Journal of Aesthetic & Reconstructive SurgeryISSN 2472-1905

2020Vol.6 No.2:7

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Research Article

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DOI: 10.36648/2472-1095.6.2.56

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Webster Ronaldo1*, Labbe Daniel2, Ely Pedro Bins1,

Oxley Andrea3 and Battisti Caroline3

1 DepartmentofPlasticandReconstructiveSurgery,UniversityFoundationofMedicalSciencesofPortoAlegre,PortoAlegre

2 HPSMHospitalPriveSaintMartin,France3 DepartmentofAnatomy,University

FoundationofMedicalSciencesofPortoAlegre,PortoAlegre

*Corresponding author: Dr.RonaldoWebster,PhD.

webster.ronaldo@gmail.com

Tel: 005551992884098

Department of Plastic and ReconstructiveSurgery, University Foundation of MedicalSciencesofPortoAlegre,PortoAlegre,Brazil.

Citation:RonaldoW,DanielL,BinsEP,AndreaO,CarolineB(2020)IntraoralFacialLifting:ATacticalModification.JAesthetReconstrSurgVol.6No.2:7

Intraoral Facial Lifting: A Tactical Modification

AbstractTherewasimprovementinseveraltechniquesforelevatingthemiddlethirdofthefaceinsearchoflowersurgicalscarsandmorbidity.Conservativeapproacheshaveemergedusingendoscopy,transconjunctivalaccess,malarimplants,directlifting,multivectorialandmultiplane.Wehighlightinthisarticle,atechnicalmodificationoftheauthors,usingtheexclusiveintraoralaccessforuseinthesurgicalelevationof themiddle thirdof the face.Webster-Labbe’s technicalmodification (LFI) toelevate themiddle third of the face using an intraoral incisionwas efficient inthefaceliftinthepresentcase,followingtheexpectedbehaviorconcerningthepreviousanatomicalstudy.

Keywords: Reconstructive surgical procedures; Facial paralysis; Surgery; Plastic;Facialasymmetry;Malarlift;Midface;Faciallifting

Received: Jyly07,2020; Accepted: July21,2020; Published: July28,2020

IntroductionThere was improvement in several techniques for elevatingthe middle third of the face in search of lower surgical scarsand morbidity. Conservative approaches have emerged usingendoscopy, transconjunctival access, malar implants, directlifting,multivectorialandmultiplane[1].

Infacialparalysis,thereisaptosisinthemiddlethirdofthefaceduetosaggingdenervatedmuscles,contributingtoitsasymmetryand lagophthalmos.Theelevationof the facialmediumthird isa safe and effective technique for the static treatment of themalpositioningofthelowereyelid,orafterchronicfacialparalysisorafterretractionofthelowereyelid[2].

We highlight in this article, a technical modification of theauthors,usingtheexclusiveintraoralaccessforuseinthesurgicalelevationofthemiddlethirdoftheface.

Research MethodologyThe studyofanatomicaldissection in fresh frozencadaveranditsinitialclinicaltrialstagefollowedthe1950GenevaConventionn°IVandwasvalidatedusinginformedconsentaccordingtotheEthicsCommitteeoftheSantaCasadaMisericordia,PortoAlegre.

The surgical procedure, under general anesthesia, begins withthecutaneousmarkingofthetractionpoints(Figure 1).

Insoftparts,thethreeanchorpointsareorientedasfollows:

1. Theintersectionbetweenahorizontallinefromthenasalbase to the tragus and a vertical line through the oral

commissure, defining the first orbital medial anchoragepoint.

2. The second point is located at the intersection of thehorizontallinefromthenasalbasetothetraguswiththeverticallinethroughtheoutereyelidepicanthus.

3. If necessary (upper lip ptosis), a third attachment pointmaybemademidwayalongtheverticallineofthelateralendbetweenthebaseofthenasalwingandtheupperlip.

Theintraoralaccessbeginswithanincisionlocated2mmabovethegingivolabialsulcus,2-3cmlong,centeredintheuppercanineregion.Dissectionprogressesinthesub-periostealplaneoverthemaxillary body, zygoma, piriform opening, and inferior orbitalmargin,advancingabout1cmontheinferiororbitalfloor,lateraltotheinfraorbitalforamen(Figures 2 and 3).

Intheboneportion,afterthesubperiostealdissectiondescribed

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Journal of Aesthetic & Reconstructive SurgeryISSN 2472-1905

Approximatespacingbetweenholes1.5-2.0cm.Ifnecessary,wecanmakeathirdholepointatthelateralportionofthepiriformopening,0.5cmfromtheboneedge.Wesuggestalowrotation1.5mmto2.0mmdrillbitforbonedrilling(Figure 4).

Afterward,thesuturesareintwosteps,asfollows:afterocularprotection by inter-eyelid suture, a slight external pressureintrusion of the eyeball using a periorbital surgery retractor isperformed(Figure 5).ThemaneuverallowsthefirsttimeofsuturewhereitisperformedwiththedirecttranscutaneouspassageofMononylon®3-0 suture, ina craniocaudaldirection,withentrythroughtheorbitalfloorboneholeandexitattheorbitalmarginanteriortothemaxillarybody,alwaysunderdirectmonitoringofthe infraorbitalnerve,throughthetransoral incision (Figure 6). Thesameoperationisappliedtotheotherbonehole.

Sequentially,at thesecondtimeofsuturepassage, theportionof theMononylon® threadexternal to the skin ispulled to thesubperiostealplaneinitiallydissectedintheintraoralapproach.With the sutures already attached to the bone holes andpositioned in the dissected area with intraoral access, witha Casagrandeneedle, the suture is anchored to the softtissueportion to be elevated, transfixing SMAS and muscles to beelevatedasrequired,previouslyprovided(Figures 7 and 8).Afterfinalrevisionandhemostasis,thegingivalincisionissuturedand

above,we canmakeup to threeboneholes. Twoboneholes,lateral to the infraorbital foramen, entry point 0.5 cm caudalto the inferior orbital margin in the maxillary body, with 45°inclination to the frontal plane exiting on the orbital floor.

Figure 1 Operatory sequence (cadaver) LFI: Softtissue anchormarkings.

Figure 2 Operatorysequence(cadaver)LFI:Intraoralaccessview.

Figure 3 Operatory sequence (cadaver) LFI: Infraorbitary nervedissection.

Figure 4 Operatorysequence(cadaver)LFI:Suggestedanchoringpoint’s location, close to the inferior orbital rim andpririformisaperture.

Figure 5 Operatory sequence (cadaver) LFI: Transcutaneousaccesstotheintraosseoustunnels.

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Journal of Aesthetic & Reconstructive SurgeryISSN 2472-1905

correctionofeyeexposureand,inApril2018,underwentdynamicfacial suspension using fascia lata elongated orthodromictemporalmuscle.Duetothelossofmalarsupportcausedbythesofttissuedescentbecauseofherfacialparalysis,thepatientstillhadmild lagophthalmosandwantedto improvehersymmetryofthemiddlethirdoftheface.InAugust2018,shewasincludedinthemiddlefacialliftingprotocolinthelefthemiface,withthetechnicalmodificationintroducedbyWebster-Labbe,accordingtothetechniquedescribedaboveinFigures 11 and 12[3].

The procedure took an operative time of 45 minutes andproceeded as planned.Weopted for two sutures anchored intheinferiororbitalmargins(Figure 13).

Inperioperative care,weusedpreventivemeasuresof venousthrombosis, with intermittent lower limb compression deviceand early ambulation. There was antibiotic treatment, usingAmoxacillin and Sodium Clavulanate, according to the localhospitalarprotocol for intraoralsurgerieswithwidedissection.

theelevationofthemiddlethirdofthefaceisrechecked(Figures 9 and 10).

Case ExampleA female patient, 27-years-old, with facial paralysis due tosequelae of pontocerebellar angle tumor resection. In 2017,sheunderwent the inclusionof 1.2 gof eyelid goldweight for

Figure 6 Operatorysequence(cadaver)LFI:Intraosseoustunnels:Alreadywiththestickpassedthrough.

Figure 7 Operatory sequence (cadaver) LFI: Additional stitchat piriformis aperture, all stitches in the intraosseoustunnels.

Figure 8 Operatorysequence(cadaver)LFI:Finalaspect , intra-oralview.Allstitchesanchoredinthesofttissue.

Figure 9 Operatory sequence (cadaver) LFI: Left- soft tisnemarkings,pre-suspension,Right:softtissuesuspensionwith LFI technique on the right side of the cadaver.Antero-posteriorview.

Figure 10 Operatory sequence (cadaver) LFI: Soft tissuesuspensionwithLFItechniqueontherightsideofthecadaver,Inferiorview.

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Figure 11 Operatorysequence(cadaver)LFI:Left-pre-operatorymarkings,Center-intraoralview,Right-Infraorbitarynervedissection.

Figure 12 Operatorysequence(cadaver)LFI:Left-Transcutaneousneedlepassageforsofttissueanchoringintheintraosseoustunnels,Center-needlebeingpulledthroughtheintraosseoustunnel,Right-anchoringsofttissuesintheintraosseoustunnels.

Figure 13 Left:Immediatepre-operatory;Right:Immediatepost-operatory-LFI.

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Itwasfollowedtheroutineofexternalfacialapplicationofcoldcompressesaswellasoralhygienewithaqueouschlorhexidinesolution, and food was restricted to clear liquids without anyresidueandnon-dairyduringthefirst48h.Postoperativeedemawasmild andwithoutmajor implications such as chemosis ortendencytolagophthalmosreaction.

The painwas considered tolerable, level 3/10 of the standardpainscaleadoptedintheinstitution,yieldingwiththeeventualuseofnon-steroidalanti-inflammatorydrugs. Inotheraspects,the patient evolved without postoperative complications. Thereturntotheusualactivitiestookaboutoneweek.

The patient’s degree of satisfaction with the procedure was8/10concerning theexpectedbenefit. In theevaluationof thesurgicalteam,weachievedconsistentimprovementoftheeyelidclosure(paralyticlagophthalmos)repositioningthemiddlefacialthird,improvingtheappearanceoftheapparentscleraandtheemptyingof themiddlepartof theface, thus improvingglobalfacialsymmetry(Figures 14 and 15).

DiscussionThesurgerywentasexpectedcomparedwiththeexperimentalsurgeryperformedonafreshfrozencadaver,followingtherulesestablishedinapreviousstudyfromtheauthors[3].Sales-Sanzetal.describedhowfacialparalysisaffectstheorbitalsupport.They explain that facial palsy is associated with an abnormallower eyelid position, which results in ectropion, bulbar andcorneal conjunctiva exposure, lagophthalmos, and inadequateteardrainage.Theparalyticconcomitantptosisofthemalarsofttissueisresponsibleforstretchingandprogressiveweaknessofligamentousstructuresofthemiddlethirdandtheconsequentloss of support on the lower eyelid. Thus, it is possible tounderstandwhythemiddlethirdisasuitableliftingtreatmentinfacialparalysis[2].

In 1994, Ramirez et al. pioneered in the description andpopularization of endoscopic third lifting medium with sub-periostealdissectiononthemalarprominenceandinferiororbitalrim, the temporal and intraoral approach, promoting effectiveincreaseofthejunctionbetweenthelowereyelidandthemiddlethird[4].Sales-Sanzetal.describedtheelevationofthemiddlethirdbytransoralincision,butassociatedwithtransconjunctivalandtemporalaccess forsubperiostealdissectionof themiddlethirdandfixationtothedeeptemporalfascia[2].Theyarguethattheoral incision isuseful for achieving complete subperiostealdissection and performing distal periosteotomy, which wouldallowcompleteelevationofthesofttissueofthemiddlethird.Mofid et al. published the technique of transoralmiddle thirdelevation in association with temporal endoscopic approach[5]. The procedurewould avoid complications associatedwithviolatingtheanatomicalstructuresofthelowerorbitaljunctionand present a marked better visualization of the structureswith an incision that allowsmuchwider access. The proposedtechnique would perform all subperiosteal dissection of themiddlethirdthroughtransoralaccessandfixsofttissuestothemaxillarybonethroughsmallholescreatedbyperforatingtheminthedesiredposition,allowingafirmerandlastingfixation.

According to Engle et al. of all complications associated withsubperiosteal lifting, themiddlethirdmotornerve injury is themost feared [6]. Sales-Sanz et al. state that the subperiostealplane prevents facial nerve damage [2]. Schwarcz et al. whocomparedthewell-knownfacialmiddlethirdfacelifttechniquesandtheircomplications,observedthattheendoscopictechnique(whichhasthegeneralcharacteristicsofthetechniquedescribedin this article) is extremely effective [7]. We have shown inthe present publication that, through exclusive transoralsubperiostealdissection,itispossibletovisualizetheinfraorbitalvascular-nervebundle,thuspreventingitsinjurywithprecision,andprotectingthefacialnerve,ifprecisedissectionismaintainedinthesubperiostealplane.

Another much-feared complication in facial surgery is ahaematoma.Subperiostealdissectionhaematomaratesarelessthan1%,accordingtoEngleetal. [6].However,theyemphasizethat we should pay attention since bruising may be moredifficult to identify compared to typical rhytidectomies due tothethicknessoftheflap.Preventivemeasuresofperioperativeinfectionrelatedtoantisepsisandantibioticuseweresuccessful.We used antibiotic treatment for seven days postoperativelyassociated with oral antisepsis with chlorhexidine-based oralsolutions,accordingtoSales-Sanzetal.andPerryetal.[8].Thepatient reported that she was able to abstain from care withexternal bandages characteristic of a traditional postoperativefacial suspension, which was a subjective factor of significantpostoperative well-being. Points in favor of the technical

Figure 14 Right: Pre-operatory; Left: One year post-operatory,noticeablefullnessinthemiddlethirdwithreductionofscleralshowwithoutadditionalproceduresinpalpebralarea.

Figure 15 Detail: Malar fullness restoration after the procedure.

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modification introducedbyWebster-Labbe in the liftingof themiddle facial third are the absenceof external scars, speedofexecution and the possibility of the patient to resume theirusualactivitiesinarelativelyshorttime.Theabovefeaturesarebeneficial both in the sphere of reconstructive and aestheticprocedures.

We understand that the osseous anatomy changes with ageand the position of the bone perforations may need someadjustments, even subtraction of one of the fixation point.Correaetal.,whodescribedasimilartechniquethatusedonlyoneperforatedholeformiddlethirdelevationperformedin12patients,which showed thepersistenceof the result one yearaftertheprocedure[9].Aswithotherfacialliftandblepharoplastytechniques,theperceptionofriskoflowerobliquemuscleinjuryor eyeball perforation should always be in mind. Otherwise,although we have not completely resolved our patient'slagophthalmclinically,wegreatly reduced thescleralexposureontheparalyzedside.Inaninterventionwithcharactertending

moretoanaestheticprocedurethanreparative,as inthecasedescribed,atheoreticalfactorwithanegativeinfluenceonthismodificationpresented is thatwe can inducea relativeexcessskin in the lower eyelid, which may require complementarytreatment. We do not necessarily need to be aggressive inresolvingthisexcessskinbyviolatingthestructurespreservedbythefacelift,suchastheorbitalseptumandmusculature.TheCO2 laserandconservativepinchblepharoplastymaybemorethansufficientalternativesforthissituation.Wecan,therefore,inferthatwecanpotentiallyhavegoodlongevityofresults,withoutthecostsofendoscopicsurgeryandthecomplicationsofinvasivetemporal and eyelid access surgery, making Webster-Labbe'stechnicalmodificationaviableoptionintheuniverseofsurgicaltechniques suspension of themiddle facial third, including forexclusiveaestheticpurposes.Wehavetheprospectoftechnicalimprovementbyimplementingandfacilitatingthepassageofthestitchesusingbonemini-anchorsonlybyintraoralapproach,thusnotrequiringskintransfixionbyaneedle(Figure 16).

Figure 16 Mini-anchorProject-Webster-LabbeTechnique.

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Conclusion Webster-Labbe’s technical modification to elevate the middlethirdof the faceusingan intraoral incisionwasefficient in thefacelift in the present case, following the expected behaviorconcerningthepreviousanatomicalstudy.

AcknowledgementThe authors of the technical modification are grateful to

the Department of Anatomy, Plastic Surgery of the UFCSPA-IrmandadeSantaCasaofPortoAlegreandSurgeryoftheHospitalPrivet Saint-Martin-Caen-France, for their support in providingthe structure for anatomical dissection and diagramming, andtheprioranatomicalarticleinthepersonoftheirservicechiefs,residentsandstaff,co-authorsinvolvedinthepublications.

References1 MittelmanH,HershcovitchM (2015)Managementof themidface

duringrhytidectomy.FacialPlastSurgClinNorthAm23:195-200.

2 Sales-SanzM,BarrancosC,Won-KimHR,Sales-SanzA,ColmeneroC(2017)Reconstructivesubperiostealmidfacelift:Athreenonvisibleincisionapproach.Orbit36:256-263.

3 WebsterR,Labbe D,ElyPB,OxleyA,BattistiC,etal.(2018)Transoraland transconjunctival routes for a middle third facial lift: ananatomicalstudy.AdvPlastReconstSurg200-203.

4 Ramirez OM, Maillard GF, Musolas A (1991) The extendedsubperiostealface-lift:adefinitivesoft-tissueremodelingforfacialrejuvenation.PlastReconstrSurg88:227-236.

5 MofidMM(2011)Anoveltechniqueforrepositioninglowereyelidfat via the transoral approach in association with midface lift.AestheticPlastSurg35(4):563-568.

6 Engle RD, Pollei TR, Williams EF (2015) Endoscopic midfacialrejuvenation.FacialPlastSurgClinNorthAm23:201-208.

7 SchwarczRM,KotlusB(2015)Complicationsoflowerblepharoplastyandmidfacelifting.ClinPlastSurg42:63-71.

8 Perry CB,Allen RC(2016)Thesubperiosteal,drillhole,midfacelift.Orbit35(5):250-253.

9 CorreaBJ,EisemannB,EisemannM(2013)Transconjunctivalmidfacelift:Awholedifferentfixation.JCraniofacSurg24(3):987-991.