title: Triple-layer midface lifting: long-term follow-up of an effective approach to aesthetic surgery of the lower eyelid and the midface.
abstract: BACKGROUND
  It is becoming more and more accepted that better aesthetic results can be obtained when the lower eyelid is considered as part of the midface when contemplating surgical rejuvenation. Descent of the orbicularis muscle and midface tissue causes malar bags, loss of volume over the tear-trough, apparent vertical lengthening of the lower eyelid, and an accentuation of the orbit-cheek junction.
  
  
  METHODS
  We describe a triple-layer technique that effectively corrects these problems, performed under local anesthesia and via a standard subciliary incision, to separately reposition the postseptal fat, suborbicularis oculi fat, and the musculocutaneous layer of skin and orbicularis oculi. We present a detailed analysis of the complications arising from a series of over 500 patients, in which this technique has been performed by the senior author.
  
  
  RESULTS
  The average patient age at the time of surgery was 51 years old (± 7.9), with a median follow-up of 7 months (range 3-121). Complications were observed in 77 of 512 cases. In total, 44 of these cases required surgical reintervention under local anesthesia (rated as major complications and all reinterventions lasted <30 min) and 33 cases were treated conservatively (minor complications).
  
  
  CONCLUSIONS
  The triple-layer midface lift is an effective way to reverse the combination of ptosis and changes in volume of the aging midface. It yields long-lasting results with a minimal risk for complications, particularly when a tarsal tuck is performed simultaneously in patients at high risk for the development of scleral show.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors.affiliation: Bergman Clinics, Private Clinic, Binckhorstlaan 147, The Hague, The Netherlands, stevens.hp@gmail.com.
authors.forename: Hieronymus P Jerome D
authors.initials: HP
authors.lastname: Stevens
authors.forename: Joep C N
authors.initials: JC
authors.lastname: Willemsen
authors.forename: Piyush
authors.initials: P
authors.lastname: Durani
authors.forename: David
authors.initials: D
authors.lastname: Rasteiro
authors.forename: Ogbe J
authors.initials: OJ
authors.lastname: Omoruyi
mesh_terms: D000273:Adipose Tissue / Q000601:surgery; D000328:Adult; D019882:Blepharoplasty / Q000379:methods*; D001763:Blepharoptosis / Q000601:surgery*; D005260:Female; D006801:Humans; D008875:Middle Aged; D064827:Myocutaneous Flap; D009801:Oculomotor Muscles / Q000601:surgery; D012060:Rejuvenation; D015361:Rhytidoplasty / Q000379:methods*