Vertical preperiosteal rejuvenation of the frame of the eyelids and midface.

Aging usually shows first on the eyelids, the periocular frame, and the midface, which is the anterior mobile area of facial expression. The author, therefore, recommends performing a blepharoplasty and rhytidectomy of the upper two-thirds of the face in patients from their mid-30s on. Instead of a subcutaneous approach, correction can be performed at the deep level, with either a lateral or a vertical approach to the midface. The deep lateral approach to the midface was initiated by Skoog in 1974, the vertical subperiosteal approach by Tessier in 1979, and the vertical preperiosteal midface approach by Hinderer in 1985, followed by de la Plaza in 1988. The author's technique is analyzed according to the level of undermining, the transection of the retaining ligaments, the vector of tissue elevation, the stabilization of the superficial musculoaponeurotic system, and the safety of the procedure, mainly regarding the facial nerve. The related anatomy is described. The technique is reliable. No damage to the facial nerve occurred in a consecutive series of 535 patients who were operated on from 1983 through 1998; this was because the author respected the pathway of the nerve, which was determined using cadaver dissections when the technique was first developed. Long-term follow-up, some lasting 15 years, has shown that the results are long-lasting; this is because of the stabilization of the vertically elevated soft tissues, which is done by suturing the temporoparietalis fascia to the temporalis fascia and by using the author's orbicularis suspension technique. A short-scar variation instead of the coronal approach can also be used; the latter is indicated for patients with high foreheads or large forehead ptosis. The author prefers to use the preperiosteal approach, which elevates the soft tissues themselves, after transecting the retaining ligaments, rather than the vertical approach.