The Subperiosteal Mid-Face Lift Using Bioabsorbable Implants for Fixation*

Chapter 86 The Subperiosteal Mid-Face Lift Using Bioabsorbable Implants for Fixation 279

and continued subperiosteally into the midface beyond the zygomaticomaxillary buttress. A straight periosteal dissector is useful in the proximal portion of the dissection to the prominence of the zygoma. Further inferior, a gently curved dissector is useful to approach the anterior face of the maxilla. Medially the dissection exposes the piriform aperture and anterior nasal spine. Laterally the dissection degloves the zygoma, and exposes approximately 5–6 mm of the medial edge of the masseter muscle. As needed, dissection may be continued to the frontal processes of the maxilla medially (Figure 86.3A). From a temporal approach, the dissection is accomplished with minimal risk of injury to the infraorbital neurovascular bundle.4 The dissection releases the origin of the zygomaticus major and minor muscles, which some authors feel may contribute to an unnatural appearance postoperatively (we have not found this to be the case).5 At the level of the gingivobuccal sulcus (LeFort I level), the periosteum is incised using an up-biting periosteal elevator to optimally open the periosteum. The midface soft tissue envelope is then stretched (using a periosteal elevator or digitally) for maximal mobilization (Figure 86.3B).

As needed, an intraoral gingival buccal incision may be created to allow subperiosteal midface dissection under direct visualization. This is useful for surgeons beginning to perform subperiosteal mid-face lifting or as a route for placement of malar implants. The incision is begun high in the region of the zygomatic buttress at the level of the first molar tooth, 10–15 mm above the mucogingival junction. Care is taken to avoid the orifice of Stenson’s duct. As the incision proceeds anteriorly, it is directed more inferiorly as it approaches the pyriform rim adjacent to the canine tooth, staying approximately 5 mm superior to the mucogingival junction. This avoids trauma to the alar portion of the nasalis muscles. The resulting cuff of mucosa facilitates closure and prevents contraction of the sulcus postoperatively. Under direct visualization, the subperiosteal dissection continues superiorly to the inferior orbital rim, exposing the infraorbital neurovascular bundle. The intraoral dissection is easily connected to the previously created temporal dissection.

Upon completion of the dissection cavity, malar implants may be placed as indicated in the subperiosteal pocket. The orbital septum may be approached and opened through the intraoral approach. The fat pads may be draped over the orbital rims and secured to the undersurface of the periosteal release.

With adequate release, the midface is then advanced superiorly. Using a bird’s-eye view, the power of the mid-face lift is apparent. Fixation is accomplished using bioabsorbable implants that may be placed through a temporal approach or retrograde through a sublabial approach. The Endotine Midface ST bioabsorbable implant (Coapt Systems, Inc., Palo Alto, CA) has tines to fix the midface soft tissue envelope (Figure 86.1).

The leash allows fixation to the deep temporalis fascia. Advantages of the midface implant include more rapid placement than sutures as well as the ability to elevate the midface without necessarily having to make a gingivobuccal incision. The device is typically nonpalpable and asymptomatic, resorbs over a period of 6 months. The mid-face soft tissue and periosteum at the level of the malar fat pad is pushed onto the prongs

280 D.E.E. Holck et al.

until they are engaged (Figure 86.4). The leash is pulled from the temporal incision until the desired elevation is achieved (Figure 86.5). The leash is fixed to the deep temporalis fascia using multiple 3-0 PDS or Vicryl sutures, with excess leash trimmed after suture xation (Figure 86.6).

Alternatively, fixation of the midface is accomplished by suturing midface periosteum to the deep temporalis fascia from the temporal hairline dissection. We place two to three sutures (typically 2-0 ePTFE, or PDS sutures) in the mid-face periosteum: one at the level of the suborbicularis oculi fat pad, one more inferior at the periosteum of the low alar groove in proximity to the buccal sulcus incision, and possibly a third in the maximal projection of the malar fat pad. These fixation points may be somewhat tenuous and take some effort and multiple passes to fixate. The fixation sutures may be modified based upon the degree of lift desired.

If opened, the gingivobuccal incision is closed with a running 4-0 chromic gut suture. Care is taken to avoid tension. The temporal hairline incision is closed with 35R staples. Postoperatively, the patient gently rinses their mouth with antiseptic. The scalp is covered with a cotton mesh dressing for 24–48 hours. The staples are removed at 7–10 days postoperatively.

We have found that this resorbable midface lifting device has reliably and predictably elevated the midface in a vertical vector of pull (Figure 86.7). The device allows increased surgical efficiency, allowing predictable symmetric mid-face lifting with minimal increase in operative duration using an endoscopic or open browlift approach. An additional observation is elevation of the lateral canthal angle without a lower eyelid surgical approach. We have found that the resorbable fixation device is neither palpable nor uncomfortable for the patient. Keys to success using this technique includes wide surgical undermining, adequate stretching of the mid-face soft tissue envelope after periosteal release at the Le Fort 1 level, judging symmetry upon placement of both

xation devices, and multiple point fixation of the leash to the deep temporalis fascia.