Background
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 the image below).
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 the images below). [5]
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.
Problem
The subperiosteal facelift repositions the deep facial tissues overlying the bone, re-establishing the facial skeletal and facial soft tissue relationship (see the image below).
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.
Epidemiology
Frequency
According to the American Society of Plastic Surgeons, over 121,000 facelifts were performed in the United States in 2018. [6]
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. [7] 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 the image below).
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 the image below). 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 superficial muscular and aponeurotic system (SMAS) is incised to facilitate a deep plane dissection.
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.
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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.
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A cheek flap is developed in preparation for a deep plane dissection.
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The superficial muscular and aponeurotic system (SMAS) is incised to facilitate a deep plane dissection.
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The superficial muscular and aponeurotic system (SMAS) is imbricated and secured in a more superior posterior position with sutures.
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Creation of partial thickness Endotine hole for placement of device.
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Subperiosteal midface dissection via a transconjunctival approach.
