Download midface lift. the protocol

Serdev Suture Techniques
MID FACE LIFT. THE PROTOCOL
Nikolay SERDEV, MD, PhD
Important fixations:
AA1 – nonmovable fixation (to periosteum and temporalis tendon)
BB1 – movable fixation (of the movable zygomatic extension of the SMAS) and lifting to AA1
Anatomy:
- The s.c. “temporal pocket” has a difficult to understand anatomy, because descriptions in
anatomy books and publications use different terms. In American books it is simplified:
superficial temporal fascia (galea aponeurotica) is movable and deep temporal fascia is no
movable. Such description is simple, but can lead to misunderstanding as described below.
- The movable galea aponeurotica described also as movable superficial temporal fascia is in
realty not only temporal. Above it is fixed to the vertex and covers parietal, frontal, temporal
and occipital areas, presenting the Upper SMAS.
- The Temporal fascia starts from the upper temporal line. Above, it is a single layer, attached
to the entire extent of the superior temporal line; but below, where it is fixed to the
zygomatic arch, it consists of two layers – superficial layer of temporal fascia and deep layer
of temporal fascia, both non movable, one of which is inserted into the lateral, and the other
into the medial border of the arch. A small quantity of fat covers the orbital branch of the
superficial temporal artery, and a filament from the zygomatic branch of the maxillary nerve,
are contained between these two layers. Splitting of the above single temporal fascia is
about 2 cm above the zygomatic bone. Movable superficial temporal fascia (galea
-
aponeurotica) should not be mixed with the non movable superficial layer of temporal fascia,
below which the nerve, artery and vein are located.
The “danger area”, where perforation can lead to bleeding, hematoma, and nerve injury, is
the square of 2/2cm in front of the tragus and above the zygoma. In this “danger area” the
superficial layer of the temporal fascia is just below the galea aponeurotica and skin. The
superficial layer of the temporal fascia is non movable, covers vessels and nerves, and should
not be mixed with the movable galea aponeurotica that is described as superficial temporal
fascia in some books. In the “danger area” needle passes should be careful and superficial
just below the movable tissue (skin and galea aponeurotica). When performing a midface lift
in this area the needle should be able to move lateral and up. If fixed, it has perforated the
non movable superficial layer of the temporal fascia that is dangerous. Prolonged pressure
usually stops bleeding in this area.
Directions
- B-(A1)-B1. Point A1 is only a mark. It should be drown for orientation and should not be
perforated. NB. The needle pass B-A1 is in the “danger area” – should be superficially below the
skin. The needle passes over the zygomatic bone and in the line A1-B1 below the zygomatic mid
line to catch the movable zygomatic extension to the SMAS – the author has found this fascia
connecting the SMAS with the Zygoma to be movable).
- A-B1 is a connecting pass in the “danger area”. The needle should pass superficially below the
skin to bring the thread from point B1 to A.
- A-B is the stable fixation under the temporalis tendon.
Mid face suture lift means:
- lifting of the movable A1-B1 (zygomatic extension of the SMAS) to A-B (Temporalis tendon
and periosteum)
Vectors: 2 vectors are effective with this lift:
- Direction from the chin to point A (upper point of the ear where is the fixation to the
temporalis tendon) with strong effect on the marionette folds and additional effect on the
nasolabial folds
- Direction from the cheekbone to the point A with strong effect on the nasolabial and tear
trough folds with additional effect on marionette folds.