Subperiosteal, vertical and preservation facelifts

What these lifts are

They differ from a standard lift in two ways:

• Layer: a subperiosteal lift works on the bone, under the periosteum, the thin membrane that covers it, so skin, fat, SMAS and periosteum move together as one unit (PMID 2473674). A deep plane or preservation lift works just under the SMAS and releases the ligaments that hold the cheek down (PMID 39072376).
• Direction: the lift is mostly upward. The right direction differs between patients and between the two sides of one face, so surgeons set it after the tissue is released (PMID 38657095).

"Preservation" means leaving the skin attached to the deeper layer as much as possible and keeping deep structures in place (PMID 40104381). The term has no standard definition: published preservation and conservation lifts are different operations (PMID 40104381, PMID 42630822).

Where it came from

• 1989: Paul Tessier described the "mask lift": the soft tissue of the cheekbones, cheekbone arches and eye sockets is freed from the bone and lifted as one unit, through a scalp incision or a short incision inside the mouth (PMID 2473674).
• Early subperiosteal lifts injured facial nerve branches too often. In 1991 Oscar Ramirez changed the dissection in the temple to stay beneath both layers of the temporal fascia and anchored the cheek to that fascia, and reported no nerve injuries with the new method (PMID 1852815).
• 1994: Ramirez did the same operation through an endoscope, with small incisions in the hair, and treated patients up to their late 40s without removing skin (PMID 7817884).
• 2002: Patrick Tonnard's MACS lift brought a vertical pull to the short-scar facelift with purse-string sutures (PMID 11994618).
• 2011: Andrew Jacono combined a deep plane release of the cheek ligaments with a vertical lift through a shorter incision (PMID 22065880).
• 2020s: endoscopic deep plane lifts without the incision in front of the ear (PMID 38152870, PMID 40576459) and preservation lifts that limit how much skin is separated (PMID 40104381, PMID 42630822).
• The full subperiosteal facelift stayed rare: among board-certified plastic surgeons it accounted for about 1 in 100 facelifts (PMID 38302713).

Who it suits

• Subperiosteal midface lifts suit people whose cheeks have dropped below the eyes, leaving a long lower lid and a hollow under the eye (PMID 9727455, PMID 36342769). They are also used to correct a lower lid pulled down by earlier surgery (PMID 29464383).
• Endoscopic lifts without skin removal suit younger patients with good skin; the endoscopic full facelift treated patients up to their late 40s that way (PMID 7817884).
• Endoscopic deep plane lifts without the incision in front of the ear suit mild to moderate skin laxity, because the deep layer carries the lift and little skin needs to be removed (PMID 37931912).
• People with more loose neck skin need skin removal added; the ponytail lift adds a neck skin excision for full rejuvenation (PMID 38152870).

How it is done

Subperiosteal lift

• Through incisions in the scalp, the temple, the lower eyelid or inside the mouth, the surgeon lifts the soft tissue off the cheekbones, the cheekbone arch and the rims of the eye sockets, then fixes it higher (PMID 2473674, PMID 9727455).
• It is often combined with a brow lift; in one large series every patient had one (PMID 9727455).
• Midface versions fix the lifted cheek through drill holes in the rim of the eye socket (PMID 42009921), inside the eye socket (PMID 36342769), or with barbed sutures and a tightened outer eye corner (the concentric malar lift) (PMID 29464383).

Vertical lifts

• The SMAS or the deep plane flap is suspended upward rather than backward, by sutures (PMID 11994618, PMID 39843874) or after a deep plane release (PMID 22065880). Some are done under local anesthesia (PMID 21276163).

Endoscopic deep plane lifts

• Through small incisions in the temple hair, with a camera, the surgeon releases the ligaments under the SMAS and lifts the face vertically with strong sutures, with little skin undermining (PMID 40576459, PMID 39850537).
• One surgeon lifts the face and neck as one composite flap this way and uses sutures behind the ear to take up the extra skin in front of it (PMID 37931912).

Preservation and conservation lifts

• A preservation lift combines deep plane and high SMAS methods while separating as little skin as possible, and rotates a flap of SMAS along the jaw to sharpen the jaw angle (PMID 40104381).
• A conservation lift moves the cheek fat pad, skin and fat as one unit with limited undermining (PMID 42630822). Limited delamination of the extended deep plane follows the same principle (PMID 39072376).

Results and how long they last

• Releasing the ligaments and then lifting keeps the face's own support fibers in their working direction; lifts that drag tissue without release, such as thread lifts, turn those fibers and put the weight on the stitches (PMID 37747400). That is the anatomical case for durability; no long-term trial has tested it (PMID 37747400).
• Midface lifts fixed inside the eye socket held without relapse or a flat cheek in primary patients (PMID 36342769).
• The concentric malar lift caused no new eyelid malposition and improved eyelids that had been pulled down (PMID 29464383).
• An endoscopic deep plane lift shortened the lower eyelid and reduced the need for lower eyelid surgery (PMID 39850537).
• One surgeon's endoscopic composite lifts matched his own earlier open composite lifts in similar patients (PMID 37931912).
• The preservation lift had shorter drain times and fewer complications than the same surgeons' extended deep plane lifts (PMID 40104381).
• For the jowl, fat grafting with little or no skin release corrected the jowl and the hollow in front of it more than cutting the mandibular ligament (PMID 39001648).

Risks and how surgeons lower them

• Facial nerve: the forehead branch crosses the cheekbone arch. Dissecting beneath both layers of the temporal fascia lowered the nerve injury rate of early subperiosteal lifts (PMID 1852815). In later series, forehead weakness was temporary and resolved within weeks to months (PMID 9727455, PMID 39850537).
• Large endoscopic series reported no permanent nerve injury (PMID 38152870, PMID 40576459), and the ponytail series no loss of skin (PMID 38152870). A conservation lift series reported no nerve complications (PMID 42630822).
• Revision: about 1 in 20 endoscopic deep plane patients had a revision for cosmetic reasons, most of them among the surgeon's first cases (PMID 40576459). Without an incision in front of the ear, extra skin can bunch in front of the ear or at the temple and need a revision (PMID 39850537).
• In a large subperiosteal series, about 1 in 20 patients had a complication (PMID 9727455). About 1 in 100 needed further surgery (PMID 9727455).
• Hematoma still occurs with tissue-sparing lifts: it followed about 4 in 100 lifts in a conservation lift series that had no nerve complications (PMID 42630822).
• Most of these reports come from the surgeon who developed the technique, without comparison groups or patient questionnaires (PMID 40576459, PMID 38152870).

Recovery

• Open subperiosteal lifts can cause facial swelling, hair loss and scalp numbness; endoscopic technique was introduced partly to reduce them (PMID 7817884).
• Temporary forehead weakness after the transtemporal endoscopic lift resolved within 3 weeks to 3 months (PMID 39850537).
• A preservation lift needed its drains for a shorter time than an extended deep plane lift (PMID 40104381).

Questions to ask a surgeon

• Ask which layer the lift works in, and in which direction it will pull (PMID 38657095).
• Ask what "preservation" means in this surgeon's hands, since the term has no single definition (PMID 40104381).
• Ask how many endoscopic lifts the surgeon has done, since revisions cluster in a surgeon's early cases (PMID 40576459).
• Ask what happens to extra skin in front of the ear if there is no incision there (PMID 39850537).
• Ask how the forehead branch of the facial nerve is protected at the temple (PMID 1852815).

Open questions

• "Preservation facelift" has no standard definition, and the published techniques differ (PMID 40104381, PMID 42630822).
• Endoscopic series report low complication rates without comparison groups or patient-reported outcomes (PMID 40576459, PMID 38152870).
• The argument that release lifts last longer is anatomical; long-term trials have not tested it (PMID 37747400).
• Subperiosteal lifts became safer with technical changes and remain rare in practice (PMID 1852815, PMID 38302713).

Terms

• Subperiosteal: under the periosteum, the membrane on bone (PMID 2473674).
• Mask lift: Tessier's subperiosteal lift of the facial soft tissue as one unit (PMID 2473674).
• Midface lift: lifting the cheek tissue below the eye (PMID 36342769).
• Vertical vector: a lift direction close to straight up (PMID 38657095).
• Endoscopic facelift: a lift done through small hidden incisions with a camera (PMID 40576459).
• Preservation face lift: a tissue-sparing deep plane and high SMAS lift that separates little skin (PMID 40104381).
• Delamination: separating the skin from the SMAS flap (PMID 40104381).
• Retaining ligaments: fibrous bands that hold the facial soft tissue to deeper structures (PMID 37747400).

Papers