Subperiosteal Rhytidectomy Provides Superior Correction of Midfacial Aging

I completely agree with using a more superficial technique for the neck and lower portions of the face. I will often undermine all the way around, defat, and perform superficial musculoaponeurotic system work in the lower portions of the face. But when it comes to correcting midfacial aging, primarily nasolabial fold problems, inferior locations of the nasal jugal line, concavity in the lower lid, and laxity in the lateral canthal area, I perform the subperiosteal dissection. My approach can be performed either through a subciliary lower lid incision or through a gingival buccal incision. Subperiosteal dissection is then carried out over the maxilla, malar zygomatic, and lateral orbital rim area; the arch itself is dissected subperiosteally in an anterior-to-posterior direction. Through the temporal incision, the plane of dissection is superficial to the deep temporal fascia. This is carried inferiorly to the sentinel vein. The posterior one third of the arch is then identified. The periosteum is incised, and subperiosteal dissection proceeds in a posterior to anterior fashion completing the subperiosteal tunnel. With a Cottle elevator (Padgett Instruments, Inc., Kansas City, MO) in this tunnel, a gentle sweeping movement in an upward direction transects the fusion of fascia above the arch completing the dissection.