The subperiosteal bicoronal approach to total facelifting: the DMAS--deep musculoaponeurotic system

[Forehead rejuvenation]

The goal of this article is to provide a systemic approach to forehead rejuvenation. Fillers, botulinic toxin injections, transpalpebral, endoscopic or bicoronal brow lift must be usual techniques for every plastic surgeon in overall facial rejuvenation. Achieving a long lasting and aesthetically pleasing forehead is possible only with surgical techniques when aging is obvious.

The vertical midface lift. An improved procedure

We describe a novel procedure for an anatomically-based face lift to correct vertical vectors in the ageing face. It has the advantage of surgical simplicity, minimal tissue removal and minimal risk. It provides an effective readjustment of cheek volume and correction of periorbital hollowness. Natural facial expression is preserved largely because there is no change in the position of the lateral canthus. The cheek is mobilised subperiosteally through a blepharoplasty incision. A second dissection is made via a short temporal incision, to join the infraorbital dissection. A Hagedorn needle is then inserted through a point inferior to the lateral canthus and in line horizontally with the nasal ala. It is passed to the orbital incision, charged with a loop of suture material, and pulled down again to the cheek incision, from where it is pushed back to the orbit to suspend the cheek. The upper border of orbicularis oculi is fixed firmly to the temporalis aponeurosis at the level of the temporal incision. We now frequently use an Endotine Midface device for fixation. Of the first 150 patients, results were excellent or good in 145. This represents a revival of the subperiosteal mask lift, and abandons the use of endoscopic techniques. In spite of its simplicity, the operation involves subperiosteal dissection as well as delicate eyelid surgery that necessitate plastic surgical skill.

The Extended Minimal Incision Approach to Midface Rejuvenation

Recent major advancements in comprehensive facial rejuvenation have focused on management of midfacial aging. Multiple techniques have been described to treat the aging midface; the mere nature of so many approaches is evidence that no one technique has prevailed. Although the nasolabial region remains a challenge to correct, the approach described herein provides comprehensive rejuvenation of the midface, lateral brow, and jawline. The technique is performed via a minimal incision brow-lift approach and has been performed (with minor modifications) by the senior author in more than 650 patients over the past 9 years. The technique has proven to be safe, reliable, and effective.

Endoscopic-Assisted Face Lift

The use of endoscopic techniques in facial esthetic surgery has gained increasing popularity in the last decade. Endoscopic forehead rejuvenation became a reliable technique and an attractive option for both the surgeon and the patient. The use of the endoscope in face and neck lift surgery did not gain the same popularity, as explained by the relative few indications for this technique. In this study, we retrospectively review a series of 200 patients who underwent endoscopic-assisted face-lifts alone or in combination with other esthetic procedures. We divided the patients into 4 groups according to the type of incisions and the surgical approach used in each of them. We also reviewed the current status of using the endoscope in face and neck lift surgery. The technique described in this study uses limited access incisions (limited postauricular, submental, and temporal scalp) to reposition the ptotic facial elements, while avoiding the preauricular and postauricular scarring when indicated. Under endoscopic visualization, the composite face-lift flap elevates the malar fat pad above the zygomaticus muscle to the nasolabial fold. The lower-lid orbicularis oculi muscle is incorporated and lifted with composite flap through the lower blepharoplasty incision. The jowl area is contoured by tangential excision and tightening of the lateral platysma. Pretunneling and hydrodissection defines the plane of dissection and helps to reduce the bleeding during facial and cervical flap elevation. In this study, endoscopic techniques were applicable in selected patients undergoing facial rejuvenation with goals of decreased scarring. Indications for using the technique include young patients (eg, less than 50 years) with a relatively small amount of skin excess or older patients with thick skin and minimal skin redundancy. The technique is particularly attractive to the male patient, by avoiding the preauricular incision and the disruption of the beard line. Patients with excess skin underwent the standard cervicofacial incision. In this group the endoscope was used as a tool for better magnification and illumination.

Midfacial Rejuvenation Via a Minimal-Incision Brow-lift Approach

OBJECTIVE

To evaluate the surgical technique, cosmetic results, and complications of patients who underwent a midface-lift via a minimal-incision brow-lift performed by the senior author (E.F.W.).

SETTING

Private, ambulatory surgical center.

DESIGN

A retrospective review of 325 midface-lifts performed over a 5-year period by a single surgeon. Patients A total of 325 consecutive patients who underwent a midface-lift, with or without concurrent rhytidectomy and other adjunctive procedures, and who completed 3 months of follow-up were reviewed for perioperative complications. One hundred patients who had complete photographic and chart records and who had a minimum of 6 months of follow-up were randomly selected for photographic rating and chart review. Of the patients who had a minimum of 1 year of follow-up, 50 were randomly selected to determine if midfacial elevation led to any evidence of lateral-canthal distortion.

MAIN OUTCOME MEASURES

Midfacial elevation was assessed in 3 facial zones by 3 independent evaluators. Zone I represents the malar-infraorbital complex; zone II, the nasolabial sulcus; and zone III, the jawline. The zones were rated on a scale from 0 to 2 (0, no improvement; 1, mild improvement; and 2, marked improvement). Change in the lateral-canthal position was measured in the vertical and horizontal axis for each eye. All complications were recorded.

RESULTS

The 3 independent evaluators correlated well in their scores (kappa = 0.643) and found that most patients showed the best improvements in zone I, with 70% of patients showing marked improvement (P<.001). Moderate improvement was noted in zone III (marked improvement, 30%; mild improvement, 50%; and no improvement, 20%). Little or no improvement was noted in zone II (marked improvement, 4%; mild improvement, 60%; and no improvement, 36%). Patients who underwent a rhytidectomy along with a midface-lift showed better elevation in zone III. However, patients who underwent a brow/midface-lift alone also showed favorable improvement along the jawline (zone III). Although the postoperative lateral-canthal position revealed statistically significant vertical elevation of the lateral canthus on the right side, this finding did not correlate with any perceived clinical significance by the reviewer or patient (P<.01). Temporary morbidity included 2 subperiosteal abscesses and 3 frontal and 1 buccal facial nerve neuropraxias that resolved by 6 months. Permanent complications included 1 case of unilateral cranial nerve V2 paresthesia. Five patients had alopecia requiring scar revision. Many of these complications, including subperiosteal abscess and alopecia, have subsequently been avoided by minor technique modifications.

CONCLUSION

The technique of midface-lift via transbrow approach is a safe, reliable method of midfacial rejuvenation and avoids the unnatural lateral-canthal distortion previously described in the literature.

Subperiosteal and full-thickness skin rhytidectomy

Subperiosteal lateral brow and midface elevation, upper lid blepharoplasty, transconjunctival retroseptal fat removal, lower lid skin excision, and full-thickness skin rhytidectomy are combined in one operation to rejuvenate the entire face. This combination of procedures is designed to restore both anthropometric and subjective attributes of youth. The attributes of a youthful face may be summarized as brows with an apex lateral slant, eyes that are narrow, lower lids that are short, cheeks that are full, and necks that are well defined. In addition to restoring a youthful appearance, the techniques described avoid some common iatrogenic sequelae of facial rejuvenative surgery. In a clinical experience with 28 patients over 3 years, this combination of procedures has proved to be safe and predictable.

Fibrin glue fixation in forehead endoscopy: evaluation of our experience with 206 cases

The endoscopic approach has totally replaced the bicoronal approach for the treatment of forehead aging in our practice since November of 1993. The fixation in proper position is obtained with fibrin glue. Results of a series of 206 procedures performed in 196 patients are presented. Eyebrow positioning and muscle weakening were rated on a scale of 1 to 4. The evaluation has been made at a minimal follow-up time of 6 months. The comparison of the results between the first series of 28 patients during the first 6 months of our experience and the second series of 69 patients during the following period showed a significant increase in the number of excellent results (from 47 to 78 percent). Altogether, the satisfactory results (rated excellent or good) increased from 71 to 86 percent. Fibrin glue provides a stable fixation with the possibility of displacement in several directions, including transversal expansion. Complications have been minimal. Secondary procedures and association with other facial operations have been analyzed.

Subperiosteal facelift: open and endoscopic approach

The endoscopic subperiosteal facelift as an isolated procedure is indicated for patients with grade I rhytidosis. It is also indicated in cases of grades II and III rhytidosis in males in whom the coronal incision is contraindicated due to alopecia and without conspicuous damage to the forehead. In these cases, the procedure is combined with subcutaneous rhytidectomy of the neck. It can also be used in cases of secondary facelift. The small incisions used in this procedure allow sufficient and effective access for dissection and suspension of the tissues released during the facelift. The coronal incision is not necessary, thus avoiding the resulting discomfort and scar. These patients do not receive anesthesia and experience almost no paresthesia in the frontal region, as in cases in which a coronal incision is performed. The endoscopic approach reduces surgical trauma as well as postoperative edema. Since neither the veins nor the lymphatic vessels of this area are sectioned, swelling subsides faster and recovery is shorter.

Subperiosteal brow and midface lifts

The subperiosteal browlift and midface lift combination is a total mobilization of the composite full-thickness soft tissues from the bony skeleton with superior suspension. The object is to correct midfacial ptosis and the "tired" look of the lateral eyelids. It is done in conjunction with a browlift so that a composite correction of the upper and midface is achieved. When indicated, a modified lower cheeklift and the usual procedures for correcting neck deformities are utilized in combination. We believe the procedure is safe and the results reported are natural and long-lasting. This review of 130 cases also stresses technical aspects and the safety of the procedure.

The subperiosteal lift

The subperiosteal lift developed by Tessier is a technique for rejuvenating the face and emphasizing beauty. It is performed using two approaches: intraoral and bicoronal or precapillary. It entails a total subperiosteal undermining of the face beginning 2 cm over the orbits and continuing on the orbital rims, the zygomatic arches, and the malar bones. This allows total lifting of the soft tissues of the face (DMAS, deep musculo aponeurotic system). The lateral and vertical traction allows elevation of the superior two thirds of the face, eyebrows, and cheeks. Lifting pulls up from the forehead to the mandibular line. The fixation of the superficial layer of the temporal aponeurosis in traction to the upper part also has an effect on tissue elevation. The best candidates for this procedure are women in their late 30s or early 40s but can be used on those from 30 to 50 and more. It is highly specialized operation which requires substantial surgical experience both in selecting the patient and in execution.