45
formed between 1992 and 2003. Though suspen- sion issues were not completely solved, this second surgical procedure gave us great satisfaction. We introduced an oblique tension vector with an oblique SMAS flap below the parotida. We suc- cessfully corrected heavy cheeks, nasogenial sulcus and repositioned the malar cheeks. The lower-eye- lid fat bags were treated with the traditional proce- dure.
Despite a satisfying outcome, we made a critical analysis of our experience and compared our re- sults with the beauty and youthfulness described in magazines. We noticed that the skeletonization of the orbital region and the periorbital senile shade remained. We understood that we had to im- prove the orientation of our vectors, in order to give a more appropriate answer to the senile pto- Today, when no periorbital skeletonization is ob- sis.
served, we still perform an isolated oblique SMAS flap.
3. In 2002, Besins introduced a new “package” with the suspension of the cheek and orbicularis oculi muscle and improved the fixation problems with a temporal hanging. It appeared as a turning point in facial rejuvenation and embellishment surgery:
the reverse and repositioning effect (RARE) proce- dure [2].
We have been using this vertical midface lift since 2003 and have observed dramatic improvements in our clinical results.
45.2
Anatomical Considerations
The jugomalar adipose tissues are divided into two planes by the orbicularis oculi and the zygomaticus major muscles. The superficial plane is represented by the superficial malar adipose tissue. It is limited me- dially by the nasolabial fold and laterally by the fixed point of the zygomatic arch [7]. The deep malar adi- pose tissue is the zygomatic extension of the buccal fat 45.1
Introduction
The new vertical description of the face’s topographi- cal anatomy, as opposed to the former horizontal one, explains the evolutional anatomy of the aging process [1–3].
The midface (“mesoface”) progressively slides downwards between two fixed points: the ear and the nose (Fig. 45.1). A progressive skeletonization of the orbital region appears. The sagging malar cheek loses its natural curve. The nasogenial sulcus becomes more marked, thus giving an aging aspect to the pa- tient. Later, the senile mesofacial flow spreads on the mandibular area, breaking the mandibular arch and leading to a heavy cheek, increased by the osteocuta- neaous fixed point of Furnas.
The understanding of this senile mesoface ptosis leads to the introduction of new rejuvenation vertical vectors, for a more appropriate midfacial reposition- ing. In our experience, we have evolved in three surgi- cal stages since 1989:
1. The subperiosteal mask lift was first described by Tessier [26–27] in 1988. He first introduced the idea of a total facial deep subperiosteal detachment associated with canthopexy and onlay bone grafts.
This principle was further developed by Krastino- va [14].
In 1989, our European group (Gaston Maillard, Bernard Cornette de Saint Cyr), together with the Israeli Michael Schefflan, and Oscar Ramirez si- multaneously published a series of numerous ex- tensive open subperiosteal face lifts with a strong deep suspension of the face: the deep musculo- aponeurotic system (DMAS) without canthoplasty.
Endoscopy later brought certain improvements in lessening the length of scars [10–12, 16, 21–24]. The procedure was efficient and its effect long-lasting, but the surgical repercussion was longer [4, 5, 17].
2. The oblique superficial musculo-aponeurotic sys- tem (SMAS) flap procedure described by Lelouarn and Cornette de Saint-Cyr [16], following Skoog and Hamra, was the main procedure that we per-
The Vertical Facelift
Bernard Cornette de Saint-Cyr, Claude Aharoni, Nicolas Mutaftschiev
muscles.
45.2.2 The Facial Nerve
In its intraparotidal segment, the facial nerve has five branches [10]. Dissections show a number nervous anastomosis creating a true supply plexus. Only the highest and lowest branches, temporal and mandibu- lar, are particularly vulnerable during facelift surgery [8]. The ramus temporalis has numerous terminal branches for the corrugator supercilii, the procerus and the frontalis. It flattens against the zygomatic arch between the upper continuation of the SMAS su- perficially, and the layers of Libersa and Laude (deep layer) below. This layer protects the nerve when the dissection stays in the temporal fascia plane and the zygomatic arch subperiosteal plane.
For Pitanguy [19], the landmark of the temporalis ramus follows a line going from a point situated 0.5 cm below the tragus to a point situated 1.5 cm above the lateral extremity of the eyebrow.
45.2.3
The Infraorbital Nerve
The distance between the infraorbital rim and the nerve is roughly 6–10 mm, centred on the medial line of the pupil. This nerve carries the sensibility of the lower eyelid, the ala nasi and the upper lip
45.3
Pre-operative Consultation
The first consultation appreciates the rejuvenation potential of the face and should propose a surgical strategy.
The face should be analysed as a whole. Volumes are observed and palpated; the overall facial fat melt-
case.
With a deep plane approach, smoking does not ap- pear as unfavourable.
45.4
Surgical Procedure
The midfacial facelift is a minimal scar procedure us- ing two short surgical approaches which leads to a correction of the periorbital skeletonization and the malar cheek ptosis.
The principles of the procedure are based on mid- facial area suspension (malar cheek and heavy cheeks), orbicular stretching and lower-eyelid skin excess re- section.
45.4.1
Preoperative Planning and Drawings
The “M” point (“M” for malar cheek) is located at the crossing point between a vertical line drawn across the lateral canthus and a horizontal line passing through the inferior border of the nostril (ala nasi) (Fig. 45.5). To understand the significance of the “M”
point, we should observe the facial modifications as- sociated with a forced smile. When smiling, the short- ening of the comical expression muscles between their attachment points projects all tissues in front of the malar bone. It produces a youthful unbroken roundness from the nasogenial sulcus to the zygo- matic arch and masks the orbital border. This posi- tion is associated with a natural shortening of the lower eyelid. The “M” point will be used to insert the percutaneous suspension of the malar cheek.
The subciliary approach is drawn as the classic
lower-eyelid approach with an external extension in
an oblique wrinkle at the outer corner of the eye. This
extension must not be longer than 1 cm for discretion
purposes. It will be used to resorb the lower-eyelid
skin excess after orbicular stretching and malar cheek
elevation. The deep approach can also be performed through the outer aspect of the upper-eyelid incision.
The temporal approach is performed through a 3 cm horizontal line drawn 3 cm behind the temporal hairline implantation (Fig. 45.1).
45.4.2
Orbitomalar and Zygomatic Subperiosteal Detachment The procedure begins with the subciliary approach.
The lower-eyelid skin is undermined to approximate- ly 1 cm to expose the orbicular muscle. On its lateral aspect, the orbicular muscle is opened to reach the or- bital rim.
The deep subperiosteal plane is reached and the arcus marginalis must always be respected. Tessier’s periosteal elevator is introduced deeply to detach the totality of the orbital rim, the orbitomalar and the zy- gomatic areas. Special care must be taken to respect the infraorbital nerve and the temporal ramus of the facial nerve on the midthird of the zygomatic arch.
The dissection reaches the nasal bone on the infraor- bital rim, under the medial canthus. The piriform fo- ramen and the vestibule are also dissected. The eleva- tor must be seen intraorally, through the vestibular mucosa. This mucosa should not be opened to avoid infectious risks. The zygomatic minor and the levator of the upper lip are detached from their upper inser- tions. The periosteum becomes very thin medially and the dissection must be carefully performed to avoid any muscle injuries, particularly the levator of the upper lip. All facial tissues are detached from the bone (Fig. 45.2).
45.4.3
Temporal Stage Detachment
We perform a deep temporal incision parallel to the hairline, as previously described, leading straight to the white temporal fascia (Fig. 45.3). Medially, the en- tire temporal crest is released and the frontal subperi- osteal dissection includes the upper orbital rim with a restriction area under the eyebrow medial third to prevent any supraorbital nerve injury. The whole pro- cedure is nonendoscopic, as described for the open mask lift procedure. The subgaleal posterior detach- ment must be extensive in order to absorb all the tis- sue excess resulting from the suspensions, without any intracapillary resection.
The lower dissection of the temporal area is more delicate and we advise, in order to avoid nerve inju- ries, reaching the lateral orbital rim first and follow- ing the temporal crest forward, always keeping a bony contact. Then, a posterior movement with the eleva- tor allows a safe deep temporal fascia detachment and facilitates its junction with the previously performed orbitomalar subperiosteal detachment (Fig. 45.4).
Fig. 45.1. Subciliary and temporal incisions
Fig. 45.2. Malar subperiosteal detachment through the lower- eyelid approach
45.4.4
Malar Cheek and Orbicular Suspensions
We first begin with the malar cheek suspension and we use a kind of Hagedorn needle specially described by Besins for this procedure. The “M” point (Fig. 45.5) is used to insert the percutaneous suspension of the malar cheek (Fig. 45.6). The needle is inserted straight into the bone pinching the ptotic malar fat pad toward the outer corner of the eye incision, where the 2 Vicryl or Dexon threads are introduced. A roundtrip move- ment allows a thick grip without any dimples. The thread is carried to the temporal incision under the temporal skin (Fig. 45.7).
The orbicular stretching is made with a 1 Vicryl thread, introduced into the lower malar orbicular muscle under the lateral canthus. A vertical test- ing tension on the thread must correct any scleral show without any lateral detachment of the lower- eyelid rim. A more superficial 3/0 Vicryl thread is sometimes passed on the orbicular muscle flap to secure the grip. The threads are carried under the temporal incision. We perform a double or triple sus- pension.
All threads are sutured to the temporal fascia with high tension (Fig. 45.8). Sometimes, threads can be fixed to the frontal bone using tunnels sunk through the external cortical bone or Endotine fixa- tion devices.
Fig. 45.3. The temporal incision
Fig. 45.5. The “M” point
Fig. 45.6. Malar cheek percutaneous suspension
45.4.5
Lower-Eyelid Skin Excess Resection
The skin excess is drawn on both sides. We cautiously remove around 50% of the amount of the apparent skin excess, to avoid ectropion complications. Closure is realized with 6/0 fast-resorption Vicryl.
45.4.6 Temporal Lift
In order to achieve the vertical translation of the me- soface, we perform a deep temporal lift to absorb all the tissue excess at the outer corner of the eye result- ing from the suspensions [13]. Three or four 2/0 PDS or Vicryl threads fasten the raised galea to the tempo- ral fascia. We do not make any intracapillary resec- tion. The resulting wave will disappear within a few weeks (Fig. 45.9). Skin closure is achieved with 4/0 fast-resorption Vicryl.
At the end of all these stages, the symmetry is veri- fied and an additional face filling using Coleman’s procedure can be realized in order to soften the slope and emphasize cheek volume.
Additional procedures may be performed, such as neck lifting, following Labbe’s procedure [15].
45.4.7 Neck Lift
The posterior bordure of the platysma muscle is fixed by a subcutaneous retroauricular approach to the fas- cia of Lore. After the suspension, the residual cervical detachment remains minor with a low risk of haema- toma.
The neck is repositioned following a horizontal vector, thus tightening the mandibular line. In short, we create a vertical vector on the face and a horizontal vector on the neck. Both sides are performed sym- metrically.
Fig. 45.8. Result after complete unilateral suspension. Note the lower-eyelid skin excess
Fig. 45.9. Early result. Provisional temporal wave Fig. 45.7. The thread is carried to the temporal incision under
the temporal skin
45.5 Results 45.5.1 Global Results
The mean age of the patients was 55 years old (31–88).
All patients underwent the same procedure (94 wom- en and six men) (Figs. 45.10–45.14). An associated necklift was performed in 55 patients. This procedure was the first facelift in 84 patients.
Patients were checked up the day after surgery, at 2 weeks to remove residual threads and at 3, 6 and 9 months. At 1 year, they were clinically evaluated.
Patients with unfavourable evolution were seen every week until total satisfaction was achieved.
The recovery period was evaluated by the patient between 3 and 4 weeks as being able to be socially re- introduced with a subnormal or normal appearance without sunglasses.
Fig. 45.10. A 40-year-old woman. Before (left) and 1 year postoperatively (right)
Fig. 45.11. A 52-year-old woman. Severe tear trough and malar bags corrected by a vertical midface lift
Fig. 45.12. A 54-year-old woman given back her own original beauty
Fig. 45.13. A 49-year-old woman. No preauricular scar. No one in her family circle noticed the facelift . She was congratulated for her freshness
45.5.2 Complications 45.5.2.1 Haematoma
The deep subperiosteal plane is an exsanguine plane and drains have never been used. Haematomas do not seem to be a common complication of this facelift procedure.
45.5.2.2 Infection
One case of infection has been observed, concerning the temporal incision with a favourable evolution. Its low incidence is explained by the fact that we avoided the intraoral approach and by the short duration of the procedure (less than 1 h).
45.5.2.3 Skin Necrosis
Skin necrosis does not appear to be a complication of this facelift procedure. Deep facelifts, by sparing the blood supply of most anatomical planes, allow the perfectly safe creation of an extensive skin flap. It is very interesting in smokers.
45.5.2.4 Eyelid Eversion
Eyelid eversion occurred in seven cases. The incidence fell from 12% in the first 50 cases to 2% in the follow- ing 50 cases (and to zero in the next 50), thus showing the importance of the learning curve at the onset of this complication [6]. The eyelid eversion always ap- pears early, within 3 weeks (seven cases). Two kinds of eyelid eversion are commonly described: ectropial evolution by excess skin excision and ectropial evolu- tion by orbital septum retraction with a worse prog- nosis. In the first 50 cases, four patients underwent an upper-eyelid or retroauricular total skin graft and two patients underwent a Khunt–Szymanowsky pro- cedure [25]. In all these patients, the previous history found a lower-eyelid surgery which appears as a risk factor and leads to caution for lower-eyelid skin exci- sion (in these cases, we now approach through an outer upper-eyelid incision).
The lower-eyelid skin graft is well hidden by the make-up and rapidly well integrated within 3 months (Fig. 45.15). We improved our results by introducing a third thread to secure the orbicular grip and by re- secting less skin despite the residual excess. Today, we do not resect more than half of the apparent skin ex- cess. Another very important point is to always re- spect the arcus marginalis during the dissection to avoid any orbital septum retraction [1].Now we ap- proach though the upper eyelid and lift the cheeks with endotine midface without opening the lower- eyelid muscle or the lower-eyelid skin unless at the end we need a small eyelid skin excision respecting the muscle – zero eversion.
A 52-year-old woman. Heavy cheeks and hollow eyes preoperatively (left). Postoperative result (right)
45.5.2.5 Nerve Injuries
Neurapraxy of the V Nerve
Neurapraxy of the V nerve is frequently observed in our patients (25%), giving a dysesthesia of the upper lip for 2–6 weeks. The difference between the two groups (the first 50 cases and the following 50 cases) is not significant, showing that despite all the atten- tion paid, it did not depend on the training. The nerve sideration is the result of the tissue distension all around the infraorbital foramen during the subperi- osteal dissection. Evolution is always favourable with- in 4 weeks.
Neurapraxy of the VII Nerve
The temporal ramus was injured in one case of unwise temporal fascia dissection. The evolution was spontaneously favourable within 3 months. During this period, the controlateral symmetry was obtained with botulism toxin. As previously mentioned, we stress the fact that in order to avoid any nerve injuries, the lateral orbital rim should be reached first and the temporal crest should be followed forward with a constant bony contact. Then, a posterior movement with the rasp allows a safe deep fascia detachment.
45.5.2.6 Muscle Injuries
Muscle injuries occurred in three cases in the first 50 cases. The injured muscle was the levator of the ala nasi and labii superioris. This can be explained by the fact that the periosteum becomes very thin medially, leading to planes error and muscle injuries.
Dissection must be carefully performed in this area.
The evolution is spontaneously favourable within 4 weeks.
45.6 Discussion
We present a new facelift philosophy with a rejuvena- tion effect and no altering of the patient’s identity. Pa- tients rediscover themselves as they were many years before.
The advantages are numerous. We do not perform any canthoplasty and the eye expression is always re- spected. The correction of the orbital fat hernia by the orbicular stretching avoids a senile enophtalmia (fatty hernia) evolution. We obtain a simple volumetric ef- fect on the malar cheek and Coleman lipostructure is not always required. The correction of the wrinkles at the outer corners of the eyes is obtained with an intra- capillary temporal lift during the temporal stage. We do not perform any preauricular incision on rather young patients with minimal heavy cheek, when an associated lower facelift is needed.
The main drawback of this procedure is the risk of ectropial evolution of the lower eyelid. We have intro- duced new devices to eliminate this complication.
The two others drawbacks are the surgical repercus- sion, which is longer than for a simple blepharoplasty, and the necessary surgical experience in the subperi- osteal facelift [4]. No definitive neurological compli- cations have been observed (infraorbital nerve, facial temporal ramus). The indications are the skeletoniza- tion of the orbital region and the malar cheek ptosis.
Fig. 45.15. Right lower-eyelid early eversion. Skin graft day 1.
Results at day 45
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