The fallen malar fat pad produces
midfacial ptosis, with an increase of the nasolabial and melolabial folds.
Mobilization of the malar fat
A, Preoperative photograph of
42-year-old patient with mild malar ptosis. B, Postoperative photograph taken
1 year after closed technique.
A, Preoperative photograph of
50-year-old patient with more-pronounced malar ptosis. B, Postoperative photograph
taken 1 year after closed technique.
A, Preoperative photograph of
49-year-old patient before surgery of the midface, jowls, and neck. B, Postoperative
photograph taken after open technique (face-lift) and tip rhinoplasty. C,
Preoperative oblique view. D, Postoperative oblique view.
Keller GS, Namazie A, Blackwell K, Rawnsley J, Khan S. Elevation of the Malar Fat Pad With a Percutaneous Technique. Arch Facial Plast Surg. 2002;4(1):20-25. doi:
From the Division of Head and Neck Surgery, University of California,
Copyright 2002 American Medical Association. All Rights Reserved.
Applicable FARS/DFARS Restrictions Apply to Government Use.2002
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).
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
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.
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.
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
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.
At 3 months after surgery, all patients had significant elevations of
their malar fat pads, with the exception of 2 early patients, who underwent
revision surgery, with satisfactory results. The elevation was of an extremely
natural appearance. Excellent volume replacement of the cheek region was obtained.
Results, in the senior author's opinion, were improved over those seen in
deep-plane face-lifting with malar fat pad fixation. The average malar pad
elevation before creation of the temporal pocket was 2 to 3 mm. After the
surgical procedure incorporated the creation of the temporal pocket, 4 to
5 mm of elevation was uniformly achieved.
Temporary asymmetries were seen in 8 patients, but resolved within the
3-month period. Temporary unilateral pain complaints were expressed by 3 patients,
but also resolved within the 3-month period. Two patients, as mentioned above,
underwent revision surgery to remove the palpable temple polytef bolster used
in the early subcutaneous fixation technique.
All patients at 1 year after surgery (excluding the exceptions mentioned
above) have maintained their malar elevation. These results are in contrast
to those seen with deep plane face-lifting, after which the senior author
has seen a regression of malar fat pad elevation in some of his (and other
surgeons') patients. In fact, the technique provides an easy, minimally invasive
"tune-up" in the malar area for rejuvenation of patients with previous face-lifts
(Figure 5, Figure 6, and Figure 7).
No facial nerve problems, no excessive pulling, and no muscle fixation
problems were noticed. There were spots of bruising in many patients, but
they could generally be covered with makeup after about 72 hours. Four patients
had prolonged infraorbital edema that required 2 weeks to resolve.
A simplified method of malar fat pad elevation is described. This method
allows for elevation of the malar fat pad without extensive dissection. Complications
were minor with this procedure when compared with endoscopic midface-lifting
and complex deep-plane face-lifting procedures.
The procedure may be performed in conjunction with a face-lift (open
technique), allowing for a more conservative face-lift technique than is customarily
used to elevate the malar pad. It may also be performed without a face-lift
to allow minimally invasive rejuvenation of the midface in the younger patient,
in the older patient who has previously had a face-lift, or in the older patient
whose aging is confined to the middle third of the face.
Accepted for publication November 7, 2001.
This study was presented at the American Academy of Facial Plastic and
Reconstructive Surgery Spring Meeting, Palm Desert, Calif, May 13, 2001.
Corresponding author and reprints: Gregory S. Keller, MD, 222 W Pueblo
St, Santa Barbara, CA 93105 (e-mail: firstname.lastname@example.org).