The Transmalar Subperiosteal Midface Lift with Minimal Skin and Superficial musculoaponeurotic System Dissection: A Durable, Natural-Appearing Lift with Less Surgery and Recovery Time
Robert G. Aycock, M.D.
Greenbrae, CA
Over the past several years we have employed a procedure to elevate the mid-face using an approach developed and championed by E. Ronald Finger, MD in Savannah, Georgia. I had the pleasure of being business partners with Dr. Finger for several years while I was in practice in Savannah. I have kept in close contact with Dr. Finger since my move to California, and we frequently discuss our latest ideas in new ways to do the things that we enjoy most in plastic surgery. During one of my many trips to Savannah Dr. Finger was in the early stages of development of what would become the transmalar subperiosteal midface lift. After working with Dr. Finger on several of these procedures we began slowly integrating this procedure into our practice here in California. Since that time we have done many of these procedures and have been very happy with the results obtained with this addition to our face lift procedure. This procedure is often performed in conjunction with endoscopic brow lift procedures where we use three small incisions in the scalp instead of the old bicoronal incision from ear to ear across the top of the scalp.
The transmalar subperiosteal midface lift is a procedure that we use in conjunction with our standard deep plane face lift. The point of entry into the subperiosteal space is over the zygoma allowing for easy approach to the periosteum to which the muscles of facial expression are attached. This is also in the area of maximum tension on the facelift so that less effort is needed to get the same amount of lift. This dissection is made through a small opening in the obicularis muscle and periosteum. Using a periosteal elevator the periosteum is easily elevated over the zygoma and out onto the zygomatic arch for the mid-face dissection. Once this blind dissection is completed, the mid-face is elevated and held in place by fixation using a non-absorbable stitch from the periosteum to the temporal fascia. There are many reasons for our using this approach: limited chance of ectropion because we do not use a lower eye lid incision, more lift in the area of the mid-face without excess tension because of the close proximity of the stitch to the point of maximum tension, no stigmata of "tight face lift" with wind-blown look, easy approach without significant complication rate. In our procedure the skin and SMAS are elevated only minimally for exposure and we feel this actually improves the appearance of the patient while allowing for a quicker recovery. Our goal in this procedure is to provide a younger, more rested look while not leaving behind the tight, pulled, or stretched look. Through the skin incision the SMAS-platysma flap is elevated to tighten the neck by rotation of this flap up to the mastoid process. This is held into place with absorbable suture. With less dissected tissue (one plane instead of multiple planes of tissue) the recovery is quicker because there is less swelling in the post-operative phase. In the past many face lift techniques have been described. In recent years there has been an emphasis on the middle third of the face. In performing face lifts attention must be paid to the smallest of details since these can affect the final results. The original transmalar subperiosteal mid-face lift was designed 7 years ago to simplify the midface lift with a more direct approach. IN the past this procedure has been done through the lower eyelid incision, through the buccal sulcus incision and endoscopically. This more direct approach reduces the area of tissue dissected while yielding a natural-looking, safe, and equally permanent lift.1 This procedure provides a natural look with none of the telltale signs of facelift such as draping of the skin or that "wind blown look."
In this procedure the boundaries of dissection for the mid-facelift are the infraorbital rim lateral to the infraorbital foramen, around the infraorbital nerve to the nasal alar crease, then down over the lower part of the maxilla above the upper lip for approximately 1 cm. The lateral boundary is 1 to 2 cm over the masseteric fascia, and from there the direction is superiorly to about the middle of the aygomatic arch. The midface lift is performed first then the SMAS (superficial musculoaponeurotic system) and this sequence is much better than the other way around. There is significant movement with the mid-face lift requiring less elevation of the SMAS for the same amount of lift. There should be very little or no tension on the skin after the lift of the mid-face. This limited undermining of the skin and SMAS results in less swelling, bruising and quicker healing time. This is all done to improve the post-operative phase of the procedure and improve the final results while avoiding excessive undermining of the skin in the face. Tis dissection usually goes only out to the extent of the SMAS undermining. This limited undermining in the SMAS and skin has dramatically reduced the amount of post-operative swelling and bruising while providing a strong lift in the face and neck. More planes of tissue elevation cause more disruption of the arteries, veins and lymphatics in each plane while compromising the layers above as well. Therefore the more levels dissected the more compromise there is to these systems. If all three layers are dissected to the maximum levels, the post-operative phase is full of increased bleeding, swelling, and risk such as skin necrosis. The mid-face lift does not by itself increase swelling but increased levels of dissection will increase the morbidity of this procedure.
This procedure offers a simple and direct approach to improving our results in face lifts. We get permanent fixation of the zygomaticus muscles to the very strong temporalis fascia. Because of the avoidance of the lower lid in this approach there is less likelihood of ectropion and the lower lid can actually be enhanced by this procedure. This procedure requires less dissection than many described mid-face procedures, therefore the complication rate is less and results are better. The elevation of periosteum also elevates the zygornaticus major and minor, levator anguli oris, levator labii superioris and orbucularis oculi muscles. This gives a natural appearing result without the stigmata of the "wind-blown" or the tight face lift look. There is no excessive tightening of the SMAS or skin sutures to give draping or the lines from the lateral commisure of the mouth to the ear. The lower portion and the lateral portion of the periosteum are released to allow significant elevation over the maxilla. This extensive movement is demonstrated by the fact that even with extensive elevation of the SMAS no significant improvement can be achieved after the mid-face has been secured to the temporalis fascia. This procedure adds about 10 minutes of operative time to each side and a 7 year follow-up has demonstrated effectiveness and safety. Plastic surgery is constantly changing and we as plastic surgeons are constantly trying desperately to keep up with these changes. This was one change that we made that proved to be both a pleasure to perform while giving a significant improvement to our face lift procedures from the past.
1. Finger, E.R. Transmalar subperiosteal midface lift: Technical modifications new suggestions and limitations. Aesthetic Surg. J. 18:222, 1998.
Facelift Surgery Before and After Photos
Please feel free to contact us online at any time to discuss your facelift surgery options. Or, visit our plastic surgery offices located in Walnut Creek, California (CA) and Greenbrae, California (CA). Our offices are conveniently located near the San Francisco Bay Area region.
