Fig. 39.1 Aged anatomical findings shown on the right and youthful contours shown on the left

Aging face

Increased vertical eyelid length

Periorbital hollowing

Tear trough deformity

Low malar fat pad

Proeminent nasolabial fold

Platysmal ptosis

Jowling

Youthful face

Short vertical eyelid length

Inferior orbital rim

High malar fat pad

Soft nasolabial fold

in young and middle-aged patients. Following the studies of Tessier, Psillakis [6, 7], Santana [8], and others have improved the application of subperiosteal dissection in face rejuvenation. Ramirez [9, 10] led to the popularization of this technique in United States with the introduction of the endoscope.

The authors describe their preferred technique for subperiosteal face-lift and discuss its indications, complications, advantages, and limitations.

39.2 Technique

39.2.1 Preoperative Evaluation

A complete medical history has to be obtained before any aesthetic surgery of the face, including allergies, medications, medical problems, previous surgery, and drinking and smoking habits. Smoking cessation is advocated before and after surgery; however, patient disagreement may not affect final results due to the thickness of the flap created during the subperiosteal

face-lift. As well, emotional and psychological evaluation is important for elective aesthetic surgery. Preoperative photographs are essential, helping on preoperative planning, intraoperative decisions, patient communication, and medicolegal documentation. At the time of the preoperative consultation the patients are oriented about the planned procedure with written and verbal information provided. Written informed consent is also requested [3].

Subperiosteal face-lift is especially advantageous to patients who had undergone other face-lift procedures, need skin resurfacing, soft tissue augmentation, skeletal disproportion, and patients who need alloplastic implants. The association to forehead-lift is common and produces excellent results [11, 12]. Ramirez [9, 10] and Psillakis [6, 7] demonstrated that subperiosteal face-lift could be applied across the full spectrum of facial aging.

39.2.2 Surgical Technique

The surgery is usually performed with the patient under sedation and local anesthesia (2% lidocaine with

1:100,000 epinephrine) is infiltrated in all areas of planned surgery for anesthesia and vasoconstriction.

Important anatomic structures to consider are the frontal branch of the seventh nerve and the infraorbital neurovascular bundle. The important dissection planes include the dissection deep to the temporoparietal fascia along the deep layer of the deep temporalis fascia and the subperiosteal midface dissection. The surgical technique is divided into three major steps: (1) the endoscopic creation of a temporal pocket, (2) mobilization of the midface by subperiosteal dissection, and

(3) elevation and suspension of the mobilized midface to the deep temporalis fascia.

In the temporal region, a 5 cm incision, perpendicular to the temporal line, is placed 3 cm behind the hairline. The dissection is performed to identify the deep layer of the deep temporalis fascia (Fig. 39.2). As the pocket is enlarged, the endoscope is introduced for visualization. The frontal branch of the seventh nerve is contained in the overlying temporoparietal fascia that is analogous to the SMAS found in the lower face, facilitating the mobilization of the entire zygomatic arch periosteum and protecting the frontal branch of the facial nerve from injury. Identification of the superficial temporal fat pad is an important landmark that assures the surgeon that the frontal branch of the facial nerve is lateral to the endoscope.

The dissection continues medially and inferiorly exposing the medial third of the zygomatic arch and orbital rim. An incision is made on the zygoma periosteum and lower subperiosteal elevation is performed to malar imminence, gingival buccal sulcus, and nasolabial fold. It is important to respect the arcus marginalis,

the confluence of the periosteum of the orbital rim and the periorbital, in order to minimize the risk of edema and lid eversion in the final result. Care is taken to avoid damage to the infraorbital nerve.

The dissection is extended to the pyriform aperture medially, the oral vestibular mucosa inferiorly, and the superior/anterior border of the masseter muscle laterally. All the dissection detach the eyelids, external canthi and Lockwood ligaments, parotid fascia inferiorly and temporalis fascia superiorly, zygomatic muscles and levator labii superioris, and other muscles from their superior origins (Fig. 39.3). The periosteum is very thin medially and a careful dissection avoids muscle injury.

The final step involves suspension of the mobilized midface to the deep temporal fascia by using three 2–0 polyester sutures (Ethibond, Ethicon, Inc., Somerville, NJ) to secure the cheek. The sutures are crossed and secured to the deep temporalis fascia, creating appropriate superior and lateral vectors of force. Systematization of the midface lifting is made by three main points: Bichat’s fat pad, malar fat pad, and suborbicularis oculi fat (SOOF) (Fig. 39.4). The first point is the “B point” (Bichat’s fat pad). It is located at a point of intersection of a vertical line from the lateral canthus and a horizontal line from the nasal base. Suspension of this point promotes volumetric augmentation of the midface, elevation of the corner of the

Fig. 39.2 Cadaver dissection showing the temporoparietal fascia (forceps) and the underlying deep temporalis fascia

Fig. 39.3 Extent of undermining for the transtemporal subperiosteal face-lift