The concentric malar lift: malar and lower eyelid rejuvenation.

Midface rejuvenation surgery is most challenging. The margin of error for the lower lid is on the order of 0.5 mm, and the cosmetic result can sometimes look unnatural. A minimally invasive technique for malar and lower lid lift is proposed. Two incisions are used: the standard subciliary lower eyelid incision and one on the lateral part of the upper eyelid. Through these incisions a skin flap lower eyelid dissection and a subperiosteal malar dissection are performed. The arcus marginalis itself is not transected as is the case when the malar area is entered from the lower eyelid. Rather, a subperiosteral release of the arcus marginalis is performed through a muscle-splitting incision at the lateral canthus. Eyelid malposition is avoided because the muscles, vessels, and nerves converging toward the medial canthus are not interrupted. The subperiosteal dissection of the arcus marginalis extends to the medial canthus and also releases the insertion of the orbicularis oculi superior malar part. Consequently, all the attachments of the tear trough are released. Two subperiosteal suspensions connect the central part of the nasolabial volume and, more laterally, the central part of the malar area to the inferolateral orbital rim. The elevation of the malar volume resulting from these suspensions is concentric with the orbit. A final third suspension vertically connects the orbicularis oculi muscle with the underlying periosteum to the bone of the lateral orbital rim. Significant skin excess is removed from the lower eyelid. Complete disinsertion of the tear trough attachments combined with the malar elevation treats the entire palpebromalar groove. The lifted fat volume fills the space resulting from the subperiosteal disinsertion. A safer, more natural and more reliable result is achieved because the vectors of traction with this technique are exactly opposite those of the midface aging process, and because a very stable fixation is created between the lifted malar periosteum and the malar and latero-orbital rim bones.