What are the pros and cons of transconjunctival deep-plane mid face lift?

Question

I am 47 and am considering having a facelift in the next few years. I saw a video of a renowned British PS performing a TDML and securing the lifted layers with titanium screws inserted into tiny holes drilled into the patient's cheekbones. What are the potential drawbacks of this operation? And could it be combined with a traditional face- and neck-lift for maximum vertical and horizontal rejuvenation?

P. Daniel Ward, MD · Answer

Hi Peyton,I think the main question to ask is if you need all of that extra work with the associated increased risk of complications and the increased recovery time. The idea behind the more invasive facelift procedures is to give a better, longer-lasting result, a goal that all of us would love to achieve! However, there are several studies that question whether the increased complexity actually leads to any better result than other techniques. I advise you to find a good plastic surgeon in your area--one who specializes in facial plastic surgery--and see what he or she has to say after examining you. Ask them if they think you need a more invasive surgery or whether a less invasive, complex, and risky procedure is the right one for you. They will be able to recommend a procedure that has the right level of complexity for your case.Thanks for your question and good luck!!!

Houtan Chaboki, MD · Answer

Most plastic surgeons probably perform a cheek lift with volume augmentation or via the facelift itself, not how you've described. Performing a mid face lift through the lower eyelid is not typically performed for a variety of reasons, as outlined by other facelift surgeons on this site. That being said, lower eyelid surgery, volume augmentation (ex. fat injection, fillers, etc), and a facelift or neck lift are commonly performed together. An office examination with a plastic surgeon would be required to provide the best facelift options for you.Best,Dr. Chaboki

Vincent N. Zubowicz, MD · Answer

This is a very tricky operation when the ligament that separates the lower lid from the cheek is released. It should only be perform by surgeons who do this regularly. Aesthetic problems resulting from this operation are sometimes impossible to fix.

Christian Subbio, MD · Answer

Your question is a difficult one because so many different doctors would approach that given problem via so many different approaches.  Some would add volume with fat, some with fillers.  Some would address the midface  as a temporal approach, some via an eyelid approach, and some via a transconjunctival approach. Few would use screws, some would use barbed devices, others dissolvable plastic-like devices and yet others sutures.  The pros and cons are so complicated and in depth, I suggest a different way of approaching this.I think you should begin with a consultation with a few different plastic surgeons to get different opinions.  I think you becoming enamored with any one given method of addressing facial aging may be problematic.  Your midface may be less of an issue and may be addressed secondarily via one of the more classic approaches.  I think it is more important to start with your anatomy, via submitting photos, or even better, talking with plastic surgeons and getting in person examinations.  Then, your surgeon can come up with the best operation given your anatomy rather than the other way around.  I hope this helpsBest of luck!Dr. SubbioBoard-Certified Plastic SurgeonNewtown Square/Philadelphia, PA

Jeffrey M. Darrow, MD · Answer

There are many different techniques described for facial rejuvenation from minimally invasive to very extensive.  Common sense dictates that if 1 technique gave much better and longer lasting results, then everyone would use that, and it would be presented at all the major plastic surgery meetings.  I know of no one in my locale who does this type of facelift and I have never heard it presented at any of the major plastic surgery meetings I attend yearly.  It was used in the past but now has fallen into disfavor due to long recovery and higher complication rates.  Excellent facial rejuvenation can be achieve with less invasive procedures which have a recovery of 7-10 days.  See a board certified plastic surgeon who can show you an extensive experience in faclift results for a detailed consultation so you can find what would work best for you.

Johnny Mao, MD, FACS · Answer

Since you saw the video, you see the entry point incision to access the deep plane is thru the conjunctiva of the lower eyelid so you may have conjunctival swelling (chemosis) but should resolve in 3 months worse case scenario.  Eyelid malposition is also another risk albeit less than the subciliary or external approach.  The tiny titanium screws rarely cause problem as I routinely use them in facial fracture repairs.  You may be able to feel them but should not see them as a little bumps unless you have extremely thin skin.  There is a nerve in the mid cheek that provides sensation to the cheek/lateral nose/upper lip, that structure is in the area of surgery and is at risk for injury.  But in the right hands nerve damage is probably minimal, I say less than 1%. It can be combined with a traditional face/necklift as you are making an additional incision thru the lower eyelid (transconjunctival), but you will release the soft tissue in the medial cheek more effectively.  Often times in facelifting surgery, it is more the "release" of the tissue, and less how you secure it (sutures vs screws vs endotines) that affects the desired result.  Tissues will ultimately "descent" in time but the more lifted the less the fall.

Arnold Almonte, DO · Answer

Depending on where your skin laxity is, the mid facelift can be performed as a solo procedure, or in combination with a traditional lower facelift. The major "pro" of the transconjunctival approach is that the incision is placed inside the eyelid and spares you an external incision. The "con" is that if you have excess eyelid skin that needs to be removed, that approach doesn't fix that. In that situation, you end up needing that external incision anyway. How the midface tissue is suspended can vary from surgeon to surgeon. Some use screws, others use suture. That's just a matter of preference and training. Both are effective. Personally, I perform an "orbicularis sling" technique which holds up the midface quite well. This sutures the lower eye muscle to the temporalis tissue just above the eye. I suggest to not get hung up on one approach vs another. A thorough consultation will reveal what will work best for you. Take your time and get several opinions. I wish you the best!

Jonathan S. Jacobs, MD, DMD · Answer

This can be an effective correction for aging about the midface. It is not effective for the neck/jowl or submental region. If anchoring is inadequate  it can lead to drooping of the lower eyelid.

Benjamin C. Paul, MD · Answer

Each patient comes with distinct anatomy and concerns. Without seeing you, it is hard to say the best approach. In general, a transconj approach to a deep-plane midface lift has a very vertical vector of pull, which is not always the ideal vector of pull.Best of luck with your journey.

Dean P. Kane, MD, FACS · Answer

Dear Peyton2012:Thank you for this question. It is interesting and complicated. A photo would help but you will need a proper consultation. Yes, one downside to the classic facelift is the inability to fill and elevate the medial cheek. So, a mid-face lift or high SMAS facelift with filler or fat may help in this area for maximum vertical rejuvenation and volume augmentation. The "deep-plane" may mean different things to different surgeons. For me, it means dissection in between the muscle layers and potential for nerve injury. There are other dissection planes to consider. Ultimately, it comes down to patient selection for proper selected procedure(s).Is it skin texture or skin and soft tissue drooping / laxity that is the problem?If you can "pinch more than an inch" of skin along the jawline; you must consider a surgical skin excision, ie a facelift.If it is skin laxity, wrinkles and lines, consider skin rejuvenation and tightening.Do you need volume or replacement of drooping volume to its more youthful position?Fillers and implants will replace volume but your drooping jowls, jawline and neck tissues persist.Do you have fat bags under the eyes that need removal or repositioning?Is there skin excess under the eyelashes?The transconjuctival approach to blepharoplasty and mid-face lift is provides a very small area of surgical exposure adding to the complexity of a already advanced technique and tends to produce hollow lower eyelids with no removal or redraping of excess lower lid skin. The mid-face lift is a powerful tool for facial volume replacement but can cause a pulling of the eyelid, ectropion if done poorly or in the wrong patient. The use of screws is one option but there are many techniques available and should be explored such as the use of :barbed sutures, periosteal suspension, screws (permanent or dissolving), bone tunnel suture suspension, permanent or dissolving sutures.subcutaneous or sub-periosteal elevation of tissuestemporal, gingival, facelift and / or eyelid (cutaneous or trans-conjunctival) incisionsI love the long term results and significant rejuvenation of the mid-face lift for the properly selected patient. It is also a useful technique in facial reconstruction from where the cosmetic application came from. It may be unforgiving in the wrong patient.Please consult with a skillful, talented and well experienced, Board Certified Plastic Surgeon for this advanced technique. I wish you well!

What are the pros and cons of transconjunctival deep-plane mid face lift?

Answers (13)

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