Subperiosteal Face Lift Research Articles

Technique and auxiliary maneuvers for a face-lift without preauricular scars

The principle of the subperiosteal face-lift based on the vertical lifting of the deep soft tissues, associated with the indirect traction of the skin and other auxiliary maneuvers as the step-wise suspension and the posterior ear rotation, has made it possible to avoid the preauricular scars in approximately 80% of our cases. With the application of endoscopic techniques, we have achieved the same results while also avoiding a coronal scar. In this article, we describe in detail these procedures and their indications.

Subperiosteal facelift: open and endoscopic approach.

The endoscopic subperiosteal facelift as an isolated procedure is indicated for patients with grade I rhytidosis. It is also indicated in cases of grades II and III rhytidosis in males in whom the coronal incision is contraindicated due to alopecia and without conspicuous damage to the forehead. In these cases, the procedure is combined with subcutaneous rhytidectomy of the neck. It can also be used in cases of secondary facelift. The small incisions used in this procedure allow sufficient and effective access for dissection and suspension of the tissues released during the facelift. The coronal incision is not necessary, thus avoiding the resulting discomfort and scar. These patients do not receive anesthesia and experience almost no paresthesia in the frontal region, as in cases in which a coronal incision is performed. The endoscopic approach reduces surgical trauma as well as postoperative edema. Since neither the veins nor the lymphatic vessels of this area are sectioned, swelling subsides faster and recovery is shorter.

The subperiosteal rhytidectomy: the third-generation face-lift.

The subperiosteal frontal rhytidectomy described by Tessier was the departure point for a new approach for facial rejuvenation. Psillakis described the subperiosteal face-lift "as an improved concept for correction of the aging face." However, this technique has a high incidence of frontal nerve injury and because of the limitations in the subperiosteal dissection, the facial soft tissues cannot be lifted reliably to the desired position. Other authors have repeated the Psillakis experience with the same frustrations and complication rate. In this report, I describe the evolution of the subperiosteal face-lift and the significant modifications that I have introduced, making this procedure safer and improving results in the degree of facial rejuvenation. My approach of subperiosteal rhytidectomy has been used in 34 patients with a minimal complication rate. This technique also addresses the rejuvenation of the central portion of the face and the restoration of tension of the facial mimetic musculature not obtained by current brow/face-lift procedures.

The Extended Subperiosteal Face Lift

The subperiosteal face lift described by Psillakis has been criticized for not showing a more dramatic improvement over conventional brow/face lift procedures. His approach also has a significantly high incidence of nerve injury. This study reports our anatomic findings and surgical modifications, which have permitted a significant improvement in the safety of execution and clinical results using the subperiosteal face lift concept. Pertinent points of applied local anatomy and dissection techniques are as follows: First, we use extensive interconnected subperiosteal dissection that includes the entire zygomatic arch. This allows better repositioning of the deep soft tissues of the entire upper face, most of the midface, and indirectly, key structures of the lower face. Second, the upward pull of the muscles of the cheek and mouth will produce an elevation of the corner of the mouth, affecting positively the smiling mechanism, the oral frowning, and the jowls. Third, the dissection deep to both layers of the temporal fascia decreases the risk of injury to the frontalis nerve. Fourth, the temporal fascia is used as a lifter and anchoring element of the entire cheek-perioral soft tissues as opposed to the periorbital fibrofatty tissues. This will decrease the risk of injuring the frontal and zygomatic branches of the facial nerve. These modifications have been used in 28 patients. Our rate of patient satisfaction has been high, and no complications with regard to nerve injury have been observed. This compares favorably with our initial 60 patients, in whom the Psillakis or Tessier approach was used. In these patients, there was an 11 and 20 percent rate of nerve injury, respectively.

Skeletal Alterations as a Basis for Facial Rejuvenation

A slight decrease in overall facial bone bulk coupled with the increased soft-tissue expansion associated with aging produce effects that should be reversed in both the bone and soft tissue where possible. The changes are best done at the ledge areas: the supraorbital-temporal ridge areas, malar-midface, and chin mandible. However, the overall bone bulk may be increased in addition in the temporal fossae, in the infraorbital rim, at the lateral canthus, in the paranasal area, and at the alveolar ridges and dental areas. A combination of autogenous and synthetic materials is currently best, with synthetic materials most useful in the malar-midface, posterior mandibular, infraorbital, and paranasal areas. In the supraorbital ridge-temporal areas, it is a near equal choice between autogenous and synthetic materials. In the chin, the preferred method is by osteotomy using autogenous augmentation. The concept of increasing bone mass and decreasing expanded soft-tissue mass has application within the judgment of the surgeon coupled with the patient's desires. Subtle increases of bone mass to compensate for soft-tissue thinning as well as bone shrinkage, at the same time taking up lax soft tissue, can be done in conjunction with one another, effectively producing a three-layer face lift. The subperiosteal face lift is in reality an extended brow lift and can be used to enhance the brow-forehead area and the temporal, zygomatic, and paranasal areas. At the same time, the perioral, jowl, and submandibular regions must be treated by a combination of standard face lifting procedures and augmentation of the bone structures of the face.

Temporal and Malar-Zygomatic Reduction and Augmentation

The temporal fossa, zygomatic arch, and malar-midface should be considered jointly when augmentation of the temporal area or reduction of the zygomatic arch are to be carried out. These anatomic areas relate so closely to one another that altering one affects the other. In addition, augmentation of the malar-midface area may be done if one of the other two procedures is to be considered, or if a brow lift, subperiosteal face lift, or other reason for using a coronal incision exists. Use of the coronal incision for malar augmentation is probably not justified because of the large amount of surgery required in spite of the lesser morbidity associated with this approach in terms of amount of infections, lip stiffness, and hypesthesia. Planning a surgical procedure must be done in the office, by examining the patient at eye level to determine the amount of zygomatic arch reduction and the amount of temporal fossa augmentation necessary. Similarly, the three zones of the malar-midface complex must be assessed, with the amount of augmentation of each zone determined prior to the day of surgery. The surgical procedure is then executed through a coronal incision, with the dissection extending down to the zygomatic arch. If the temporal muscle is to be elevated out of its fossa, it is cut on its anterior, superior, and posterior edges, elevating it out of its fossa so that a Proplast implant, typically 3 to 4 mm thick and finely tapered on its superior and posterior edges, with suturing done anteriorly, may be inserted. The muscle is then resutured to its aponeurosis on all three edges. If the zygomatic arch and malar-midface area are to be approached, the dissection is carried to the deep and superior edge of the zygomatic arch, and the periosteal elevator is used to elevate the soft tissue off the lateral and inferior edge. The arch and malar-midface are cleared of soft tissue, extending the tunnel to the upper buccal sulcus. The arch is then reduced with a contouring burr to the thinness desired. Alternatively, the malar-midface area may be augmented with synthetic material precisely positioned, with a suture around the zygomatic arch, holding it in position as measured from the lateral orbital rim. The incision in the temporal fascia is then resutured, and the coronal incision is closed.(ABSTRACT TRUNCATED AT 400 WORDS)

Subperiosteal facelift and correction of facial skeleton for severe romberg fat atrophy

A patient with the skin and bony changes of bilateral Romberg's disease is presented. She was treated with a subperiosteal facelift, bony contouring, fat grafting for enophthalmos, and rhinoplasty. A good result was achieved.