Midface lift

This article covers what a midface lift aims for in the malar and cheek area, the incision routes used, its relationship with the lower eyelid, recovery and risks. Where it differs from fat transfer and from neighbouring facial operations is explained as well.

What is a midface lift?

A midface lift is an operation in which the soft tissues of the malar and cheek area are released and fixed in a higher position. The position of the cheek tissue and the transition from the lower eyelid to the cheek are assessed together. The aim is a distribution of tissue that suits the person's face.¹

The cheekbone and the soft tissue over it are not the same structure. The operation does not change the shape of the bone; it repositions the tissues above it. Where there is also a lack of volume in the cheek, that is assessed separately from the tissue sitting low. Fat transfer can be used in the same session to add volume; it is not regarded as an equivalent procedure that replaces the lift.²

This article describes the transcutaneous lower eyelid, transconjunctival, endoscopic temporal and intraoral routes. These routes are chosen according to the examination and the correction to be made, and can be used together where needed. The incision route, the plane in which the tissues are released and where they are fixed are separate decisions.³⁴

Who is it suitable for?

A midface lift can be considered in people troubled by the position of the cheek tissues or by the appearance of the transition between the lower eyelid and the cheek. Suitability is not decided by looking at the depth of a single line. General health, conditions that can affect healing and expectations are considered together.⁵

In some people the position of the cheek predominates, in others a lack of volume or excess skin. Laxity of the lower lid, bags under the eye or a previous operation can also change the plan. In a study of one particular transconjunctival midface lift technique, marked skin redundancy and the pouches above the cheek known as festoons were set out among the limits of the method.³ It is therefore not assumed that every complaint about the area under the eye will be resolved by the same operation.

Chronological age is not a criterion of selection on its own. The examination establishes what change is wanted, which tissue it relates to, and whether the operation can meet that aim. Deciding also calls for understanding the incision site, the recovery period and the possibility of further procedures. If the expected change does not convince the person, not having surgery is also an option.

What does the examination look at?

The malar area and cheek: The malar prominence, the distribution of the cheek tissues, the differences between the two sides and any excess skin are examined. How the appearance changes when the tissue is lifted by hand is assessed. That examination is a way of understanding which tissue affects the appearance; it is not an exact preview of the surgical result.

Under the eye and the nasolabial area: The nasojugal groove, running from the inner corner of the eye towards the cheek, and the nasolabial fold, running from the side of the nose to the corner of the mouth, are examined separately. Although these areas lie close together, they are not the same structure. Studies of the midface have also assessed the malar prominence, the nasojugal groove and the nasolabial fold as separate outcome areas.⁶

The lower eyelid: The contact of the lid with the eye, its laxity, the height of its margin and closure of the eye are assessed. Dryness, stinging, watering or any previous eye surgery should be declared. The importance of ophthalmic assessment in people with existing eye complaints is also emphasised in a study of malar lifting involving the lower lid.⁷

Profile and support: The forward position of the eye and the bone and cheek support beneath it are examined together. The relationship in which the eye sits further forward than that support is called a negative vector. That is not the same thing as the outer corner of the eye sloping downwards. A study investigating the addition of fat transfer to a lift in people with negative vectors is an example of this feature being addressed separately in planning.²

Previous procedures and incision areas: Previous facial and eyelid operations, and fillers, fat transfer, thread lifts and botulinum toxin treatments should be declared. Existing scars, the hairline, hair density and the access areas to be used are examined. Differences in sensation and expression present before surgery are recorded; not every difference noticed afterwards is assumed to be new.

How is the operation planned?

What change is aimed for in malar and cheek fullness?

The aim is to move the existing cheek tissue to a position in harmony with the face as a whole. Fullness over the malar area and the lower eyelid to cheek transition are assessed separately. A higher or fuller cheek is not the same aim for every face.

When tissue is moved, the appearance of fullness in a particular area can change; that does not mean new fatty tissue has been added there. The study measuring midfacial height from photographs states that its own measurement does not show three-dimensional volume.⁸ At the examination too, a change of position and a need for volume are not used interchangeably.

How far can the nasolabial area be affected?

The appearance of the nasolabial fold is assessed as part of the plan. The aim is not, however, simply to erase that line. A study of malar lifting describes the effect remaining limited in some facial structures, particularly where there is excess skin in the nasolabial area.⁷

The point of fixation and the direction of pull can affect different areas differently. In an observational study of 350 people with a mean follow-up of 24 months, temporal fixation was reported to give more marked benefit in the malar area, and fixation to the orbital rim in the nasojugal groove.⁶ That finding does not show that one method is superior in every area, or that the nasojugal results apply equally to the nasolabial fold.

Is a midface lift needed, or a face lift?

The cheek and the lower eyelid transition are the focus of this operation. Laxity along the jawline is assessed separately within a face lift, and corrections directed at the neck skin and neck muscles within a neck lift. A study of a lateral midface suspension also states that a marked lower-face problem may not be adequately corrected by that method alone.⁹

Some facelift methods also cover the midface; the boundary between operations is not drawn by looking at the name of the incision alone. Which area will be changed is set out in the surgical plan. A temporal lift is assessed separately, with the outer brow and temple as its aim. Forehead lift, upper eyelid surgery, lower eyelid surgery and almond eye surgery are likewise not automatically part of a midface lift.

How is the transcutaneous lower eyelid route used?

The incision is made in the skin just below the lower lashes. The lower eyelid and midface tissues are reached by that route. How any excess skin will be handled, the area in which the tissues will be released and the points of fixation are planned beforehand. Malar lifting methods using a lower eyelid approach have been described as distinct techniques in the literature.⁷

Because it lies close to the incision, the position of the lower lid margin matters particularly. Lifting the midface tissue and removing skin from the lower lid are not the same procedure. How well the lid margin sits against the eye, and its support, are assessed together with the correction to be made.

How does the transconjunctival route differ?

The conjunctiva is the tissue lining the inner surface of the eyelid. In this approach the midface is reached from the inner surface of the lower lid. A midface lift technique working under the muscle and in front of the periosteum, through the conjunctiva, has been published.³ The name of the entry route therefore does not by itself describe the plane in which the work is done.

The incision for this route is not in the outer lid skin. Where excess skin needs removing, that is decided separately. Entering from the inner surface does not remove the need to follow the position of the lid and the surface of the eye.⁴

How is the endoscopic temporal route performed?

An endoscope is an instrument with a camera at its tip that helps to view the operative field. It is generally used to reach the midface from an incision within the hair-bearing scalp at the temple. The tissues are released under endoscopic guidance and fixed with sutures in the planned position.

Different methods of fixation have been described in the literature for the endoscopic temporal route.¹⁰ Using an endoscope and choosing a fixation method are not the same decision. In the practice described here, fixation is done with sutures. Reaching the midface from the temple does not mean the brow is also lifted in every person.

What does the intraoral route provide?

The midface tissues are reached from the area between the upper lip and the gum inside the mouth. This route can also be used together with the temporal route, depending on the release to be performed. There is a publication describing the intraoral route together with endoscopically assisted midface lifting.⁴

Where an intraoral incision is used, mouth care and a feeding routine are added to the care plan. This route is not regarded as an additional incision required in every operation. Which routes are used together is determined by the area being targeted.

What do surgical suspension and fixation do?

The released tissues are held in the intended position with sutures. The point of fixation, the direction of pull and how far the tissue will be moved are planned together. Suspension with sutures can be the fixation stage that follows a lower eyelid, transconjunctival or endoscopic approach.⁶⁹

The surgical suspension described here is not the same procedure as a thread lift passed through the skin without releasing the tissues. In addition, the fixation sutures that carry the tissue inside and the sutures that close the edges of the incision serve different purposes. Dissolving stitches or stitches that need removing may be used to close the incision.

Is separate support needed for the lower eyelid?

Canthopexy and canthoplasty are procedures directed at the outer corner of the eye and the support of the lower lid. Which of them may be needed is assessed together with lid laxity, the current position, previous operations and the correction to be made. Lower lid support is a separate decision that depends on the examination.

In one particular malar lift series, lateral lid support was applied as part of the method.⁷ That does not show that the same support is needed in every midface lift. The purpose of the support and a wish to change the shape of the corner of the eye should also be kept apart.

When can fat transfer be added?

Fat transfer can be performed in the same session in order to add volume. The aim of the lift is to reposition tissue, while the aim of fat transfer is to provide volume where it is needed. Whether they are done together is determined at the examination.

In a randomised study of 56 people with a negative lower eyelid vector, a midface lift alone was compared with a midface lift plus fat transfer. At a mean follow-up of 2.1 years, FACE-Q assessments were reported to be better in the combined group.² The study had no arm receiving fat transfer alone; that result does not show the two methods to be equivalent, or that everyone should have them together.

Is the same correction made on both sides?

The position of the cheek, lid support and excess skin may not be the same on the two sides. The direction and amount of correction are planned with those differences in mind. Asymmetry present at the outset is recorded; complete symmetry is not promised.

Asymmetry or a need for further correction can arise after surgery.¹ A difference in swelling early on and a difference in position remaining after healing is complete are assessed separately.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹¹ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹² A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹³ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹⁴ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment. Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Eyes and previous procedures: Eye complaints, any drops used, contact lens use and previous eyelid operations are declared. Where there is an existing lid problem or a complaint about the surface of the eye, assessment is completed before surgery.⁷ The area and timing of previous procedures are stated as clearly as possible.

Home and transport: Someone is arranged to accompany you home on discharge. The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

What is recovery like?

The timetable below is the clinical framework used for a midface lift. The procedure performed, the physical demands of the job and the course of healing can change these periods. Where other facial procedures are added, the timetable is assessed separately.

• The operation is carried out under general anaesthesia and takes 1-2 hours.
• The hospital stay is planned as 1 night.
• The first check-up is in the first week.
• Stitches that need removing are taken out after 1 week, with the incision checked. Dissolving stitches may also be used.
• 1 week is planned for returning to desk work.
• A range of 1-3 days is assessed for driving; no one drives before the conditions for safe driving are met.
• Return to sport is planned within 2-4 weeks, in stages according to the sport.
• 4 weeks is anticipated for a full return to daily life.

Bruising is expected to settle over 7-10 days and marked swelling over 2 weeks. These intervals do not mean everyone reaches the same appearance on the same day. Being fit to return to work can come before all the bruising and swelling has gone.

How long can mild swelling in the cheek last?

Marked swelling subsiding and mild cheek swelling clearing completely are separate stages. The shape becomes possible to assess over 2-3 months, while mild swelling in the cheek can last up to 3-4 months. Assessing the shape therefore does not mean that all swelling has finished by that day.

In a series of midface lifting performed together with lower eyelid and wider facial procedures, early oedema and longer-lasting swelling and firmness were also assessed separately.¹⁵ How the swelling develops, the route used and the lid findings are monitored together at check-ups. Swelling that increases, is painful or is markedly one-sided is not explained by recovery time alone.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Strips and check-ups: No dressing or bandage is used. Wound closure strips are applied to the outer incision line at the end of the operation; these can be changed at suitable intervals. No drain is used. The instructions given for the care and changing of the strips are followed; no different dressing is applied on your own. Care of the intraoral and conjunctival incisions is arranged separately.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

In this operation the instructions given about the outer incision strips coming into contact with water are followed. The information below on washing the hair applies where a scalp incision has been used at the temple.

Washing your hair: When the hair is first washed is decided by your surgeon according to how healing is going. There is no fixed day that applies to everyone. When the hair is washed, the care instructions given for the incision line and the strips are followed. Hair dye, salon treatments and applying products around the incision are also checked for suitability first.

Mouth care: Where the intraoral route has been used, a mouthwash is used 4 to 6 times a day. Feeding begins with liquids and continues with soft food. How long that routine lasts and its details vary with your surgeon's instructions; the same day of transition is not set for everyone.

Eye care: Where a transcutaneous lower eyelid or transconjunctival incision has been made, eye drops are provided and used as instructed. A return to contact lenses is decided by assessing the surface of the eye and healing; there is no fixed interval. No new drop or product for the eye area is started on your own. Difficulty closing the eyes, or a steadily increasing eye complaint, should be reported.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There may be tenderness, tightness and pain in the cheek and around the eye.⁵ The painkillers provided are used as instructed. Pain that keeps increasing, becomes marked on one side in particular, or comes with eye pain should not be watched and waited out. The surgical team is told if a new painkiller or additional medicine is to be used.

Returning to work and sport: 1 week is set aside for returning to desk work; in physically demanding jobs healing is assessed separately. Return to sport within 2-4 weeks is staged. It begins with light activity; the surgeon's approval is awaited for movements that keep the head down for long periods, that require straining, or that carry a risk of impact to the operated area. The 4 weeks given for a full return to daily life does not mean the scar has also finished maturing.

Driving: A return to driving can be assessed within 1-3 days. The effects of the anaesthetic on attention and reflexes must have passed, and there must be no visual problem, dizziness or use of painkillers that cause drowsiness. You should be able to turn your head, follow the traffic comfortably and perform sudden manoeuvres without pain. Where those conditions are not met, no one drives even if the interval has passed. On discharge you go home accompanied.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head, the cheek and the area around the eye, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising, tenderness and tightness in the cheek and around the eye, and numbness or altered feeling under the eye, can occur.⁵ What matters is less the presence of a mild finding than how it changes. Swelling that increases rather than settling, pain that progresses, or a new visual problem should not be judged as ordinary healing.

How do the scars change?

Where does the scar sit, according to the incision used?

With the transcutaneous lower eyelid route the incision scar lies in the skin of the lower lid, and with the temporal route within the hair-bearing scalp. The incisions for the transconjunctival and intraoral routes are on inner surfaces. Where more than one route has been used, the scars are assessed according to the incisions made.³⁴

Outer incisions can leave a conspicuous scar.¹ Maturing of the scar is expected to take between 6 months and 1 year. An incision line that looks red, firm or more prominent early on is assessed over that period. The final appearance of the scar is not settled on how it looks at the first check-up.

Silicone gel and massage are advised for the scar below the lashes. When they are begun and how they are applied are determined by the surgeon according to how the incision is healing. For the scalp scar, silicone gel, silicone sheeting and massage are not advised. The incisions for the transconjunctival and intraoral routes are on inner surfaces, so this care is not applied to them. The plan given by the surgeon is followed for care of the incision; apart from the scar massage advised by the surgeon, the area is not rubbed and crusts are not picked off. Where there is wound separation, discharge or increasing tenderness, it is not treated as merely part of the scar maturing; assessment is requested.

Can hair loss occur where a scalp incision is used?

Hair loss around the incision is among the reported risks of a midface lift.¹ Hair density and the position of the scar are assessed together when a scalp incision is planned. Hair covering the scar does not mean there is no scar.

The incision line is not strained when the hair is washed or combed. Where new thinning is noticed, it is shown at a check-up; how it is developing and its relationship with the scar are assessed.

Risks and complications

Risks are considered together with the incision route, the area released, lid support and the procedures performed alongside. Different methods and patient groups in the research are not merged as though they were the same operation.³⁷ The examination explains which risks matter particularly in the person's own plan.

Problems of the lower eyelid and the eye surface

Downward pulling of the lower lid is called retraction, and outward turning of its margin ectropion. More of the white of the eye showing is not the same thing as ectropion. Malposition of the lower lid is among the problems reported in midface and eyelid surgery.⁴

Chemosis is swelling of the conjunctiva that covers the surface of the eye. Chemosis and dryness can develop after midface lifting performed together with lower eyelid surgery.¹¹⁵ Problems with eyelid closure can also occur.⁴ Swelling in the cheek and these changes on the surface of the eye are assessed separately.

A correction performed in someone with an existing lid problem and an operation done for aesthetic reasons for the first time do not produce results from the same group either. Le Louarn's series includes both aesthetic malar lifting and operations performed for existing lid retraction.⁷ A single lid risk applicable to everyone is not derived from series of that kind.

Problems of altered sensation and the facial nerve branches

Sensation: The infraorbital nerve carries sensation from the lower lid, the cheek, the side of the nose and the upper lip. It is different from the nerve that moves the facial muscles. An anatomical study has shown that the branches of this nerve lie close to the working area when the midface is released or fixed.¹⁶ Numbness or altered feeling on touch is examined separately from facial movement at the check-up.

The facial nerve: The zygomatic and buccal branches of the facial nerve take part in the movement of the muscles around the eye, the cheek and the upper lip. The temporal branch, also called the frontal branch, relates to movement of the forehead and brow. Involvement of the motor branches in the operative field can lead to weakness or asymmetry of facial movement.⁴

In a series of 6 people in whom a midface lift by the intraoral route with endoscopic assistance was performed together with repositioning of lower eyelid fat, temporary weakness of the zygomatic and frontal branches was reported in 1 person. Movement in that person is stated to have recovered during follow-up.⁴ Other facial procedures were also performed in the series; a general percentage or a definite recovery time for everyone is not derived from such a small group. Where there is new loss of movement, assessment is requested rather than waiting for it to settle.

Problems of swelling, shape and symmetry

The course of swelling and tightness can differ between the two sides. Mild cheek swelling lasting longer is not a reason to accept swelling that increases or becomes marked with pain as ordinary. In a study of wider lifting performed together with the lower lid, early and late findings were assessed separately.¹⁵

Asymmetry, failure to achieve the expected change, or a need for further correction can arise.¹ The position of the fixed tissue, any remaining difference in volume and the healing scar are assessed together. The results of the study on suture suspension also differ according to the medial and lateral areas and to whether eyelid surgery was performed.⁹

Bleeding, infection and wound problems

Bleeding and haematoma: A collection of blood in the operated area can cause swelling and tightness.⁵ Where swelling increases rapidly on one side in particular, or pain becomes steadily more severe, the scheduled check-up is not waited for. Further intervention may be needed depending on the examination.

Infection and the wound: Infection and fluid collection can develop.⁵ Where redness spreads, or there is discharge, fever or separation of the incision edges, assessment by the surgeon is needed. Where an intraoral incision has been used, complaints in that area are also reported. Prevention of infection and treatment where needed are decided according to the person's situation; there is no single medication plan for everyone.

Anaesthetic and general surgical risks

Assessment relating to general anaesthesia is made together with the medical history. Any previous problems with anaesthesia and drug allergies are declared. The measures to be taken are planned according to the person's situation.

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Can the position of the cheeks change again over time?

Surgery does not stop the ageing process; appearance continues to change over time.¹ Maintaining the position of the cheek, regional fullness and the appearance of the lower lid are not the same measure of outcome. They need monitoring separately in long-term assessment.

In the series of 143 patients reported by Shtraks and colleagues, all patients had transconjunctival lower eyelid surgery, 133 had fat transfer, and 130, that is 90.9 per cent, had an endoscopic brow lift in the same session. In the 5 to 15 year follow-up group of these patients who underwent combined procedures, a median decrease of 2.1 mm was reported in the WIZDOM-MC measurement, which assesses midfacial height from photographs, compared with before surgery.⁸

That figure cannot be separated out as the effect of the midface lift alone; it is the result of a series in which combined procedures were performed. The measurement does not show how much volume a person's cheek gained or how much the nasolabial fold was reduced. In the same study, the long-term course of the cheek fullness assessments also differs from the height measurement.⁸ No promise of the same number of years or millimetres is therefore made to everyone for the result.

Where further correction is considered, the current position of the cheek, lid function, volume, the scar and the person's expectations are assessed together. Early swelling and a change developing later are distinguished; the decision is not made by looking at a single photograph alone.

What can be expected from the result?

The aim is a correction that assesses the position of the cheek tissue and the lower eyelid to cheek transition together with the person's face. The nasolabial area, any need for volume and lower lid support are defined separately before surgery. That makes clear which change is aimed at by the lift and which by an additional procedure.

In a retrospective series of 124 people treated with one particular transconjunctival lift technique, further corrections of different kinds were reported in 2 people at a median follow-up of 56 months.³ That data belongs to the method and to a selected group of patients; it is not used as a rate of success or of further surgery for every route.

The shape becomes possible to assess over 2-3 months, while mild swelling in the cheek can continue for up to 3-4 months. The result is not assessed on fullness alone; closure of the lids, expression, sensation, the balance of the two sides and the incision are monitored as well.

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations:

• Rapidly increasing swelling and tightness in the cheek or around the eye, on one side in particular
• Pain that increases rather than settling, or becomes marked despite the pain treatment given
• Fever, spreading redness or discharge from the incision line
• Separation of the wound or bleeding that does not stop
• New loss of facial movement or a marked difference in movement
• Difficulty closing the eyes, a new change in the position of the lower lid margin, or a steadily increasing eye complaint

Increasing swelling, severe pain, fever and discharge from the incision are findings that call for early assessment after a midface lift.⁵ Sudden reduction in vision, loss of vision or severe eye pain calls for urgent assessment; the routine check-up day is not waited for.

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing or visual problem in particular, urgent assessment is not delayed while trying to reach the surgeon.

About the numbers in this article

The intervals given for the operation, the hospital stay, stitch removal, returning to work and activity, and for bruising, swelling, assessing the shape and the scar maturing are a framework of clinical practice. The frequency of mouthwash in the mouth care section is likewise an instruction of practice. They are not presented as results of research to be applied to every patient.

Numbers of people and of eyelids are different units in the research. A distance measured from a photograph, volume, and an outcome score reported by the person do not measure the same thing either. The results of groups who also had eyelid, brow or fat transfer procedures are not attributed to the midface lift alone.⁸²

The studies on stopping smoking cover different operations. The relative risk reductions in those studies do not amount to a complication rate specific to a midface lift, or to separately proven effects for every nicotine product.

References

1. International Society of Aesthetic Plastic Surgery. Midface Lift (Cheek Lift). Accessed 6 September 2026. isaps.org ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

2. Barone M, Cogliandro A, Salzillo R, et al. Midface lift plus lipofilling preferential in patients with negative lower eyelid vectors: a randomized controlled trial. Aesthetic Plast Surg. 2021;45(3):1012-1019. doi:10.1007/s00266-020-01971-0 ↩ ↩² ↩³ ↩⁴

3. Seitz IA, Llorente O, Few JW. The transconjunctival deep-plane midface lift: a 9-year experience working under the muscle. Aesthet Surg J. 2012;32(6):692-699. doi:10.1177/1090820X12452292 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

4. Mofid MM. A novel technique for repositioning lower eyelid fat via the transoral approach in association with midface lift. Aesthetic Plast Surg. 2011;35(4):563-568. doi:10.1007/s00266-011-9665-4 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

5. Cleveland Clinic. Cheek Lift. Accessed 6 September 2026. clevelandclinic.org ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

6. Pascali M, Botti C, Cervelli V, et al. Midface rejuvenation: a critical evaluation of a 7-year experience. Plast Reconstr Surg. 2015;135(5):1305-1316. doi:10.1097/PRS.0000000000001189 ↩ ↩² ↩³

7. Le Louarn C. Concentric malar lift in the management of lower eyelid rejuvenation or retraction: a clinical retrospective study on 342 cases, 13 years of experience. Aesthetic Plast Surg. 2018;42(3):725-742. doi:10.1007/s00266-018-1079-0 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

8. Shtraks JP, Fundakowski C, Yu D, et al. Investigation of the longevity of the endoscopic midface lift. JAMA Facial Plast Surg. 2019;21(6):535-541. doi:10.1001/jamafacial.2019.1015 ↩ ↩² ↩³ ↩⁴

9. Byun JS, Kim KK. Cutaneous layer and SMAS suspension (CaSS) lift as a minimally invasive lateral midface lift. J Craniofac Surg. 2024;35(2):378-383. doi:10.1097/SCS.0000000000009817 ↩ ↩² ↩³

10. Saltz R, Ohana B. Thirteen years of experience with the endoscopic midface lift. Aesthet Surg J. 2012;32(8):927-936. doi:10.1177/1090820X12462714 ↩

11. American Society of Plastic Surgeons. Managing the risks of smoking in plastic surgery patients. Practice reference, 9 October 2024. Accessed 5 September 2026. plasticsurgery.org ↩

12. Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144-154.e8. doi:10.1016/j.amjmed.2010.09.013 ↩

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