Subperiosteal Rhytidectomy Provides Superior Correction of Midfacial Aging

I completely agree with using a more superficial technique for the neck and lower portions of the face. I will often undermine all the way around, defat, and perform superficial musculoaponeurotic system work in the lower portions of the face. But when it comes to correcting midfacial aging, primarily nasolabial fold problems, inferior locations of the nasal jugal line, concavity in the lower lid, and laxity in the lateral canthal area, I perform the subperiosteal dissection.

My approach can be performed either through a subciliary lower lid incision or through a gingival buccal incision. Subperiosteal dissection is then carried out over the maxilla, malar zygomatic, and lateral orbital rim area; the arch itself is dissected subperiosteally in an anterior-to-posterior direction.

Through the temporal incision, the plane of dissection is superficial to the deep temporal fascia. This is carried inferiorly to the sentinel vein. The posterior one third of the arch is then identified. The periosteum is incised, and subperiosteal dissection proceeds in a posterior to anterior fashion completing the subperiosteal tunnel. With a Cottle elevator (Padgett Instruments, Inc., Kansas City, MO) in this tunnel, a gentle sweeping movement in an upward direction transects the fusion of fascia above the arch completing the dissection.

The periosteum is not responsible for the malposition of the soft tissues. The periosteum is nothing more than a mechanism for transportation and fixation. The reattachment of the periosteum holds the repair at a more superior level. On one occasion when I performed a revision over the malar area and lateral orbital rim, I found a dense reattachment anchored to the bone. It was every bit as dense as the original dissection.

On average, without working on the brow, it takes me 4½ to 5 hours to treat the lower lids, perform a sub-periosteal face lift, and close. When I'm making my sutures in the suborbicularis oculi fat and advancing the malar fat pad on the malar bone, that vector is almost perpendicular to the nasolabial fold. It's more of an oblique upward vector.

Harvey L. Heinrichs, MD, Newport Beach, CA is a board-certified plastic surgeon and an ASAPS member.

Before I began using the subperiosteal technique, a significant number of my patients (as many as 15% to 18%) returned with complaints specific to the midfacial area.

When I perform the skin repair, it is almost in a straight posterior or transverse vector. Those two technical considerations are important to achieve a nice, natural look without that “swept” look.

It is easy to avoid injuring the infraorbital nerve because I'm looking at it directly either through a buccal incision or through a subciliary lower lid incision. In 300 of these dissections, not one patient has experienced permanent injury of the temporal branch of the facial nerve. I've had about six patients in whom weakness has lasted just a few days and only one whose weakness lasted 3 to 4 weeks.

Otherwise, I find it to be a trouble-free operation because I'm not disrupting the lymphatic circulation that might be affected in a composite face lift. Even if there is more periorbital swelling during the initial postoperative period, the edema resolves very quickly.

I am concerned about patients who smoke because I also go through the neck. With the technique I use, the devascularization in the face is considerably less than in a subcutaneous dissection, so I'm not quite so tense there. But certainly, if the patient is a smoker, I'm very nervous when in the postauricular area.

Before my patients resume most social activities, I want them to recuperate at home for 2½ to 3 weeks. Recovery takes 6 weeks for a relaxation of the slight overcorrection in the lateral canthus.

It's a beautiful operation for a person with a long, elongated narrow face, but not for someone with a very round face who lacks bony definition. It doesn't work as well in that case because the zygomatic width is increased, adding to the roundness. In a person with a longer face, the procedure seems to compress the length of the face.

I believe lasering can be done safely in the periorbital areas. I laser the lower lids because I am using a skin muscle flap. On occasion, I laser the entire face with reduced power.

Before I began using the subperiosteal technique, a significant number of my patients (as many as 15% to 18%) returned with complaints specific to the midfacial area. Now, I don't have as many of these problems. Only three or four of my patients have had slight asymmetry in the position of the lateral canthus, and this has been the primary reason for revisionary surgery.