9
404 A ESTHETIC S URGERY J OURNAL ~ J ULY /A UGUST 2006 S CIENTIFIC F ORUM Background: A paradigm promoted for midface rejuvenation by Besins in his reverse and repositioning effect (RARE) tech- nique considers 3 vertical sectors of the face. It relies on thread-based suspensions of the malar area and the orbicularis oculi with long cable suture forehead anchoring. Objective: The author reports on the use of short cable suture anchorage points as an alternative suspension method that helps to avoid and/or correct asymmetry and ectropion. Methods: An oblique malar elevation with short cable suture transorbital anchoring, in conjunction with a Hester-Flowers orbicularis oculi transzygoma anchoring technique, was performed using a new technique for fascia roll, multi-loop temporal anchoring and auricular tightening. Results: A series of 295 patients have undergone the procedure since Spring 2002, with follow-up of up to 31 months. A strong oblique malar elevation, focused on nasolabial fold correction, eyebrow elevation, and better jaw definition, along with a natural appearance of the face were found to be stable over time. Conclusions: Transorbital anchoring allows strong malar elevation and lower lid support for rejuvenation and correction of complications. It should be combined with a Hester-Flowers orbicularis oculi transzygoma anchoring technique and can be performed in conjunction with a fascia roll, multi-loop temporal lift, submental fat and partial submaxillary gland removal, and auricular tightening as part of a full face lift procedure. (Aesthetic Surg J 2006;26:404–412.) Trans-Inferior Orbital Rim Anchorage and Fascia Roll Multi-Loop Temporal Anchorage in Midface Rejuvenation Pierjean Albrecht, MD, PhD Dr. Albrecht is in private practice in Marbella, Spain. A new paradigm was recently suggested for perfor- mance of the full face lift. Besins 1 put forward the 3-sector concept of the aging face, which he called the reverse and repositioning effect (RARE) technique. It is based on anatomic considerations, mainly involving the Furnas 2 ligaments, and also embryological considerations, based on the pro-face, meso-face, and meta-face embry- ological layers. Briefly, Sector 1, the pro-face in embryolo- gy, consists of the nose, medial lip, chin, and medial forehead, considered as fixed and held tightly in place by prominent bones and strong, short muscles. Sector 2, the meso-face, is the “aging face,” consisting of the adipose and muscular area of the face, from the temporal area (with most of the eyebrow) to the mandible. Sector 3, the meta-face, consists of the Furnas ligaments and fibrotic superficial musculoaponeurotic system (SMAS), from the preauricular area to the sternocleidomastoid muscle. The “centrofacial” or midface lift, previously described by Hester et al 3,4 and Ramirez, 5 is the basis of this new paradigm. The technique consists of a wide subperiosteal malar dissection through a precanthal incision, malar suspension through long cable suture temporal anchoring, and orbicularis oculi suspension through long cable suture forehead anchoring. It is associated with a temporal lift, an Endotine-assisted (Coapt Systems, Palo Alto, CA) forehead lift, a lower neck and jawline lift, and respect for the Furnas liga- ments. Besins, 1 like Hamra, 6 believes that the malar portion of the orbicularis oculi is the key to full-face rejuvenation because of its tight continuity/imbrication with the malar fat. This technique requires performance of a strong malar elevation and has a steep learning curve, especially with respect to achieving proper symmetry of both lateral can- thi and avoiding further scleral show or ectropion in asso- ciation with excess skin in the orbicular area. My two first patients reported discomfort caused by malar and orbicularis anchoring with long cable sutures, and tempo- ral and forehead anchoring with thick nonabsorbable threads (2/0 Gore-Tex; W. L. Gore & Associates, Newark, DE), which required their removal. I also had to touch up 4 cases of ectropion and 3 asymmetrical results, which caused me to rethink the anchor point strategy. Like Hester, 7 I prefer short cable suture anchorage points in any subperiosteal thread-based suspension tech- nique because of the realities of postoperative

Trans-inferior orbital rim anchorage and fascia roll multi-loop temporal anchorage in midface rejuvenation

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Page 1: Trans-inferior orbital rim anchorage and fascia roll multi-loop temporal anchorage in midface rejuvenation

404 A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 2 0 0 6

S C I E N T I F I C F O R U M

Background: A paradigm promoted for midface rejuvenation by Besins in his reverse and repositioning effect (RARE) tech-

nique considers 3 vertical sectors of the face. It relies on thread-based suspensions of the malar area and the orbicularis oculi

with long cable suture forehead anchoring.

Objective: The author reports on the use of short cable suture anchorage points as an alternative suspension method that

helps to avoid and/or correct asymmetry and ectropion.

Methods: An oblique malar elevation with short cable suture transorbital anchoring, in conjunction with a Hester-Flowers

orbicularis oculi transzygoma anchoring technique, was performed using a new technique for fascia roll, multi-loop temporal

anchoring and auricular tightening.

Results: A series of 295 patients have undergone the procedure since Spring 2002, with follow-up of up to 31 months. A

strong oblique malar elevation, focused on nasolabial fold correction, eyebrow elevation, and better jaw definition, along with

a natural appearance of the face were found to be stable over time.

Conclusions: Transorbital anchoring allows strong malar elevation and lower lid support for rejuvenation and correction of

complications. It should be combined with a Hester-Flowers orbicularis oculi transzygoma anchoring technique and can be

performed in conjunction with a fascia roll, multi-loop temporal lift, submental fat and partial submaxillary gland removal,

and auricular tightening as part of a full face lift procedure. (Aesthetic Surg J 2006;26:404–412.)

Trans-Inferior Orbital Rim Anchorage andFascia Roll Multi-Loop Temporal

Anchorage in Midface RejuvenationPierjean Albrecht, MD, PhD

Dr. Albrecht is in private practice in Marbella, Spain.

Anew paradigm was recently suggested for perfor-mance of the full face lift. Besins1 put forward the3-sector concept of the aging face, which he called

the reverse and repositioning effect (RARE) technique. Itis based on anatomic considerations, mainly involving theFurnas2 ligaments, and also embryological considerations,based on the pro-face, meso-face, and meta-face embry-ological layers. Briefly, Sector 1, the pro-face in embryolo-gy, consists of the nose, medial lip, chin, and medialforehead, considered as fixed and held tightly in place byprominent bones and strong, short muscles. Sector 2, themeso-face, is the “aging face,” consisting of the adiposeand muscular area of the face, from the temporal area(with most of the eyebrow) to the mandible. Sector 3, themeta-face, consists of the Furnas ligaments and fibroticsuperficial musculoaponeurotic system (SMAS), from thepreauricular area to the sternocleidomastoid muscle.

The “centrofacial” or midface lift, previouslydescribed by Hester et al3,4 and Ramirez,5 is the basisof this new paradigm. The technique consists of a widesubperiosteal malar dissection through a precanthalincision, malar suspension through long cable suturetemporal anchoring, and orbicularis oculi suspension

through long cable suture forehead anchoring. It isassociated with a temporal lift, an Endotine-assisted(Coapt Systems, Palo Alto, CA) forehead lift, a lowerneck and jawline lift, and respect for the Furnas liga-ments. Besins,1 like Hamra,6 believes that the malarportion of the orbicularis oculi is the key to full-facerejuvenation because of its tight continuity/imbricationwith the malar fat.

This technique requires performance of a strong malarelevation and has a steep learning curve, especially withrespect to achieving proper symmetry of both lateral can-thi and avoiding further scleral show or ectropion in asso-ciation with excess skin in the orbicular area. My twofirst patients reported discomfort caused by malar andorbicularis anchoring with long cable sutures, and tempo-ral and forehead anchoring with thick nonabsorbablethreads (2/0 Gore-Tex; W. L. Gore & Associates,Newark, DE), which required their removal. I also had totouch up 4 cases of ectropion and 3 asymmetrical results,which caused me to rethink the anchor point strategy.

Like Hester,7 I prefer short cable suture anchoragepoints in any subperiosteal thread-based suspension tech-nique because of the realities of postoperative

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A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 2 0 0 6 405Trans-Inferior Orbital Rim Anchorage and FasciaRoll Multi-Loop Temporal Anchorage in MidfaceRejuvenation

S C I E N T I F I C F O R U M

periosteal/bone healing time,8 since experience showsthat the dissected and elevated areas take 30 days to healproperly and readhere to bone. Therefore, any move-ment of the dissected tissues should be prevented toguarantee good long-term results. For that purpose, Ihave developed the trans-inferior orbital rim anchoragepoint technique for malar suspension, combined with theHester7-Flowers9 transzygoma ascending branch anchor-age point technique. During the last 3 years, I have per-

formed 295 face lifts using this technique with satisfacto-ry outcomes, as summarized below.

Trans-Inferior Orbital Rim Anchorage Technique

Preoperative marking and drawing

Preoperative marking (Figure 1) for malar suspensionwas done with the patient standing, and focused onLittle’s10 safe point (Figure 2, point A), also described inthe RARE technique, down from the lateral canthuswhen the line crosses the nose alar groove lower level.There is only a limited opportunity, at that point, forascension of the vertical/oblique vector, and the orbicu-laris oculi is only able to elevate the upper part of thecheek, without correcting the nasolabial fold. It was pos-sible to evaluate its actual elevation potential by askingthe patient to open her mouth widely. Two other suspen-sion points were added along a 45-degree line drawnfrom the safe point to slightly above the infraorbitalnerve hole (Figure 2, points B and C, and Figure 3).

Anesthesia

Local anesthetic and sedation were administered,starting with concentrated Klein mix infiltration andwaiting the appropriate time for maximum adrenalinevasoconstriction effect.

Figure 1. Preoperative markings in a 62-year-old woman who was acandidate for a temporal lift with malar suspension and blepharoplasty.Notice the 3 suspension points from the Little safe point to the infraor-bital nerve, orbicularis oculi suspension point, and lower lid incisionline.

Figure 2. Malar elevation suspension (A,B,C) and anchoring points(a,b,c). Orbicularis oculi suspension (D,E) and anchoring points (d,e).Infraorbital nerve warning point.

Figure 3. Orbital rim anchoring points for malar soft tissues (blue) canbe more or less external depending on suspension vectors. Hester-Flowers ascending zygoma branch anchoring points (green) for orbicu-laris oculi suspension if canthopexy is performed.

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Operating technique

The classical subciliary incision was modified at its lat-eral third to achieve a 120-degree angle with the pretarsalincision. Dissection of the lower lid skin/muscle flap wasperformed toward the arcus marginalis, which wasreleased.11 Wide subperiosteal undermining under directvision (Figure 4) was then performed with a curved (orangled Rugine-type) raspatory around the infraorbitalnerve and along the zygomatic arch. After that, theperiosteum was softly transected at its lower end. A 14-gneedle was then passed through the soft tissue at the first(A) marked suspension point (Little) down to the bone toguide the needle of a 2/0 Vicryl (Johnson & Johnson,Somerville, NJ) used to lift that point towards the firstorbital rim (a) hole for anchorage. The same maneuverwas repeated for 2 other suspension and anchoragepoints (B lifted to b, C lifted to c) (Figures 2 and 5). Awide portion of the malar end of the orbicularis oculi wasthen dissected to allow performance of a Hester-Flowerssuspension (Figure 2, points D and E) and anchoring tothe zygomatic ascending branch (Figure 2, holes d and e).

Associated fascia roll multi-loop anchorage in tempo-ral lift (Figures 6 and 7)

In most cases, the malar suspension had to be per-formed in conjunction with a temporal lift to readjust orredrape skin excess caused by the deep tissue malar ele-vation, and a gentle forehead lift to accommodate for theexcess canthal skin caused by the orbicularis oculi eleva-tion. Although these maneuvers were described by Besinsin his RARE technique, I believe the temporal muscle

anchorage in his approach remains too weak to guaran-tee long-lasting results, due to the cheese-cutting effect ofthe threads. I have developed a new and stronger fixationtechnique to prevent any potential “delaceration” of theskin when fixed to the temporal muscle.

Figure 4. Subperiosteal malar undermining with suborbital nerve exposure.

Figure 5. A-C, The 3 drilling points exposed.

A

B

C

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This new technique, based on the use of 3 to 4 loopsof thread (Figure 6, L1, L2, L3) and a tied temporal fas-cia roll (Figure 6, R), affords extra strong fixation of notonly the temporal skin’s oblique lift (Figure 6, A, vectorsV2 and V3), but also a preauricular vertical vector lift(V1), that will lift the posterior third of the mandiblearea (Figure 7).

Results

I have performed 295 malar suspension procedureswith the orbital rim anchorage points technique sinceSpring 2002. It has proven to be a strong and safe wayto elevate the malar area and a very efficient way toreconstruct moderate to severe lower eyelid surgery com-plications such as ectropion (Figures 8-11). In mostcases, the procedure was combined with a temporal lift,submental fat removal, and auricular tightening. Onlysevere jaw and neck corrections had to be addressedthrough an additional lower face lift.

Associated auricular tightening

In young patients who did not need a lower face lift, afew preauricular folds might persist after a vertical vec-tor temporal lift. The auricular tightening consisted ofanchoring the concha to the mastoid periosteum posteri-

orly with nonabsorbable monofilament threads. Thisheld the ear tightly 0.5 cm back from and 0.5 cm higherthan its previous position and made the preauricularfolds disappear completely. In older patients who need alower face lift, this procedure prevented further rotationof the ears that would have reduced the “mouth commis-sure-to-ear-lobe” distance (Figure 12).

Associated lower face lift

While I did perform a lower face lift in patients withsevere facial aging, I believe this more extensive surgerycan be delayed in many cases as a result of the verticalvector lift achieved by the temporal lift combined withsubmental fat removal. Before performing the malar lift,it was useful to separate the submental skin from its fatand remove the subplatysmal fat, achieving perfect def-inition of the jaw line along two thirds of the mandible.DePina’s12 procedure for removal of the upper third ofthe submaxillary gland was often a useful complement.

Discussion

The following points are based on 3 years’ experiencein performing this technique. The malar area barelymoves vertically when the mouth is open wide. It movesfollowing a vector perpendicular to the nasolabial fold

Figure 6. A, Fascia roll (R) multi-loops (L1, L2, L3) temporal anchoring, and elevation vectors (V1, V2, V3). The loops are made of 3 passes of slow-absorption 2/0 Vicryl. The fascia roll is made of a 4 � 4-cm fascia flap tightened with slow-absorption 2/0 Vicryl. The elevation is achieved through 3passes of the same Vicryl to lift the loops to the roll. B, See the fixation loops (L1, L2, L3), the elevation loops (eL), and the elevation vectors (V1, V2,V3). The L1, L2, and L3 fixation loops are exposed, and elevation loops are being made. See fascia roll and temporalis muscle fibers.

A B

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Figure 7. A, Dissection of temporalis fascia flap. B, Temporalis fascia flap exposed before rolling it. C, First pass with slow 2.0 Vicryl to achieve a 3-loop fixation system. D, The 3-loop fixation system will allow 3 traction vectors when joined to the anchorage roll. E, Preparation of the fascia roll andmulti-loop anchorage system before elevation. F, When all the elevation loops are mounted on a mosquito holder, they can be tightened and the skinelevated toward the fascia roll. G, One or 2 Gillies hooks can help elevate the soft tissue to prevent excess tension on the fixation loops (L1, L2, L3).

A B

C D E

F G

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A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 2 0 0 6 409Trans-Inferior Orbital Rim Anchorage and FasciaRoll Multi-Loop Temporal Anchorage in MidfaceRejuvenation

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Figure 8. A, Preoperative view of a 48-year-old patient. B, Postoperative view 6 months after upper and midface lift with extra strong traction andfixation system, transorbital malar fixation, and upper and lower blepharoplastics.

Figure 9. A, Preoperative view of a 52-year-old patient. Lower face lift and lip augmentation using an unknown product were performed by anothersurgeon. B, Postoperative view 1 month after upper face lift with extra strong traction and fixation system, and upper and lower blepharoplastics.

A B

A B

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Figure 10. A, Preoperative view of a 39-year-old patient. B, Postoperative view 6 months after upper face lift with extra strong traction and fixationsystem, fat transfer in the periorbital and temporal areas, and upper and lower blepharoplastics.

Figure 11. A, Preoperative vew of a 45-year-old patient. B, Postoperative view 6 months after upper face lift with extra strong traction and fixationsystem, fat transfer in the periorbital and temporal areas, and upper and lower blepharoplastics.

A

A B

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only. Therefore the best vector for lifting the malar areais not vertical, but exactly perpendicular to the nasolabi-al fold. This vector lift is not achieved when temporalanchoring is used and is the reason why nasolabial foldsare not properly corrected. The RARE technique, like allmalar elevations, relies primarily on proper suspensionof the orbicularis oculi due to its elasticity and its tightconnections to the malar fat. Consequently, the vectorcan and must be vertical or very slightly oblique to avoiddiastasis.

Most thread-based suspensions with long cable sutureanchorage will descend. The forces applied on the softtissues by the thread when the patient moves, especiallywhen opening the mouth and sleeping on one’s side, willsimply cut them or at least squash them. These suspen-sions also allow the soft tissues to move during thepatient’s mimetic activity and sleep in the lateral positionduring the postoperative period, and therefore preventgood scar tissue from building up as the periosteumreadheres to the bone, which takes a minimum of 30days. One can partly compensate for such movementduring the early postoperative phase through use of suffi-ciently tight dressings and bandages while waiting forscar tissue to build up. Nevertheless, even if a patientwears a tight bandage for 30 days without opening themouth wide or smiling to allow strong scar tissue to affixthe lifted structures in their higher position, it can be pre-

dicted that the structures will eventually settle back intheir original position to allow proper facial dynamics.

In my view, it is necessary to consider the “dynamicface” in addition to the anatomic and embryologic reali-ties before performing any face lift in order to developthe optimal surgical plan and avoid errors. This has ledme to consider the following:1. Most preoperative markings are made with the

patient in a vertical position, whereas the proceduresare performed with the patient in a horizontal posi-tion.

2. Preoperative and postoperative photographs areobviously static and are usually taken with themouth closed. They do not give any idea of facialdynamics, such as smiling, turning the head fromright to left, or moving the chin up and down.

3. The skin characteristics of older patients undergoingface lifts are more characteristic of a rope than arubber band. In other words, if one would cut a thinvertical or horizontal strip of the skin and pull bothends, in younger patients the strip would be relative-ly elastic, whereas in older patients it would not.Therefore, the final results of a face lift procedurecannot be better than those seen when we lift theskin while the patient opens the mouth widely (forthe malar lift), or lifts the chin up, or turns the headto right and left (for the neck lift).

Figure 12. A, Patient at 20 years old. B, Patient at 59 years after full rhytidectomy performed by another surgeon and soft-tissue granulomas causedby the use of an unknown permanent filler (cheeks, orbits, jaw line). C, Postoperative view 12 months after global revision, endoscopic granulomaremoval, transorbital anchorage, blepharoplasty, and temporal lift. Note repositioning of the ear.

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4. Using Mirror software (Canfield Clinical Systems,Fairfield, NJ), I have measured the before-and-afterdistances from the mouth commissure to the earlobe and to the lower edge of the tragus in mostavailable publications about face lifts. These dis-tances have been reduced from up to 5 mm for thetragus to up to 1.5 cm for the ear lobe in 74% ofcases. This effect should be prevented.

5. As described by Furnas,2 the concha can be consid-ered as a “fixed point” compared to the surround-ing soft tissues. Nevertheless, I have observed aslight clockwise rotation of the left ear and counter-clockwise rotation of the right ear in many cases. Ihave improved the naturalness of the face lift resultssimply by anchoring the concha as far back as pos-sible prior to preauricular skin resection and stitch-ing. In many cases in young patients, this simplemaneuver will be sufficient to tighten the skin of thejaw and eliminate the preauricular folds if it is com-bined with a temporal lift with vertical vector asdescribed previously.

6. In many cases, jaw-line definition is contingent onremoval of submental and jaw fat, together with aportion of the submaxillary gland, as described byDePina.12

Conclusion

Generally speaking, the face lift is a static procedurethat works against facial dynamics. Sagging midfaceskin is more likely caused by loss of skin elasticity andfacial mimetics than by gravity. Overtightening alwaysleads to a static, less expressive face, while humanmimetic tendencies naturally lead to eventual looseningof the skin. Consequently, if we want our patients topreserve optimal facial expression after undergoing aface lift, we must not excise more skin than is requiredfor the patients to perform the natural movements pre-viously described. ■

References1. Besins T. The R.A.R.E technique (reverse and repositioning effect):

the renaissance of the aging face and neck. Aesthetic Plast Surg2004;28:127-142.

2. Furnas D. The retaining ligament of the cheek. Plast Reconstr Surg1989;83:11-16.

3. Hester TR, Codner MA, McCord CD. Subperiosteal malar cheek liftwith lower blepharoplasty. In: McCord CD, Codner MA, editors. EyelidSurgery: Principles and Techniques. Philadelphia: Lippincott-Raven;1995.

4. Hester TR, Codner MA, McCord CD. The “Centro facial” approach forcorrection of facial aging using the transblepharoplasty subperiosteal

cheek lift. Aesthetic Surg Q 1996;16:51-58.

5. Ramirez OM. Fourth-generation subperiosteal approach to the mid-face: the tridimensional functional check lift. Aesthetic Surg J1998;18:133-135.

6. Hamra ST. Composite Rhytidectomy. St Louis: QMP Inc; 1993.

7. Hester TR. The trans-blepharoplasty approach to lower lid and midfa-cial rejuvenation revisited: the role and technique of canthoplasty.Aesthetic Surg J 1998;18:372-376.

8. Boutros S, Bernard RW, Addona T, Stokes B, McCarthy JG. The tem-poral sequence of periosteal attachment after elevation. PlastReconstr Surg 2003;111;1942-1947.

9. Flowers R. Malar rejuvenation. Aesthetic Surg J 2001;21;153-154.

10. Little JW. Three dimensional rejuvenation of the midface: volumetricresculpture by malar imbrication. Plast Reconstr Surg 2000;105:267-285.

11. Hamra ST. Arcus marginalis release and orbital fat preservation inmidface rejuvenation. Plast Reconstr Surg 1995;96:354-362.

12. DePina DP, Quinta WC. Aesthetic resection of the submandibularsalivary gland. Plast Reconstr Surg 1991;88:779-787.

Accepted for publication March 14, 2006.

Reprint requests: Pierjean Albrecht, MD, PhD, C/Los Gladiolos, NuevaAndalucia, Marbella 29660, Spain.

Copyright © 2006 by The American Society for Aesthetic Plastic Surgery,Inc.

1090-820X/$32.00

doi:10.1016/j.asj.2006.06.005

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