Are All Midface Lifts Done Endoscopically These Days?

Is it now common for the procedure to be done endoscopically? Are there any advantages to having mid facelift done NOT endoscopically (can you see more, have more control, precision)? Is it enough the "standard of care" that I should look skeptically at a surgeon who doesn't do this procedure? I'm thinking of having it done to improve the sagging of my cheeks but not sure its the right procedure.

Doctor Answers 18

No, there are many approaches

Looking at your photo, even with a slight smile, your cheek soft tissues are sagging. The good news is that you do not have jowls, or loose skin on the neck and it looks that you have good skin elasticity. I prefer to do a mid cheek lift via a small incision in the gum line just above the teeth. There's also a small incision in the temporal area in the hair bearing scalp (I part the hairs, do not shave them). I often combine a mid cheek lift with a lateral brow lift done through the scalp incision. The intraoral approach to the cheek lift is a subperiosteal dissection (right on the bone under direct vision with a fiberoptic retractor). The suture suspension is done through the deep tissues and this not only allows for elevation and repositioning but also folds the tissue on itself creating anterior projection and a soft cheek roll without an implant. I often see photos by surgeons demonstrating their cheek lift via whatever technique and the cheeks end up too high, too angular and sometimes out right bizare. The idea of an isolated cheek lift is a volumetric redistribution of the soft tissues to give you a more youthful look without any skin excision.

Bellevue Plastic Surgeon
4.8 out of 5 stars 38 reviews

Be careful what you wish for

Dear Asiangal

First, it is important for you to understand that all midface surgery is so individualized that no one can exactly predict the outcome of the procedure. Essentially, it represents a type of surgical experiment. This means the potential outcome and your satisfaction are unknown and unforeseeable!

Second, with the exception of my published method of performing a vertical midface lift through the lower eyelid, all other midface surgeries involve pulling up the cheek fat from a temple incision. The problem here is that the malar fact pad that is filling up the lower portion of your cheek and even a bit of the jaw line at the "jowl," did not come from the temple. No, once upon a time you had a heart shaped face with very full cheeks right up to your lower eyelid creases. In time this malar fat has fallen down vertically. However, very few surgeons have the knowledge to vertically lift the cheek fat back up to the orbital rim. It is anatomically much easier to reach down from the temple put a stitch into the malar fat pad and try to pull it up in a superior temporal direction. This is great from a surgeon's point of view because the anatomy is clear, there is great stuff to sew to, its fast, and it is easily added to an endoscopic forehead lift.

The only problem is that the malar fat did not come from this direction. For certain people a subtle lift of the malar fat pad to the temporalis fascia can be an improvement. However, I think that this type of result is sufficiently rare that the only people who get this type of benefit are the ones in the before and after pictures on plastic surgery websites (i.e. its rare). There are some pretty bad outcomes from this procedure. The first is an overpulled malar fat pad (think Joan Rivers). This can be made even more dramatically awful when the doctor places a submalar implant or a combined malar-submalar implant.

When the doctor has been particularly aggressive in lifting the temple, there can be long term loss of temple fat. It looks like someone has taken a bite out of the side of the face. I call this complication "plateau midface.' I am talking about this condition at the upcoming ASOPRS meeting in Laguna Beach in July. This post surgical deformity is particularly bad because the cushion of fat around the eyes helps hold the gaze on the eye during conversation. People with this problem feel like no one will look at them in conversation--it's a bad thing.

I am struck by how youthful your face is. I actually think that rather than having a high risk procedure, you could have your lower eyelid hollow and top of cheek filled with Restylane and Perlane in an office visit with no surgery and easily have many years of benefit with this approach without having to resort to surgery.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Mid facelift can be done endoscopically or open

A mid facelift can be done endoscopically or open depending upon the surgeon’s choice. An additional procedure that works quite well for volumetric augmentation of the cheeks is a cheek augmentation procedure. Silastic implants are placed through a gingival incision to volumetrically augment the cheek area. Cheek augmentation is a reversible procedure, as the implants can always be removed. Mid facelifts can make the eyes look smaller.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 145 reviews

Midface lifts can be performed open or endoscopically

All midface lifts are not done endoscopically and there is no "standard of care" for techniques. I would be more suspect of someone who tells you that any particular operation needs to be done any particular way. There are advantages and disadvantages to every technique and no specific technique can guarantee a result.

The miface is a confluence of the lower lids, cheek, and nasolabial folds. This area of the face must take into account the complex anatomy of the skin, fat, cheek mass/volume, muscles, and fascia. An open or "endoscopic" approach much be able to address all of the anatomy in the region to give you the best result. Good luck!

Charles K. Lee, MD, FACS
San Francisco Plastic Surgeon
5.0 out of 5 stars 15 reviews

Many techniques

Midfacelifts are performed in many different ways. There really isn't a procedure that qualifies as the standard of care as with most facial plastic procedures. I prefer a midface lift via a percutaneous technique with gortex suture, however, endoscopic lifts are also commonly performed.

Kevin Ende, MD
Manhattan Facial Plastic Surgeon
4.6 out of 5 stars 10 reviews

Open midface lift is most commonly done and has advantages

Most experienced surgeons are still using traditional open face lifting techniques. There are many complex reasons, but the most important are that traditional methods produce a more reliably excellent result and in my opinion are safer.

The open approcah allows for more accurate re-draping of the cheek and skin, removal of damaged excess aged skin, and a more thorough restoration of the youthful cheek by restoring the malar fat pad to a proper position.

Limited visibility through the endoscope increases the risk of nerve injury in my opinion.

Notice the cheek elevation in the after picture of the traditional facelift.

Interesting question

When you ask "standard of care" questions, it sounds like you are an attorney!

That said, they are different techniques for addressing the same area, but with different goals (slightly).

Either may be appropriate given findings at exam. For myself, I like the open approach for the midface generally speaking, so I will only address this part of your question.

Open technique will allow for removal of excess skin. Also, the SMAS (strength layer under the skin, and over muscles) can be tightened to suspend the jowls without distorting the skin. The mid-face lift, or cheek lift or mini-face lift can be done in the office under local and sedation or a sleeping pill. Results are long lasting and natural.

Just be sure to choose a skilled and experienced surgeon.


Scott E. Kasden, MD, FACS
Dallas Plastic Surgeon
4.8 out of 5 stars 106 reviews

It is the right procedure for you!

First and foremost, from you photo, you look like an excellent candidate for a mid face lift. You cheeks have fallen and you have developed a crease above your Nasolabial fold. You do not have jowling or loose skin in your neck. You still have fullness but it has migrated south. Doing a mid face lift will correct your problem without needing a more extensive face lift at this time.

As far as how the procedure is performed, some surgeons use a endoscope and others do not. This however should have no effect on the final result. The incisions are basically the same whether the endoscope is used or not. I personally like to use the scope during one portion of the procedure only. The skill ,judgment and training of your surgeon is what counts.

Leslie H. Stevens, MD
Beverly Hills Plastic Surgeon
4.2 out of 5 stars 10 reviews

Midface lift should not be done endoscopically.


1) Offering a midface lift to the appropriate patient is "standard of care" for a plastic surgeon treating the aging face.

2) In New York, we do a midface lift with an incision in the temple behind the hair and an incision inside the mouth. It's done under direct vision with fiberoptic lighting, and there are no visible scars. There is no role for endoscopy. (We do endoscopic brow lifts, but that is another issue.)

3) You look like a good candidate for a midface lift. It will really pick up your central cheeks.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
4.8 out of 5 stars 9 reviews

Endoscopically not the norm

There are any number of approaches to the midface. Many surgeons make a temporal hairline incision then bluntly dissect to the cheek. Then either a suture or a dissolvable anchor is used to support the cheek to the deep temporal fascia. As a surgeon who has done a lot of facial cosmetic and trauma surgery I use an upper eyelid incision and one in the mouth. This has the advantage of giving me great access and avoids the temporal branch of the facial nerve which is a concern with the other approach. I anchor my suture to the same temporal just behind the orbital rim. At a recent conference I convinced several other surgeons who were always concerned about the nerve to do the midface lift in this fashion. There is really no role for endoscopic equipment in a midface lift.

Christopher L. Hess, MD
Fairfax Plastic Surgeon
4.4 out of 5 stars 34 reviews

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.