eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Rhytidectomy, Subperiosteal Facelift

Author: Adam J Cohen, MD, Eyelid and Facial Aesthetic and Reconstructive Surgery, Diseases and Surgery of the Orbit and Lacrimal System, Cosmetic Laser Surgery
Coauthor(s): Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Contributor Information and Disclosures

Updated: Oct 13, 2008

Introduction

Subperiosteal rhytidectomy can be used to reverse facial aging of the midfacial and lower facial region. The evolution of the facelift began with simple cutaneous remodeling and expanded to address subcutaneous layers. As techniques advanced, desire to improve the appearance of the nasolabial fold resulted in deep-plane rhytidectomy.

History of the Procedure

Subperiosteal facelifting is a point along the facial rejuvenation continuum. In 1969, Skoog reported techniques for treating deeper facial structures; in 1974, he put forth the sub-SMAS technique that altered the soft tissues of the face in a conjoined fashion. Prior to this time, facelifting involved predominantly subcutaneous dissections (see Image 2).

Tessier described the subperiosteal approach for the superior and lateral periocular area in brow rejuvenation and facelifting.1 He termed the procedure "orthomorphic subperiosteal face lift." Psillakis,2 Vasconez in 1986, Ramirez,3,4 and others have expanded and modified the subperiosteal approach.

Authors such as Barton and Hamra sought alternative ways to improve rhytidectomy outcomes and the appearance of the nasolabial folds. Barton described the modified sub-SMAS technique in 1989, and Hamra described the deep-plane facelift (see Image 3, Image 4).5

Problem

The subperiosteal facelift repositions the deep facial tissues overlying the bone, re-establishing the facial skeletal and facial soft tissue relationship (see Image 1).

Pathophysiology

Weakening of the retaining ligaments of the face are related to facial changes. Furnas provided a description of these ligaments that suspend the more superficial and mobile anatomical structures from the deeper and akinetic facial constituents.6 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).

Indications

Subperiosteal facelifting is indicated for the elimination of rhytides and improvement of the nasolabial folds' appearance.

Relevant Anatomy

Superior to the zygoma, the skin has a robust blood supply 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 arise from the internal carotid artery, including the supraorbital and supratrochlear branches.

The facial musculature and the superficial fascia of the parotid and cheek area are referred to as the superficial muscular and aponeurotic system (SMAS; see Image 3). Most authors acknowledge the galea as the SMAS superior boundary and intermingling with the platysma as the lowest SMAS extension. Where the SMAS courses over the deep temporal fascia, it is commonly labeled the temporoparietal (superficial) fascia and contains the superficial temporal artery and frontal branch of the seventh cranial nerve.

The temporal branch of the facial nerve traverses the zygomatic arch in an anterior and unprotected fashion. Although often referred to as singular, the temporal branch of the facial nerve has a variable number of nerve rami and patterns. During dissection of the periosteum overlying the zygoma, be aware that the SMAS is completely intertwined within the periosteum.

As the SMAS passes over the parotid gland, it attaches to the deep fascia and skin via parotid-cutaneous ligamentlike tissue projections. The SMAS courses anterior to the masseter muscle, then dives to enshroud the muscles of facial expression. The buccal branches of the facial nerve are in a sub-SMAS distribution in this area. A subperiosteal route of dissection is best used to avoid neural structures of the midface and allow for improved appearance of the nasolabial fold.

Contraindications

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.

More on Rhytidectomy, Subperiosteal Facelift

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References
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References

  1. Tessier P. [Subperiosteal face-lift]. Ann Chir Plast Esthet. 1989;34(3):193-7. [Medline].

  2. Psillakis JM, Rumley TO, Camargos A. Subperiosteal approach as an improved concept for correction of the aging face. Plast Reconstr Surg. Sep 1988;82(3):383-94. [Medline].

  3. Ramirez OM, Pozner JN. Subperiosteal minimally invasive laser endoscopic rhytidectomy: the SMILE facelift. Aesthetic Plast Surg. Nov-Dec 1996;20(6):463-70. [Medline].

  4. Ramirez OM. High-tech facelift. Aesthetic Plast Surg. Sep-Oct 1998;22(5):318-28. [Medline].

  5. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. Jul 1990;86(1):53-61; discussion 62-3. [Medline].

  6. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. Jan 1989;83(1):11-6. [Medline].

  7. Heinrichs HL, Kaidi AA. Subperiosteal face lift: a 200-case, 4-year review. Plast Reconstr Surg. Sep 1998;102(3):843-55. [Medline].

  8. Quatela VC, Sabini-P. Techniques in deep plane facelifting. Facial Plast Surg Clin North Am. May 2000;8(2):193-209.

  9. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg. Apr 1995;22(2):295-311. [Medline].

  10. Toth BA, Daane SP. Subperiosteal midface lifting: a simplified approach. Ann Plast Surg. Mar 2004;52(3):293-6. [Medline].

  11. Patrocinio LG, Patrocinio JA, Couto HG, et al. Subperiosteal facelift: a 5-year experience. Braz J Otorhinolaryngol. Sep-Oct 2006;72(5):592-7. [Medline].

  12. Gentile RD. Subperiosteal deep plane rhytidectomy: the composite midface lift. Facial Plast Surg. Nov 2005;21(4):286-95. [Medline].

  13. Sclafani AP. Comprehensive periorbital rejuvenation with resorbable endotine implants for trans-lid brow and midface elevation. Facial Plast Surg Clin North Am. May 2007;15(2):255-64, viii. [Medline].

  14. Newman J. Safety and efficacy of midface-lifts with an absorbable soft tissue suspension device. Arch Facial Plast Surg. Jul-Aug 2006;8(4):245-51. [Medline].

  15. Cheng ET, Perkins SW. Rhytidectomy analysis: twenty years of experience. Facial Plast Surg Clin North Am. Feb 2005;13(1):15-31. [Medline].

  16. Cornette de Saint Cyr B, Maillard GF, et al. The subperiosteal lift. Aesthetic Plast Surg. Spring 1993;17(2):151-5. [Medline].

  17. Guyuron B, Watkins F, Totonchi A. Modified temporal incision for facial rhytidectomy: an 18-year experience. Plast Reconstr Surg. Feb 2005;115(2):609-16; discussion 617-9. [Medline].

  18. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg. Oct 1998;102(5):1646-57. [Medline].

  19. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg. Dec 1996;98(7):1135-43; discussion 1144-7. [Medline].

  20. Maillard GF. The subperiosteal bicoronal approach to total facelifting: the DMAS--deep musculoaponeurotic system.

  21. Mercandetti M, Cohen AJ. Anesthesia, Local With Sedation eMedicine Journal [serial online]. 2001;Available at: http://www.emedicine.com/plastic/topic112.htm. [Full Text].

  22. Scheflan M, Maillard GF, Cornette de St Cyr B, et al. Subperiosteal facelifting: complications and the dissatisfied patient. Aesthetic Plast Surg. Winter 1996;20(1):33-6. [Medline].

  23. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. Mar 1992;89(3):441-9; discussion 450-1. [Medline].

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Further Reading

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Keywords

subperiosteal facelift, facelift, face lift, 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, orthomorphic subperiosteal face lift

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Contributor Information and Disclosures

Author

Adam J Cohen, MD, Eyelid and Facial Aesthetic and Reconstructive Surgery, Diseases and Surgery of the Orbit and Lacrimal System, Cosmetic Laser Surgery
Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons
Disclosure: Medicis None Speaking and teaching; Contura None Board membership; Cascade Medical Grant/research funds Independent contractor; Cascade Medical None Board membership

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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