Quantitative evaluation of jowl position following endoscopic subperiosteal midfacial elevation
Edwin F. Williams, M.D., F.A.C.S.*
Williams Center for Facial Plastic Surgery
New England Laser and Cosmetic Surgery Center
1072 Troy Schenectady Rd.
Latham, NY 12110
Edward D. Buckingham, M.D.
Buckingham Center for Facial Plastic Surgery, Austin, TX
* corresponding author
(Word Count 1,607)_
Objectives: To objectively confirm and quantify jowl elevation following endoscopic subperiosteal midfacial surgery without concurrent lower facial rejuvenation surgery.
Methods: Twenty consecutive patients undergoing endoscopic subperiosteal midfacial elevation for rejuvenation of the brow and periorbital region without concurrent lower face rhytidectomy in a private practice out-patient setting were prospectively evaluated to quantify jowl elevation. Preoperatively, in the sitting position the patient was positioned in Frankfurt horizontal. The inferior lateral border of the mandible was then visualized, palpated, and marked. The center of the jowling was then identified and marked. The distance from this point to the previously marked mandibular border at 90 degrees from Frankfurt horizontal was then measured in millimeters using a caliper and recorded. Patients then underwent endoscopic subperiosteal midfacial elevation. At one week post-op the lateral border of the mandible, a fixed point, was again marked. The distance from jowl center marked pre-operatively to the mandibular border was again measured. The difference between preoperative and postoperative distance from the jowl center to the inferior mandible was then calculated and the results from the two sides combined to give a total of 40 measurements.
Results: The difference in preoperative and postoperative position of the jowl ranged from 0.0 cm to 12.5 cm. The mean change in position was 7.0 mm of elevation. Statistical evaluation proved significance. (p<.001)
Conclusions: Subperiosteal midfacial elevation which was designed to rejuvenate the periorbital and malar regions also elevates the jowl region an average of 7.0 mm. This elevation is in a vertical vector countering directly the gravitational descent. This procedure can be safely and effectively be used alone or simultaneously with a lower face-lift for additive surgical rejuvenation of the jowl and jaw-line.
Midfacial lift, upper face lift, subperiosteal facelift, endoscopic browlift
Surgeons for many years have recognized the youthful contour of the neck and jawline. Additionally, forehead rejuvenation has been well described and undertaken for many years through trichial, coronal, and more recently endoscopic techniques. These surgeries addressed the upper and lower facial regions, but left the middle third of the aging face essentially untouched. In the last decade, several authors have recognized and brought needed attention to surgery to address the middle third of the face. (1-4) The major areas most commonly addressed by this midfacial surgery are the periorbital, malar, and nasolabial. Many authors have described different surgical approaches and dissection planes to address the midface all concerning primarily these regions. (5-20) More recently however attention has also been given to the additional benefit offered from midfacial elevation toward rejuvenation of the jowl and jawline region as well. (5)
The author currently utilizes a subperiosteal endoscopic browlift approach to surgically elevate and re-suspend the entire midface. In a recent review of 325 patients, followed for 6 to 50 months this approach showed subjectively that 57% of patients had mild to marked improvement in the jowl region. (5) This study was the first to indicate that this approach, while designed to rejuvenate the periorbital and malar area, also had a beneficial effect on the jowl area; a region traditionally treated with lower facelift surgery. The purpose of this study is to objectively confirm that this approach elevates the tissue of the jowl and to quantify the movement.
From July 2002 to May 2003 twenty consecutive patients undergoing endoscopic subperiosteal midfacial elevation by the senior author (EFW) for rejuvenation of the brow and periorbital region were prospectively evaluated to quantify jowl elevation. All patients undergoing any lower facial surgery including neck liposuction, chin augmentation, submentoplasty, or lower facelift surgery were excluded. Verbal and written consent to participate in the study was obtained from all patients preoperatively. In the pre-operative area while in the sitting position the patient’s head was placed in Frankfurt horizontal. The inferior lateral border of the mandible was visualized and palpated. Taking care not to manipulate the skin envelope position over the bone, the inferior border of the mandible was marked adjacent to the area of maximal mandibular jowling. The center of the jowling was then identified and a single fine point marked. The distance from this point to the previously marked mandibular border at 90 degrees from Frankfurt horizontal was then measured in millimeters using a calibrated caliper and recorded as either a positive distance if the point was above the mandibular border or a negative distance if the point was below the border. Patients then underwent endoscopic subperiosteal midfacial elevation. While under anesthesia a 6-0 silk suture was placed through the registered mark on the jowl to preserve identification for the post-operative period. (Figure 1)
An endoscopic subperiosteal brow elevation was first preformed using bone tunnel and permanent suture fixation. Through the existing temporal incision the dissection was carried inferiorly on top of the deep temporal fascia until the bone of the zygoma and temporal process of the zygoma was encountered. At this point the subperiosteal plane was entered and dissection was carried inferiorly over the face of the zygoma, maxilla, and anterior border of the masseter muscle. The zygomatic major muscle was completely released and used as a landmark for suspension. A Gortex ™ stitch was then placed from the periosteum, malar fat pad, and zygomatic muscle to the deep temporal fascia and the midface elevated and suspended. (Figure 2) Two additional Gortex sutures were placed from the deep temporal fascia on the posterior aspect of the temporal incision to the temporal parietal fascia on the undersurface of the anterior skin flap. All incisions are then closed.
At one week post-op the inferior lateral border of the mandible, a fixed point, was again identified and marked with the patient in Frankfurt horizontal. Taking care not to disturb the natural position of the soft tissue envelope over the bone the distance from the silk stitch placed intra-operatively to the mandibular border was again measured with the same caliper and recorded. The difference between preoperative and postoperative distance from the jowl center to the inferior mandible was then calculated and the results from the two sides combined to give a total of 40 measurements. Statistical analysis with paired student’s T-test was performed.
The twenty consecutive patients consisted of nineteen females and one male. The ages ranged from forty-two to fifty-eight years with the oldest patient being the sole male in the study group. All patients underwent a subperiosteal endoscopic brow and midfacial elevation without concurrent lower facial surgery. Many had an adjunctive procedure as well including upper or lower lid blepharoplasty, chemical peel, or rhinoplasty.
The mean elevation in jowl position for all forty measurements was 7.0 mm. This reached statistical significance at p < .001. All patients showed at least minimal elevation in jowl position on at least one side with the minimum elevation for a single patient being 2 mm. That same patient showed no elevation on the contralateral side however. This was the only patient to show no elevation and was the sole male subject. The range of elevation extended from 0.0 mm to 12.5 mm with a mean elevation of 7.0 mm for the right side, 7.0 mm for the left side. The range of differences in elevation between right and left sides for each patient varied from 0.5 mm to 3.5 mm.
Recognition of the midface as a distinct clinical entity in the rejuvenation of the aging face is a recent development. The pursuit of techniques to address this region occurred in response to the nasal-jugal line or “tear trough” deformity of the lower orbital rim, the related descent of the malar fat pad and orbicularis oculi muscle sling, and the difficult to treat nasolabial area. Two generalized approaches to this region have been developed: those performed through an inferior orbital incision, (13-20) either subciliary or transconjunctival, or those performed through a temporal incision either as part of a lower face rhytidectomy or in conjuction with a brow elevation (5-12). Debate exists regarding the advantages and disadvantages as well as success of the differing approaches with probably the most important factor being surgeon preference. Rarely however have any of these previous articles commented on the affects of midfacial elevation on the jowl and jawline region however.
Previously the authors retrospectively reviewed 325 patients selecting 100 for photographic analysis looking for improvement of the jowl and jawline following endoscopic subperiosteal midfacial elevation. With follow-up of 6 to 50 months 57% showed mild to marked subjective improvement of the jowl region. (5) This study indicated that this procedure improved the jowl region which persisted in at least a majority of patients with long-term follow-up. While ideally the current study would also have the benefit of long-term follow-up, this was not the aim. Additionally, no method to track the long term position of the soft tissue could be devised which would be acceptable to the patient. The purpose of the current study was to objectively evaluate if subperiosteal midfacial surgery elevated the soft tissue of the jawline and if so quantify the elevation which could be achieved.
The study results confirmed that this procedure elevates the soft tissue of the jowl region an average of 7 mm. All patients showed at least some elevation and many had marked elevation of this soft tissue which traditionally has only been addressed through lower face rhytidectomy. (Fig 3 a,b, Fig 4a,b) While the range of elevation between patients varies from zero to 12.5 mm, the range between sides in the same patient differed at most 3.5 mm. This would seem to indicate that some inherent patient factor may influence the amount of elevation that can be achieved. This factor may be related to skin thickness, lack of bony structure i.e. the round face, degree of facial aging, or some other unidentified factor. Additionally, the one male patient in the study group showed the least elevation. While no conclusions can be drawn from this, the difficulty in performing lower facial surgery in males is well known and this may be an indication of the limitations that male anatomy imparts on this procedure as well and warrants further study.
In order to remove the confounding variable of lower face rhytidectomy these patients were excluded from this study. However, subperiosteal midfacial elevation is preformed in conjunction with lower face rhytidectomy frequently. Hamra emphasizes the importance of the vertical vector of facial descent and the advantage of surgically counteracting this vector. (1) When the malar fat pad, zygomatic major muscle, and orbicularis are repositioned during this procedure, the vector of pull of the suspension suture is directly superior to the deep temporal fascia. Combining this vertical vector of suspension of the mid and lower face with the posterior-superior vector of a lower facial rhytidectomy appears to additively enhance the jawline and improve the results compared to each procedure independently. (Figure 5) This however has not yet been objectively evaluated and also presents an area of future research.
Subperiosteal midfacial elevation which was designed to rejuvenate the periorbital and malar regions has been shown to subjectively improve the jowl and jawline on long-term subjective analysis. This study confirms objectively that this procedure elevates the soft tissue in this region and quantifies the average elevation at 7.0 mm. This elevation is in a vertical vector countering directly the gravitational descent. This procedure can be safely and effectively used alone or simultaneously with a lower face rhytidectomy for comprehensive surgical rejuvenation of the midface, jowl, and jaw-line.
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Figure 1: Close-up one week post-op photo with silk stitch in place. Faint mark persists at stitch where inferior border of mandible was marked pre-operatively. New inferior marking demonstrates new post-operative soft tissue position relative to mandible.
Figure 2: Stitch placed through periosteum, malar fat pad, and zygomaticus major muscle is suspended to the deep temporal fascia with permanent suture.
Figure 3a,b and 4a,b Pre and 3 month post-operative lateral views of patient showing degree of improvement in mandibular contour and overall midfacial appearance.
Figure 5: Midfacial lift repositions soft tissue in superior vector while standard lower facelift techniques reposition tissue in a more posterior vector.