39.5 Conclusions

The subperiosteal face-lift by temporal approach is a procedure designed to rejuvenate the upper and middle thirds of the face. After subperiosteal detachment, the soft tissues of the cheek, forehead, jowls, lateral canthus, and eyebrows can be lifted to reestablish their youthful relationship with the underlying skeleton. It is a technique that produces satisfactory cosmetic results in most of the cases, causing malar augmentation, nasolabial fold improvement, and mild jowl improvement.

References

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40.1 Introduction

When compared to non-cosmetic surgical procedures, rhytidectomy is a relatively young procedure, approaching its 100th birthday. Considering this, it is interesting that it has undergone such a high degree of modification, refinement, scrutiny, and in some cases mimicry. As knowledge of facial and neck anatomy grew, the safety, efficacy, and longevity of the procedure have also been maximized. Through the decades, as more “non-mainstream” cosmetic physicians began performing facial procedures, there arose a trend of what has come to be known as “minimally invasive” operations which were portrayed as reasonable facsimiles to the more traditional operation. As with any procedure, patient selection is paramount to success. As younger patients presented for improvement of facial features, these less-invasive procedures gained some popularity, especially with the false stigmata of the term “facelift.” Time is showing that when the chief complaint of facial aging includes flattening of the midface, deepening of the nasolabial and mesolabial folds, jowling, and platysmal banding, the “time-tested” traditional rhytidectomy which deals with repositioning of facial musculature, and removal of excess skin and fat, provides the highest intersection of safety, efficacy, and longevity.

The early twentieth century saw the procedure performed primarily by “beauty doctors” in private offices and clinics. Surgical traditionalists felt that the procedure was not worthy of publication. This negativity

W.G. Chernoff

Chernoff Cosmetic Surgery, Indianapolis, IN, USA e-mail: greg@drchernoff.com

was at a peak in the early 1920s as evidenced by publications that called for a ban on cosmetic procedures [1]. The majority of the original papers reporting the procedure were in fact retrospective. Texts claiming original contributions arose from America and Europe. These have been attributed to Miller [2], Lexer [3], Hollander [4], Passot [5], Joseph [6], and Noel [7].

The first-described techniques consisted of incisions placed behind and in front of the ears, coupled with minimal excisions of skin strips. Bourguet [8] and Bettman (1920) [9] have both been credited with the first cases involving extensive subcutaneous undermining and lipectomy. Interestingly, the incisions used were similar to those of today, beginning temporally, extending pre-auricular, and posteriorly to the lobule. Joseph, in 1928 [10], introduced the post-tragal refinement.

The subsequent evolution of the technique has occurred primarily in North America [11]. The organization of surgical specialty boards helped foster tech- nique-specific research and the spirited jousting of which techniques were superior. An ongoing evolution of acceptance of the procedure has mirrored the progression of the educated consumer to accepting a theory of maintenance over long propagated misconceptions of vanity. Concurrent improvements in anesthesia and postoperative care have helped the education process accentuating safety and reliability. Ongoing refinements have sought to improve both feature correction and longevity. It has been the latter that has looked down upon some of the supposed “less-invasive” techniques, especially when patients who have undergone them began complaining openly of what was perceived to be “minimal results” with early recurrence of the features which led them to seek the operation in the first place.

Surgical refinement continued to be reported. In 1960, Aufricht [12] proposed improving longevity by suturing deep to fat. Skoog, in 1974 [13], coined the

term “buccal fascia,” which incorporated the platysmal muscle and the superficial fascia of the lower third of the face. This fascia was undermined to the level of the jowl and melolabial fold and then sutured to the mastoid fascia and parotidomasseteric fascia, respectively. In 1976, Mitz and Peyronie [14] described the superficial musculoaponeurotic system (SMAS). This finding confirmed a fascial layer distinct from the underlying parotidomasseteric fascia, which invests the facial musculature. They found that the SMAS was in a tissue plane continuous with the platysma in the neck, and the temporoparietal fascia in the scalp. Fibrous adhesions to the overlying subcutaneous tissue and skin allowed for SMAS manipulations to effect desired skin improvements. This benefit can be lost if the relationship between SMAS and overlying skin is not maintained due to extensive undermining. This “SMAS rhytidectomy” has remained a popular technique, which combines a subcutaneous dissection with a separate SMAS elevation via plication (pulling back, folding over, and suturing), as described by Webster in 1982 [15] or imbrication, (advancement, shortening, and suturing), as described by Lemmon and Hamra [16]. Throughout these papers, maintaining a natural look while minimizing complications was repeatedly advocated.

The 1990s and the first decade of this century showed research into improving the midface, the most difficult region of the face to obtain consistent longterm results. Deep-plane and composite rhytidectomy, as pioneered by Hamra [17, 18], were the next steps in the evolution of facelift. Versions of this technique then evolved as the biand tri-plane dissections by Baker [19] and modifications by Kamer [20]. Ramirez [21] took the deep-plane to its full extent by reporting a subperiosteal approach.

The most important aspect of providing meticulous results is the ability of modifying one’s technique proportional to what the patient would benefit from, based upon the chief complaint at the time of the initial consultation. Applying all that has been learned over time from skin excision to composite dissections must be weighed with the potential for complication and delivering the result that has been assured. Assessing the degree of midfacial aging, nasolabial and melolabial folds, jowling, platysmal banding, subplatysmal fat, and skin quality play into the surgeons’ decision of choosing the appropriate rhytidectomy for the patient. What is paramount is that the surgeons have available

in their armamentarium all potential techniques and know when to offer each one.

40.2Limited Flap Rhytidectomy Procedures

Various limited techniques have been popularized under different names. These include the short flap technique, the S-lift, the mini-lift, the “lunchtime lift,” the “weekend lift,” and the most recent moniker – the “lifestyle lift.” This essentially comprises a limited pre-auricular incision terminating at the lobule, a short amount of skin undermining, limited SMAS imbrication or plication, coupled with platysmal plication and cervical liposuction.

Indications include younger patients with limited midfacial ptosis and jowling and mild skin laxity. Professed advantages include shorter operative and recovery periods, increased safety, and the ability to be more aggressive with concomitant skin exfoliative procedures with chemicals or lasers. As one might expect, detractors profess limited and transitory benefits yielding patient dissatisfaction and the need for reoperation. It does seem appropriate for the patient who seeks a subtle, safe procedure with a shorter recovery time than the procedures discussed hereafter.

40.3Extended Flap Rhytidectomy Procedures

This group encompasses several techniques, which involve extensive tissue undermining on the lateral face, and may extend across the midline in the submental region. Indications include those patients with more advanced signs of aging, such as flattening of the midface, moderately deep nasolabial and melolabial folds, significant platysmal banding, and significant elastosis. Multiple procedures can be performed simultaneously without adding to recovery time or compounding postoperative discomfort. The procedure has increased potential for complications, given the extensive undermining. Surgical skills with uncompromising anatomical knowledge are prerequisites to the successful completion of this rewarding procedure.