the malar fat pad without extensive dissection. Excellent results are obtained with very little morbidity.
REVERSAL OF midfacial aging has become a focus of facial rejuvenation. Recently, the causes of midfacial aging have become well defined. The sagging of the Malar fat pad over the relatively fixed areas of the muscular and ligamentous connections of the nasolabial and labiomental folds produces a deepening of these structures. The downward migration of the fat pad produces hollowness in the midfacial and infraorbital areas that accentuates the aging process. Descent of the malar fat pad also contributes to the mid-face portion of the jowl (Figure 1).
Figure 1.
The fallen malar fat pad produces midfacial ptosis, with an increase of the nasolabial and melolabial folds.
While midfacial aging is apparent in the older, classic face-lift patient, changes in the midface also appear in the 35- to 45-year-old patient who does not manifest other signs of aging. Many of these younger women, disturbed by the early signs of aging, seek classical face-lifts in an attempt to reverse aging confined to the midface.
Standard face-lifting techniques, associated with superficial musculoaponeurotic system plication, rotation, or resection, have resulted in only modest improvement of the nasolabial and mentolabial folds. The volumetric reduction of the fallen midface and infraorbital hollow associated with aging is also not fully responsive to these standard techniques.1-2 More aggressive techniques, such as deep-plane face-lifting, suprafibromuscular face-lifting, and subperiosteal face-lifting, appear to be more successful in addressing the midface in older patients, but are not widely adopted because of their increased morbidity and because they require advanced surgical training.3-8
In the younger patient, endoscopic techniques are used to avoid the surgical scarring associated with classic face-lifting. While successful, these techniques require complex instrumentation, sophisticated surgical technique, and a lengthy recovery period (that younger, working patients often do not have the time for). Most of them rely on suture elevation of the ptotic malar fat pad. Dissections and suture placement are difficult and/or associated with surgical morbidity.9-10 Surgeons also use techniques of malar fat pad elevation through a blepharoplasty incision. While useful for the correction of ectropian and eyelid contraction, these techniques have surgical morbidity and scarring in the lateral canthus.11-13
A simplified method of malar fat pad elevation to rejuvenate the midface, nasolabial folds, labiomental folds, infraorbital hollows, and jowls has obvious merits. Direct percutaneous suture suspension techniques to achieve these goals were attempted by the senior author (G.S.K.) and others over the last 10 years. While useful for stabilization of the malar fat pad, elevation of fallen structures was unable to be performed by direct suture without a pucker being produced at the site of suture placement.
In 1995, Su14 reported a successful technique for a "closed suspension mini–cheek lift to reduce the nasolabial fold," during which percutaneous suspension sutures are passed through the skin of the nasolabial fold with a Keith needle. The sutures are anchored to the deep temporalis fascia with a French eye needle after limited undermining with a closed-channel liposuction cannula.
Recently, Sasaki15 successfully elevated the midface with a direct percutaneous technique. Our 15-month results with a modification of this technique and sutures in 118 patients have confirmed its validity.
This percutaneous malar fat pad face-lift allows for reliable elevation of the midface with a relatively simple technique that can be performed by most skilled surgeons after they take part in an observational session, during which the critical parts of the procedure are elucidated. Surgical morbidity is minor. The procedure can be reversed, augmented, or modified in the postoperative period quite easily, in the event that changes are mandated or desired by the patient. It does not "change" a patient's appearance in the manner of a midfacial implant. It is also more reliable than autologous fat replacement and does not require multiple sessions to achieve a result.
The procedure is indicated in patients whose concerns of aging are confined primarily to the midface. Such patients are often younger, and are not ready for a face-lift. Males and older patients without excessive skin laxity (previous face-lifts, ethnic with elastic skin, etc) are also excellent candidates.
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