You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Rhytidectomy, Subperiosteal FaceliftArticle Last Updated: Aug 9, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Partner, Myers Wyse Center for the Eye; Director, North Shore Center for Facial Rejuvenation; Founding Partner, HC Consulting, Inc Adam J Cohen is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons Coauthor(s): Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota; Edward W Chang, MD, DDS, Consulting Staff, Department of Cosmetic Services, Head and Neck Surgery, Kaiser Permanente of Northern California at Santa Rosa Editors: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: subperiosteal facelift, facelift, facial aging, face-lift, rhytidectomy, deep-plane rhytidectomy, deep-plane facelift, facelifting, superficial muscular and aponeurotic system, SMAS, sub-SMAS technique, facial rejuvenation, rhytide, deep-plane rhytidectomy, subperiosteal dissection INTRODUCTIONSection 2 of 10
  Subperiosteal rhytidectomy can be used to reverse the effects of facial aging of the midfacial and lower facial region. The evolution of the facelift began with simple cutaneous remodeling and has expanded to address the subcutaneous layers in achieving a more youthful appearance. As techniques advanced, some practitioners desired alternative methods to improve the appearance of the nasolabial fold. The deep-plane rhytidectomy was developed to enhance the appearance of these folds and achieve a youthful, harmonious facial appearance postoperatively. History of the ProcedureSubperiosteal facelifts are a point along the continuum of surgical facial rejuvenation. In 1969, Skoog reported on the techniques of treating the deeper facial structures and, in 1974, put forth the sub-SMAS techniques, which altered the soft tissues of the face in a conjoined fashion. Prior to this time, facelifting involved predominantly subcutaneous dissections (see Image 2). In 1979, Tessier espoused the subperiosteal approach for the superior and lateral periocular area in brow rejuvenation and facelifting. He termed it the "orthomorphic subperiosteal face lift." Psillakis in 1984 and 1988, Vasconez in 1986, Ramirez in 1991 and 1998, and others have expanded and modified the subperiosteal approach. Authors such as Barton and Hamra sought alternative ways to improve rhytidectomies and the appearance of the nasolabial crease and fold in conjunction with their facelifts. Barton described the modified sub-SMAS technique in 1989, and Hamra described the deep-plane facelift in 1990 (see Image 3, Image 4). ProblemThe subperiosteal facelift arose from the evolution of facial rejuvenation attempts. The repositioning of the deep facial tissues overlying the bone sets these structures back into their normal positions. This process re-establishes the facial skeletal and facial soft tissue relationships, allowing for improvement in the skin and facial features and improvement in the nasolabial crease and fold (see Image 1). EtiologyEver acting gravitational forces, senescence, and ultraviolet exposure result in an aged and tired facial appearance. PathophysiologyWeakening of the retaining ligaments of the face are implicated in contributing to age related facial changes. In 1989, Furnas provided a description of these ligaments. These ligamentous structures suspend the more superficial and mobile anatomical structures from the deeper and akinetic facial constituents. Fasciocutaneous and osseocutaneous ligaments have been described, with the former extending from the dermis to the facial fascia and the latter from dermis to periosteum. Loss of bone and atrophy of facial fat are also believed to result in the skin sagging and drooping over the facial skeleton (see Image 5). ClinicalPatients presenting for evaluation will often describe a tired or aging face. They often describe unsightly rhytides and asymmetrical facial structures. INDICATIONSSection 3 of 10
Subperiosteal facelifting is indicated for the elimination of rhytides and improvement of the nasolabial folds' appearance. RELEVANT ANATOMYSection 4 of 10
As with any surgical endeavor, a complete understanding of anatomical architecture is paramount for successful outcomes. The human face is a magnificently complex structure, which can challenge any surgeon. In particular, one must firmly understand the blood supply and the rapport of the skin, fascia, fat, musculature, and periosteum in the cervicofacial area. Superior to the zygoma, the skin has a robust blood supply emanating from the superficial temporal artery. Below the zygoma, the facial and the transverse facial arteries provide blood flow to the skin before anatomization with the superficial temporal artery in the subdermal region. These 3 vessels emerge from the external carotid artery, while other tributaries have origins from the internal carotid artery and include the supraorbital and supratrochlear vessels. The facial musculature and the superficial fascia of the parotid and cheek area are referred to as the SMAS (superficial muscular and aponeurotic system) (see Image 3). This system has an extensive domain, with most authors acknowledging the galea as the superior boundary and the intermingling with the platysma as its lowest extension. Where the SMAS courses over the deep temporal fascia, it is commonly labeled the temporoparietal fascia and contains the superficial temporal artery and frontal branch of the seventh cranial nerve, which can be easily insulted during dissection and retraction in the region of the zygoma. As the SMAS moves inferiorly, it passes over the parotid gland and attaches to the deep fascia and skin via parotid-cutaneous ligamentlike tissue projections. The SMAS courses anterior to the masseter muscle then dives to engulf the muscles of facial expression. The buccal branches of the facial nerve are in a sub-SMAS distribution in this locale and should not be ignored during dissection. A subperiosteal route of dissection is best used to avoid neural structures of the midface and allow for substantial improvement of the nasolabial fold aesthetics. CONTRAINDICATIONSSection 5 of 10
This procedure is contraindicated in patients who are not medically stable or cannot tolerate anesthetic agents and in patients who do not have realistic expectations of the surgical outcome. WORKUPSection 6 of 10
Lab Studies
Imaging Studies
TREATMENTSection 7 of 10
Surgical therapyA surgeon should be able to visualize in his or her mind the subcutaneous anatomy, including landmarks and regions containing vital structures. Demarcation of planned cutaneous incisions and the path of the frontal branch of the facial nerve should be outlined with a surgical marking pen. Recall from the anatomy section, the frontal branch of the seventh cranial nerve courses through the temporoparietal fascia and its trajectory should be outlined before surgery. Starting at the otic lobule, a straight line should be drawn midway between the lateral canthal angle and tragus. Drawing a line parallel and 2 cm anterior to the frontal nerve demarcation line denotes the SMAS dissection plane. Sub-SMAS dissection boundaries can be marked via a curvilinear ray originating from the lateral orbital rim and terminating 2 cm lateral to oral commissure. In males, demarcation of the temporal hairline incision is carried in a pretragal fashion at the helical root and moves posteriorly until conjoined with the temporal incision retroauricularly. After adequate intravenous access is established and all cardiopulmonary monitors are properly functioning, begin IV sedation. Plug the external auditory canals, properly position a Foley catheter in the urinary bladder, and attach an oxygen supply to a nasal trumpet. Inject 1 or 2 percent lidocaine with 1:100,000 epinephrine into the marked incision lines and inframental region. Create stab incisions at the horizontal hair tuft, retroauricular, and pretragal areas and the submental crease for tumescent fluid infiltration. The authors prefer to use 1 liter of sodium chloride (0.9% sodium chloride) with 50 cc of 2-percent lidocaine (without epinephrine), 1 cc of 1:1000 epinephrine, and one quarter of a milliliter of 40 mg/cc triamcinolone. Infiltrate this solution on both sides of the face. The authors' experience has been to use approximately 50-75 cc on each side of the face and, usually, to allow 15 minutes to elapse before beginning dissection. Subcutaneous dissection commences at the preauricular region with the elevation of a cutaneous flap extending 2 cm anterior to the tragus. Oblique lighting can help identify the subdermal plexus, which has a cobblestonelike appearance and should be preserved. At the retroauricular preoperative marking, fashion an incision that proceeds inferiorly. As the earlobe is approached, maintain a superficial dissection to avoid the posterior branch of the greater auricular nerve. Once the anterior lip of the sternocleidomastoid muscle has been reached, a deeper dissection plane may be engaged, extending from the inferior earlobe to the neck in a diagonal fashion. Compared to nonsubperiosteal approaches, the skin undermining is limited. The subperiosteal dissection can be approached from a temporal dissection usually combined with a forehead lift, which can be an endoscopic or coronal based approach. Combining a forehead approach with the subperiosteal facelift prevents tissue bunching in the lateral canthal area and provides a more aesthetically balanced appearance. If no temporal elevation is needed, an infraciliary lower lid blepharoplasty-type approach can be used. To further assist the dissection, a Caldwell-Luc approach in the gingivobuccal mucosa can be added to allow for ready access to the inferior periosteum overlying the malar bone. From the temporal approach, the deep temporalis fascia is accessed. This fascia lies immediately over the temporalis muscle and extends inferiorly toward the zygomatic arch where it separates into the superficial and deep layers of the deep temporalis fascia. The superficial layer attaches to the anterior aspect of the zygomatic arch and the corresponding deep layer attaches to the posterior aspect of the zygomatic arch. Anatomic variations are not uncommon, and Ramirez (1991) described these layers as fusing 1 cm above the superior margin of the arch. A fat pad separates the superficial and deep layers of the deep temporalis fascia. Some authors approach the zygomatic arch posteriorly, behind the deep layer of the deep temporalis fascia, and dissect toward the anterior surface of the arch from this dissection plane. Be cognizant that the temporal branch of the facial nerve is most vulnerable at this location. Alternatively, approach the arch from the intermediate fat pad between the superficial and deep layer of the deep temporal fascia. At the superior border of the zygomatic arch, incise the periosteum toward the posterior edge of the zygoma and elevate it from the anterior face of the zygomatic arch to allow access to the midfacial area. Enter and elevate the subperiosteal plane, lifting the zygomaticus major and minor muscles. Continue this dissection toward the piriform opening over the entire maxilla while avoiding the infraorbital nerve. Undertake dissection in the area of the masseter tendon to separate the overlying fascia in order to mobilize midfacial structures. These tissues are elevated superiorly and suspended by various suture techniques (eg, a 2-0 or 3-0 Vicryl) to the temporalis fascia or, if less lift is needed, to the deep layer of the deep temporal fascia. Then, undertake the skin dissection component of the facelift, with the extent of the dissection limited to the area overlying the parotid gland. Similarly, the dissection in the neck and platysma area is less than with a nonsubperiosteal approach. Alternatively, a Caldwell-Luc–type approach from the gingivobuccal mucosa can be used. This allows direct access to the subperiosteal space overlying the maxilla. This dissection can then be carried in a superior fashion to conjoin with the dissection emanating from the temporal approach. Preoperative detailsAll patients should receive a complete medical examination by the appropriate specialist, including complete blood counts, metabolic chemistries, ECG and, if indicated, a chest roentgenogram. Instruct the patient to not ingest alcohol or use tobacco products 2 weeks prior to surgery. Aspirin, nonsteroidal antiinflammatory agents, anticoagulants, vitamin E, multivitamins, and Alka Seltzer should be discontinued 3 weeks prior to surgery. Also, any homeopathic remedies should be discontinued, and 500-1000 mg of vitamin C should be taken for at least 3 weeks prior to facial rejuvenation. The authors usually provide a broad-spectrum antibiotic to be taken the night before surgery, and the antibiotic is usually continued for 7 days postoperatively along with prednisone. The patient should also be instructed to wash his or her hair, face, neck, and external ears on the night before and the morning of surgery. The patient should refrain from using cosmetics, perfumes, after shave, and moisturizers on the morning of surgery. Hair coloring should not be performed within 10 days of surgery. On the day of surgery, the patient should wear comfortable clothes with a button down shirt and bring a scarf and sunglasses. Intraoperative detailsAs in any surgical procedure, the surgeon should be made aware of the patient's overall status as monitored by the anesthesiologist. Postoperative detailsIn the recovery room following surgery, the patient should be evaluated for pain, nausea, or vomiting. If present, pain medication and antiemetics should be administered. Prior to surgery, the patient should receive instructions for the postoperative period. The following guidelines are contained in the printed handout distributed by the authors.
Follow-upPatients are evaluated on the first postoperative day, allowing removal of dressings and drains. The flaps are carefully inspected for hematoma formation. A wrap is placed, and a follow-up visit is scheduled for the fifth postoperative day. At this time, the tragal sutures are removed, and on day 7 any staples or sutures that remain are removed. COMPLICATIONSSection 8 of 10
As with any surgical endeavor, complications are unfortunate and unforeseen. When complications do arise, the physician must address these in an expeditious and appropriate fashion to minimize poor outcomes and avoid litigious actions by the patient. A meticulous review of the patient's medical history and use of medications is essential, as is ascertaining the psychosocial state and expectations of the surgical candidate. If the patient has a history of dissatisfaction with other surgeons, unrealistic expectations, or a high level of psychosocial stressors, it may be prudent to forego operating. The physician should document the patient's clear understanding of the risks and possible complications before proceeding. Reducing intraoperative and preventing postoperative hematomas is essential. All patients should be instructed to discontinue aspirin, nonsteroidal anti-inflammatory agents, vitamin E, and other anticoagulative agents 2 weeks prior to surgery. Also, any homeopathic or herbal remedies and alcohol consumption should be stopped 2 weeks prior to surgery. Intraoperative hemostasis is best achieved with bipolar cautery and ligation of larger vessels. Tumescent anesthetic infiltration and allowing 10-15 minutes before proceeding with surgery can aid in hemostasis. Before reapproximating any flaps that have been fashioned, the field should be meticulously inspected for any bleeding and must be dry. If bleeding persists, saline irrigation may aid in identifying the source of bleeding. After closure of skin flaps, hematoma formation may occur immediately or later in the postoperative period. Hematomas arising immediately following rhytidectomy are addressed by removing skin closure materials to open the area of hematoma formation. Pressure should be applied after evacuation of the clot, and, if bleeding persists, the wound should be explored in a sterile fashion under anesthesia. The culprit bleeder should be remedied and the skin reapproximated. Clot formation that occurs at a later time can be evacuated by open or closed techniques. If small enough, a large bore needle can be used to evacuate the unwanted serosanguinous fluid pool. All hematomas should be addressed to prevent overlying skin necrosis. Labile blood pressure should be controlled and postoperative pain addressed. The patient should minimize coughing, exertion, and Valsalva maneuvers to reduce hemorrhaging. Facial nerve insult is a dreaded sequela of rhytidectomy. Fortuitously, the deficits are rarely permanent in most cases because of nerve regeneration. Patients can exhibit lagophthalmos with resultant exposure keratopathy and ptosis of the brow and forehead. Nasal valve obstruction, midfacial and labial flaccidity with distortion of speech, and masticatory dysfunction are potential complications. Frontal and mandibular branch transection produce deficits with a higher frequency of permanence than buccal or zygomatic branch injury. Unfortunately, these branches do not often intermingle with other facial nerve offshoots. Buccal and zygomatic division insult can usually transcend any permanence because of their numerous anastomoses with one another and their locale within the SMAS. Regeneration of nervous tissue lumbers along at 1 mm per day, with most buccal and zygomatic divisions restored by 4-6 months. Lacerations of the nerve located proximal to the pupillary axis should repaired immediately. This neurorrhaphy should be performed in a fashion that avoids synkinesis and reconstructs a normal neuroanatomical arrangement. Overly aggressive fat excision from the central preplatysmal adipose tissue can allow for platysma muscle and skin adhesions, with the resultant platysmal resections becoming visible through the skin. Excess debulking of fat in the submandibular gland region may allow for increased visibility of these glands. The "devil's ear" and tragal distortions are auricular distortions that can ensue following a rhytidectomy. A distorted earlobe or devil's ear is stretched toward the mandible and can be avoided by closing the cheek skin flap to an area of skin below the earlobe with nominal tension. Preventing anterior tragal distortion is achieved by draping the preauricular skin flap over the tragus to ascertain the laxity needed to avoid tragal displacement. Careful preoperative assessment of hairlines can preclude postoperative misplacement of sideburns and forehead hairline. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Rhytidectomy, Subperiosteal Facelift excerpt Article Last Updated: Aug 9, 2006 | ||||||||||||||||||||||||||||||||||||||||
