You are in: eMedicine Specialties > Plastic Surgery > RHYTIDECTOMY Facelift, SubperiostealArticle Last Updated: Oct 3, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Keith M Robertson, MD, LRCSI, LRCPI, FACS, Consulting Staff, Chesapeake Plastic Surgery Associates, Suburban Hospital, Esthetique Internationale; Consulting Staff, Department of Plastic Surgery, Greater Baltimore Medical Center Keith M Robertson is a member of the following medical societies: American College of Surgeons Coauthor(s): Oscar Ramirez, MD, Clinical Assistant Professor, Department of Plastic Surgery, Johns Hopkins University, University of Maryland Editors: David W Furnas, MD, Clinical Professor Emeritus, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California at Irvine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: subperiosteal facelift, rhytidectomy, forehead and mid facelift, endoscopic facelift, scarless facelift, face lift, face-lift INTRODUCTIONSection 2 of 11
  The subperiosteal facelift provides a vertical lift to the soft tissues of the face. It allows soft tissue remodeling and repositioning of the soft tissues at the level of their bony origins. The subperiosteal technique provides unparalleled results in rejuvenation of the forehead, cheek region, and the chin area. When this technique is combined with standard techniques, the authors can obtain an excellent and long-lasting rejuvenation. The subperiosteal method is the only technique that allows one to redefine the soft tissue-to-skeletal relationship. History of the ProcedureTessier first described the technique in 1980. This technique showed a clear advantage over the classic coronal brow lift, especially in the area of the superior and lateral orbital rims. The elevation of periorbital soft tissues also was much improved. Later, he extended the subperiosteal dissection for treatment of the mid face. Others working on this at the time included Santana and Psillakis. As a result of the frequent occurrence of frontal nerve injury, dissection was often limited to the anterior one third of the zygomatic arch. Although Psillakis performed significant undermining of the upper and mid face, it was impossible to perform a vertical elevation of the soft tissues since they were still tethered at the region of the zygomatic arch. It became obvious that a safe plane of dissection needed to be found to perform a more complete release of the periosteum without resulting nerve damage. EtiologyWith aging, the facial skeleton loses volume in all dimensions. This is most noticeable in the vertical dimension. This leads to an apparent widening of the orbital apertures and less anterior projection of the cheek and brow regions. The mandible tends to loose vertical height, especially at the gonial angle. This is more noticeable in edentulous patients. The diminishing bony support, as well as diminished skin tone, contributes to sagging of the soft tissues of the face. This can be seen clinically as descent of the brows over the supraorbital rim, descent of the lateral canthus, and descent of the suborbicularis oculi fat (SOOF) and malar fat exposing the inferior orbital rim and accentuating the nasolabial fold. In the lower face, soft tissue laxity is largely responsible for the development of an obtuse cervical mental angle but bony resorption of the mandible can contribute to ptosis of the chin (witch's chin deformity). Resorption of bone at the gonial angle (angle of the lower jaw) combined with loss of vertical height of the mandible results in poorer definition between the planes of the face and the neck. This is more obvious in those who are born with relatively weaker mandibles. INDICATIONSSection 3 of 11
The subperiosteal facelift is indicated in those who have significant ptosis of the lateral canthus, nasal glabellar soft tissues, tip of the nose, cheeks, angle of the mouth, and jowls. Subperiosteal dissection also may be performed over the body of the mandible to reposition the soft tissue pad of the chin or to insert implants such as the mandibular matrix system. The subperiosteal technique is suited to those who require reduction of frontal bossing (Neanderthal forehead) or recontouring of forehead irregularities. It is the approach of choice when inserting facial implants in the mandibular, cheek, or periorbital regions. Patients with moderate-to-severe neck skin laxity or with excessive fat are not candidates for the pure subperiosteal technique. For these patients, the subperiosteal technique is combined with a standard face and neck lift. This is performed with a deep plane cervicoplasty and removal of the subplatysmal fat. Most of the author's patients are in their 40s but occasionally patients in their 30s are operated upon if they are predisposed to facial aging by virtue of poor facial bony support. These younger patients are more likely to need concurrent facial implant insertion. Additional indications for the subperiosteal facelift include those patients requesting a secondary or tertiary rhytidectomy, those with excessive scleral show or ectropion, and the patient who smokes. RELEVANT ANATOMYSection 4 of 11
While the subperiosteal plane is the safest plane in which to perform facial rejuvenation, it is important to be intimately familiar with the anatomy of the skull. The surgeon must know the course of the branches of the trigeminal nerve as it exits the skull, particularly the supratrochlear, supraorbital, zygomaticotemporal, zygomaticofacial, and infraorbital nerves. It is critical to stay deep to the superficial temporal fat pad in the area of the zygomatic arch to avoid damage to the frontal branch of the facial nerve. The supratrochlear nerve exits the orbit passing through the corrugator supercilii muscle and supplies sensation to the medial part of the forehead. It is located approximately 16 mm from the midline. The supraorbital nerve leaves the orbit via a notch in two thirds of patients and through a foramen in one third of patients. It is located 27 mm from the midline at the supraorbital ridge. It divides into a superficial division that passes over the frontalis muscle supplying the forehead skin and a deep division that runs across the lateral forehead between the galea and the pericranium. It travels as far posterior at the vertex. This branch can be found reliably 0.5-1.5 cm medial to the temporal line of fusion. In 10% of patients, the authors have found an accessory supraorbital nerve, which may be located 35-55 mm from the midline. Occasionally, multiple accessory nerve branches are present. The frontal branch of the facial nerve travels beneath the superficial temporal fascia, dividing into 3 branches. It crosses the zygomatic arch at the midpoint of a line joining the tragus and lateral canthus. The frontal nerve then travels in the superficial fat pad and enters the frontalis muscle as several separate branches. The most inferior branch continues to innervate the transverse belly of the corrugator muscle. The zygomaticofacial nerve is found approximately 1 cm below and lateral to the lateral canthus. It may be easily injured during a subperiosteal dissection unless the endoscope is used. The infraorbital nerve is directly beneath the pupil 7-10 mm below the infraorbital rim and just medial to the zygomaticomaxillary suture line. The infraorbital nerve also sends sensory branches to the corner of the mouth, and these are located just above the periosteum. It is important not to include these in any suture bite taken in this region. The mental nerves may be viewed intraorally. They are located approximately 20 mm from the midline and 15 mm from the inferior border of the mandible. They usually lie directly below the first and second premolar teeth. Muscles The occipitalis muscle originates from the superior nuchal line of the occipital bone and inserts into the galea. The frontalis muscle originates from the galea. The galea splits to surround this muscle, and the frontalis inserts into the brow skin. Many of its fibers penetrate the fibers of the orbicularis oculi muscle. The frontalis muscle has multiple dermal attachments in the forehead area. The procerus muscle takes origin from the junction of the nasal bones and the upper lateral cartilages and inserts into the forehead skin. This muscle is directly beneath the skin and may cause a transverse crease at the junction of the nose and the forehead. The corrugator supercilii muscle arises from the medial end of the orbit. It runs laterally and superiorly, interdigitating with the fibers of the orbicularis muscle. It has multiple insertions into the skin of the supraorbital region. This muscle causes vertical glabellar lines. The muscle lies deep to the frontalis muscle. The zygomaticus major muscle originates from the lateral part of the zygomatic body and inserts into the modiolus. The zygomaticus minor originates just medial to this. The zygomatic branch of the facial nerve runs superficial to the zygomaticus minor and deep to the zygomaticus major muscle. The levator anguli oris muscle also may be encountered while performing the subperiosteal dissection of the mid face. This originates immediately inferior to the infraorbital neurovascular bundle. The mentalis muscle originates from the region of the mental symphysis and inserts directly into the dermis of the chin. On either side of this muscle lying in the more superficial plane is the depressor labii inferioris and, superficial to this, the depressor anguli oris muscle. The platysma originates from the inferior border of the mandible. Fascia of the temporal region The facial nerve lies deep to the superficial temporal fascia and runs within the substance of the superficial temporal fat pad. In the face, deep to the parotid gland lies the masseter muscle. Continuing up to the temporal region, the zygomatic arch and the intermediate temporal fat pad lie within the same plate. The fascia, which overlies this plane, is known as the intermediate temporal fascia. The intermediate temporal fascia in the temporal region is a direct continuity of the masseteric fascia and the periosteum overlying the zygomatic arch. In this plane, the temporal dissection is performed. On the deep surface of this intermediate temporal fascia lies the intermediate temporal fat pad. This is covered by another sublayer of the intermediate temporal fascia. Beneath the fat pad lies the deep temporal fascia. This deep temporal fascia is continuous with the periosteum overlying the deep aspect of the zygomatic arch. The deep temporal fat pad lies beneath the deep temporal fascia. Please see Facelift, Mid Face for further anatomic description. CONTRAINDICATIONSSection 5 of 11
A relative contraindication to subperiosteal facelift is the patient with previous facial fractures. The authors have found it more challenging to raise the subperiosteal plane when multiple contour irregularities are present. Since the advent of endoscopic subperiosteal surgery, baldness is no longer a contraindication to subperiosteal brow lifting. TREATMENTSection 6 of 11
Preoperative DetailsThe best candidates for pure endoscopic facial surgery are patients in their late 30s or early 40s. They generally have good skin tone and have developed only early signs of aging with ptosis of the brows, sagging of the cheeks with deepening of the nasolabial crease, and ptosis of the corners of the mouth. For those patients in their late 40s or 50s, it may be necessary to combine this pure endoscopic subperiosteal approach with an excisional approach. Older patients already have too much skin laxity, especially in the lower one third of the face. The patient is evaluated while she or he is looking in a mirror. The asymmetries of the face are pointed out. It is also important to note the position of the hairline. If the hairline is low, the patient benefits aesthetically from an endoscopic forehead lift. If the hairline is high, this may have to be combined with a biplanar forehead lift or hair transplantation as a second stage. The presence of vertical and horizontal glabellar creases is noted and the patient is asked to animate his or her face to assess the activity of the corrugator and procerus muscles. The position of the lateral canthus, the projection of the cheek, depth of the nasolabial creases, and the volume of both buccal fat pads are assessed. When examining the mid face, determine whether any deficit in this region lies laterally, medially, or in the submalar zone because the mobilized buccal fat pad then can be used to augment this area. Some patients also need the addition of an alloplastic implant. Examining the lower one third of the face, the patient's occlusion is noted. Asymmetries in the mandible, the area of the geniomandibular grooves, and the projection of the gonial angles are noted. Patients also are examined from a lateral position to determine whether they would benefit from 3-dimensional chin implants. This can be performed concurrent with a subperiosteal mentopexy. Intraoperative DetailsThe authors use an endoscopic camera with a XENON light source connected to two video monitors, a 4-mm 30° angled endoscope, selected elevators, and endoscopic manipulators. The face and mouth are prepped. The forehead, mid face, and mandibular region are injected with lidocaine 0.5% with epinephrine 1/200,000. This injection is performed at the periosteal level. A total of 70 mL is used for the whole face. A 12-mm incision is made 2 cm behind the temple hairline. The incision lies perpendicular to a line through the nasal ala and the lateral canthus. The superficial temporal fascia (STF) is identified and incised. Between the STF and the temporal fascia proper (TFP) lies a delicate layer of connective tissue that has the appearance of "angel hair pasta." This layer is easily cleaned off the TFP with a No 4 periosteal elevator. A plastic port protector is inserted into the incision. Dissection advances towards the temporal line of fusion and a No 8 periosteal elevator is used to enter the subperiosteal plane, traveling beneath the lateral branch of the supraorbital nerve. The dissection then proceeds towards the midline of the skull using a No 2 elevator. This is followed by dissection of the orbital rim and zygomatic arch. After several centimeters of dissection with the temporal fascia proper lying beneath the elevator, a color change is noted. The intermediate temporal fascia (ITF) with its underlying intermediate temporal fat pad (ITP) appears yellow. The authors stay directly above the intermediate temporal fascia. Approaching the zygomaticofrontal suture, a No 0 elevator should be used. This has a rounded tip to avoid damaging the sentinel veins and zygomaticotemporal nerves in this area. Temporal vein #1 is the most superior vein. It is small and may be divided if necessary. The authors like to leave a small cuff of fascial attachments around these structures to prevent tearing. The temporal vein #2 is found more inferiorly along the lateral orbital rim. This is a large vein and should be preserved. The zygomaticotemporal nerves may be found on either side of this vein. The anterior one third of the zygomatic arch is dissected almost to the lateral canthus and then inferiorly almost to the zygomaticofacial nerve. The posterior one third of the zygomatic arch is dissected through the temporal incision using a No 9 elevator and traveling over the intermediate temple fascia to just above the zygomatic arch. This may be done blindly, keeping the elevator directly anterior to the tragus. Then the middle one third is dissected in the same plane. Approximately 2 mm above the zygomatic arch the intermediate temple fascia is incised using this periosteal elevator. This ITF and some of the ITP are raised superiorly and dissection then continues inferiorly, raising the periosteum of the arch. This provides protection to the frontal nerve as it crosses the zygomatic arch. Vein #3 is found at the junction of the middle and posterior thirds of the zygomatic arch. It is not necessary to divide the veins or nerves to achieve good vertical mobilization. Epinephrine-soaked pledgets are then placed in this region through the temporal incision. Just posterior to the hairline, 3 cm on either side of the midline, a 12-mm vertical incision is made down to the level of the periosteum. The periosteum is then raised using a No 9 elevator. Port protectors are then placed. It is important to make sure that the periosteum is raised with the scalp. A No 2 periosteal elevator is then inserted. The posterior dissection is done to the vertex of the scalp. This may be performed without the endoscope. There is little chance of dissecting beneath the temporalis muscle since the lateral dissection has already been performed from the temporal port. The No 2 elevator is then used to elevate the periosteum of the forehead down to the glabella. This may be performed safely without the endoscope since the supratrochlear nerves are always more than 16 mm from the midline. The upper half of the forehead also may be elevated using this dissector. It is important to use the endoscope to dissect zone 4 (lower half of the forehead). This region may have multiple small sensory nerves directly exiting the skull. The authors believe it is important to divide these as far from the skull as possible since this decreases the time to reneurotization. Dissection is continued to the orbital rim. This may be aided by placing a No 3 elevator through the temporal port. This elevator holds the forehead and periosteum away from the frontal bone, allowing for a complete release using endoscopic scissors. Failure to release the periosteum over the lateral brow is the most common reason for inadequate elevation of the tail of the brow. Dissection is then continued medially until the supraorbital nerve is identified. The periosteum may be dissected behind this nerve and on toward the midline. When the periosteum is elevated, the bellies of the corrugator muscles may be observed. It is important to perform a spreading motion to separate the fibers of the corrugator muscles and preserve the branches of the supratrochlear nerve. Large veins often are observed within the muscle. These must be identified and cauterized. The authors have found it useful to exert medial pressure with an assisting hand from outside. This helps to deliver the corrugator muscle in to the jaws of the endoscopic biter. A subtotal resection of the corrugator muscle is performed. Beneath this lies the fascia of the depressor supercilii muscle. If clinically indicated, this muscle also may be removed. Following removal of these muscles, a 0.5-1 cm horizontal section of the procerus muscle is resected just below the glabellar prominence. This is a subcutaneous muscle, which tends to bleed as it is being removed. Following removal of these muscles, the area is then packed with epinephrine-containing pledgets. The mouth and skin are prepped with povidone-iodine (Betadine), an incision is made over the first premolar tooth, and a No 9 periosteal elevator is used to elevate the periosteum sharply in a single plane. This dissection is continued almost to the piriform aperture medially, to the inferior orbital rim superiorly, and to the body of the zygoma. The endoscope is then inserted to dissect around the infraorbital nerve, zygomaticofacial nerve, and the anterior two thirds of the zygomatic arch. This dissection is facilitated using one of the series of narrow curved periosteal elevators (Ramirez Minus Series, Snowden Pencer, Inc, Tucker, GA). Dissection is then continued inferiorly from the zygomatic arch to raise the masseter fascia from the muscle for about 25 mm. This allows a vertical lift of the lateral superficial soft tissues. If it is desirable to remove or to redrape the orbital fat, then a No 4 periosteal elevator is used to incise the periosteum over the inferior orbital rim. This is done through the gingivobuccal incision. Light pressure on the globe causes prolapse of the orbital fat pads. The lateral and middle compartments may be freed using endoscopic scissors. It is important not to tear the thin fascia that covers these fat pads. The fat pads are then sutured over the orbital rim to the malar periosteum or to the SOOF. This is performed using 4-0 polydioxanone (PDS, Ethicon, Inc) suture. A suture is then placed in the inferior half of the SOOF using 3-0 PDS. This suture is fed over the zygomatic arch and exits the temporal incision. If the corners of the mouth are ptotic, then a 4-0 PDS suture is placed in the inferior malar periosteum fascia/fat near the intraoral incision. This flimsy structure is grasped in a tangential weaving motion. Multiple small branches of the long buccal nerve must be avoided when performing this maneuver. The free ends of this suture are passed over the zygomatic arch and exit the temporal incision. Generally, this suture is secured at a point superior and medial to that of the SOOF. The region of deficit in the cheek is remarked. The buccal fat pad (BFP) is released and repositioned to this area. If the patient is believed not to have a deficit in the malar region, the fat pad may be removed or left in situ. This is done through the same intraoral incision. The periosteum and buccinator muscle are spread, and gentle teasing of the buccal fat pad can be performed using two smooth bayonet forceps. The fat pad can be gently teased from the overlying fascia. It is important not to tear the connective tissue covering the fat pad since this tissue carries its blood supply and gives it structural integrity. Once the fat pad has been released it herniates. If it is to be removed, it should be clamped and amputated using cautery. If it is to be suspended, then a 4-0 PDS suture is woven through the fat pad and its overlying capsule. If more lateral fullness is required, the suture is passed over the zygomatic arch, medial and superior to both other sutures. However, if more anterior fullness is desired, the suture holding the fat pads may be attached around the suture suspending the SOOF. The temporal incision is retracted inferiorly and the 3 sutures are secured to the temporal fascia proper, anterior and inferior to the incision. Usually, the SOOF suspension suture is placed most laterally while the BFP suture is placed most medially and superiorly. The suture that suspends the inferior malar soft tissues is placed between these two. When performing the procedure on the opposite side, tension can be adjusted as the sutures are being tied to achieve symmetry with the first side. Butterfly drains are then connected to a Vacutainer (Becton-Dickinson, Rutherford, NJ). The free end of the drain is directed over the zygomatic arch into the mid face. The STF is then suspended superomedially to the temporal fascia proper with 4-0 PDS sutures. The skin is closed with interrupted 4-0 gut sutures. Prior to closing the oral incision, the cavity is irrigated with saline and then antibiotic-containing solution. The incisions are closed using 4-0 chromic sutures. This is done using a horizontal mattress technique. This everts the wound edges and creates a valve system, decreasing the probability of saliva entering the wound. The epinephrine-soaked pledgets are removed from the temporal region and from the glabella region prior to closing the incisions. A similar drain is inserted through a separate stab incision in the vertex region, and the tip of this drain is directed to the glabella. Gentle traction is then placed on the forehead to achieve the patient's aesthetic goals. The scalp is secured to the skull using a 1.1-mm drill bit with a 4-mm stopper and two 14-mm long endoscopic posts with 4-mm stoppers and 1.5-mm diameter (Synthes, Paoli, PA). Subperiosteal release of the tissues overlying the mandible may be performed either through an intraoral or a submental incision. When the authors are performing a deep plane neck lift or inserting alloplastic implants for the gonial angles or chin, the submental approach is preferred. This approach has a much lower risk of infection and heals well when placed in the correct position. The mentalis muscle is dissected from the mandible. The subperiosteal dissection continues around the mental nerves. It is important to leave a cuff of periosteum around the nerve to protect it from traction. To minimize bleeding, the authors elevate the digastric muscles at their tendinous insertion, not through their bellies. If the soft tissues of the chin are ptotic, they may be rotated anteriorly and secured in position with a transosseous suture. It is important to perform a complete subperiosteal dissection traveling beneath the masseter and pterygoid muscles all the way to the angle. Failure to maintain a deep plane of dissection may result in injury to the marginal mandibular nerve. Beaded nylon implants have been designed by one of the authors (Ramirez). These implants provide 3-dimensional augmentation of the gonial and chin regions. They are technically difficult to insert. This process may be made easier by insertion of a plastic sleeve (Porex Surgical Inc, College Park, GA). If the patient has additional skin in the pretragal area, the authors perform a standard subcutaneous cervicofacial rhytidectomy as indicated. In this case the incision is limited superiorly to the level of the root of the helix. Postoperative DetailsIced saline compresses are applied to the face in intervals of 20 minutes on, 20 minutes off for the first 24 hours. Drains are advanced at 24 hours and removed at 48 hours. Perioperative antibiotics are taken for 5 days. The patient may not swish liquids and should brush his or her upper teeth with a child's toothbrush. Patients are asked to clean the gingivobuccal incision twice daily with Betadine for one week. Patients must keep their head elevated and avoid chewing for the first week. Follow-upPatients are observed daily for 4 days. The helmet dressing is removed on the first postoperative day. The drains are removed on the first or second postoperative day. Seromas are rare but occasionally are seen when implants have been placed concurrently. Conforming adhesive tape is applied to the forehead and cheek area for 10 days to keep the edema to a minimum. The posts that anchor the forehead are removed after 14 days. Patients are seen for follow-up care at 3-month intervals for a year. COMPLICATIONSSection 7 of 11
In experienced hands this is a safe procedure with few complications. The authors have had no permanent instances of frontal nerve palsy and only two episodes of temporary frontal nerve palsy, which resolved completely within 1 month. There was one episode of temporary inferior orbital paresthesia from a small hematoma adjacent to the nerve. Approximately one patient in six complains of scalp itching and paresthesia. This tends to resolve within 1 month. Alopecia occurs in 2% of patients. This tends to resolve within 2-3 months. Interestingly, the area of alopecia does not correspond to the area of the incision or the areas of the scalp upon which the patient's cranium rests during the operation. Infection is rare, even in those cases where an implant has been placed. Porex implants (Porex, Newman, GA) are used. These are placed in the subperiosteal plane. These tissues do not cause a local tissue reaction and capsule formation. No periosteal resorption is associated with them. The authors have had the opportunity to re-explore a patient several years later and found that both bone and nerves were growing through this implant. OUTCOME AND PROGNOSISSection 8 of 11
Endoscopic facial surgery has been performed at this practice for approximately a decade, and no patient has yet required re-elevation of his or her mid face or forehead. The operation produces reliable and reproducible results that can improve transverse forehead creases, glabella frown lines, brow position, position of the lateral canthus, and the corners of the mouth. It can improve the tear trough and projection of the cheek. It is the technique of choice for patients younger than 45 years and when implants are to be placed. FUTURE AND CONTROVERSIESSection 9 of 11
Although the subperiosteal facelift has been used for many years, it was the advent of endoscopic surgery that has made this technique more popular. Initially, the technique was plagued by reports of persistent facial edema. This problem has been overcome with increasing speed of dissection and decreasing soft tissue trauma. The authors believe the subperiosteal plane allows better optical cavity than subgaleal or subcutaneous dissection. The bone is bright and almost bloodless, allowing for light reflection rather than light absorption. The bony landmarks and attachments of muscles useful for orientation are clearly seen. These landmarks are not always available in the subgaleal or intermediate plane techniques. The subperiosteal plane allows the forehead and mid face to be dissected in the same plane. This plane does not contain branches of the facial nerve. The vascularity of the face is not compromised. This may be a consideration in patients who smoke. It is the only technique that allows repositioning of the soft tissues with relation to their bony attachments. These advantages combined with the longevity of the procedure make it the procedure of choice for facial rejuvenation. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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