Goals/Purpose:
Rejuvenation of the midface remains a challenging aesthetic area to attain natural-looking, safe, and long-lasting results. There are numerous subperiosteal approaches that achieve successful rejuvenation. While many of these approaches are very safe and effective in skilled hands, extensive subperiosteal dissection and surgical manipulation can be unforgiving. Our goal was to find an approach that is relatively easy to apply with minimal risk and significant benefit. We feel that the combination of transconjuctival exposure and preservation of the periosteum results in less morbidity. We will present the benefits and limitations of this approach, as it may compare to more traditional approaches.

Methods/Technique:
A retrospective chart review was conducted of 25 consecutive patients, treated by a single surgeon (JWF) using the transconjuctival submuscular midface lift approach. The surgical technique consists of a combination of subcilliary and preperiosteal dissection under direct vision to release the orbital-malar ligament.  The zygomaticofacial retaining ligaments are release via a lateral upper blepharoplasty exposure, which is a nature extension of the lateral retinacular release. The combination of the two exposures allows for varying degrees of release.  An extended, insulated needle tip cautery facilitates the dissection, leaving no tissue on the periosteum, minimizing the risk for nerve injury. All patients were treated with either canthoplasty or cantopexy, in addition to lower lid skin pinch excision.  All patients were treated over a six year period, 2000 to 2006. Data collected included the following: patient demographic, operative technique, concomitant procedures, and postoperative results. Complications and revisions were reviewed to evaluate the safety and long term efficacy of the procedure.
 
Results/Complications:
A retrospective review from 2000 to 2006 identified 25 female and 6 male patients with a minimum of 12 month’s postoperative follow-up. The mean age for the group was 54 years. The median follow-up was 32 months (range 12 to 78 months). No significant complications were recorded over an average of 36 months.  The mean operative time for upper blepharoplasty with transconjuctival midface lift (with canthal suspension) was less than 150 minutes. No patient experienced facial nerve injury, prolonged chemosis, prolonged periorbital swelling, hematoma, seroma, ectropion, or lower eyelid malposition. One patient required re-excision of redundant lower eyelid skin, and one patient experienced chemosis that resolved in less than 10 days. Patient satisfaction was 96%. Three patients with extensive preoperative festoons required secondary excision or traditional midface lift, as described by the Paces group,

Conclusion:
The transconjuctival submuscular midface lift is safe and effective. The technique is readily applicable and more forgiving than the traditional midface lift. There is excellent operative exposure without the need for endoscopic equipment/training, and limited soft tissue dissection which reduces operative morbidity and promotes rapid recovery. Patients with extensive midface redundancy and/or festoons should be treated with more traditional techniques.