Effects of Subperiosteal Midfacial Elevation via an Endoscopic Brow-Lift Incision on Lower Facial Rejuvenation
Rami K. Batniji, M.D.1 and Edwin F. Williams, III, M.D., F.A.C.S.1,2
Many techniques have been developed for rejuvenation of the midface. This article describes the technique of subperiosteal midface elevation via an endoscopic brow incision approach developed by the senior author and reviews the results of this technique, with specific emphasis upon the effect on lower facial rejuvenation.
KEYWORDS: Endoscopicmidface lift, midfacial rejuvenation, lower facial rejuvenation, jowl, jawline
One of the goals of surgery for the aging face is to achieve the youthful contour of the neck and jawline. Techniques aimed at lower facial rejuvenation have demonstrated success in achieving this goal. Hamra’s technique of the composite rhytidectomy not only addressed the lower face but also addressed the midface.1 Since then, many techniques for midfacial rejuvenation have been described in the literature.2–5 The midface has been approached via several incisions: a deep-plane rhytidectomy incision, a transblepharoplasty incision, and a temporal-brow incision. Since 1996, the senior author (EFW) has performed a subperiosteal elevation for rejuvenation of the midface via an endoscopic brow incision approach. A recent review not only demonstrated the safety and efficacy of this technique but also showed an added benefit of lower facial rejuvenation.6 Specifically, 57% of patients in the study had a subjective improvement along the jawline. The purpose of this article is to describe briefly the surgical technique of endoscopic subperiosteal elevation of the midface and report on the effect of this technique on lower facial rejuvenation.
The surgical technique of endoscopic subperiosteal midfacial elevation has been previously described; the following is a brief overview.7 To rejuvenate the upper
Figure 1 Illustration demonstrating the five standard endoscopic brow lift incisions: one midline, two paramedian, and two temporoparietal incisions. The midface is approached via the two temporoparietal incisions.
face and midface as one complex, a browlift is performed prior to the midface lift. To that end, five standard endoscopic brow lift incisions are utilized for access: one situated in the midline, two located in the paramedian position, and two incisions located more temporally (Fig. 1). Following endoscopic browlift via the midline and paramedian incisions, the midface is approached through the more lateral, temporoparietal incisions. Dissection is carried down through the temporoparietal fascia (TPF) to gain access to a plane of dissection between the TPF and temporalis fascia, thus protecting the frontal branch of the facial nerve (Fig. 2). Under direct visualization with the assistance of a headlight and Converse retractor, dissection is carried down to the orbital rim with a small, sharp periosteal elevator.
During the release of the arcus marginalis from the superolateral orbital rim with the periosteal elevator, the surgeon’s assistant places a finger along the lateral margin of the orbital rim to limit excessive release of periosteum from the lateral canthus, thus limiting lateral canthal elevation (Fig. 3).
Next, dissection is performed inferiorly toward the temporal fat pad to release the periosteal attachments overlying the zygomatic arch. The zygomaticus major and minor muscle attachments to the underlying malar bone are then released with the periosteal elevator (Fig. 4). The midface is then suspended with an expanded polytetrafluoroethylene (ePTFE, or Gore-Tex, W.L. Gore and Associates, Flagstaff, AZ) CV-3 suture passed through the temporalis fascia and through the malar fat pad (Fig. 5). The vector of suspension should be vertically oriented and the suture through the malar fat pad should be situated more laterally over the malar prominence, thus minimizing distortion of the lateral canthus. Then, two CV-3 sutures are passed through the TPF and temporalis fascia to pull the overlying brow and soft tissue superolaterally. The skin incisions are closed with surgical clips.
Figure 2 Intraoperative photograph of the temporoparietal incision demonstrating the appropriate plane of dissection between the temporoparietal fascia and temporalis fascia; this plane provides safe access to the midface by protecting the frontal branch of the facial nerve.
Figure 3 Intraoperative photograph of subperiosteal dissection with a periosteal elevator. The surgeon utilizes the “smart-hand” technique in which the arcus marginalis is released blindly with tactile feedback. Note that the assistant’s finger is placed at the lateral orbital rim to limit excessive release of periosteum from the lateral canthus, thus limiting lateral canthal elevation.
Rejuvenation of the midface via an endoscopic brow incision approach raised concerns regarding potential morbidity and the risk of lateral canthal distortion. A review of the senior author’s technique for midfacial rejuvenation demonstrated a less than 1% risk of facial nerve paresis, all of which resolved within 6 months.8 The proposed etiology of paresis is neuropraxia secondary to retraction with the Converse retractor. In addition, to minimize the morbidity of lateral canthal distortion, the technique has been modified to limit the release of the lateral canthal periosteum and limit medial dissection over the malar eminence. In doing so, the senior author has achieved a more natural elevation. Williams et al critically evaluated the senior author’s 5-year experience in subperiosteal midface elevation via an endoscopic brow incision to determine the efficacy of midfacial rejuvenation.
Figure 4 Illustrative drawing demonstrating the (A) approach to the midface with the periosteal elevator and (B) subsequent release of the zygomaticus muscle from the underlying malar bone.
Three independent facial plastic surgeons retrospectively assessed three facial zones: zones I (malar/infraorbital complex), II (nasolabial sulcus), and III (jawline) (Fig. 6). The zones were rated on a scale from 0 to 2 (0¼no improvement; 1¼mild improvement; 2¼marked improvement). The three independent evaluators correlated well in their scores (kappa¼0.643). The majority of patients had marked improvement in zone I (70% marked, 30% mild, 0% no improvement). Most individuals had mild improvement in zone III (30% marked, 50% mild, 20% no improvement). Of the patients with marked improvement in zone III, 81% underwent concurrent lower facelift surgery. Interestingly, 57% of patients who underwent endoscopic browlift and subperiosteal midfacial elevation without concurrent lower facelift surgery demonstrated mild to marked improvement in zone III (Fig. 7).
More recently, a prospective study was designed to evaluate objectively the effects of endoscopic subperiosteal midfacial elevation on the jowl. Twenty patients undergoing endoscopic subperiosteal midfacial elevation for rejuvenation of the midface were prospectively evaluated to quantify jowl elevation. Exclusion criteria included lower facial rejuvenation surgery (lower facelift surgery, neck liposuction, chin augmentation, submentoplasty).
Figure 6 Depiction of facial zones I (malar/infraorbital complex), II (nasolabial sulcus), and III (jawline).
A suture was placed in the center of the jowling and pre- and postoperative distances from the inferolateral mandibular border were obtained. The results demonstrated that, at 1 week following surgery, the mean elevation of the jowl was 7.0 mm. This objective data demonstrating jowl elevation corroborate the previously reported subjective improvement in the jawline.
The endoscopic subperiosteal midfacial elevation of the midface via an endoscopic brow incision approach is a safe, reliable method of midfacial rejuvenation. Further evaluation of this technique demonstrated the added benefit of lower facial rejuvenation as well; both subjective and objective jowl elevation has been appreciated following this technique. Although experience has demonstrated the benefits of this technique, the limitation of inadequate effacement of the nasolabial fold has been appreciated. Therefore, more recently, the senior author has performed facial contouring with lipostructure to supplement the endoscopic subperiosteal midfacial elevation of the midface for midfacial rejuvenation with promising results (Fig. 8).
Figure 7 (A) Preoperative photograph. (B) Postoperative photograph demonstrating marked improvement in zone III following endoscopic browlift and subperiosteal midfacial elevation without concurrent lower facelift surgery.
Figure 8 (A) Preoperative photograph. (B) Postoperative photograph following facial contouring with lipostructure to supplement the endoscopic subperiosteal midfacial elevation of the midface for midfacial rejuvenation.
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