eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Rhytidectomy, Subperiosteal Facelift

Adam J Cohen, MD, Eyelid and Facial Aesthetic and Reconstructive Surgery, Diseases and Surgery of the Orbit and Lacrimal System, Cosmetic Laser Surgery
Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota

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.

Workup

Laboratory Studies

Preoperative complete blood counts, coagulation profiles, and chemistries should be obtained.
An ECG and chest roentgenogram may be indicated for review by the appropriate specialist preoperatively.

Imaging Studies

Standard preoperative photos are useful for intraoperative reference and reminding the patient of his or her presurgical appearance when critiquing the outcome.

Treatment

Surgical Therapy

Subperiosteal facelift should be performed as follows.^{7,8,9,10,11,12}

Starting at the otic lobule, a straight line should be drawn midway between the lateral canthal angle and tragus. Drawing a line parallel and 2 cm anterior to the frontal nerve demarcation line denotes the SMAS dissection plane. Sub-SMAS dissection boundaries can be marked via a curvilinear line originating from the lateral orbital rim and ending 2 cm lateral to oral commissure. In males, demarcation of the temporal hairline incision is carried in a pretragal fashion at the helical root and moves posteriorly until conjoined with the temporal incision retroauricularly.

Inject 0.5% buvipicaine with 1:400,000 epinephrine and hyaluronidase into the marked incision lines, midface, and inframental regions. If a tumescent technique is chosen, create stab incisions at the horizontal hair tuft, retroauricular, and pretragal areas and the submental crease.

Subcutaneous dissection begins at the preauricular region with the elevation of a cutaneous flap extending 2 cm anterior to the tragus. Compared to nonsubperiosteal approaches, skin undermining is limited. Oblique lighting can help identify and preserve the subdermal plexus. This plexus has a cobblestonelike appearance.

At the retroauricular marking, create an incision that proceeds inferiorly. As the earlobe is approached, maintain a superficial dissection to avoid the posterior branch of the greater auricular nerve. Once the anterior lip of the sternocleidomastoid muscle has been reached, a deeper dissection plane may be used extending from the inferior earlobe to the neck in a diagonal fashion.

The subperiosteal dissection can be approached from a temporal dissection, usually combined with a forehead lift, via endoscopic or coronal approach. Combining a forehead approach with the subperiosteal facelift prevents tissue bunching in the lateral canthal area, providing a more aesthetically balanced appearance.

From the temporal approach, the deep temporalis fascia is exposed. This fascia lies immediately over the temporalis muscle and extends inferiorly toward the zygomatic arch, where it separates into the superficial and deep layers of the deep temporalis fascia. The superficial layer attaches to the anterior aspect of the zygomatic arch and the corresponding deep layer attaches to the posterior aspect of the zygomatic arch.

Anatomic variations are not uncommon, and Ramirez (1991) described these layers as fusing 1 cm above the superior margin of the arch. A fat pad separates the superficial and deep layers of the deep temporalis fascia. Some authors approach the zygomatic arch posteriorly, behind the deep layer of the deep temporalis fascia, dissecting toward the anterior surface of the arch.

Alternatively, approach the arch from the intermediate fat pad between the superficial and deep layer of the deep temporal fascia. At the superior border of the zygomatic arch, incise the periosteum toward the posterior edge of the zygoma and elevate it from the anterior face of the zygomatic arch to allow access to the midfacial area. Enter and elevate the subperiosteal plane, lifting the zygomaticus major and minor muscles. Continue this dissection toward the pyriform opening over the entire maxilla while avoiding the infraorbital nerve.

Dissection in the area of the masseter tendon separates the overlying fascia in order to mobilize midfacial structures. A gingivobuccal approach can be added to allow for additional access to the periosteum overlying the malar bone. This dissection can then be carried superiorly to conjoin with the temporal dissection. These tissues are elevated superiorly and suspended to the temporalis fascia or, if less lift is needed, to the deep layer of the deep temporal fascia.

Endotine resorbable implants allow for fixation of tissue in several directions. Placement of an Endotine B implant via a subciliary approach allows for vertical elevation of the midface. Use of the same implant or an Endotine ST via a temporal approach results in superotemporal elevation.^13,14

Skin dissection of the neck and platysma is limited versus a nonsubperiosteal approach.

Preoperative Details

All patients should receive an age and morbidity appropriate medical examination by the appropriate specialist.

Instruct the patient to not ingest alcohol or use tobacco products 2 weeks prior to surgery. Aspirin, NSAIDS, anticoagulants, vitamin E, multivitamins, homeopathic remedies and Alka Seltzer should be discontinued 3 weeks prior to surgery; 500-1000 mg of vitamin C is recommended 3 weeks prior to surgery.

The patient should refrain from using cosmetics, perfumes, after shave, and moisturizers on the morning of surgery. Hair coloring should not be performed within 10 days of surgery.

On the day of surgery, the patient should wear comfortable clothes with a button down shirt and bring a scarf and sunglasses.

Postoperative Details

In the recovery room, evaluate the patient for pain, nausea, or vomiting. If these are present, administer pain medication and antiemetics as appropriate.

Prior to surgery, give the patient instructions for the postoperative period. The following guidelines are adapted from the printed handout distributed by the authors to their patients.

Rest at home, but complete bed rest is not necessary. While in bed, elevate the head and keep it straight. Use pillows to prevent the face or body from turning during sleep.
Refrain from physical exertion, bending, heavy lifting, and sexual activity for two weeks.
Do not use tobacco products, alcohol, aspirin, nonsteroidal anti-inflammatory agents, vitamin E, or nicotine gum or patches for 5 days.
Do not drive or fly for one week. Being a passenger in a motor vehicle is acceptable, but do not operate it.
Showering and hair washing are permitted the day after surgery.
Avoid the sun for two months following surgery.
Do not undergo dental procedures for at least 6 weeks, unless emergent dental intervention is needed.
Finish all medications as directed.

Follow-up

Patients are evaluated on the first postoperative day, allowing removal of dressings and drains. The flaps are carefully inspected for hematoma formation. A wrap is placed, and a follow-up visit is scheduled for the fifth postoperative day. At this time, the tragal sutures are removed, and on day 7 any staples or sutures that remain are removed.

Complications

Hematoma or seroma
Transient anterior neck hypothesia
Prominence of platysmal bands
Prominent jowls
Cobra neck deformity
Skin dimpling and scar contracture
Skin wrinkling or laxity
Lagophthalmos and corneal decompensation
Otic deformity
Facial nerve injury
Hairline distortion and repositioning
Asymmetry

After closure of skin flaps, hematoma formation may occur immediately or later in the postoperative period. Hematomas arising immediately following rhytidectomy are treated by open drainage. Pressure should be applied after evacuation.

Clot formation that occurs at a later time can be evacuated by open or closed techniques. If small enough, a large bore needle can be used.

Facial nerve insults are rarely permanent.

Patients can exhibit lagophthalmos with resultant exposure keratopathy and ptosis of the brow and forehead. Nasal valve obstruction, midfacial and labial flaccidity with distortion of speech, and masticatory dysfunction are potential complications. Frontal and mandibular branch transections produce deficits with a higher frequency of permanence than buccal or zygomatic branch injury. Unfortunately, these branches do not often intermingle with other facial nerve offshoots. Buccal and zygomatic division insults are usually not permanent because of their numerous anastomoses with one another and their locale within the SMAS.

Overly aggressive fat excision from the central preplatysmal adipose tissue can result in platysma muscle and skin adhesions.

Submandibular gland prominence may result from aggressive fat debulking.

The "devil's ear" is a distorted earlobe stretched toward the mandible and can be avoided by closing the cheek skin flap to an area of skin below the earlobe with nominal tension.

Preventing anterior tragal distortion is achieved by draping the preauricular skin flap over the tragus to assess the laxity needed to avoid displacement.

Hairline assessment can preclude postoperative misplacement of sideburn and forehead hairline.

Multimedia

Media file 1: When an endoscopic forehead lift is done in conjunction with a facelift, the lateral port can be used as an access site for a midface lift as shown here.

Media file 2: A cheek flap is developed in preparation for a deep plane dissection.

Media file 3: The superficial muscular and aponeurotic system (SMAS) is incised to facilitate a deep plane dissection.

Media file 4: The superficial muscular and aponeurotic system (SMAS) is imbricated and secured in a more superior posterior position with sutures.

Media file 5: Creation of partial thickness Endotine hole for placement of device.

Media file 6: Subperiosteal midface dissection via a transconjunctival approach.

References

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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].
Ramirez OM, Pozner JN. Subperiosteal minimally invasive laser endoscopic rhytidectomy: the SMILE facelift. Aesthetic Plast Surg. Nov-Dec 1996;20(6):463-70. [Medline].
Ramirez OM. High-tech facelift. Aesthetic Plast Surg. Sep-Oct 1998;22(5):318-28. [Medline].
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Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. Jan 1989;83(1):11-6. [Medline].
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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].
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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

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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