Advances in open surgical mid-facial rejuvenation

Mid-facial rejuvenation through open approaches has traditionally included either a temporal or periorbital approach. Resorbable biomaterials have opened up another avenue for mid-facial rejuvenation. Here, fallen soft malar tissue can be resuspended with a sturdy resorbable apparatus (in lieu of a suture) deployed through these traditional approaches. Device resorption occurs after mid-facial tissues have healed in a new, elevated position. Temporary postoperative tenderness in the mid-face over the engagement lines has been noted to be the most common disadvantage of these devices. When using any of these devices or suture techniques, caution is warranted when dissecting from the temporal region over the lateral orbital rim because of the close proximity of the temporal branch of the facial nerve superficial to the plane of dissection.

The advent of injectable soft tissue fillers has decreased enthusiasm for ‘hard’ cheek implants for malar augmentation. This is evidenced by the paucity of quality articles on cheek implants from the medical literature over the past year. Concerns with regard to cheek implants include the long-term visibility of the implant as the surrounding face ages, bony resorption deep in the implant, and generalised asymmetry side-to-side.

As interest has grown for less aggressive facelifts for the lower third of the face, some pioneers in this field have begun to incorporate the mid-face in their techniques. One such procedure, the minimal access cranial suspension lift (MACS-lift), uses one or two loops of suture that suspend the superficial muscular aponeurotic system (SMAS) to deep temporal fascia through a limited pre-auricular incision. The recently described extended MACS-lift using a third suture that suspends malar fat, and the authors claim that both softening of the nasolabial fold and support for the lower eyelid are achieved.

Pros and cons

Dermal fillers

Although injectable facial fillers can offer an efficacious alternative to surgery for the ageing face, they also have their limitations. It is important for the aesthetic surgeon to recognise specific circumstances that may be best managed with an alternative to fillers, including superficial contour defects too shallow for fillers, areas with significant skin laxity in which filler injection may result in lumpiness, and deep defects or folds in areas of dynamic movement that may result in filler dislodgement or visible filler implants.

As with any procedure, surgical or non-surgical, soft-tissue augmentation is not without risks. Many complications have been reported with facial filler use. In fact, interpreting the literature for a particular filler can be frustrating, as it is common to find multiple case series with contradictory efficacy and side-effect profiles. It is unclear as to the exact aetiology of these contradictions; however, surgeon inexperience with filler injection, improper patient selection, and filler mismatch likely play an integral role. Although most side-effects to facial fillers are transient and minor in nature, it is important to discuss these complications with patients prior to injection. Bleeding is commonly associated with patient anticoagulation owing to concurrent and/or recent use of aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), or blood-thinning medications. In addition, the use of large-bore needles and injection into highly vascular areas, such as the lip, can also increase the risk of bleeding.

Infectious complications are rare; however, patients with susceptibility to infection or a history of herpes simplex infections may be candidates for prophylactic antiviral and/or antibacterial therapy.

Acute allergic reactions are a serious concern for fillers containing bovine and other xenogenic components. To minimise this risk, product recommendations for allergies and allergy testing should be followed. Patients who have had a prior hypersensitivity reaction to a specific filler should not be treated with that filler again. Given the availability of injectable human collagen, allergy testing prior to bovine collagen injection is now predominately only of historical interest.

Post-injection pain is common and can be reduced using the smallest needle possible for injection. For less viscous fillers, this may be a 30-gauge or 32-gauge needle; more viscous fillers may require a 27-gauge needle (e.g. calcium hydroxylapatite), or even a 25-gauge needle (poly-L-lactic acid) to avoid clumping or clogging. Topical or regional anaesthesia, including nerve blocks, can be used when required. Some injectables may contain small amounts of lidocaine as part of their injection carrier. Caution is advised when using local injectable anaesthesia as this may alter and obscure the contour defects.

In general, all fillers create some form of histological reaction that generally evolves over time. This inflammatory reaction is of particular concern for the semi-permanent and permanent fillers as its persistence may lead to a more chronic inflammatory process. More severe granulomatous reactions can also occur and have even been reported with more biologic products, such as the HAs. Granulomas can often be treated with simple excision.

Improper injection technique can also lead to complications. If a filler is inappropriately injected at the incorrect skin depth, location or volume, a myriad of unwanted skin changes can occur, including palpable bumps, contour deformities, and superficial beading. These unwanted changes may resolve slowly. Serious complications are rare, but can include anaphylactic reactions, skin necrosis, blindness, and death.