Mendelson prezygomatic and premaxillary deep plane lift

What the case shows

Before: fat bagging the lower lids (pseudoherniation), festoons over the cheekbone, a deep groove between lid and cheek (the palpebromalar groove) and deep nasolabial folds. After: one smooth lid-to-cheek line, softened folds, and a face that still reads as a man’s.

The operation in seven steps

1. 1

   Subciliary entry, muscle strip preserved

   A skin incision 2 mm below the lash margin; the orbicularis muscle is divided 4–5 mm lower, so an intact strip stays in front of the lid cartilage to support the lid and the outer corner.

2. 2

   Preseptal dissection and ligament release

   The avascular plane is followed down to the orbital rim; the tear trough ligament is released medially and the orbicularis retaining ligament laterally — the two tethers that carve the deep groove.

3. 3

   Open the prezygomatic space

   Mendelson’s triangular space over the cheekbone is entered, bounded by the lid muscle above and the deep fat over the origin of the cheek-lifting muscles, freeing the malar mound and festoon as one unit.

4. 4

   Release the zygomatic ligaments

   The stout ligaments along the lower border of that space are divided just above the origin of zygomaticus major, staying on the surface of the lip-elevator muscles so the motor branches entering their deep surface are protected.

5. 5

   Extend into the premaxillary space

   The dissection is carried medially over the front of the maxilla, deep to the medial cheek fat pad, and stops just above the infraorbital foramen to protect the infraorbital nerve and vessels.

6. 6

   Release the maxillary retaining ligaments

   The attachments along the pyriform aperture and the nasomaxillary buttress are divided so the dropped medial cheek is free to rise — this is what softens the nasolabial fold without cutting skin there.

7. 7

   Reposition the fat and suspend

   The arcus marginalis is released and the orbital fat pads are moved across the rim; the composite flap — sub-muscular cheek fat, deep fascia and lid muscle — is then suspended upward and slightly outward to the outer orbital rim periosteum and the deep temporal fascia, giving one smooth lid–cheek line without a feminizing cheek flare.

Where the dissection stops

Two rules guide the dissection. Over the cheek, it stays on the surface of the lip-elevator muscles so the motor branches entering their deep surface are left alone. Medially, it stops just above the infraorbital foramen, protecting the sensory nerve and vessels to the cheek and lip. Knowing where to stop matters as much as knowing where to cut.

Why through the lower lid

A fine incision just under the lash line gives direct access to the lid, the orbital fat and the rim in one field, so the lids and the midface are treated as one problem. The strip of muscle kept in front of the lid cartilage is what protects the lid from drooping.

Who it is for

A midface lift is for real midface descent — festoons, a deep groove, a dropped cheek mass. Routine under-eye bags usually do not need it; the lower blepharoplasty page explains how that is decided.

Frequently asked questions