Is a mid face lift or cheek lift even worth it? (photo)

I'm a 38 y/o female, recently lost 40 lbs & working on last 20. Just developed dark circles & nasolabial lines with this. Cheeks dropping a bit. Really liked my face and high cheekbones. But fear will get worse as I continue to lose (and age). Looking at midface/cheek lift, but don't find many before/after pics impressive. PLUS reading horror stories of major nerve damage possible. Reviews here are very mixed. Any doctors truly confident in doing this procedure?? Worth it to patients?

Doctor Answers 23

High cheekbone versus sagging cheeks .. what does that mean?

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Hi Jams1976,

I don't offer midfacelifts anymore, so I won't comment on whether they are worth it or not, I will let the surgeons who still actively promote midfacelifts and cheeklifts give their opinion on why they think it is worth it.

I suspect that the dark circles and the cheeks dropping are related. People with high cheekbones will not have dark circles under their eyes. People with dark circles under their eyes will appear to have sagging cheeks. Why? If a person have a dark circle with or without eyebags, then their cheeks will not appear any higher than the bottom of the dark circle/eyebag.

Note that the more weight you lose the more it appears the dark circles are worsening and the cheeks are "falling." What is really happening is the fat that borders the lower eyelid fat and the upper cheek is losing volume. This creates a groove below the lower eyelid and the upper cheek which causes the cheeks to "fall" because visually the cheeks cannot be higher than the groove.

Interestingly, if you can not see the groove between the lower eyelid and upper cheek, all of a sudden the cheek appears much higher, and it is really hard to tell where exactly the lower eyelid is located. Ideally the cheek appears to begin somewhere between 1/8" to 1/4" below the eyelash line, but if there is significant hollowing then this volume loss is increasing the amount of visible lower eyelid and in turn reducing the high point of the cheek.

As people lose a significant amount of weight, the first pocket of fat that gets lost is the buccal fat, which is the "baby cheek fat" which is located under the cheek bone. As this buccal fat is lost often times the tear troughs (dark circles) will develop. A plastic surgeon observed that when buccal fat removal is performed often times the patient may develop tear troughs months to years after the procedure which were not present prior to the buccal fat removal. I suspect that the buccal fat is completely full, a finger of this buccal fat goes up along the side of the nose to help push the cheek fat under the tear trough area fuller and higher. After the buccal fat removal, this finger-like extension of the buccal fat may get pulled down along with the buccal fat reduction resulting in the dark circle.

As far as the nasolabial fold getting deeper, this also appears to be a common element with significant weight loss. The smiling muscles (zygomaticus major and minor) when contracting cause the nasolabial folds. There are no (opposing) muscles to relax these smile lines. For example, the biceps flex the forearm to the upper arm, but the opposing triceps extend the forearm relative to the upper arm. The zygomaticus muscles can contract, but there are no opposing muscles to then stretch them out. Currently the treatment for nasolabial folds is injecting fillers directly along this wrinkle/fold. This helps to soften the nasolabial fold, but to my eye more filler does not yield a better result. Sometimes it can look strange when the nasolabial fold is so filled that even when the person is authentically smiling that no nasolabial fold is seen. This appearance looks puffy to me. Ideally when the person is not smiling the nasolabial fold is minimal and when they smile, the person can still form a sharp crease which indicates an authentic smile.

If you google image buccal fat pad, you will see that the zygomaticus major and minor lay directly over the buccal fat pad. Is this a coincidence? Perhaps the buccal fat pad volume helps to passively stretch the zygomaticus muscles when they are not actively contracting. When the zygomaticus muscle contract, the fat is no match for these muscles and the nasolabial fold forms. When the muscle relaxes (not smiling) the pure volume of the buccal fat pad stretches out the zygomaticus major and minor muscles so that the fold is not so obvious.

Another observation that is that the nasolabial folds always look worse when the same patients have dark circles or tear troughs. The two lines are approximately parallel and visually play off of each other. If the dark circles are no longer there, then the nasolabial folds by themselves are not so bothersome, since the nasolabial folds act as the natural border between the high cheeks (apple cheeks) and the mouth area. Essentially below the lower eyelashes, ideally there are only 3 "sections" the left and right cheeks and the mouth area, with the nasolabial folds being the natural divider between these three sections. If the dark circles are present in addition to the nasolabial folds, then the area below the lower eyelashes then get divided into 5 areas: two lower eyelids with the lower border at the tear troughs, lowered cheekbones bordered above by the tear trough, and below by the nasolabial folds, and the last section which is the mouth area.

Since all of the fillers are initially FDA approved for nasolabial folds, the majority of injectors are most comfortable with nasolabial fold filling. Also, due to direct to consumer marketing such as Juvederm for "parentheses lines" that don't belong on the face, patients will come in and ask for fillers in the smile lines even if it may not make sense to fill that area as a first location. If nasolabial folds are filled as a first area, we are essentially trying to leave the dark circles and combine the cheek and mouth area into a single area, and leave the tear trough/dark circles as the second and third area. This doesn't make much sense to me. I suspect when we see people who have had filler in their smile lines, but have other areas which are not filled, our brains notice that there is some mismatch to the way that the face is aging and makes use notice that their smile lines have been filled.

If the tear trough/dark circles are improved as much as possible, then the nasolabial folds can be partially improved without drawing attention that one area has been filled while another area has not been addressed.

Having made the previous points, I ask the surgeons who perform midfacelifts regularly, can a midfacelift reposition the cheeks enough to hide the tear troughs and blend the lower orbital rim exposure towards the outer part of the eye.  Is there enough fat on the upper cheek/orbital rim to position it high enough to create a high cheekbone appearance?  Are some of the effects of the midfacelift from prolonged swelling from a subperiosteal (releasing the entire cheek off of the cheekbone) which can give a 6 month period of extended swelling which can look like volume, but when the swelling is fully gone after 12 months the tear troughs and lateral orbital rim do not need any additional volume using fillers or fat transfer.  Is is possible to simultaneously perform facial fat transfer accurately to those areas, while performing the endoscopic subperiosteal midfacelift? These are the questions I would want answered if I were the patient interested in a midfacelift/cheeklift.


Dr. Yang

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New York Facial Plastic Surgeon
4.8 out of 5 stars 35 reviews

Mid-face / Cheek Lift

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Dear Jams:

I love the mid-face lift! It does wonders for lifting, re-volumizing the central face following aging and weight loss. Please link to the reference below to see how the fat compartments of the face separate, lose volume and descend creating the facial folds of the:
  1. eyelid-cheek fold
  2. tear trough (naso-jugal) fold
  3. naso-labial fold
  4. marionette fold
These are tell tales of aging and weight loss that at present face lift does not address well and fillers only volumize without the lifting, redraping and compacting qualities of a surgery.

BUT! This procedure must be well matched with the patient and skill of the surgeon. It's major risk is that of ectropion, a pulling or rounding of the lower eyelid if performed through the eyelid incision. Others have performed this using endoscopic approaches but the results are not long lasting. In my hands, Thread Lifts have been long lasting in the properly selected patients. 

The Mid-face Lift will not address the jawline, neck or excess skin of the face.

I recommend you obtain the evaluation of a well experienced, Board Certified Plastic Surgeon or Facial surgeon. 

I hope I have been helpful. All the best!

Dean P. Kane, MD, FACS
Baltimore Plastic Surgeon
4.9 out of 5 stars 103 reviews

Midface Lift: What is it and what does it accomplish?

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A midface lift is a surgical procedure which addresses hollowing around the eyes, the prominence of the nasolabial folds and the fullness of the jowls.  An easy way to think of it is to imagine it as the upper half of a facelift. The procedure can be done traditionally with an incision running along the temporal hairline or endoscopically.  Because the procedure addresses only aging changes in the upper face, it is not ideal for most patients.  
There are several technical issues that make this a more difficult procedure for plastic surgeons.  One of the major ones is risk to the facial nerve.  Anatomically, as you move from the ear to the nose, the facial nerve goes from being deep to being superficial.  Unless you have a great deal of experience as a surgeon, the area of the procedure for a midface lift is a danger zone. The facial nerve is only a few millimeters away from the proper surgical plane and getting 'lost' can have tragic consequences.  The majority of inexperienced surgeons will compensate by stopping short, staying safe and as you have identified getting underwhelming results. The second technical issue is that the vector of lift is entirely different than a traditional facelift.  Think of it like this:  in a traditional facelift, the surgeon is pulling the tissue tight in a line parallel to the jawline, in a midface lift the surgeon is lifting the tissue in a line perpendicular to the jawline.  If you do this in the mirror, it becomes apparent what the problem is for the surgeon: the skin bunches up in the lower eyelid and crow's feet area.  The more lift you accomplish with the procedure, the greater the skin redundancy that has to be dealt with.  Sometimes, the only way around this is to add an additional procedure such as a lower lid blepharoplasty or a brow lift but generally this can be addressed with CO2 laser tightening of this area.  
In summary, the midface lift is a great  procedure for the person with aging changes mostly in the cheek and lower eyelid.  It is a more difficult procedure, so choose a board-certified plastic surgeon with significant experience, i.e. doing 5-10 facelift procedures per month.  

Joseph Campanelli, MD
Portland Facial Plastic Surgeon

No need for a facelift any kind at this time.

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I'm not a big fan of the midface lift but any kind a face that seems premature. I think fillers would be a good way to enhance some of the cheek features. Nothing more than this however.

Treatment of face after weight loss

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Thank you for your question. 
  1. Do not do anything until you finish losing the weight and keep it off for at least 3 months.
  2. Fat goes into the face when we gain weight - the face will deflate and age as you lose weight.
  3. It makes to refill the volume of the face. 
  4. Facial fat injections and/or facial filler will probably give you a better result, in my opinion, than a mid-face lift.
  5. However - no one can tell you with a face-to-face examination after you reach your goal.
  6. Well done on the weight loss - being healthy and trim is essential to maintaining our youth. Best wishes.

Mid-face/Cheek Lift

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There are many variations of this procedure, not all of them good and with differences in the risks. I have personally quit doing a separately identified mid-face lift and have incorporated it into my lower blepharoplasty.This includes disconnecting the arcus marginalis (the connection of the muscle around the eye to the orbital bone) and elevating all the tissues of the cheek, suspending them from the lateral orbital tissues. I do not do a sub periostal dissection and do not dissect as far as was initially done. I also roll the orbital fat over the orbital rim and never resect it unless there is a congenital excess. This markedly improves the result and reduces the problems and complications. In you. if you had a nice youthful face that did not look over fat, then you could consider fat grafting the area to refill it and return your pre weight loss appearance. If your face was too full initially, you need the surgical tightening of the area.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

Mid Face Lift Options

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Treating the mid face really does make people look youthful and it is a key to any well done facelift operation.  However, given that you are only 38 years old, My advice?
At your age and despite a 40 lbs weight loss...I would trial some soft tissue fillers out of a box before going on to have a very expensive and challenging operation.  I know, I'm a surgeon and I'm not supposed to say that.  I really do LOVE to perform these procedures...They're my favorite!  But a I have to give advice as if you were my family if I'm going to sleep at night.
A little Radiesse, Juvederm, Voluma, you pick the product is worth a shot at seeing SOME of the effects that a cheek lift would provide.  No, it's not the same thing - NOT AT ALL, but you will begin to understand why the mid face is so important and it will help you decide if you want to have the real deal later on.

Thomas P. Sterry, MD
New York Plastic Surgeon
4.8 out of 5 stars 23 reviews

Mid face lift

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Dear jams,
   From your description of your face - naso labial folds, dark circles which is a result of lower lids bags and descent of the cheeks , your best and safest option is partial MACS face lift and possibly lower lid tuck ( blepharoplasty ) . With this technique, the improvement of the naso labial folds and check bone height is dramatic and long lasting. It is also very safe in regard to major nerve damage that your are appropriately concerned about. That is because the dissection of the face is not deep and the improvement is based on permanent  sutures that weave through the tissue , elevating it. Following that part, the skin is elevated without much tension which adds to the safety of the procedure.  Consequently the improvement is powerful and long lasting. Consult with board certified plastic surgeons who are familiar with the MACS ( Maximal Access Cranial Suspention ) technique and perform surgery in accredited surgery center for your safety. Most importantly, check the before and after pictures to make sure that you like the results. Most patients do not feel comfortable with having their facial pictures on the internet, so you will have to visit the surgeons' offices and examine larger number of before and after pictures in order to feel confident in the ability of the surgeons to deliver good result.
              All the best,
                                    Dr Widder

Midface lift

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Once you are at the weight you desire you and you doctor will need to decide if you have enough fat left in the face to just move this up onto the cheek.  If you do then a mid-face lift will work.  The results can be subtle but very natural. While it won't eliminate NLF it will soften them.  If you have lost a lot of the fat here, doing a mid-face lift will have limited success.  In that case you should add volume instead to build up the cheek. 

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
5.0 out of 5 stars 31 reviews

Are mid face and cheek lift procedures "worth it"

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Results from "mid face lifts" and "cheek lifts" which were in vogue a decade or so back were extremely variable and as you noted there were a lot of complications. Part of the problem was trying to do a lot through small, lower eyelid incisions, and having the suspension of the cheek from the edge of the eye stretch out, pulling down the lid and ....well you know the rest.

If you have premature aging due to your facial  skeletal shape and the volume loss from weight loss you may be ready even now for a properly designed and executed facelift. Certainly volume addition in the form of temporary fillers or fat transfer ( as long as you don't put the weight back on!!!) are worth considering.

Seek out advice from a certified plastic surgeon, a member of the American Society of Aesthetic Plastic Surgeons. 

Work through doing your research carefully.

Good luck

Benjamin Gelfant, MD
Vancouver Plastic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.