Midface Lift or Full Facelift for Midface Drooping After a Stroke?

When you look in the mirror after facial paralysis, the change you see is often not just sagging; it is the loss of your face’s natural balance and expression. This sagging in the midface region causes the cheeks to shift downward, facial contours to become less defined, and facial expressions to weaken. This condition not only gives the person a more tired or aged appearance but also affects social communication and the way they express themselves. This is precisely where the most critical question arises: Is a targeted procedure like a midface lift sufficient to address this issue, or is a more comprehensive approach—such as a full facelift—necessary to address the entire face? If you’re curious about the answer to this question, feel free to explore our content.

What Is Midface Drooping After Facial Paralysis?

Mid-face ptosis following facial paralysis is a functional and aesthetic problem caused by the downward displacement of tissues due to a loss of muscle tone in the mid-face segment, which encompasses the cheek (malar region), zygomatic bone, and nasolabial area. This problem progresses over time, disrupting not only the overall appearance of the face but also the natural flow of facial expressions and the integrity of facial expression.

As muscle activity decreases, soft tissues sag downward due to the effects of gravity, cheek volume decreases, and nasolabial lines become more pronounced. As a result, asymmetry develops between the two halves of the face, and the person may appear more tired, older, or expressionless. Additionally, this sagging in the midface region can negatively affect the transition between the under-eye area and the cheeks, leading to a sunken appearance.

From a functional perspective, issues such as mismatched lip movements during speech, drooping at the corners of the mouth, and in some cases, difficulty controlling oral fluids may arise. Particularly in cases of long-term facial paralysis, muscle atrophy and loosening of connective tissue become more pronounced; this leads to the loss of mid-face support and sagging reaching more advanced stages. For this reason, mid-face sagging is an important clinical condition that must be evaluated with a comprehensive approach, considering both aesthetic and functional aspects, in the treatment planning following facial paralysis.

What Causes Midface Drooping After Facial Paralysis?

There are many causes of midface changes following facial paralysis. These causes include the following:

• Loss of Tone in Facial Muscles: The primary muscles that lift the central region of the face (the zygomaticus major and minor, and the levator anguli oris) are controlled by the 7th cranial nerve (facial nerve). Following nerve damage, these muscles lose their ability to contract and their resting tension (tone), becoming unable to resist gravity.
• Displacement of Fat Pads: The deep and superficial fat pads that provide fullness to the midface region are normally held in place by the muscles and the SMAS (Superficial Musculoaponeurotic System) layer. When the muscles become paralyzed, this support mechanism collapses, and the fat pads shift downward and inward, beginning to accumulate around the mouth.
• Loosening of the SMAS Layer: The SMAS layer, which serves as the underlying supportive structure beneath the facial skin, loses its tension due to muscle atrophy (wasting). This causes the soft tissues above the cheekbone to sag downward and the midface to flatten.
• Deepening of the Nasolabial Fold: The downward shift of the tissues between the upper lip and the cheek causes them to accumulate over the nasolabial fold, known as the “smile line.” This accumulation creates a more aged and tired appearance on that side of the face.
• Disruption of the Lower Eyelid and Cheek Connection: When the midface sags, the cheek tissue supporting the lower eyelid is also pulled downward. This can cause the under-eye hollow (tear trough) to become more pronounced and the lower eyelid to be pulled downward (risk of ectropion), leaving the eye more exposed.
• Pressure from Antagonist Muscles: While the muscles on the unaffected side of the face continue to function normally and pull the face toward their side, the tissues on the paralyzed side offer no resistance. This imbalance in force causes the drooping on the paralyzed side to appear more pronounced.
• Loss of Skin Elasticity: In cases of long-term paralysis, the mechanical stresses on the skin, which is deprived of muscle support, change. Over time, the skin loses its elasticity, paving the way for the sagging to become permanent.

The Role of the Midface Lift in Midface Drooping Following Facial Paralysis

In cases of midface sagging following facial paralysis, a midface lift is a targeted surgical approach that provides both aesthetic and functional improvement by anatomically repositioning sagging cheek tissues to a higher and more natural position. In this approach, particularly the malar fat pads and midface soft tissues are repositioned upward and laterally through appropriate surgical planning to restore the face’s natural contour. During this procedure, the face’s dynamic expressions and existing asymmetry are carefully analyzed; thus, the goal is not only to elevate the tissues but also to optimize the face’s overall balance and expression.

The midface lift procedure provides static support in areas where muscle activity has been lost due to facial paralysis, thereby limiting the downward displacement of tissues. As a result, the depth of the nasolabial folds decreases, cheek volume becomes more defined, and the transition from the under-eye area to the cheeks achieves a more homogeneous appearance. Additionally, by indirectly contributing to the improvement of drooping at the corners of the mouth, it helps the face appear more balanced and symmetrical. When necessary, combining the procedure with fat grafting (lipofilling), suspension techniques, or other reconstructive procedures can yield more comprehensive and long-lasting results. In this regard, midface lift surgery is an important surgical option for midface reconstruction following facial paralysis, as it enhances both aesthetic improvement and the comfort of social expression.

The Role of a Full Facelift in Mid-Face Sagging Following Facial Paralysis

In cases of mid-face sagging following facial paralysis, a full facelift is a comprehensive surgical approach aimed at restoring the face’s overall balance by providing a broader anatomical correction that encompasses not only the mid-face but also the lower face and neck regions. In this approach, the SMAS (Superficial Musculoaponeurotic System) layer is repositioned to strengthen the face’s deep support structures, thereby providing an indirect lifting effect on the mid-face tissues. As a result, nasolabial folds are softened, the jawline is defined, and sagging in the neck area is tightened, leading to a more balanced overall facial contour. Especially in patients with severe asymmetry and widespread tissue sagging, a full facelift offers both aesthetic and structural improvement. When necessary, combining the procedure with fat injections, static suspension techniques, or other reconstructive procedures can yield more natural and long-lasting results. In this regard, full facelift surgery is an important and effective surgical option for restoring not only the harmony of the midface but the entire face following facial paralysis.

For Which Patients with Facial Paralysis Is a Midface Lift Appropriate?

• Individuals with sagging in the cheek and zygomatic bone area, while the lower face and neck regions remain relatively intact.
• Individuals in whom the malar region has shifted downward on one side, significantly disrupting facial symmetry.
• Individuals with pronounced nasolabial folds due to loss of midface support.
• Additionally, cases where correction of tissue position is required rather than dynamic movement.
• Patients whose jawline and neck contour are largely preserved.
• Individuals whose transition from under-eye to cheek areas has become more pronounced, causing the face to appear more tired.
• Additionally, individuals whose issue is limited to the midface region.
• Individuals who may benefit from fat injection (lipofilling) or suspension techniques in conjunction with a midface lift.

For Which Patients with Facial Paralysis Is a Facelift Appropriate?

• Individuals who have developed significant sagging not only in the cheeks but also in the jawline and neck area following facial paralysis.
• Individuals whose overall facial structure has collapsed due to muscle atrophy and connective tissue laxity.
• Cases where the overall facial balance has been disrupted following unilateral facial paralysis, and where treatment limited to the midface alone would be insufficient.
• Patients whose lower facial contour has lost its definition and whose lower face has sagged.
  Individuals who have experienced laxity not only in the face but also in the neck region following facial paralysis.
• Individuals seeking a balanced and harmonious appearance across all facial regions.
• Cases where support for the lower face and neck must be provided alongside midface correction.
• Individuals for whom a midface lift, fat grafting (lipofilling), or suspension techniques can be performed in conjunction with a full facelift.
• Those seeking not only an improved appearance but also enhanced facial expression and comfort in social interactions.
• Individuals whose acute phase has passed, whose current condition has stabilized, and for whom a permanent correction can be planned.

Can a Facelift and a Midface Lift Be Performed Together in Cases of Midface Drooping Following Bell’s Palsy?

In cases of midface sagging following facial paralysis, a full facelift and a midface lift are combined surgical approaches that can be performed together when appropriate patient selection is made, often yielding more balanced and comprehensive results. For this reason, while a midface lift targets sagging in the cheek and zygomatic bone areas to lift the midface, a full facelift addresses laxity in the lower face and neck regions to reshape the face’s overall contour.

The combined use of these two techniques enables not just a localized correction but the achievement of harmonious symmetry and aesthetic balance across the entire face. Especially in cases of long-term facial paralysis, where significant tissue sagging is observed in both the midface and lower face regions due to loss of muscle tone, a single surgical method may prove insufficient. At this point, a combined approach provides both static support and helps reposition tissues in a more anatomically correct manner. Additionally, when supported by fat grafting (lipofilling), suspension techniques, or other reconstructive procedures, the results can be made more natural, long-lasting, and functionally satisfying. For this reason, the combined application of a midface lift and a full facelift is an effective treatment strategy frequently preferred for patients with severe asymmetry and widespread tissue loss following facial paralysis.

If you’re wondering which procedure would be best for you to address mid-face changes following facial paralysis, you can contact Dr. Berke Özücer and his team, who specialize in facial plastic surgery in Turkey.