Subperiosteal midface lift: why are surgeons still doing this?

When performed in experienced hands, the subperiosteal midface lift is the only procedure that safely restores the mid face in a “natural” manner.  Newer technology (endotine and goretex loops) allow a less invasive endoscopic procedure that avoids areas that can cause nerve injury ( the lateral third of the zygoma). With these limited endoscopic procedures, swelling is comparable to fat injections, which can cause more bruising, absorb irregularly, and cause lumps.   There is certainly a place for implants and injections, but the subperiosteal midface lift produces a natural result that removes years in an in apparent natural fashion.

Thanks for the question. As you say, it is a risky process, but the risk is reduced by the measures taken and the long year experience. For this reason, surgeons continue to perform this operation. I wish you all the best.

You ask a question that many of us ask.  However, although I cannot speak to the preferences of an individual Surgeon, I can speak to the logic of facial rejuvenation. A subperiosteal approach is a trauma approach, utilized by most of us in training for mid-facial trauma, etc.  Since the midfacial periosteum (lining of the bone) does not stretch or descend with aging, rather wide undermining is required to lift the midface.  Since the midface can be elevated using high SMAS techniques, I do not see the need to extend dissection beyond what can be readily accomplished with less swelling and less risk. Since one of the objectives of facelift is elevation of deeper tissues to accommodate removal of skin laxity, a subperiosteal approach would have to be combined with a SMAS approach to allow for this step. Lastly, the chances of looking unnatural with a subperiosteal approach are increased.

I think the first question one has to ask is why the subperiosteal midface lift has been recommended for them.  When the procedure is performed correctly the aesthetic result is very striking and does not cause a distorted look once swelling has resolved.  The most common complication is prolonged edema but I have not experienced any of the other issues you have mentioned.  Having said that, I have found that a deep plane face lift with midface suspension is also extremely effective.  I love fat injections to the midface as well, however, midface elevation is still superior to fat injections alone.  

A subperiosteal plane is very difficult to suspend.  The swelling is generally extensive and long lasting.  This has not proven to be a widely practiced technique for these and other reasons.

Subperiosteal lifts obtain a longer lasting result than skin only or SMAS lifts.  However, they can look unnatural and take months to recover from.  

In my opinion and experience, no of my colleagues in my immediate area are performing subperiosteal midface lifts.  Some surgeons believe that a better lift of the cheek if the approach is subperiosteal and anatomically that makes sense.  In today's environment, patients desire less invasive procedures with quicker recoveries thus are opting for fillers such as fat, Voluma®, Scuptra®, etc.  

This is an interesting question, and reflects the fact that there are a considerable variety of approaches to facelift procedures.  At many of the plastic surgery meetings, skilled surgeons continue to debate the pros and cons of the approaches, and many surgeons "swear" by their preferred technique with almost religious fervor!  Facelift procedures may be done as deeply as the subperiosteal level (which is just above the facial bones) or as superficially as just under the skin.  And some surgeons prefer to simply add volume (ex. fat) only, without a direct pull on the tissues.  Suffice it to say, plastic surgeons base their preferences on multiple factors, including their own results, the factors they believe are contributing to aging, safety with regard to nerves, the length and location of incisions, recovery after surgery, and other considerations.  I do not personally offer the subperiosteal lift in the midface; instead, I use an approach that treats the other layers, and is customized for each person's situation.
Saul R. Berger, MD

Dear Ballet8988, This is an excellent question because addressing the midface is one of the most difficult regions of the face. I perform subperiosteal midface lifts with endotines. I typically perform this procedure in conjunction with facelifts and other facial rejuvenation procedures. I very rarely perform alone. Nerve damage is something that can happen with any procedure. The midface is more technique sensitive  to access but when performed by an experienced surgeon the risk of nerve injury is no more that of a facelift. With any procedure there are pros and cons. The significant midface lift that can be attained through subepriosteal lift is undeniable. There is definitely more swelling to the face when this procedure is performed. The hourglass look is not something I have observed, but as with any aesthetic facial surgery procedure, then artistic eye and taste of the surgeon must guide the results of the case. The other ways to address the midface are through fillers, fat injections, cheek implants, and SOOF lifts. All have their pros and cons. A full discussion with your surgeon is important 

 Hi, you are correct.  That type of lift is a very aggressive and invasive facelift that I never really was able to embrace for numerous reasons.  In today's society, who has the time to recover for a year from a facelift?   I have performed many SMAS facelifts for over 30 years and have performed many minimally, invasive SMAS facelifts.  If "jowls” are present in the lower face, they represent sagging facial tissues that remain the primary  indication for some form of a SMAS facelift.  The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last).  The excess skin is then removed and the facelift incisions closed.
 My most popular SMAS facelift is the minimally invasive, short incision SMAS facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:
very small incisions and no incisions extend or are placed within the hair.
minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
can be performed in 90 minutes or less, with or without general anesthesia
no incisions within the hair = no hair loss
excess fat can be removed from the face and neck
excess skin removed from the face and neck
cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
most patients fly back home to parts all over the world in as little as 3 days post-op
 In addition, I combine facial shaping with every facelift procedure.  When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face. Following my beauty principles, women look the most feminine, youthful and attractive with heart shaped faces.  Heart shaped faces have cheeks that are full and round in the front.  If the cheeks are flat or concave in the front, cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.
 If the chin is weak, this creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin.  Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face.   I have found placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.
Hope this helps.