Subperiosteal Face-Lift

39.1 Introduction

Fullness of the cheek represents youthfulness. Aging process initiates during the third decade and in response to gravitational forces, the fat and soft tissue of the cheek drift downward in relation to the underlying bony skeleton. In this process of aging, a constant hollowness of the midface develops. As a result, a patient may display an appearance that is tired, old, or sad [1].

Weakening of the malar and orbital ligaments is a major component of the aging process. The result is a downward and medial displacement of the malar fat pad and other soft tissues over the fixed ligaments of the nasolabial fold. The fat over the malar eminence is left standing, accentuating the malar bag. Another anatomical change that occurs is the weakening of the orbital ligaments that contributes to hollowness under the orbit. The malar fat pad, which in youth was at the level of the orbital rim, falls downward and medially,

L.G. Patrocinio ( )

Division of Facial Plastic, Department of Otolaryngology, Medical School, Federal University of Uberlandia, Uberlandia, Minas Gerais, Brazil and

Rua Arthur Bernardes, 555 – 1o. andar, Uberlândia, Minas Gerais 38400-368, Brazil

e-mail: lucaspatrocinio@clinicaotoface.com.br

M.M. Naves and T.G. Patrocinio

Division of Facial Plastic, Department of Otolaryngology, Medical School, Federal University of Uberlandia, Uberlandia, Minas Gerais, Brazil

e-mail: marcellnaves@yahoo.com.br; tomaspatrocinio@hotmail.com

J.A. Patrocinio

Department of Otolaryngology, Medical School, Federal University of Uberlandia, Uberlandia, Minas Gerais, Brazil e-mail: patrocinio@clinicaotoface.com.br

producing this hollowness. This concavity that is below the convexity of the ocular globe and orbital fat, accentuates and no longer covers the bulge of herniated orbital fat. This produces the “double contour” deformity characteristic of the aging orbital/midface complex. A volume loss of the midface also contributes to the aging process. Finally, the collapse of the zygomaticus major and minor muscles, which suspend the ligamentous and muscular connections of the midface, results in a droop of the corner of the mouth and deepens the labiomental fold (Fig. 39.1) [2].

The purpose of the face-lift procedure is to reverse the aging process that has occurred. This can be achieved through various techniques that have been developed to date. The evolution of face rejuvenation consists in deciding which facial plane is going to be accessed [3].

At the beginning of the nineteenth century, the prior technique consisted of interrupted incisions placed both in front of and behind the ears in natural wrinkles and were combined with limited strips of excised skin. Then in the beginning of the twentieth century, there were the first descriptions of extensive skin undermining and lipectomy. More recently, the discovery of the SMAS (subcutaneous muscle-aponeurotic system) improved the technique (plication, suture, partial sectioning, etc.) aiming for long-lasting results. Trying to address the nasolabial fold, which so far has not been modified by other techniques, the deep plane and composite face-lift were described. They consisted of a deep SMAS dissection, accessing the nasolabial fold; however, their use has been increasingly questioned because of the risk of facial nerve injury [4].

Recent studies emphasize the central third of the face, often referred as midface, the most difficult region of the face to effectively address. In 1979, with the subperiosteal approach, Tessier [5] has revolutionized the treatment of the aging face reducing signs of aging