Triple layer

ORIGINAL ARTICLE AESTHETIC
Triple-Layer Midface Lifting: Long-Term Follow-Up
of an Effective Approach to Aesthetic Surgery of the Lower
Eyelid and the Midface
Hieronymus P. Jerome D. Stevens •
Joep C. N. Willemsen • Piyush Durani •
David Rasteiro • Ogbe J. Omoruyi
Received: 28 October 2013 / Accepted: 11 May 2014
! Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract
Background It is becoming more and more accepted that
better aesthetic results can be obtained when the lower
eyelid is considered as part of the midface when contem-plating
surgical rejuvenation. Descent of the orbicularis
muscle and midface tissue causes malar bags, loss of vol-ume
over the tear-trough, apparent vertical lengthening of
the lower eyelid, and an accentuation of the orbit-cheek
junction.
Methods We describe a triple-layer technique that
effectively corrects these problems, performed under local
anesthesia and via a standard subciliary incision, to sepa-rately
reposition the postseptal fat, suborbicularis oculi fat,
and the musculocutaneous layer of skin and orbicularis
oculi. We present a detailed analysis of the complications
arising from a series of over 500 patients, in which this
technique has been performed by the senior author.
Results The average patient age at the time of surgery
was 51 years old (±7.9), with a median follow-up of
7 months (range 3–121). Complications were observed in
77 of 512 cases. In total, 44 of these cases required surgical
reintervention under local anesthesia (rated as major
complications and all reinterventions lasted 30 min)
and 33 cases were treated conservatively (minor
complications).
Conclusion The triple-layer midface lift is an effective
way to reverse the combination of ptosis and changes in
volume of the aging midface. It yields long-lasting results
with a minimal risk for complications, particularly when a
tarsal tuck is performed simultaneously in patients at high
risk for the development of scleral show.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Midface lift ! Lower blepharoplasty !
Postseptal fat ! Suborbicularis oculi fat (SOOF)
Introduction
The lower eyelid is no longer considered in isolation when
contemplating surgical rejuvenation; rather, it is a part of
the midface. The midface is the central third of the face
between two parallel imaginary horizontal lines: the
superior line passing through the lateral canthi and the
inferior line at the level of the columella. The youthful
orbit-cheek junction is convex with no visible orbital rim
[1]. Signs of aging in this area include (a) ptosis of lower-eyelid
skin, orbicularis muscle, suborbicularis oculi fat
(SOOF), and midface tissues, giving an accentuated naso-jugal
fold (‘‘tear trough deformity’’), malar bags or ‘‘fes-toons,’’
and apparent vertical lengthening of the lower
H. P. J. D. Stevens (&) ! J. C. N. Willemsen
Bergman Clinics, Private Clinic, Binckhorstlaan 147,
The Hague, The Netherlands
e-mail: stevens.hp@gmail.com
H. P. J. D. Stevens
Rotterdam, The Netherlands
P. Durani ! O. J. Omoruyi
The Dutch Association for Facial Plastic and Reconstructive
Surgery, Rotterdam, The Netherlands
D. Rasteiro
The Dutch Association for Facial Plastic and Reconstructive
Surgery, Hospital de Sa˜o Jose´, Lisbon, Portugal
123
Aesth Plast Surg
DOI 10.1007/s00266-014-0345-z

eyelid; (b) intraorbital fat atrophy, and (c) laxity of the
orbital septum which results in bulging of the orbital fat
and the impression of surplus fat in this area (pseudosur-plus)
[2].
In standard lower blepharoplasty [3], the orbicularis
muscle is elevated from a subciliary incision to the infra-orbital
rim. Postseptal fat that is judged to be excessive is
excised, and the skin-muscle flap redraped and trimmed.
This excision of pseudosurplus fat can give a hollow look
to the eyes which is aging in itself. To counter this prob-lem,
De la Plaza [4] replaces the intraorbital fat and con-tains
it by suturing the capsulopalpebral fascia to the
periosteum of the infraorbital rim, thus reinforcing the
attenuated septum and avoiding fat resection. Hamra [1],
on the other hand, uses fat repositioning via arcus mar-ginalis
release, or septal reset [5], to create a smooth
transition from eyelid to cheek, camouflaging the infraor-bital
rim.
The effect of the standard lower blepharoplasty is lim-ited.
It fails to address the fundamental problem of the
descent of midface structures, specifically the orbicularis
oculi muscle, the SOOF, and the malar fat pad. This results
in a visible infraorbital rim and an apparent lengthening of
the lower eyelid (vertical lengthening). Three definitive
surgical planes have been used so far to correct descent of
the midface by vertical repositioning:
1. The subperiosteal approach, introduced by Tessier [6]
and modified by Hester et al. [7], uses the periosteum
to elevate the midface structures via sutures in the deep
temporal fascia. This involves extensive dissection and
is routinely associated with prolonged postoperative
edema [8]. It also involves elevation of an anatomical
structure that does not become ptotic with age: the
periosteum.
2. The suborbicularis plane, first described by Furnas [9]
for the treatment of festoons, has been popularized by
many authors, including Hinderer et al. [10], Hamra
[11] (as the plane for his composite rhytidectomy), and
Fogli [12]. This plane allows elevation of the orbic-ularis
oculi and malar fat pads but could cause
problems with edema and lower-lid retraction. The
abundance of orbicularis muscle and exudate promotes
fluid accumulation in the skin, creating edema that
causes skin quality to deteriorate.
3. Hamra [13] modified the suborbicularis dissection to
address these problems by continuing deep to the
zygomaticus muscles: the zygorbicular dissection. This
approach is used either alone, as part of a lower
blepharoplasty, or in conjunction with a deep-plane
rhytidectomy so that the composite eyelid flap is
advanced vertically on a ‘‘mesentery’’ of zygomatic
muscle [13]. Hamra makes no mention of the SOOF in
Aesth Plast Surg
his description of the zygorbicular technique, or
whether this structure is included in the composite flap.
4. Other authors have utilized flaps of isolated orbicularis
muscle to address a conspicuous orbit-cheek junction
and to obliterate festoons [12, 14]. The muscle flap is
suspended to the periosteum at the lateral orbital rim to
achieve vertical support to the eyelid. The benefit of
suspending an isolated muscle flap is that the upward
force vector achieved will neutralize possible down-ward
forces after skin excision which could result in
lower-lid retraction. This mirrors the principle of
superficial muscular aponeurotic system (SMAS)
resection-plication rhytidectomy, where the tension is
transmitted via the SMAS rather than the skin [14].
However, the orbicularis suspension alone will not
achieve elevation of all the midface structures unless
the dissection proceeds beyond the infraorbital rim.
In this article we describe a technique that involves the
separate manipulation of three anatomical structures—the
postseptal fat, the SOOF, and a musculocutaneous flap-in
order to obscure a prominent infraorbital rim and improve
the orbit-cheek junction, thus rejuvenating the midface and
periorbital areas.
Methods
The Triple-Layer Midface Lift
The surgery is performed under local anesthesia: 1 %
lidocaine with 1:200,000 epinephrine, buffered with a 1:10
ratio of 0.7 % sodium bicarbonate solution. The anesthesia
is used to block the sensory branches of the maxillary
division of the trigeminal nerve, i.e., the lateral zygomat-icotemporal,
medial zygomaticotemporal, zygomaticofa-cial,
and infraorbital nerves. In addition, local anesthetics
are applied below the septum just prior to marginal release
and incision of the septum, blocking infraorbital sensory
nerve supply. The skin incision is infiltrated to utilize the
vasoconstrictor effect of epinephrine. On average, a total of
6 cc is used. A bilateral procedure takes the senior author
about 45 min to perform.
A high subciliary incision is made through the skin at
the lateral extent of the skin markings. Curved scissors are
used to develop a plane deep to the pretarsal orbicularis
oculi muscle. The skin and muscle are then cut simulta-neously
along the length of the incision with the scissors.
The upper blade of the scissors should be angled superiorly
to bevel the incision, leaving 2–3 mm of muscle on the
superior flap. This preserves sensation to the eyelid margin,
which occurs via infraorbital nerve branches passing from
deep to superficial through the orbicularis muscle. A 4/0
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Prolene suture is used to retract the posterior lamella
superiorly, which aids dissection and protects the globe
from desiccation. Skin hooks are placed in the myocuta-neous
flap and used to gently retract the anterior lamella
superiorly at a 45" angle. This slight tension on the anterior
lamella aids the subsequent dissection.
Dissection of the anterior lamella continues in a plane
between the septum and orbicularis to the arcus marginalis.
The dissection then continues beyond the arcus marginalis
in the supraperiosteal plane in order to elevate the SOOF
(Fig. 1a, b). Dissection here should be performed lateral to
the midpupillary line. This avoids damaging the infraor-bital
nerve which lies 1 cm inferior to the infraorbital rim
in line with the medial limbus. The inferior limit of dis-section
is at the level of the alar rims. The lateral extent of
the dissection is in line with the lateral orbital rim. The
zygomaticotemporal nerve may be encountered toward the
lateral edge of the dissection (this has occurred in *10 %
of our cases). The nerve should be preserved, if encoun-tered,
as damage causes numbness of the midface, albeit
transient. The senior author favors the use of diathermy
with an insulated Colorado needle for dissection, to provide
a bloodless field (Fig. 1a). An additional benefit of the use
of diathermy is that the patient will feel discomfort as the
zygomaticotemporal nerve is approached despite local
anesthetic infiltration, warning the surgeon that the nerve is
close and to discontinue any further lateral dissection at
this point.
When the dissection is completed, a triple-layer
approach is used to create the most optimal continuation of
tissue from the cheek into the lower eyelid (Table 1).
Layer 1 release of the arcus marginalis is performed,
again using diathermy with the Colorado needle. The septa
dividing the lower orbital fat into compartments are divi-ded,
allowing the fat to herniate across the entire infraor-bital
rim. The fat is carefully teased inferiorly and redraped
over the lower orbital rim from the levator labii alaeque
nasi medially to the lateral canthus laterally (Fig. 3a, b).
The fat is fixed to the periosteum with 5/0 Vicryl inter-rupted
sutures (Figs. 2b, 3a). Knots should be placed in the
plane between the fat and the periosteum (inverted) to
prevent palpable irregularities through the thin skin of the
lower eyelid.
Layer 2 the SOOF is then lifted superiorly and fixed to
the lateral orbital rim periosteum with 4/0 Prolene inter-rupted
sutures (Figs. 2c, d, 3b), just inferior to the lateral
canthus.
Layer 3 ultimately, the myocutaneous flap is then ele-vated
and fixed to the periosteum just superior to the SOOF
fixation with a 4/0 Vicryl suture through the orbicularis.
Care is taken to dissect no more than 1 cm of muscle free
from the skin (if any) to minimize postoperative edema in
this area. True vertical repositioning is guaranteed by
taking a bite of muscle 1 cm vertically inferior to this
anchoring point (Figs. 2e, f, 3c, d).
The retraction suture is removed and skin resection is
performed. To avoid over-resection of skin, the skin
resection is performed with the patient’s eyes and mouth
open to their maximum extent. The incision margins should
still be opposed after resection with the patient in this
position. A 3-mm strip of orbicularis is trimmed from the
margin of the inferior flap to prevent postoperative prom-inence
at the site of the skin incision. The skin incision can
then be closed. The senior author prefers to close just the
skin lateral to the lateral canthus with three interrupted
Prolene sutures (6/0). The subciliary margins will oppose
without the need for any sutures or Steri-Strips, which can
cause discomfort. We have had no problems with wound
healing using this method. A detailed video of the entire
procedure as described can be viewed without charge
Fig. 1 a The perioperative approach to undermining the SOOF in the
supraperiosteal plane is depicted. b The extent of undermining over
the orbital rim shown in a lateral view
Table 1 A short overview of the triple-layer midface lift from deep
to superficial planes of dissection
Layer 1: deepest layer
Dissection: marginal release of intraorbital fat by incision of the
septum just over the orbital rim
Suturing: redraping of this fat and fixation to the periosteum (5/0
Vicryl inverted points)
Layer 2: middle layer
Goal: strictly vertical lifting of SOOF
Suturing: full bite of SOOF with nonresorbable 4/0 Prolene visi
black needle and fixation to lateral orbital rim 5 mm below
lateral canthus
Layer 3: superficial layer
Goal: strictly vertical lifting of musculocutaneous flap (without
separating skin from the muscle)
Suturing: full bite of orbicularis muscle without making a dimple
in the overlying skin (with a resorbable Vicryl 4.0 suture) and
fixation to lateral orbital rim between lateral canthus and suture
of layer 2
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Fig. 2 a, b Point of traction of the SOOF, c, d the point of traction of the musculocutaneous flap is shown from a cranial and a lateral view
at www.surgytec.com/video/lifting-the-midface-including-the-
soof.
The Preventive Tarsal Tuck
Patients with eyelid laxity who presented a risk for
postoperative complications were identified preoperatively
using the ‘‘anterior distraction’’ test (i.e., delayed return to
the resting position after the lower eyelid is pulled ante-riorly
away from globe) and the ‘‘snap back test’’ (i.e.,
delayed return to the resting position after lower eyelid is
pulled inferiorly). In such cases, a preventive tarsal tuck
was also performed as follows: A 4/0 Prolene suture is
used starting from the inner side of the orbital rim 5 mm
cranial to the lateral canthus via a separate incision (or
via the lateral part of the incision of an upper blepharo-plasty).
A puncture hole is then made with an 11 blade
through the most lateral part of the tarsus (just where the
last eyelashes are seen) and used as an exit point for the
needle. The curvature of the needle is used to exit again,
back through the same puncture hole, just next to where
the needle was introduced to facilitate suture tying
through the periosteum. As a result, the lateral part of the
tarsus is tightened and lifted and the curvature of a
youthful eye is restored without skin excision or lateral
canthopexy.
Extra operating time in such cases is no more than 5 min
per side, and the extra effort is considered worthwhile to
prevent serious complications without causing eye distor-tion,
frequently observed after formal lateral canthopexy.
In a small number of cases (n = 8), a minimal quantity
of fat was injected in the areas adjacent to the surgical
plane of dissection as an adjuvant from the 6th postoper-ative
month onward (8 cc was equally divided over the
nasolabial fold, central part of the midface, tear trough,
malar eminence, and anterior part of the cheek, gradually
fading out to the temporal region). Cases in which
Fig. 3 Drawings of the different perioperative steps of the triple-layer
midface lift are presented. a Layer 1, step 1: marginal release of
the septum is performed, allowing the intraorbital fat to prolapse over
the orbital rim, b layer 1, step 2: the intraorbital fat is fixed to the
periosteum, c layer 2, step 1: the point of traction of the SOOF,
d layer 2, step 2: the point of anchoring of the SOOF to the lateral
orbital rim, e layer 3, step 1: the point of traction of the
musculocutaneous flap, f layer 3, step 2: the point of anchoring of
the musculocutaneous flap
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Table 2 Procedure distribution among patients with number of complications
Procedure No. patients Complications
lipofilling was used to address more profound facial vol-ume
loss in the same session were excluded from this
overview.
Between 2000 and 2012, a total of 512 consecutive patients
were treated with the triple-layer midface lift as described.
Complicationswere notedmeticulously during this period and
categorized as minor (treated conservatively) or major
(requiring surgical reintervention under local anesthesia).
Results
The average patient age at the time of the operation was
51 years old (±7.9), with a median follow-up of 7 months
(range 3–121). A total of 225 patients had additional sur-gical
procedures in the same session as the triple-layer
midface lift (see Table 2). In 44 cases, eyelid laxity was
confirmed preoperatively by an anterior distraction test time
[5 s and a negative snap back test. In these cases, the
triple-layer midface lift was combined with a tarsal tuck to
prevent scleral show.
Complicationswere observed in 77 of 512 cases. Forty-four
cases required surgical reintervention under local anesthesia;
these were rated as major complications and all reintervention
procedures lasted30 min. Thirty-three cases were treated
conservatively andwere all transient; thesewere rated asminor
complications (see Table 3 for specifications). Scleral show
was the most common major and minor complication.
Case 1
A 40-year-old female visited our outpatient clinic asking
for an improvement of moderate signs of aging, particu-larly
of the lower eyelid and midface. She felt that she
None Minora Majora
Triple-layer midface lift only 287 257 15 15
Triple-layer midface lift ? upper-eyelid blepharoplasty 117 95 8 14
Triple-layer midface lift ? tarsal tuck 44 39 0 5
Triple-layer midface lift ? MACS-lift 22 17 3 2
Triple-layer midface lift ? endoscopic forehead lift ? upper-eyelid blepharoplasty 18 12 4 2
Triple-layer midface lift ? full-face rhytidectomy 10 6 2 2
Triple-layer midface lift ? endoscopic forehead lift 6 3 0 3
Triple-layer midface lift ? MACS-lift ? upper-eyelid blepharoplasty 4 3 1 0
Triple-layer midface lift ? upper-eyelid blepharoplasty ? lateral brow-lift 4 3 0 1
Total 512 435 33 44
a Minor complications were treated conservatively and major complications required surgical correction which in all cases was a procedure done
under local anesthesia and taking30 min
Table 3 Specification of complications
n % Of total
(512
patients)
Major complicationsa
Total number of scleral show requiring tarsal tuck 12 2.3
After primary triple-layer midface lift 8 1.6
Secondary tarsal tuck after relapse 3 0.6
Secondary tarsal tuck after triple-layer midface
1 0.2
lift combined with preventive tarsal tuckb
Skin surplus requiring resection 7 1.4
Persistent edema ([3 months) 5 1.0
Lack of effect 4 0.8
Bleeding requiring surgical intervention 4 0.8
Festoon 5 1.0
Scar irregularities requiring correction 3 0.6
Redraping 2 0.4
Palpable subcutaneous suture 1 0.2
Ectropion 1 0.2
Total number of major complications 44 8.6
Minor complicationsa
Minimal scleral show treated with Steri-Strips 11 2.1
Infection 9 1.8
Conjunctival irritation 7 1.4
Scar irregularities treated with massage 4 0.8
Edema (3 months) 1 0.2
Bleeding 1 0.2
Total number of minor complications 33 6.4
a Minor complications were treated conservatively and major com-plications
required surgical correction which in all cases was a pro-cedure
done under local anesthesia and taking30 min
b 0.2 % of total number of cases (n = 512), 2.2 % of triple-layer
midface lift combined with preventive tarsal tuck cases (n = 44)
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123

looked less fit and energetic because of a deep tear trough
and flattening out of her midface (Fig. 4a–c). Under local
anesthesia, a triple-layer midface lift was performed; the
mild ptosis of the cheek and the hollowing-out of the
orbital rim were also addressed. Long-term results after
8 years (Fig. 4d–f) show a stable outcome with a shorter
palpebra-cheek junction and elevated midface, conveying a
less tired and more energetic overall appearance.
Case 2
A 51-year-old female presented with concerns about her
tired appearance, particularly localized in the midface
(Fig. 5a–c). A triple-layer midface lift was performed
(without any ancillary procedure). Postoperative results
after 1 year show a clear improvement throughout the
midface (Fig. 5d–f). These results show that vertical
repositioning of the midface fullness and better continua-tion
of the cheek into the eyelid is associated with a
healthy, younger appearance. Resection of any fat seems
counterproductive; instead, extra filling could be consid-ered
to further improve the result.
Discussion
In this article we describe an effective method of
addressing the complex combination of aging in the mid-face
by ptosis and changes in volume distribution in three
separate layers. With aging comes the descent of midface
structures, together with fat atrophy intraorbitally and of
the midface itself [2]. At the same time there is develop-ment
of malar bags or festoons due to attenuation of the
orbital septum and laxity of the orbicularis oculi muscle.
Surgical procedures have focused on restoring the youthful
contour of the orbit-cheek junction by resuspension of the
soft tissues and providing soft tissue cover over the infra-orbital
rim. This has been performed by suspension via
subperiosteal dissection [5, 6] or by manipulation of the
postseptal fat [1, 3, 5], orbicularis oculi muscle [9–14], or
SOOF [15–17]. We believe that the combination of these
Fig. 4 a–c A 40-year-old
female visited our outpatient
clinic asking for an
improvement over the moderate
signs of aging, particularly of
the lower eyelid and midface.
Under local anesthetics a triple-layer
midface lift was
performed, addressing also the
mild ptosis of the cheek and the
hollowing out of the orbital rim.
d–f Long-term results after
8 years show a stable outcome
with a shorter cheek-palpebra
junction, elevated midface, and
less fatigued overall appearance
Aesth Plast Surg
123

Aesth Plast Surg
techniques into a single procedure is a preferable option.
The triple-layer midface lift incorporates filling of the tear
trough by redraping, vertical lifting of the SOOF, and a
musculocutaneous lifting of the eyelid. This combination
addresses both ptosis and changes of midface volume with
the available tissue. Cases in which lipofilling was used to
address more profound facial volume loss in the same
session were excluded from this overview.
A strictly vertical vector for repositioning the mus-culocutaneous
flap is desirable; therefore, in our tech-nique,
the anchor point for the flap is the inner
periosteal surface of the orbital rim, using a resorbable
suture (4/0 Vicryl). A frequently used alternative is to
attach a sling to the temporal fascia; however, we
believe this results in too much of an oblique vector in
the face. Initially, the technique involved separating
muscle from the skin; in the last 5 years, the technique
has evolved and now there is a strong preference to
leave the muscle attached to the skin. This should
preserve the superficial lymphatic drainage system of the
skin, preventing in almost all cases any prolonged
swelling in the area of the skin muscle flap (from 20 to
30 % to 2 %). Such prolonged postoperative swelling
in this area of the face is recognized as a major draw-back
of the classical technique which involves disrupting
the skin-muscle interface.
Despite the multiple anterior anchoring points as
described per layer, the manipulation of the septum, middle
lamella, SOOF, and musculocutaneous flap resulted in such
a significant degree of cicatrization that even mild scleral
show persisted; in these cases, lipofilling by microfat
grafting was considered the preferred adjuvant therapy.
Correction using suture placement causes further tension so
it was not felt to be an appropriate solution. Lipofilling in
such cases was performed from the 6th postoperative
month onward. An average of 8 cc of centrifuged microfat
particles, harvested by a Tonnard type of harvesting can-nula
(Tulip#), was injected as three-dimensional dispersed
Fig. 5 a–c A 51-year-old
female complained about a tired
look mainly concentrated in the
midface. A triple-layer midface
lift was performed (without any
other ancillary procedure). d–f
Postoperative results after
1 year show a clear
improvement over the entire
midface. It is becoming even
clearer that vertical
repositioning of the fullness of
the midface and a better
continuation of the cheek into
the eyelid is associated with a
healthy younger appearance
123

droplets using a curved cannula from lateral to medial and
medial to cranial directions. The 8 cc was equally divided
over the nasolabial fold, central part of the midface, tear
trough, malar eminence, and anterior part of the cheek,
gradually fading out to the temporal region.
Scleral show was the most common complication. It
occurred in 4.4 % of all cases, requiring surgical cor-rection
in 12 patients (2.3 %). In 11 patients (2.1 %) it
was only a temporary complaint that resolved with
conservative management. The recent case review by
Hester et al. [18] showed similar percentages, with 4.8 %
of all cases requiring at least one correction for malpo-sition
of the eyelid after a midface lift. Proper exami-nation
prior to the procedure is paramount to identifying
cases that are prone to developing scleral show. In this
series, 44 patients were identified as high risk and
underwent a simultaneous preventive tarsal tuck. McCord
et al. [19], who advocated modified lateral canthoplasty
in selected cases, drew similar conclusions. Despite this
preventive tarsal tuck, scleral show still occurred in one
case (2.2 %) of our group (n = 44). Compared to the 11
of 468 with a normal physical examination (2.4 %), we
believe that the preventive procedure decreased the
potential number of scleral show complications. In
addition, patients who received a tarsal tuck after the
initial procedure were more at risk of developing a
relapse (3 of 8 cases, 37.5 %) compared to patients who
underwent a preventive procedure (no relapse in 44
cases). There are most likely several confounding factors
that influence the reported complication rate in this
study, which is a clear limitation of the study design.
Well-defined patient cohorts with strict inclusion criteria
may be the key in identifying these confounders in future
studies, with the goal of lowering the complication rates
further.
Although there are alternative techniques using different
approaches to the midface [15, 20–23], we believe a direct
subciliary approach to the midface has several advantages.
First, technically it seems to offer less experienced sur-geons
an easy-to-learn more extended technique with a
steep learning curve in case a pinch-grip lower-eyelid
correction will not be sufficient for patients with midface
issues. Second, this approach allows for easy modification
into a technique where lifting can be combined with
lipofilling.
When dissection is performed as described above but
limited to the orbital rim and not beyond, one can combine
diathermic tightening of the septum with lifting of the third
layer only (the musculocutaneous transposition). Subse-quently,
lipofilling of the midface and tear trough area can
be performed, making midface procedures through a sub-ciliary
approach a reliable working horse in an otherwise
high-risk operating field.
Conclusion
Aesth Plast Surg
The triple-layer midface technique is an effective causally
related therapy to reverse the combination of ptosis and
volume changes of the aging midface. It yields long-lasting
results with a more natural youthful appearance and a
minimal risk for complications, particularly when a tarsal
tuck is performed simultaneously in patients at high risk for
the development of scleral show.
Conflict of interest All authors declare that they have no conflicts
of interest or financial ties to disclose.
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