eMedicine Specialties > Plastic Surgery > Rhytidectomy

Facelift, Subperiosteal

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
Coauthor(s): Oscar Ramirez, MD, Clinical Assistant Professor, Department of Plastic Surgery, Johns Hopkins University, University of Maryland
Contributor Information and Disclosures

Updated: Oct 3, 2006

Introduction

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 Procedure

Tessier 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.

Etiology

With 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.

Indications

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 Anatomy

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.

Contraindications

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.

• Search for CME/CE on This Topic »

• Rhytidectomy, Subperiosteal Facelift (Otolaryngology and Facial Plastic Surgery)
• Facelift, Mid Face (Plastic Surgery)
• Rhytidectomy, Deep Plane Facelift (Otolaryngology and Facial Plastic Surgery)
• Facelift, Composite (Plastic Surgery)

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