In the preoperative holding area, the nasolabial folds and sagging malar fat pads are marked. Insertion sites for two percutaneous sutures, wich will be passed bilaterallly, are marked 1 cm lateral to the right and left nasolabial folds at the level of the alar groove. A second mark is placed 1 cm inferior to the first and parallel to the nasolabial fold. Two alignment sites are marked, the first 1 cm lateral and parallel to the lateral border of the prbital rim and a second 2 cm lateral to the orbital rim. A line is then drawn connecting the inferior and superior points to show the trajectory for suture placement. A 2-cm incision just posterior to the temporal hairline and perpendicular to the trajectory line is dawn and the hair is carefully placed in tie-back holders. The hair is trimmed at the temporal-area incision site.
The patient is taken to the operating room and placed supine. Intravenous sedation is induced and tumescent local anesthetic (using 25 mL of 1 % lidocaine with 3 mL od 1:1000 epinephrine in 500 mL of lactated Ringer solution) is injected into the areas of planned incision and within the area of projected suture passage. Full-face prep and drape are used, as is a full grown-and-glove technique.
While the surgeon waits for the maximum vasoconstrictive effects, a 4-0 clear polypropylene stitch is threaded on a long Keith needle. The suture is then passed through a 3-mm x 3-mm polytef pledget, with the opposite end of this permanent stitch also threaded on a second Keith needle. A second suture of 3-0 polyglycan is placed alongside the 4-0 clear polypropylene suture and likewise passed through the Keith needles but not through the polytef pledget. Four such sutures are prepared for the procedure.
The temporal incision is created first, with care taken to remain parallel to hair follicles so as to prevent follicular injury and secondary alopecia. The incision is taken down to the deep temporalis fascia using blunt dissection. A pancake elevator is ussed to dissect anteriorly toward the orbital rim and the zygomatico-fromtal suture line. Care is taken to stay immediately atop the deep temporalis fascia. The sentinel vein is found here and cauterized with a bipolar instrument. Only minimal posterior dissection at the temporal dissection at the temporal incision site is performed to provide adequate space for securing the suspension sutures when passed from below.
An 11 blade is used to make two stab incisions at the previously marked sites just lateral to the nasolabial groove. The Kaith needle with the suture combination is then passed through the firs site, directed toward pocket. After going into the fat pat inferiorly, the needle and suture trajectory will course at a relatively superficial level from zygomatic arch to the orbital rim and then into the temporal pocket, the Keith needle with sutures is grasped and placed aside. The second Keith needle and the second end of the suture combination are then passed through the same stab site with a similar trajectory and are likewise grasped within the temporal pocket .
Initially, the clear polypropylene stich loop with the polytef pledget remains outside the skin. The polyglycan suture is pulled into the stab site and manipulated in a back-and-forth fashion to release the superficial fascial cover of the malar fat pad, creating a short tract within the pad. an appropriate tract is evident qhen pad elevates easily approximately 8 to 10mm. Using too long a tract leads to poor pad elevation, and suture passage should be repeated. The pledget with the polypropylene suture is the gently advanced into the stab site and snugged up within the malar pad itself. The polyglycan suture is remmoved to the deep temporalis fascia in a figure-of-eight-like stitch on a French-eye needle. The second suture combination is passed through the second stab site and is likewise secured to the temporalis fascia. Two suspension sutures are placed on each side. The temporal incision is closed in a layered fashion.
