gms | German Medical Science

Rhythidectomy techniques improved substantially the last 20 years [1], [2]. Until the early eighties subcutaneous facelift techniques prevailed. In 1974 Skoog introduced the deep plane suspension technique [3] which became well known as SMAS (superficial musculo-aponeurotic system) technique [4]. The advantage of the SMAS technique is that it can sustain much more pull than the skin. At the end of the eighties the interest shifted to the midface, especially the nasolabial fold. New techniques were developed, isolated or in conjunction with extended SMAS dissections and suspension of the solid tissue of the cheek in cranio-lateral direction. To flaten the nasolabial fold many different techniques were presented. The deep plane rhytidectomy [5], [6], [7], [8] and later the composite rhytidectomy with integration of the M. orbicularis oculi [9] became important and widely spread by the literature. Nevertheless the problem of the midface was not resolved completely.

In the early eighties the subperiosteal forheadlift was presented by Paul Tessier. It was refined and extended and evolved into the midface lift [10], [11], [12], [13] [14], [15], [16], [17], [18], [19].

Today it is called the subperiosteal facelift of the 4th generation [15], [16]. By integrating the subperiosteal midface lift into the concept of facelift surgery and adding an additional vector of transposition, the midface and especially the nasolabial fold can be treated successfully. For the first time not only the superficial layers are mobilised but the whole pack of soft tissue of the cheek is mobilised subperiosteally and transposed in a dorso-cranial direction. The vector of the transposition is perfectly opposed to the gravitational forces that are responsible for the sagging of the midface soft tissues in between the suspending ligaments (Figure 1 [Fig. 1] and Figure 2 [Fig. 2]).

Because of an unacceptably long recovey, these techniques have not been adopted as standard procedures. They were to be used only for special indications. With the developement of the video-assisted endoscopic forehead lift, shown for the first time in September 1992 in Washington by Louis Vasconez and his group [20], as well as with the inauguration of the fiber endoscopic Pan facelift presented by Hönig in Los Angeles 1994, the subperiosteal vertical fronto-temporal midface lift became well accepted worldwide as a minimal invasive technique. Resorbable polyactid plates (Endotine^®) helped for the break through of this technique. These video-asisted facelift techniques are now well established worldwide. Controversies exist as far as undermining and anchoring are concerned, important factors in getting long lasting results [21], [2].

The technique of minimal invasive surgery (MIS) is based on disconnecting the osseo-ligamenteous structures and large subperiosteal undermining of the zygomatic arc, the zygoma and the maxilla in order to be able to reposition the whole chunk of soft tissue of the midface, the orbicularis muscle included, in an upward vertical direction opposite to the physiological descent. This results in a flatening of the nasolabial fold and in an elevation of the corner of the mouth. In the frontal area the subperiosteal mobilisation under endoscopic vision results in an elevation of the periorbital soft tissues especially of the eyebrow. The dorsal pull of the M. occipitalis adds to a fresher and more youthful appearance.

A slightly curved, vertical incision of 5–6 cm is placed above the axis of the ear. It is within the hearbearing zone and reaches the deep temporal fascia. The dissection is performed along the deep temporal fascia all the way to the cranio temporal insertion to the tabula externa. The fascia is then detached from the tabula externa all around the superior and lateral orbital rim down to the zygomatic arch and into the midface. The supraorbital nerv and the sentinel vein are preserved. The subperiosteal dissection continues along the anterior two thirds of the zygoma down to the sulcus bucco-alveolaris. The centro-lateral soft tissues of the midface are transposed cranially with subcutaneos suspension sutures (Figure 3 [Fig. 3]). The temporo-parietal facia with the overlying tissues, SMAS included, is suspended as well according to the techniques of Besins [22] and Knize [21]. The fixation is performed through 2 drill holes [2], [19]. This results in an elevation of the infra- and supraorbital soft tissues as well as of the nasolabial fold (Figure 4 [Fig. 4]). Finally the M. orbicularis oculi is suspended according to Loeb, modified according to Hamra. The redundant soft tissues of the lower lid are resected very defensively to avoid scleral show. After closure of all wounds a dressing with light pressure is applied for several days.

With the new video assisted fiberoptic faelift pre- and post-auricular scars as well as bicoronal scars are avoided. There is no need to excise excessive skin. The recovey is much faster. Through two small temporal incisions in the hair bearing area the soft tissues of the midface are mobilised subperiosteally similar as in the open subperiosteal facelift. The soft tissues are repositioned, and secured with suspension sutures. A lower lid blepharoplasty is performed at the end. This technique guaranties a substantially shorter recovery time, less post-operative haematoma compaired to sub-SMAS and open subperiosteal procedures. Nevertheless the indication for this technique has its clear limitation.Good candidates are patients with elastic skin who do not need skin excision after soft tissue elevation (Figure 5 [Fig. 5], Figure 6 [Fig. 6], Figure 7 [Fig. 7]).

This technique should not be used as standard method alone when marked nasolabial folds, joules and a sagging platysma muscle are to be repaired. In these cases a combination with standard facelift techniques and skin resection is recommended.

The isolated video-endoscopic facelift (VEF) is only indicated in selcted cases when no platysma work and no skin resection is required. Finally this techniques requires some training and experience. There is a high learning curve if one wants to use this technique safely! With a good indication and correct application this technique is a safe alternative to classical facelift procedures. Excellent long lasting results can be achieved.

The authors declare that they have no competing interests.