Subperiosteal minimally invasive laser endoscopic rhytidectomy: The SMILE facelift

Aesth. Plast. Surg. 20:463~470, 1996

Aes.Lthettc l-'lastlc Si]rgery © 1996 Springer-Verlag New York Inc.

Subperiosteal Minimally Invasive Laser Endoscopic Rhytidectomy: The SMILE Facelift Oscar M. Ramirez, M.D., F.A.C.S. and Jason N. Pozner, M.D. Lutherville, Maryland, U.S.A.

Abstract. Current concepts of total facial rejuvenation involve a comprehensive integrated approach to achieve a balanced youthful appearance. Recently introduced endoscopic-assisted techniques allow us to rejuvenate the face through small, remote incisions. Previously, we have considered only young patients with good skin turgor as candidates for minimally invasive procedures, but the advent of the resurfacing laser has allowed us to expand our indications for single stage minimal access rejuvenation. Full facial immediate laser resurfacing at the time of standard rhytidectomy has been avoided due to risk of flap necrosis. Subperiosteal minimally invasive endoscopic assisted techniques do not substantially interfere with facial blood supply. We can now perform endoscopic-assisted full facelifts combined with immediate laser resurfacing to reposition the tissues in a more youthful position and then tighten the skin envelope. Extended endoscopic-assisted subperiosteal forehead lift is performed through three to five scalp incisions; subperiosteal midface lift is performed through a crow's foot or intraoral incision. Cervicoplasty, if needed, is performed through a small submental incision. Full face laser resurfacing is done using a Coherent Ultrapulse laser. To date we have performed eleven subperiosteal minimally invasive laser endoscopic (SMILE) rhytidectomies. There has been no evidence of flap necrosis with this technique. Postoperative recovery has been no different from patients treated only by full face resurfacing, except perhaps for the slight increase in early facial edema. We believe the SMILE facelift is a viable alternative to standard techniques. The limitations of this procedure still need to be elucidated.

Key words: Endoscopic forehead lift lift Full face laser resurfacing

Subperiosteal midface-

Correspondence to Oscar M. Ramirez, M.D., Plastic and Aesthetic Surgical Center, 1212 York Road, Suite B101, Lutherville, MD 21093, U.S.A.

Current concepts of total facial rejuvenation involve a comprehensive integrated approach to achieve a balanced youthful appearance. Recently introduced endoscopic-assisted techniques allow us to rejuvenate the face through small, remote incisions [3-9]. Minimal scar techniques can reposition the tissues in a more anatomically pleasing position, but solar-damaged inelastic skin will often not redrape to the contours of youth. Carbon dioxide lasers have been available for quite some time, but only recently has Ultrapulse technology been available to resurface solar-damaged skin. The short-term benefits of laser resurfacing are quite obvious: elimination of old epidermis with regrowth of uniform fresh epidermis [12]. The longer-term effects are a rearrangement of collagen from a swirled solar-damaged configuration to a more compact configuration [12]. The benefit of this is increased elasticity and tightening of the skin, hence a more youthful appearance. Surgeons have been fearful to combine laser resurfacing or chemical peels with traditional subcutaneous or SMAS rhytidectomy due to the marginal flap vascularity and the risk of flap necrosis. Thirty-five percent trichloroacetic acid (TCA) peels have been described as safe with deep plane techniques, although the use of stronger peels has been discouraged because of flap risk [2]. Subperiosteal dissection, especially through minimal access incisions, allows a rich flap blood supply [10] without risk of necrosis when combined with laser resurfacing. We have postulated that anatomically correct, youthful repositioning of the tissues through minimal access endoscopic assistance with adjunctive full facial laser resurfacing is a virtually scar-free rejuvenative procedure in selected patients. We believe the subperiosteal minimally invasive laser endoscopic (SMILE) rhytidectomy is aptly named because the repositioning of the lip elevators corrects the oral frowning of age to achieve a gentle youthful smile in repose. We report our early experience with this technique.

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SMILE Facelift

Fig. 1. This drawing summarizes the deep plane subperiosteal dissection and the fixation of the endoforehead, endomidface and the optional cervical suspension. The endoforehead is routinely approached through four ports. The frontal scalp is stabilized with percutaneous removable screw posts and skin staples. The temporal scalp is suspended with 3-0 PDS sutures

anchoring the superficial temporal fascia (STF) to the deep temporal fascia (DTF). The midface is suspended with 3-0 PDS sutures anchoring the periosteum to the arcus marginalis, the Bichat's fat pad to the lateral arcus marginalis and the SOOF (suborbicularis oculi fat) to the DTF.

Materials

Operative Technique

We have performed 11 SMILE rhytidectomies to date. An additional 3 patients had extended endoforehead lifts and full face laser resurfacing and 52 patients underwent regional laser resurfacing during biplanar facelifts. SMILE patients ranged from 39 to 58 years of age. All SMILE patients underwent endoscopic forehead and facelift and full facial laser resurfacing. Four of eleven patients had an anterior approach cervicoplasty and a modified suture suspension. One patient had submental liposuction. Two patients underwent placement of Medpor (Porex, Atlanta, GA, U.S.A.) malar implantsl One patient underwent endoscopic excision of lower eyelid fat and adjunctive fat grafting to her lips at the time of rhytidectomy. Standard endoscopic plastic surgical instrumentation was used including a 4 m m 30 degree endoscope, light source, and monitors. Ramirez model periosteal elevators and manipulators (Snowden-Pencer, Atlanta, GA, U.S.A.) specifically designed for endoscopic forehead and midface lifts were used. Laser resurfacing was performed using the Coherent (Palo Alto, CA, U.S.A.) U1trapulse 5000C CO 2 laser.

All parts of this procedure have been previously individually described [3-9], but will be briefly discussed here. The operative steps outlined are to be used as a guide and do not take the place of formal endoscopic courses with cadaver dissections and videotape review. Prior to the procedure the patient is marked in a sitting position. General anesthesia is induced and the forehead and midface are infiltrated with 1/4% lidocaine with 1:200,000 epinephrine. Three to five incisions are made in the scalp, two temporal, one central and/or two paramedian (Fig 1). The temporal area is dissected under endoscopic guidance at the level of the temporalis facsia proper (TFP). The temporal line of fusion is freed and dissection continues to the lateral orbital rim. Large veins are preserved when possible, or electrocoagulated, and the temporal area is packed with epinephrine-soaked (1:50,000 solution) pledgets. The upper forehead and scalp to the vertex are dissected at the subperiosteal plane. The superior orbital rim is carefully dissected under endoscopic control. The periosteal release and spreading is accomplished as previously described [5]. The supraorbital and supratroch-

O.M. Ramirez and J.N. Pozner

lear nerves are exposed. The corrugator and procerus muscles are removed using specific biters and spreaders. The gateway to the zygomatic arch is begun by dissecting on top of the intermediate temporal fascia (ITF) using endoscopic control. The gateway is limited to the anterior third of the zygomatic arch to decrease the likelihood of injury to branches of the frontal branch of the facial nerve which can occasionally be seen superficial to the dissection plane. The midface is then dissected under endoscopic guidance via a 1.5 cm crow's foot incision. A suborbicularis skin and muscle flap is elevated to the inferior orbital rim. A 0.5-1 cm cuff of periosteum is left on the inferior orbital rim. This assures the integrity of the arcus marginalis which will be used for suspension. A subperiosteal dissection is performed to the masseter tendon laterally and the piriform aperture medially. The masseter tendon is stripped of its overlying fascia. The infraorbital nerve is clearly identified in this dissection and preserved. The origin of the zygomaticus major and minor and the lip elevators are elevated during the subperiosteal dissection and will be subsequently repositioned in a more cephalic direction. The periosteum is incised at the most caudad portion of the dissection and the Bichat's fat pad is identified medial to the masseter tendon. Adequate periosteal spreading with a #10 dissector (SnowdenPencer, Inc., Atlanta, GA, U.S.A.) is necessary to achieve midface elevation. Dissection proceeds along the anterior third of the zygomatic arch. The gateway is completed ensuring continuity with the temporal dissection. This allows adequate elevation of the midface structures into the temporal area and prevents bunching. The malar bones are assessed for projection, symmetry, and shape. In patients with flat malar bones who agree to bony augmentation a malar implant is placed subperiosteally at this time and held in place by the suspension sutures. A soft plastic sleeve is used for introduction of porous implant material such as Medpor (Porex, Atlanta, GA, U.S.A.). The midface is suspended with three sutures of 3-0 PDS (polydioxanone sutures). All suspension sutures are placed and clamped prior to final fixation. The inferior border of the midface periosteum is sutured to the arcus marginalis. Bichat's fat pad extension is weaved and sutured to the inferolateral orbital rim. The suborbicularis oculi fat pad (SOOF) is fixated to the deep temporal fascia just lateral to the lateral orbital rim (Fig. 1). Excess skin may be excised without undermining from the lower eyelid (two patients) or tightened only with the aid of the laser. Three patients underwent a modified midface lift via intraoral incisions with lower periosteal fixation to the temporalis fascia proper (TFP) in the forehead. Forehead fixation is then performed by first elevating the lateral brow by suturing the superficial temporal fascia (STF) to the TFP with two sutures of 3-0 PDS. The medial brow is elevated via temporary outer cortex screws placed in the paramedian incisions and held by sttrgical staples. A drain is placed prior to fixation (Fig. 1).

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Cervicoplasty, if needed, is approached via a submental incision [3]. A subcutaneous flap of 3-5 mm is dissected. The preplatysmal fat is excised using the Colorado tip cantery under endoscopic guidance. Subplatysreal fat is excised in a similar manner. The platysma is plicated in the midline with 3-0 Tevdek (Deknatel, Snowden Pencer, Atlanta, GA, U.S.A.) interrupted sutures with posterior fixation to the hyoid bone. Platysmal bands below the hyoid are incised. A modified suture suspension is placed if needed. Following closure of all wounds and redraping with wet towels, the laser resurfacing is begun. The endotracheal tube is protected with crumpled aluminum foil. A Coherent Ultrapulse 5000C laser is used to resurface the face. Three of eleven patients were resurfaced using the 3 mm collimated handpiece at 500 mj, 12 watts with 2 to 3 passes around the perioral area and 1 to 2 passes over the rest of the face. Eight patients were resurfaced with the aid of the Coherent computer pattern generator at 300 mj, 60 watts, density 5 with 2 to 3 passes everywhere except the periocular area where 1 to 2 passes were used. Flexzan (Dow Hickam Pharmaceutical, Inc., Sugar Land, TX, U.S.A.) is applied and the face is taped on top of the Flexzan to provide additional support in some areas. A contouring dressing is used around the neck. Results

All patients had excellent flap vascularity following laser resurfacing. There were no areas of marginal vascularity at any time during or following the procedure. Followup ranged from 1 to 8 months. The postoperative courses were uneventful except in one patient who developed a herpes simplex infection in her early postoperative period. She had no history of cold sores and did not receive prophylactic antiviral medication. Based on this case and the recent evidence of others, we now prescribe antiviral medication to all patients regardless of history [1]. Case Reports

Case 1 is a 47-year-old female who is status post upper and lower blepharoplasty. We performed an endoscopic forehead lift with five ports, endoscopic midface lift through a crow's foot incision cervical liposuction and full facial laser resuffacing (Fig. 2). Case 2 is a 48-year-old female status post dermabrasion and mini-facelift. We performed endoscopic forehead lift via three ports, endoscopic midface lift through intraoral incision and full facial laser resurfacing (Fig. 3). Case 3 is a 39-year-old female noted to have acne scarring and asymmetric malar area. She underwent endoscopic forehead lift via three ports and endoscopic midface lift through a crow's foot incision with insertion of Porex 5-ram right-, 3-ram left cheek implants and full facial laser resurfacing (Fig. 4). Discussion

SMILE rhytidectomy allows us a significant stride toward the day when a truly scarless facial rejuvenation is

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SMILE Facelift

Fig. 2. Case 1 is a 47-year-old female. (A) Postop one week after the SMILE rhytidectomy. Observe the position of the elevated soft tissues and the fresh scab from the laser and (B) the extent of the laser resurfacing which should go slightly below the mandibular line. (C) Preop frontal view showing a generalized laxity of the central oval of the face with infraorbital hollow, laxity of the cheek, and sun-damaged skin. (D) Postop frontal view at 2 months. Observe the reshaping of the brow, the gentle elevation of the soft tissues on the cheek and the more natural tightness of her soft tissues. Also observe the improvement of the texture of her skin. possible. The endoscopic-assisted subperiosteal portion allows anatomic repositioning to the more youthful location. The laser allows skin tightening and redraping. The goals of forehead rejuvenation are to correct eyebrow ptosis, eliminate forehead lines, and to resect the overactive corrugator and procerus muscles [7,9]. Our preference is to perform the endoscopic forehead lift via a subperiosteal dissection. The advantages to this approach, namely an excellent light reflex, a relatively bloodless field, similar planes in the forehead and midface, and excellent flap vascularity, have been discussed elsewhere [6,9]. The vascular supply to the forehead is via the supratrochlear, supraorbital, and superficial temporal vessels [11] which provide a rich vascular network and are all preserved during the subperiosteal dissection [10]; the dermal network is not disturbed during this

dissection. Laser resurfacing is safe as long as there is not excessive tension on the forehead. The skin tension at which the laser is no longer considered safe has not been evaluated. The central oval of the face is an area that has previously been neglected but has now been generating a great deal of interest. Changes associated with midface aging have recently been described in a comprehensive fashion by Yousif [13]. He describes a deepening of the nasolabial fold (NLF) with a lateral, inferior, and anterior projection of the midmalar tissues with age. The lateral oral commissure descends, perhaps by an attenuation of lip elevators or changes associated with bone aging, and consequently, so does the vector of these muscles. The subperiosteal approach allows separation of the mimetic muscles at their origin and reorientation in a more ce-

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Fig. 2. (continued) (E) Preop closeup view. Observe the forehead wrinkles, oblique glabellar creases, ptosis of the brow, periorbital wrinkles, and infraorbital hollow. (F) Postop closeup view. Observe the elimination of the forehead wrinkles, glabellar creases, the reshaping of the brow, improvement of the periocular wrinkles, and infraorbital hollow. (G) Preop lateral view. Observe the ptosis of the medial brow, infraorbital hollow, ptosis of the cheek, and perioral soft tissues. (It) Postop lateral view. Observe the overall rejuvenation of the upper, middle, and lower face. Note the absence of periauricular scars. (I) Preop three-quarters view. Observe the generalized laxity and tired look of this patient's face. (J) Postop three-quarters view. Observe the overall gentle rejuvenation of the face without the stigmata of a surgical procedure. phalic direction [7]. The result is correction of the frowning appearance of the aging face with creation of a smile at repose. Thus this procedure, SMILE, is aptly named. The nasolabial fold is corrected through a number of maneuvers. The tethering effect of the zygomaticus major on the nasolabiat fold is released. The overlying soft tissue is released by a wide subperiosteal dissection. Incisions in the pefiosteum medial and parallel to the NFL and along the inferior malar border allow tension free vertical reposifioning; this corrects one vector of aging. The cheek tissue becomes more anterior with age [13]. Vertical and slightly lateral reofientation changes the position of the cheek mound and visually flattens the hills and smooths out the valley of the nasolabial crease creating a more homogeneous and aesthetically pleasing aspect. Actinic damage to the fold from solar radiation

causes changes that cannot be corrected by tissue maneuvering. The laser allows correction of the milder forms of dermal damage and stimulates collagen which may contribute to nasolabial fold improvement. For very deep creases, adjunctive techniques such as fat grafting are needed and can be done at the same operative session. The blood supply to the midface is not disturbed by subperiosteal dissection [10]. The avoidance of pre- or postauricular incisions aids flap hardiness. Laser resurfacing of subcutaneously dissected skin is thought to be hazardous to blood supply. Our experimental data has shown the insult to be incurred by laser-resurfaced subcutaneously dissected facelift flaps (unpublished data). Subperiosteal midface dissection allows adjunctive laser resurfacing without risk of flap necrosis. The laser ap-

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SMILE Facelift

Fig. 3. Case 2. (A) Preop frontal view. Observe the ptosis of the brow, the mild excess of upper eyelid skin, periorbital rhytides, infraorbital circles, laxity of the cheeks, and the perioral structures. Observe the severe damage of the skin secondary to acne scarring and discoloration of the face secondary to a previous dermabrasion. (B) Postop frontal view. Observe the overall gentle rejuvenation of the face with brow reshaping, tacking of the periocular skin, improvement of the infraorbital circles, increase of the volume of the cheeks and gentle elevation of the perioral soft tissues. (C) Preop lateral view. Observe the brow ptosis, lower eyelid rhytides, sagging of the cheek and perioral

structures. Also observe the redundant submental skin. (D)Postop lateral view. Observe the brow reshaping, the elevation and increase of the volume of the cheek, the improvement of the laxity in the perioral structures, and improvement of the neck and submental area. (E) Preop three-quarters view. Observe the early aging of the face with generalized mild laxity of the central oval of the face. (F) Postop three-quarters view. Observe the gentle rejuvenation with reshaping of the brow, improvement of the infraorbital circles, increased volume of the cheeks, mild elevation of the corner of the mouth, and gentle decrease of the jowls.

pears to tighten the skin and obviate the need for excision of excess preauricular and infraorbital skin created by the vertical midface lift. Our clinical impression is that the skin tightening continues to improve for many months

following this procedure. The combination of midface repositioning and laser resurfacing can rejuvenate the midface in a manner not previously possible by pure endoscopic techniques.

O.M. Ramirez and J.N. Pozner

Fig. 4. Case 3 is a 39-year-old female presenting the typical early signs of aging. (A) Preop frontal view shows forehead creases, ptosis of the brow, periocular rhytides, infraorbital circles, mild laxity of the cheeks and perioral soft tissues. Note the flattened, asymmetric malar bones. (B) Postop 3 month frontal view. Observe the absence of wrinkles in the forehead, the reshaping of the brow. The upper eyelid had better definition without the need for an upper blepharoplasty. The lower eyelid rhytides as well as the infraorbital circles, are improved. The volume of the cheek mound has been increased with the addition of Medpor malar implants (5 mm right, 3 mm left) and the perioral soft tissues tightened a bit. In general, the patient looks younger with a natural look without the stigmata of facelifting. Increase in the lip volume is related to fat grafting. (C) Preop lateral view. Observe the brow ptosis, excess upper eyelid skin, rhytides on the lower eyelid, infraorbital circles, nasolabial fold, and ptosis of the cheeks. (D) Postop lateral view.

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Observe the reshaping of the brow, better definition of the supratarsal sulcus, tightening of the lower eyelid skin, improvement of the infraorbital circles, increased volume of the cheek, and gentle elevation of the modiolus. The patient did not have a change in the slant of the eyelid. The apparent orientalization is due to the opening of the soft tissues on the lateral eyelid raphe. The most important feature is the absence of typical rhytidectomy scars. (E) Preop three-quarters view. Observe the forehead wrinkles, the oblique glabellar creases, ptosis of the brow, excess upper eyelid skin, periocular rhytides, laxity of the cheeks, and perioral structures. (F) Postop three-quarters view. Observe the improvement of the rhytides of the forehead and glabellar areas, the brow reshaping, improvement of the periocular rhytides, and the infraorbital circles. Also observe the increased volume of the cheek and the gentle elevation of the modiolus.

470 Conclusion

This procedure is primarily directed at younger persons in their late thirties to early fifties with minimally redundant tissue seeking facial rejuvenation. The indications may be expanded as our familiarity and experience with the laser grows. The indications, patient selection, and a comparative study of the SMILE facelift versus the endoscopic assisted biplanar facelift are being assessed currently. In summary, we have shown the feasibility of performing an endoscopic full facelift in the subperiosteal plane followed by laser resurfacing. We feel this procedure is safe and can produce excellent results in well chosen patients. Long term results still need to be assessed. References

1. Adrian R: Lasers: operative techniques, histology, preoppostop care. Presented at the Endoscopic Facial Aesthetic Surgery & CO 2 Laser Skin Resurfacing Workshop. Baltimore, Maryland, November 1995 2. Dingman DL, Hartog J, Siemionov M: Simultaneous deepplane face lift and trichloroacetic acid peel. Plast Reconst Surg 93:86, 1994

SMILE Facelift

3. Ramirez OM: Cervicoplasty non-excisional anterior approach. Plast Reconst Surg (in press) 4. Ramirez OM: Endoscopic facial rejuvenation. Perspect Plast Surg 9:22, 1995 5. Ramirez OM: Endoscopic forehead and face-lift: step by step. Operative Tech Plast Surg 2:129, 1995 6. Ramirez OM: Endoscopic full facelift. Aesth Plast Surg 18:363, 1994 7. Ramirez OM: Endoscopic subperiosteal browlift and facelift. Clin Plast Surg 22:639, 1995 8. Ramirez OM: The subperiosteal approach for the correction of the deep nasolabial fold and the central third of the face. Clin Plast Surg 22:341, 1995 9. Ramirez OM: Endofacelift: Subperiosteal Approach. In Ramirez OM, Daniel RK, (ed): Endoscopic Plastic Surgery. New York: Springer-Verlag, 1996 10. Schuster RH, Gamble WB, Hamra ST, Manson PN: A comparison of flap vascular anatomy in three rhytidectomy techniques. Plast Reconst Surg 95:683, 1995 11. Whetzel TP, Mathes SJ: Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconst Surg 89:591, 1992 12. Yang CC, Chai CY: Animal study of skin resurfacing using the Ultrapulse carbon dioxide laser. Ann Plast Surg 35:154, 1995 13. Yousif NJ: Changes of the midface with age. Clin Plast Surg 22:213, 1995