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Page 2 of 6 de la Torre et al. Plast Aesthet Res 2020;7:11 I http://dx.doi.org/10.20517/2347-9264.2019.54

Figure 1. Blunt passing instrument. Note the eye for the suture is 1 cm from the tip. There is a visible mark 2 cm away from the tip

[1-8]
Numerous studies have described the etiology of ptosis of the malar fat pad . These include gravitational
pull, repetitive facial animation, laxity of the retaining ligaments, and loose attachment to the underlying
SMAS. The effects of this descent have also been well described, such as hollowing of the infraorbital rim,
[1-8]
deepening of the nasolabial folds, and the formation of jowls . Myriad techniques have been used to
rejuvenate the midface, ranging from open surgeries with extensive dissection to closed procedures with
barbed sutures and zero dissection [2,3,8-11] . Furthermore, there is extensive variability in the location of
incisions and the planes of dissection.

Despite the array of treatment options, there is an emerging interest in minimally invasive techniques.
Reasons for this development may include shorter operative time, fewer complications, and decreased
[12]
recovery time . Additionally, these types of procedures can generally be performed in the office-based
setting with local anesthesia. Patients are also more willing to accept less dramatic results for a less invasive
procedure. There are several minimally invasive techniques, such as endoscopic approach with extensive
dissection, U-suture suspension with minimal dissection, and unidirectional barbed suture suspension
with zero dissection [9,10,13-17] . We describe here the Minimally Invasive Midface Suspension (MIMS), which
is a technique with a short learning curve, reproducible results, high patient satisfaction, and low risk of
complications.

METHODS
Surgical technique
The planned incisions are marked with the patient in the upright position. The anchor point incision is
marked approximately 1-2 cm behind the hairline in the temporal region on a vertical line drawn from the
superior lateral border of the malar fat pad. The inferior incision is marked along the nasolabial fold along
the mid-pupillary line. Both incision sites are infiltrated with 0.5% lidocaine with 1:200,000 epinephrine.
In addition, local anesthesia is administered as a block to the infraorbital and supraorbital nerves. After
allowing the epinephrine to take effect, the temporal incision is made with a 15-blade approximately 2 cm
in length beveling with the direction of the hair follicles. Gentle blunt dissection can be performed to
dissect down to the level of the deep temporal fascia. A small stab incision is made near the nasolabial
fold with an 11-blade. A specially designed long, blunt passing instrument [Figure 1] is then introduced
through the naso-labial stab incision and directed through the malar fat pad toward the temporal incision
in a subcutaneous plane. Care is taken to ensure that the passing instrument does not penetrate the