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Subperiosteal Rhytidectomy Treatment & Management

  • Author: Adam J Cohen, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: Nov 17, 2015

Surgical Therapy

Subperiosteal facelift should be performed as follows.[8, 9, 10, 11, 12, 13]

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.[14] Use of the same implant or an Endotine ST via a temporal approach results in superotemporal elevation.[15, 16]

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.


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.



See the list below:

  • 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.[17] 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.

Contributor Information and Disclosures

Adam J Cohen, MD Assistant Professor of Ophthalmology, Section Director of Oculoplastic and Reconstructive Surgery, Rush Medical College of Rush University Medical Center

Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: BioD, Poferious<br/>Serve(d) as a speaker or a member of a speakers bureau for: IOP<br/>Received income in an amount equal to or greater than $250 from: IOP for speaking.


Michael Mercandetti, MD, MBA, FACS Private Practice

Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, Sarasota County Medical Society, 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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Anthony P Sclafani, MD Director of Facial Plastic Surgery and Surgeon Director, New York Eye and Ear Infirmary of Mt Sinai; Professor of Otolaryngology, Icahn School of Medicine at Mt Sinai

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, American College of Surgeons

Disclosure: Received salary from Aesthetic Factors, Inc. for consulting; Received consulting fee from Meditech Medical Enterprises for independent contractor; Received royalty from Thieme Medical Publishers for author; Received royalty from Jaypee Medical Publishers for author.

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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.
A cheek flap is developed in preparation for a deep plane dissection.
The superficial muscular and aponeurotic system (SMAS) is incised to facilitate a deep plane dissection.
The superficial muscular and aponeurotic system (SMAS) is imbricated and secured in a more superior posterior position with sutures.
Creation of partial thickness Endotine hole for placement of device.
Subperiosteal midface dissection via a transconjunctival approach.
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