察爾斯大夫 美麗殿堂 Dr. Charles Meridien Palace

Vertical Subperiosteal Mid-face-lift for Treatment of Malar Festoons（2）

Method

Indications

Video-assisted endoscopic Subperiosteal vertical upper-midface lift（SUM-lift）in conjunction with a Lower blepharoplasty and/or endoscopy-assisted Forehead plasty, if needed, is indicated in patients with moderate skin elasticity and festoons which cannot be treated by high SMAS rotation advancement surgery alone and in patients who already have undergone a traditional face-lift procedure. Patients who exhibit a vertical descent of the midface（malar flatness, festoons, malar bags）, including an oval configuration to the orbit, elongation of the lower eyelid skin, concomitant ptosis of the composite flap, including skin, muscle, and fat, prominent nasolabial fold, and early jowl formation, are ideal candidates for this procedure. Prior lower blepharoplasty patients who exhibit lid retraction and scleral show also may be improved by advancement of this upper-midface procedure [5–14].

Surgical Techniques

The procedures routinely have been performed under general anesthesia, with local anesthesia infiltration for homeostasis and perioperative intravenous antibiotics (Augmentin®, GlaxoSmithKline) for 48 h. No anticoagulation therapy was performed. Infiltration of the area was performed with a vasoconstricting solution consisting of 1 ml of 1:1000 epinephrine in 1000 ml of normal saline. Markings were performed preoperatively with the patient in a sitting position. If an upper blepharoplasty was needed, the eyebrow was held at the desired level. The redundant upper-eyelid skin was marked with the brow in an elevated position to avoid over resection. The center of the forehead at the region of the glabella was infiltrated, as were the corrugators and procerus muscles to obtain adequate vasoconstriction in the area to be dissected. The anterior temporal crest was infiltrated to produce hydrodissection and improve visualization. The infiltration continued laterally over the superior lateral orbital rim to the lateral canthus into the upper midface and the buccal sulcus.

For the forehead and upper-midface rejuvenation, six access incisions are used. The surgery is performed with a 4-mm, 30° down scope, with a protection sleeve and irrigation system to keep the field clean. The operation begins by elevating the forehead through two 2-cm sagittal incisions 1 cm behind the anterior scalp line and a standard subperiosteal forehead plasty is performed. The average lateral brow lift ranges between 4 and 6 mm as needed. For further correction of upper-eyelid pseudoptosis, loose skin of the upper lid in conjunction with a very small orbicularis oculi muscle fibers strip is resected. The protruding fat of the medial pocket is removed when needed.

Following the standard central forehead lift, the procedure proceeds to the lateral forehead and midface. The upper midface is elevated over the deep temporalis fascia (fascia temporalis profunda) in the scalp via a 3–4-cm transverse temporal incision 4 cm behind the anterior scalp in an open angle of about 120° toward the helical rim (Fig. 2). The incision is not parallel to the temporal hairline and is slightly perpendicular to the vector of repositioning. The lateral dissection extends over the deep temporalis fascia covering the temporalis muscle (sub-SMAS plane). This fascial layer is elevated with the forehead tissue by detaching it along the temporal crest by performing blunt dissection.

Fig. 2

Intraoperative view of a patient undergoing a vertical upper-midface lift (SUM-lift). The temporal incision is marked. The incision is curved slightly forward

Fig. 3

Intraoperative view of a patient undergoing a vertical upper-midface lift (SUM-lift). The endoscope is introduced under the temporal fascia into the upper midface. The scissor lies over the superficial temporal fascia and under the skin.

Next, from the temporal area over the deep temporalis fascia, the midface is approached sub-SMAS, dissecting subperiosteally inferior-lateral to the sentinel vein, between the sentinel vein and the zygomatic-temporal nerve (Fig. 3) (sensitive nerve), subperiosteally over the anterior surface of the

zygomatic arch (the facial nerve is on top of the elevator, over the fascia temporalis parietale), and entering the midface under the orbicularis oculi muscle. The dissection on the malar area is done subperiosteally under the orbicularis oculi muscle, leaving the septum orbitalis, infraorbital rim, suborbital oculi fat (pad), and zygomatic major muscle on top on the periosteal elevator.