Minimal-Incision Endoscopic Face-lift

Psillakis et al ^Article originally described the subperiosteal midface-lift in 1988. It is performed in a relatively well-defined, bloodless plane and addresses 2 attenuated retaining ligaments—the zygomatic and masseteric cutaneous. Elevation of the midfacial tissues is done easily through an intraoral or periorbital incision. To reposition the cheek tissues and to prevent a cherubic appearance, this dissection must be connected to the temporal fossa.

Psillakis et al ^Article cite a relatively high incidence of temporal branch (cranial nerve VII) weakness (up to 20% in the initial series) due to excessive traction and cauterization in the area of the zygomatic arch. Ramierz and colleagues ^{Article - Article} made several modifications to the original technique, but the procedure did not gain widespread acceptance. With the advent of endoscopic techniques has come a renewed interest in the subperiosteal approach to the midface. The original procedure involved blindly degloving the midface, but it did not gain great popularity because of the lack of visualization of key anatomical structures and the inherent risks. The endoscopic subperiosteal approach to the midface involves detachment of the soft tissues from the orbits, malar bone, upper maxilla, and nose under direct visualization ( Article ). This approach separates the attenuated zygomatic and masseteric cutaneous ligaments and allows for elevation under magnified vision of the orbicularis oculi and oris, zygomaticus major and minor, and levator anguloris muscles. ^Article

This study is a retrospective review of 20 patients, 18 women and 2 men (age range, 42-64 years). Indications for patient selection were the presence of ptotic cheek tissue with deep melolabial folds and generally with associated down turning of the oral commissure. If the patient had isolated ptosis of the cheek tissues with no significant jowling or excess facial tissues, the endoscopic subperiosteal midface-lift was performed alone. In patients with additional jowling and excess facial tissues, the subperiosteal face-lift was combined with a superficial musculoaponeurotic system (SMAS) suspension rhytidectomy. During the consultation the patient was given the option of a traditional SMAS rhytidectomy plus cheek implant when loose skin was present. In younger patients, an isolated cheek implant was discussed as a possible alternative to help restore fullness to the cheek area.

Anesthesia for the procedures was either monitored anesthesia care or general. Regardless of which method was chosen, supplemental local infiltration of a mixture of equal amounts of 1% lidocaine hydrochloride and 1:100,000 epinephrine with 0.5% bupivacaine hydrochloride was used.

The patient's excess scalp hair around the incision was isolated, and the area was then prepared and draped in a sterile fashion. Access to the temporal fossa is achieved through an isolated 4-cm incision placed just above the ear in the hairline or as a temporal extension of the face-lift incision ( Article and Article ). The plane of dissection is carried down to the deep temporalis fascia, which is glistening white and not mobile ( Article ). The temporal parietal fascia, however, is mobile. The dissection of the temporal fossa is carried superiorly to the temporal line, anteriorly to the posterior aspect of the lateral orbital rim, and inferiorly to the zygomatic arch ( Article ). At the superior level of the auricle, the deep temporalis fascia splits into superficial and deep layers, with the superficial temporal fat pad lying between them. It is important to apply firm pressure with a sharp elevator on the temporalis fascia when dissecting inferiorly toward the arch. Because the superficial layer of the deep temporal fascia is much thinner than the deep layer, along with the fat pad it will be elevated with this maneuver, thus keeping the temporal branch of the facial nerve well away from the dissection pocket. The extent of the dissection can be checked frequently with the endoscope, which can be inserted through the upper portion of the temporal incision, or a separate stab incision can be made within the hairline for insertion and stabilization of the endoscope. Once the boundaries of the temporal fossa have been clearly defined, attention is then turned to dissection of the midface.

The periosteum in the midface can be elevated from several approaches: the temporal fossa, a transconjunctival or transcutaneous blepharoplasty incision, or intraorally. From the temporal fossa the lateral orbital rim is identified and the periosteum is elevated inferiorly to the infraorbital rim. Dissection is then carried posteriorly by incising the periosteum with an elevator on the zygomatic arch. Identification of the infraorbital nerve is somewhat more difficult from this approach. Also, the medialmost dissections to the piriform aperture and medial orbital rim are more difficult.

The midface can also be approached through a transconjunctival or transcutaneous blepharoplasty approach ( Article ). These methods provide a direct approach to the midface. The eye is protected with a scleral shield, and occasionally a lateral canthotomy is necessary with the transconjunctival approach to free up the lower eyelid to allow appropriate dissection of the lateral orbital rim.

A more direct approach is through the canine fossa ( Article ). A l-cm incision is made in the canine fossa directly down to the periosteum. The soft tissues of the midface are elevated medially to the piriform aperture. As the soft tissues are elevated superiorly, care is taken to identify and preserve the infraorbital nerve. The medial and lateral tissues surrounding the nerve up to the orbital rim are elevated. Once the periosteum over the inferior aspect of the malar eminence is elevated, the lateral orbital rim is then undermined. The periosteum over the zygomatic arch is then easily elevated. The surgeon can place the thumb and index finger of one hand on either side of the zygomatic arch as guides. With the other hand, a periosteal elevator is guided along the arch, audibly elevating the periosteum to the lateral extent of the arch. Care is taken to ensure that the elevator is in a subperiosteal plane. After elevation of the periosteum, the endoscope is used to visualize the connecting of the temporal and midfacial packets. This can be performed from above or below. Once completed, it is important to carry this elevation down over the masseter fascia for a short distance. Care needs to be taken in this area to reduce any potential injury to the buccal branches, which are adjacent to masseteric fascia. The endoscope can be passed from the temporal pocket at this point to visualize the area of dissection. The boundaries of the midfacial dissection are the piriform aperture, the infraorbital rim, the lateral orbital rim, the zygomatic arch, and the masseteric fascia. The retaining ligaments are freed from the upper half of the masseter muscle. The infraorbital nerve is identified and preserved. On completion of the dissection, the tissue pocket should be wide enough to allow for proper redraping.

Fixation of the cheek tissues is then performed using a converse retractor ( Article ). Because this retractor has a fixed short horizontal portion, it can be used to consistently mark the fixation point on each side. The fixation point is generally approximately 2.5 to 3.5 cm directly below the lateral canthus. Using the converse retractor and with external digital palpation, this point can be identified underneath, and then a 2-0 polyglactin suture is used to anchor this point. After this, a needle holder is passed from the temporal pocket over the zygomatic arch and into the lower portion, where the suture is grasped and pulled through to the temporal fossa. When the suture is pulled once, one should see elevation of the malar fat pad and elevation of the corner of the mouth. One can evaluate multiple vectors to determine the most appropriate direction of pull for the area. Once determined, the suture is anchored to the temporalis fascia. When the cheek is properly suspended, we see elevation of not only the cheek pad but also the oral commissure. Some overcorrection, with showing of the maxillary teeth, is desirable. If there is deepening of the melolabial fold, the fixation suture is not placed laterally enough. If there is dimpling of the overlying skin, the suture is too superficial. The approaches to the midface are closed in the usual fashion and postoperative dressings are applied.

All patients tolerated the procedure well and had satisfactory results ( Article ). The most striking observation of the patients after the procedure is the slightly cherubic appearance. This feature was more pronounced in patients with thick fatty tissue than in thinner-skinned patients. The cherubic appearance can be minimized by a wide dissection of the tunnel connecting the midface with the temporal region.

Patients need to be carefully examined before surgery for facial asymmetry because these differences might become more readily noticeable afterward ( Article ). Postoperative asymmetries can develop if the suture is not placed symmetrically or is displaced after surgery. The converse retractor, used as a measuring device, might help ensure symmetry.

Unilateral buccal weakness was present in one patient for 2 weeks. A second patient developed periorbital weakness after her procedure. Both of these problems resolved spontaneously. The latter patient did not disclose that she had undergone previous cheek augmentation with hydroxyapatite cheek implants. This patient was also an avid exerciser with little facial fat. As a result, when the fixation suture was placed, it was replaced several times because it was too superficial and caused a depression of the overlying skin. The 2-0 polyester suspension suture was removed through the temporal incision 1 year after the procedure because of delayed skin depression. We now use a 3-0 polyglactin suspension suture for midfacial suspension to avoid this problem.

Patients frequently experience numbness of the cheek areas, which resolves within the first week or two after the procedure for many; however, occasionally a patient has protracted loss of sensation for up to 3 months. Postoperative discomfort has been variable. Most patients do not experience any significant discomfort. One patient, however, experienced discomfort lasting approximately 6 weeks. This was thought to represent a traction injury to the infraorbital nerve. The patient was given carbamazepine, which resulted in improvement of symptoms.

Two patients developed postoperative infections. One patient was a heavy smoker with poor dentition who underwent an SMAS suspension and rhytidectomy in combination with the subperiosteal face-lift and lower eyelid transcutaneous blepharoplasty. Postoperatively the patient presented with purulence at the transcutaneous blepharoplasty incision. This incision was opened intraorally and the patient was given antibiotics and the infection resolved. The second patient developed fluctuance and slight erythema of the left cheek area approximately 10 days after the procedure despite taking a course of antibiotics. Aspiration was performed with no significant results, and the patient was given clindamycin. Cultures revealed no organisms. The infection resolved uneventfully.

In conclusion, endoscopic subperiosteal face-lift is a technique that can restore a natural, youthful appearance to the midfacial area either as an isolated procedure or in combination with an SMAS suspension rhytidectomy. This is accomplished by elevating the retaining ligaments and premolar muscles to their more youthful anatomical positions. Long-term results in the melolabial fold area were less then desired, but patients maintained satisfactory elevation of the cheek tissues.

Accepted for publication August 2, 2000.

Reprints: Brian P. Maloney, MD, Premier Image Cosmetic and Laser Surgery, PA, 4553 N Shallowford Rd, Suite 20-B, Atlanta, GA 30338.