Subperiosteal Facelift 

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. Its popularity for rejuvenation of the upper two thirds of the face has increased. When this technique is combined with standard techniques, an excellent and long-lasting rejuvenation is achieved in across all age groups.

Tessier first described the technique in 1979, showing an advantage over the classic coronal brow lift in the areas of the superior and lateral orbital rims. The elevation of periorbital soft tissues also was much improved. He and others, including Santana and Psillakis, extended the subperiosteal dissection for treatment of the mid face, jawline, and neck. A review of development of the technique may be found in Paul et al.^[1]

These earliest reports with the subperiosteal technique included the frequent occurrence of frontal nerve injury, and dissection was often limited to the anterior one third of the zygomatic arch. The evolution of the technique has allowed greater access and elevation of soft tissues over the zygomatic arch with reduced morbidity. The use of the endoscope, as refined by Ramirez over the years, has minimized the incision and recovery.^[2]

With aging, the facial skeleton loses volume in all dimensions. Fat and soft tissues drift downward in relation to their bony attachments. This leads to an apparent widening of the vertical orbital apertures and less anterior projection of the cheek and brow regions. The maxilla changes contour with time.^[3] The diminishing bony support, as well as diminished skin tone, 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 expose the inferior orbital rim and accentuate the nasolabial fold. The shape of the lid/cheek junction changes from a gentle curve to a "V" contour below the infraorbital rim.

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 noticeable in edentulous patients.

The best candidates for pure endoscopic facial surgery are patients with good skin tone who have developed ptosis of the brows, sagging of the cheeks with deepening of the nasolabial crease, ptosis of the corners of the mouth, and jowls. This has been applied across a wide age group.^[4] Combining the endoscopic subperiosteal approach with an excisional approach in patients with skin laxity may be necessary, especially in the lower one third of the face. Subperiosteal dissection also may be performed over the body of the mandible to reposition the soft tissue pad of the chin. It is the approach of choice when inserting facial implants in the mandibular, cheek, or periorbital regions. Recent emphasis has focused on managing the lower lid and ptosis of the midface with subperiosteal release.

Patients with moderate-to-severe neck laxity or with excessive fat are not candidates for the pure subperiosteal technique. For these patients, the subperiosteal technique is combined with standard face, neck, and blepharoplasty techniques. Ramirez details the combination of subperiosteal techniques with other planes of dissection, suspension methods, and ancillary techniques.^[5] Additional indications for the subperiosteal facelift include patients who request a secondary or tertiary rhytidectomy and patients who smoke. The increased vascularity of the composite flap suggests that flap necrosis would be limited in smokers using this technique, though no study has looked at this outcome specifically.

Sensory nerves

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.

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, an accessory supraorbital nerve is located 35-55 mm from the midline.

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.

Fascia of the temporal region and frontal branch of the facial nerve

The 3 fascial layers within the temporal region are the superficial temporal fascia or temporoparietal fascia, and the superficial and deep layers of the deep temporal fascia. The superficial layer of the deep temporal fascia, also known as the innominate fascia, represents an extension of the galea cephalad. The frontal branch of the facial nerve and the superficial temporal vessels lie on the undersurface to the superficial temporal fascia. The superficial fascia attaches to the periosteum of the zygomatic arch and lateral orbital wall.

The deep temporal fascia is continuous with the cranial periosteum and overlies the temporalis muscle. Below the level of the superior orbital rim, the deep temporal fascia is separated in 2 layers by the superficial temporal fat pad. The superficial layer of the deep temporal fascia attaches to the zygomatic arch, while the deep layer of the deep temporal fascia is continuous with the parotid-masseteric fascia. The temporal dissection is performed in the plane of the fat pad.

The temporal branch of the facial nerve is not a single nerve branch but consists of several rami that cross the zygomatic arch.^[5]

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.

Periosteum and ligaments

The periosteum is easily elevated except in defined areas of adherence. The first is at the temporal line of fusion, where the superficial and deep layers of temporal fascia merge, and its release is necessary for mobilization of the forehead in a subperiosteal plane.

The periosteum is next thickened at the zygomatic frontal suture; again, release is necessary for brow periorbital soft tissue elevation.

The osteocutaneous ligaments located over the mandibular body and zygomatic body are sites of soft tissue anchorage to the skeleton.

A relative contraindication to subperiosteal facelift is previous facial fracture. When multiple contour irregularities are present, raising the subperiosteal plane is more challenging. Since the advent of endoscopic subperiosteal surgery, baldness is no longer a contraindication to subperiosteal brow lifting.