Subperiosteal Facelift

Updated: Oct 28, 2018
Author: Subhas Gupta, MD, PhD, CM, FRCSC, FACS; Chief Editor: Deepak Narayan, MD, FRCS 

Overview

Background

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.

History of the Procedure

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 midface, jawline, and neck.[1] A review of development of the technique may be found in Paul et al.[2]

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.[3]

Etiology

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.[4] 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.

Indications

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.[5] 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.[6]

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.[7] 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.

Relevant Anatomy

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.[7]

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 midface. 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.

Contraindications

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.

 

Treatment

Preoperative Details

The position of the hairline is noted. If the hairline is low, the patient benefits aesthetically from an endoscopic forehead lift. If the hairline is high, this may have to be combined with a biplanar forehead lift or hair transplantation as a second stage. The presence of vertical and horizontal glabellar creases is noted, and the patient is asked to animate his or her face to assess the activity of the corrugator and procerus muscles. The image below illustrates 4 zones of the face that need to be considered for the endoscopic forehead lift.

The upper part of the subperiosteal facelift (endo The upper part of the subperiosteal facelift (endoscopic forehead lift) is performed in the sequence indicated. An incision is made over the temple. The upper part of zone 1 may be dissected without endoscopic assistance. Then the anterior part of the zygomatic arch is dissected and the lateral canthal area, if indicated. The posterior third of the arch is carefully dissected followed by the middle third. Zones 2 and 3 may be dissected blindly with a curved periosteal elevator. Zone 4 must be dissected with endoscopic assistance since many patients have small accessory nerves here.

The position of the lateral canthus, the projection of the cheek, the depth of the nasolabial creases, and the volume of both buccal fat pads are assessed. When examining the mid face, determine whether any deficit in this region lies laterally, medially, or in the submalar zone because the mobilized buccal fat pad then can be used to augment this area.[8]

Examining the lower one third of the face, the patient's occlusion is noted. Asymmetries in the mandible, the area of the geniomandibular grooves, and the projection of the gonial angles are noted. Patients are assessed to determine whether repositioning of soft tissues alone will produce the desired result or whether the volume loss of aging requires implant placement.

Intraoperative Details

The authors use a 4-mm, 30° angled endoscope, selected elevators, and endoscopic manipulators. The face and mouth are prepared. The forehead, mid face, and mandibular region are injected with lidocaine 0.5% with epinephrine 1/200,000. This injection is performed at the periosteal level. A 1-cm incision is made 2 cm behind the temple hairline. The incision lies perpendicular to a line through the nasal ala and the lateral canthus. The superficial temporal fascia (STF) is identified and incised.

Between the STF and the deep temporal fascia lies an avascular plane of connective tissue that is easily elevated off the deep temporal fascia with a periosteal elevator. A plastic port protector is inserted into the incision. Dissection advances toward the temporal line of fusion, and a periosteal elevator is used to enter the subperiosteal plane, traveling beneath the lateral branch of the supraorbital nerve.

The dissection then proceeds toward the midline of the skull, followed by dissection of the orbital rim and zygomatic arch. After several centimeters of dissection with the deep temporal fascia proper lying beneath the elevator, a color change is noted. The innominate temporal fascia (IF), with its underlying temporal fat pad, appears yellow. The authors stay directly above the IF.

Approaching the zygomaticofrontal suture, a rounded tip elevator is used to avoid damaging the sentinel veins and zygomaticotemporal nerves in this area. Temporal vein #1 is the most superior vein. It is small and may be divided, if necessary. The authors like to leave a small cuff of fascial attachments around these structures to prevent tearing. Temporal vein #2 is found more inferiorly along the lateral orbital rim. This is a large vein and should be preserved. The zygomaticotemporal nerves may be found on either side of this vein.

The anterior third of the zygomatic arch is dissected almost to the lateral canthus and then inferiorly almost to the zygomaticofacial nerve. The posterior one third of the zygomatic arch is dissected through the temporal incision and traveling over the intermediate temple fascia to just above the zygomatic arch. This may be done blindly, keeping the elevator directly anterior to the tragus.

The middle third is then dissected in the same plane. Approximately 2 mm above the zygomatic arch, the intermediate temple fascia (ITF) is incised using this periosteal elevator. This ITF and some of the fat pad are raised superiorly. Dissection then continues inferiorly, raising the periosteum of the arch. This provides protection to the frontal nerve as it crosses the zygomatic arch. Vein #3 is found at the junction of the middle and posterior thirds of the zygomatic arch. Dividing the veins or nerves is not necessary to achieve good vertical mobilization. Epinephrine-soaked pledgets are then placed in this region through the temporal incision.

Just posterior to the hairline, 3 cm on either side of the midline, a 1-cm vertical incision is made down to the level of the periosteum. Make sure that the periosteum is raised with the scalp. The posterior dissection is done to the vertex of the scalp. This may be performed without the endoscope. Since the lateral dissection has already been performed from the temporal port, little chance exists of dissecting beneath the temporalis muscle.

The periosteum of the forehead is then elevated down to the glabella. This may be performed safely without the endoscope since the supratrochlear nerves are always more than 16 mm from the midline. The endoscope is used to dissect the lower half of the forehead.

This region may have multiple small sensory nerves directly exiting the skull. These are divided as far from the skull as possible to decrease the time to reneurotization. Dissection is aided by placing an elevator through the temporal port, which holds the forehead and periosteum away from the frontal bone, allowing for a complete release using endoscopic scissors.

Failure to release the periosteum over the lateral brow is the most common reason for inadequate elevation of the tail of the brow. Dissection is then continued medially until the supraorbital nerve is identified. The periosteum may be dissected behind this nerve and on toward the midline. When the periosteum is elevated, the bellies of the corrugator muscles may be observed. It is important to perform a spreading motion to separate the fibers of the corrugator muscles and preserve the branches of the supratrochlear nerve.

Large veins often are observed within the muscle. These must be identified and cauterized. The authors have found it useful to exert medial pressure with an assisting hand from outside. This helps to deliver the corrugator muscle into the jaws of the endoscopic biter. A subtotal resection of the corrugator muscle is performed. Beneath this lies the fascia of the depressor supercilii muscle. If clinically indicated, this muscle also may be removed.

Following removal of these muscles, a 0.5-1 cm horizontal section of the procerus muscle is resected just below the glabellar prominence. This is a subcutaneous muscle, which tends to bleed as it is being removed. Following removal of these muscles, the area is then packed with epinephrine-containing pledgets.

The mouth and skin are prepared with povidone-iodine solution (Betadine), an incision is made over the first premolar tooth, and a No. 9 periosteal elevator is used to elevate the periosteum sharply in a single plane. This dissection is continued almost to the piriform aperture medially, to the inferior orbital rim superiorly, and to the body of the zygoma. The endoscope is then inserted to dissect around the infraorbital nerve, the zygomaticofacial nerve, and the anterior two thirds of the zygomatic arch. This dissection is facilitated using one of the series of narrow curved periosteal elevators (Ramirez Minus Series, Snowden Pencer, Inc, Tucker, Ga).

Dissection is then continued inferiorly from the zygomatic arch to raise the masseter fascia from the muscle for about 25 mm. This allows a vertical lift of the lateral superficial soft tissues.

If the orbital fat is to be removed or redraped, then the periosteum over the inferior orbital rim is incised through the gingivobuccal incision. Light pressure on the globe causes prolapse of the orbital fat pads.

The lateral and middle compartments may be freed using endoscopic scissors. It is important not to tear the thin fascia that covers these fat pads. The fat pads are then sutured over the orbital rim to the malar periosteum or to the suborbicularis oculi fat (SOOF). This is performed using 4-0 polydioxanone (PDS, Ethicon, Inc) suture. A suture is then placed in the inferior half of the SOOF using 3-0 PDS. This suture is fed over the zygomatic arch and exits the temporal incision.

If the corners of the mouth are ptotic, then a 4-0 PDS suture is placed in the inferior malar periosteum fascia/fat near the intraoral incision. This flimsy structure is grasped in a tangential weaving motion. Multiple small branches of the long buccal nerve must be avoided when performing this maneuver. The free ends of this suture are passed over the zygomatic arch and exit the temporal incision. Generally, this suture is secured at a point superior and medial to that of the SOOF. The region of deficit in the cheek is remarked. The buccal fat pad (BFP) is released and repositioned to this area.

If the patient is believed not to have a deficit in the malar region, the fat pad may be removed or left in situ. This is done through the same intraoral incision. The periosteum and buccinator muscle are spread, and gentle teasing of the buccal fat pad can be performed using 2 smooth bayonet forceps. The fat pad can be gently teased from the overlying fascia. It is important not to tear the connective tissue covering the fat pad, since this tissue carries its blood supply and gives it structural integrity.

Once the fat pad has been released it herniates. If it is to be removed, it should be clamped and amputated using cautery. If it is to be suspended, then a 4-0 PDS suture is woven through the fat pad and its overlying capsule. If more lateral fullness is required, the suture is passed over the zygomatic arch, medial and superior to both other sutures.

However, if more anterior fullness is desired, the suture holding the fat pads may be attached around the suture suspending the SOOF. The temporal incision is retracted inferiorly and the 3 sutures are secured to the temporal fascia proper, anterior and inferior to the incision. Usually, the SOOF suspension suture is placed most laterally, while the BFP suture is placed most medially and superiorly. The suture that suspends the inferior malar soft tissues is placed between these two.

When performing the procedure on the opposite side, tension can be adjusted as the sutures are being tied to achieve symmetry with the first side. Butterfly drains are then connected to a Vacutainer (Becton-Dickinson, Rutherford, NJ). The free end of the drain is directed over the zygomatic arch into the mid face. The STF is then suspended superomedially to the temporal fascia proper with 4-0 PDS sutures. The skin is closed with interrupted 4-0 gut sutures.

Prior to closing the oral incision, the cavity is irrigated with saline and then antibiotic-containing solution. The incisions are closed using 4-0 chromic sutures.

A similar drain is inserted through a separate stab incision in the vertex region, and the tip of this drain is directed to the glabella. Gentle traction is then placed on the forehead to achieve the patient's aesthetic goals. The scalp is secured to the skull using a 1.1-mm drill bit with a 4-mm stopper and two 14-mm long endoscopic posts with 4-mm stoppers and 1.5-mm diameter (Synthes, Paoli, Pa).

Subperiosteal release of the tissues overlying the mandible may be performed through either an intraoral or a submental incision. When performing a deep plane neck lift or inserting alloplastic implants for the gonial angles or chin, the submental approach is preferred. This approach has a much lower risk of infection and heals well when placed in the correct position. The mentalis muscle is dissected from the mandible. The subperiosteal dissection continues around the mental nerves. It is important to leave a cuff of periosteum around the nerve to protect it from traction. If the soft tissues of the chin are ptotic, they may be rotated anteriorly and secured in position with a transosseous suture. It is important to perform a complete subperiosteal dissection traveling beneath the masseter and pterygoid muscles all the way to the angle. Failure to maintain a deep plane of dissection may result in injury to the marginal mandibular nerve.

Follow-up

Iced saline compresses are applied to the face in intervals. Perioperative antibiotics are taken for 5 days. Patients are observed daily for 4 days. The dressing is removed on the first postoperative day. The drains are removed on the first or second postoperative day. Conforming adhesive tape is applied to the forehead and cheek area for 10 days to keep the edema to a minimum. The posts that anchor the forehead are removed after 14 days. Patients are seen for follow-up care at 3-month intervals for a year.

Complications

Despite variations in technique, no permanent instances of frontal nerve palsy have been reported in recent literature. Episodes of temporary frontal nerve palsy resolved within 1-2 months.

Additional complications reported include temporary infraorbital nerve paresthesia, hematoma, asymmetrical smile, infections, and alopecia.[9]

In a review of the direct transblepharoplasty approach to midface subperiosteal lift, Hester et al reported a 19% revision rate related to lower lid malposition.[10] They advocated the routine use of canthopexy or canthoplasty, if appropriate, through an upper lid blepharoplasty incision. The present authors, as well as others,[11, 12] have adopted canthal tightening as a standard part of the operation. However, many have reported on modifications that avoid routine canthoplasty with good result.[3, 13, 14]

Outcome and Prognosis

The operation produces reliable and reproducible results that can improve transverse forehead creases, glabella frown lines, brow position, position of the lateral canthus, and position of the corners of the mouth. It can improve the tear trough and projection of the cheek. The images below demonstrate results of the subperiosteal facelift in 2 patients.

Subperiosteal facelift. Before. Anteroposterior vi Subperiosteal facelift. Before. Anteroposterior view. This patient wished to eliminate the slightly tense appearance to her glabella. She has mild hooding of her left eye and some ptosis of the left lateral canthus.
Subperiosteal facelift. After. Anteroposterior vie Subperiosteal facelift. After. Anteroposterior view. After an endoscopic subperiosteal facelift, she now has a more pleasing appearance with a slightly higher brow. The asymmetry of the lateral canthi has been corrected.
Subperiosteal facelift. Before. Three-quarter view Subperiosteal facelift. Before. Three-quarter view. The hyperactivity of the corrugator supercilii muscles can be clearly seen. She has early hooding of the lateral orbit.
Subperiosteal facelift. After. Three-quarters view Subperiosteal facelift. After. Three-quarters view. The tense appearance of the forehead has improved. The hooding has improved. She has a slight lift to the corner of the mouth, and a fuller appearance of the cheek.
Subperiosteal facelift. Before. Close-up three qua Subperiosteal facelift. Before. Close-up three quarter view.
Subperiosteal facelift. After. Close-up three-quar Subperiosteal facelift. After. Close-up three-quarter view.
Subperiosteal facelift. Before. Anteroposterior vi Subperiosteal facelift. Before. Anteroposterior view. This man requested correction of his transverse forehead rhytides, glabellar rhytides, brow ptosis, infraorbital hollowing, early left nasolabial creases, full submental region, and poor cheek and chin projection.
Subperiosteal facelift. After. Anteroposterior vie Subperiosteal facelift. After. Anteroposterior view. After an endoscopic subperiosteal facelift including placement of small beaded polyethylene implants and an anterior approach cervicoplasty, he has a more relaxed appearance. His brows have been raised a little. His glabellar rhytides and nasolabial crease have almost disappeared, while the transverse rhytides have softened. His infraorbital hollowing has been greatly improved.
Subperiosteal facelift. Before. Three-quarter view Subperiosteal facelift. Before. Three-quarter view. The rhytides on the forehead, glabella, and nasolabial area are all visible. He has a marked tear-trough deformity and loss of cheek volume with a full lower cheek.
Subperiosteal facelift. After. Three-quarter view. Subperiosteal facelift. After. Three-quarter view. The rhytides are greatly improved, as is the infraorbital hollowing. His upper cheek volume has been increased while the lower cheek is now more concave.
Subperiosteal facelift. Before. Lateral view. The Subperiosteal facelift. Before. Lateral view. The hooding, tear-trough, lower cheek fullness, and neck fullness are all obvious.
Subperiosteal facelift. After. Lateral view. His l Subperiosteal facelift. After. Lateral view. His lateral brow has a better relationship to the lateral orbit. The tear-trough is improved. His lower cheek is flatter. The chin has better projection. The submental area is less full. There is a better cervicomental break.

Future and Controversies

The adoption of endoscopic techniques by an increasing number of surgeons has increased the popularity of the subperiosteal approach. The bony landmarks and attachments of muscles useful for orientation are clearly seen. These landmarks are not always available in the subgaleal or intermediate plane techniques. The subperiosteal plane allows the forehead and mid face to be dissected in the same plane. This plane does not contain branches of the facial nerve. The vascularity of the face is not compromised. It is the only technique that allows repositioning of the soft tissues with relation to their bony attachments. The rate of frontal branch neurapraxia has been minimized through limited dissection or incision through the superficial layer of the deep temporal fascia. Ramirez points out that, despite evolution in the technical procedure, the principles of wide subperiosteal release, en bloc mobilization in superior and superolateral vectors, and stable suspension have remained the same.[3]