ON

AL CON
TR Update on Minimally Invasive
INT ATI

IBUTION
ERN

Face Lift Technique

Antonio Fuente del Campo, MD

Background: The aging face is characterized by loss of skin elasticity, fat resorption, loss of muscle tone and
volume, and loss of bone volume. Restorative procedures should be based on the condition of the soft tissues
and the relationship between these tissues and the existing skeletal volume and can be performed through
open, endoscopic, or minimally invasive approaches.
Objective: A minimally invasive approach to the face lift is presented, updated with useful details that the
author has incorporated into his clinical technique on the basis of 15 years of experience.

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Methods: The minimally invasive face lift is not a mini-lift but a full face lift performed through minimal inci-
sions located in the frontal hairline, temporal area, triangular fossae of the auricle, submentalis, and eyelids. A
wide dissection was performed to liberate the parietotemporal fascia from the zygomatic arch and to pull it up
in continuity with the superficial musculoaponeurotic system and the platysma as one continuous layer or com-
posite flap. These structures were selectively secured in a higher position, restoring the contour of the face and
the consistency of the soft tissues.
Results: The described procedures, or combinations of these procedures, were performed in 539 patients
during a 9-year period. Preauricular incisions were avoided in 83% of cases. Complications were minimal and
included temporary hypoesthesia of the forehead or cheek and temporary palsy of the frontotemporal branch
of the facial nerve that resolved after 2 to 4 weeks. There were few problems with hematomas.
Conclusions: The minimally invasive face lift technique described here can reduce morbidity, achieve more
durable results, and give a greater degree of satisfaction to patients. The procedures are relatively simple and easy
to carry out but require somewhat of a learning curve to achieve optimal results. (Aesthetic Surg J 2008;28:51–61.)

acial tissues are affected by the aging process in dif- The subperiosteal face lift originally proposed by

F ferent ways: the skin loses elasticity, fat resorbs,

muscles lose tone and volume, and the bone also
loses volume, which leads to the descent and increasing
laxity of the overlying soft tissues that rely on facial bone
for support. The skin, which loses elasticity with age, is
not a supporting structure. Applying direct traction to the
skin will cause further deterioration, transforming it into
an inert layer that appears hypotonic and unnatural. To
achieve natural-looking results from a face lift, the skin
should, essentially, be redistributed and redraped in-
directly, by redistribution of the deep soft tissues.
An effective method of facial rejuvenation will also
need to address the restoration of lost bony volume.
Although no one satisfactory means of achieving this is
obtainable, an alternative is to restore the condition of
the soft tissues and the relationship between these tis-
sues and the existing skeletal volume. To achieve this
effectively, a deep plane approach is required.
Dr. Fuente del Campo is in private practice in Mexico City,
Mexico. He is a member of the Mexican Association of Plastic,
Aesthetic and Reconstructive Surgery.
Tessier1 and developed by Psillakis,2 Santana,3 and our
group is a good option. It includes the advantages of a
relatively avascular plane of dissection well away from
the nerves, which allows displacement of the soft tis-
sues of the face en bloc as one continuous layer or
composite flap, without disturbing the original relation-
ship between the skin and the deep soft tissues. The
preservation of the anatomic relationship between the
periosteum, muscles, and skin provides a “cushioning”
effect that allows the traction applied to the deep soft
tissues to tense the skin in an indirect but smooth and
natural fashion.4-7
A deep plane face lift (subperiosteal or supraperiosteal)
could be performed, either through preauricular incisions
and a coronal approach or by use of small incisions with
an endoscopic method.8-11 As we gained experience with
the endoscopic approach, we found it possible to carry
out most of the maneuvers of the endoscopic face lift
through small incisions but without endoscopic assis-
tance.12,13 In this article, a minimally invasive approach to
the face lift is presented, updated with useful details that
we now use routinely in our practice.

Aesthetic Surgery Journal Volume 28 • Number 1 • January/February 2008 • 51

PREOPERATIVE CLINICAL ASSESSMENT
Patients were assessed while in repose, looking straight
ahead without contracting the frontalis muscle. In most
patients, the horizontal forehead lines are the result of
chronic contraction of the frontalis muscle, which the
patient activates out of habit, either during expression or
when elevating the eyebrows in an attempt to eliminate
the weight and shadow caused by the agglomerated skin
at the upper lid (blepharochalasis). By asking the patient
not to contract the frontalis muscle during assessment, the
real position of the eyebrows and the amount of excess
upper lid skin, with or without surgical eyebrow elevation,
could be confirmed. The redundancy and displacement of
the soft tissues of the cheeks were also evaluated. The
neck was evaluated with respect to the amount of fat pres-
ent, muscle laxity, and skin elasticity and redundancy.
We have classified the severity of the facial changes
caused by aging into four groups: grade I: Early mid-
facial laxity and descent; grade II: Established mid-facial
descent and initial cervical laxity; grade III: Early mid-
facial redundancy and evident cervical flabbiness; grade
IV: Established mid-facial and cervical redundancies.
OPERATIVE TECHNIQUE
The procedure described here has been designed to restore
the aging face by counteracting the effect of gravity on the
soft tissues through the use of vertical displacements and
selective suspensions. Variations of the procedure are indi-
cated for each patient, depending on the severity of facial
changes caused by aging, defined as grades I to IV.
The procedure was performed with patients under
either general or local anesthesia with sedation. If local
anesthesia was used, bilateral nerve blocks of the supra-
orbital, infraorbital, mandibular, and mental nerves and
the superficial cervical plexus were administered and the
area was infiltrated with a vasoconstrictor solution con-
sisting of 1:100,000 epinephrine 1 mL and 2% lidocaine
25 mL in normal saline solution 175 mL. For those
patients under general anesthesia, we infiltrated the
same solution without lidocaine.
Frontal and Eyelid Region
In this area, the goals were to eliminate horizontal lines,
to raise the eyebrows to an aesthetically appealing
height with the desired contour, and to balance the func-
tion of the muscles of facial expression.
Two ports of access were used: bilateral 2-cm
incisions just above the middle of the lateral eyebrow
at the hairline. To site these incisions correctly, 2 lines
were drawn, both starting at the lateral margin of the
nasal ala, with one continuing up through the lateral
corneal margin while the other passed through the
pupil, until both met the hairline. The incision was
placed between these two lines, parallel to the eye-
brow. In patients with grade I rhytidosis, in whom
there was usually minimal redundancy of the upper lid
skin, only a conservative brow lift was required with-
out the need for an upper lid blepharoplasty. Those
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Figure 1. Dissection areas. A, Subperiosteal. B, Under the tem-
poroparietalis fascia. C, SMAS. D, Subcutaneous incisions for the
approach to these regions.
patients with evident upper lid redundancy (grades
II–IV rhytidosis), superior orbicularis hypertrophy, or
fat bag herniation required a transpalpebral approach
through a conventional blepharoplasty incision.
A subperiosteal dissection was performed through the
hairline incisions and was carried down to the supraor-
bital rim, surrounding the emergence of the trochlear
and supraorbital nerves, which were protected by plac-
ing a finger tip on them (Figure 1). Subperiosteal dissec-
tion above the hairline incisions (the frontoparietal area)
was performed only in those cases where hairline eleva-
tion was indicated. The attachment of the temporopari-
etal fascia at the point where it blends with the frontalis
must free the superior temporal line on both sides.
We prefer the subperiosteal dissection plane; it mini-
mizes bleeding and enables moving and redraping of the
soft tissues en bloc. But, to do so, and to treat the
depressor muscles, it was necessary to open the perios-
teum, which was cut from side to side horizontally, 2 cm
above the nerves. In this way, the eyebrows were liberat-
ed from the deep soft tissues so that vertical traction
would act directly on them. Partial excision or dysfunc-
tion of the procerus and depressor supercilii muscles
was also indicated in those patients in whom elevation
of the medial third of the brow was necessary.
A conventional blepharoplasty incision was made,
resecting skin and redundant orbicularis muscle. Usually
more muscle than skin was resected to reduce the redun-
dancy while ensuring that adequate skin remained to
drape in the concave upper lid sulcus. Dissection was per-
formed bluntly with scissors, between the orbicularis and
the orbital septum, taking care to not let retroseptal fat
Aesthetic Surgery Journal
 A

B F

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D
H

I
E

Figure 2. Minimally invasive transpalpebral frontoplasty. A, Skin-muscle resection. B, Dissection behind the orbicularis oculi muscle, to the superior
orbital rim. C, Arcus marginalis strip resection. D, Subperiosteal dissection of the superior orbital rim, and exposure of the neurovascular bundles.
E, Subperiosteal dissection of the frontal region. F, Subperiosteal dissection of the lateral canthal region. G, Procerus muscle ablation.
H, Corrugators and depressor supercilii ablation. I, Horizontal incisions of the periosteum and posterior fascia of the frontalis muscle.

extrude by inadvertently opening the septum. The supra-
orbital rim was reached, and the periosteum was incised
horizontally. Through this incision, subperiosteal dissec-
tion of the superior orbital rim was carried out upward to
connect with the previous dissection performed from
above. The orbicularis oculis muscle was weakened and
separated from the frontalis muscle by resection of a strip
of the arcus marginalis (Figure 2, A to F).
Blunt dissection behind the orbicularis muscle in the
superomedial angle of the orbit led to the depressor
supercilii muscle, which is characterized by its vertical
fibers and deep red color. The dissection was performed
in 2 planes, one subcutaneous and the other subpe-
riosteal, continuing up medially to the glabellar area. The
procerus muscle lies between these two planes and was
sectioned at different levels to render it dysfunctional
(Figure 2, G). Bleeding from this maneuver was con-
trolled with local pressure. If indicated, partial or total
resection of the depressor supercilii was performed. The
corrugator muscle could also be treated by reaching in
between its medial insertion and the supraorbital nerve,
taking care not to leave it totally dysfunctional to avoid
causing excessive separation of the medial brow
(Figure 2, H, I).14,15 In those patients for whom a ble-
pharoplasty was not indicated, the treatment of the mus-
cles could be performed endoscopically from above.
Usually, the elevation of the brow significantly reduced
the appearance of the upper lid fat pads by increasing the
effect of frontalis muscle action. If these pads were still
prominent, they were grasped gently with fine forceps
and cauterized, causing contraction of the orbital septum
and intrusion of the fat pads backwards into the orbit. In
those cases where the upper lid bags were very promi-
nent, the orbital septum could also be plicated with reab-
sorbable 6-0 sutures to reduce fat herniation. The upper
lid incision was closed with an intradermal running
suture with 5/0 nylon, suturing the upper skin border to
the lower border, including the tarsal plate, to achieve
good definition of the supratarsal fold. Because the
frontalis muscle acts only on the medial brow, any proce-
dure that improves its function will result in elevation of
the medial but not the lateral part of the eyebrow, result-
ing in a facial expression of surprise or sadness, unless
the lateral part is also elevated by selective traction and
fixation to obtain an adequate brow contour.
Once hemostasis was achieved in this region, suspen-
sion of the lateral third of the brow was carried out by
use of 4/0 polyglactin sutures. A retractor was used in
the frontal hairline incision to aid passage of the suture
needle to place “backward-and-forward sutures.” The
needle was introduced downward through this tunnel in
a subperiosteal plane to the upper edge of the previously

Update on Minimally Invasive Face Lift Technique Volume 28 • Number 1 • January/February 2008 • 53
Figure 3. “Backward-and-forward” suture anchored to a monocortical
tunnel, for ciliary suspension.
performed horizontal incision to the frontal periosteum
and partially through the skin (Figure 3). Once the pos-
terior end of the needle reached the subcutaneous level,
it was returned 1 cm along this plane, grasping a thick
bite of subcutaneous tissue, and then back to the subpe-
riosteal plane where the two extremes of the suture were
joined. Bringing them back out through the hairline inci-
sion allows the application of moderate traction on the
brow without dimpling or marking the skin. The suspen-
sion could be fixed to the periosteum and subcutaneous
tissues located above this incision, or to a monocortical
tunnel if for any reason the local soft tissues were not
strong enough. A monocortical tunnel is a procedure
that is easy to perform and provides excellent suspen-
sion without the need to place screws or any other for-
eign material that could be palpated or that would
require removal at a later time.
When upper lid asymmetry was present, differential
tension was applied to correct it. Sometimes, the brow
elevation caused bunching of the skin around the hair-
line incision; in these cases, a short incision perpendi-
cular to the center of the lower edge of the hairline
incision was made, creating two small skin triangles
that were resected without increasing the original length
of the incision. Wounds were closed with subcutaneous
late-absorbing sutures.
To ensure stable fixation of the frontal soft tissue in its
new position, the residual action of the muscles in this
region was controlled with local botulinum toxin applied
to the depressor muscles 2 weeks before the surgery.
Cheeks
For practical purposes we can divide the cheeks into two
areas: medial or centrofacial and lateral or preauricular.
Centrofacial area. This area extends from the nasolabi-
al fold medially to the lateral limit of the malar/cheek
prominence. Attention here is focused on correcting the
nasolabial fold, the malar bags, and soft tissue laxity in
this zone. This area was addressed either as an isolated
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Figure 4. “Backward-and-forward” suture to take the deep subcuta-
neous tissues of the cheek as composite flap and suspend them to
the arcus marginalis or periosteum of the infraorbital rim.
procedure or combined with a blepharoplasty in patients
with rhytidosis grades I and II and combined with a full
face lift in patients with grades III and IV.16-18
The approach for this procedure was a conventional
inferior blepharoplasty skin incision. Blunt dissection
was performed through a 1-cm opening of the orbicu-
laris muscle 1 cm below the eyelid margin. The dissec-
tion was continued bluntly behind the orbicularis
muscle until the inferior orbital rim was reached, and
from there down in a supraperiosteal plane over the sur-
face of the maxilla, creating two tunnels, one medial and
the other lateral to the infraorbital nerve. With the same
“backward-and-forward” suture (Figure 4) used for sus-
pension of the brow, 2 sutures (4/0 polyglactin) were
placed via each tunnel, lifting the deep soft tissues and
fixing them to the infraorbital rim periosteum or arcus
marginalis. In cases where the periosteum was not
strong enough, 2 drill holes were made in the inferior
orbital rim. If the suspension sutures caused obvious
dimples in the skin, they were replaced at a deeper level.
The vertical suspension of the cheek tissues to the infra-
orbital rim corrected the nasolabial crest, the tear trough
deformity, and the herniated lower lid fat pads.
This procedure produced obvious elevation and
redundancy of skin and orbicularis of the lower lid that
could encourage generous resections of this tissue, but
because this skin retracts significantly, it was important
to be conservative and to usually resect no more than
half of the apparent excess to avoid ectropion. The
excess orbicularis muscle was either resected, used as a
flap to secure a lateral canthopex in place, or rolled over
it to act as a filler of the infraorbital rim area, a maneu-
ver that has proven useful in patients with an aging peri-
orbital area or to correct the excessive fat resection of a
previous blepharoplasty.
To improve “crow’s feet,” the area lateral to the low-
er lid incision was detached subperiosteally at its
Aesthetic Surgery Journal

Figure 5. Vertical and lateral traction of the orbicular oculis muscle to
correct the malar fat bag.
periphery, and the periosteum was cut in a radial fash-
ion with scalpel to allow the orbicularis muscle to
spread out and redrape.
To correct malar fat bags, the orbicularis muscle was
freed by detaching its posterior surface and pulled up in
the direction of the lateral canthus. A horizontal ellipse
was resected from its edge at the level of the outer third
of the lower eyelid incision. The muscle defect was
closed and anchored with two 4/0 polygalactin sutures
to the periosteum in this region near the lateral canthal
ligament or even higher, depending on the desired effect.
This technique has proven useful for correcting malar
bags resulting from the redundancy that develops in the
inferior orbicularis as a result of the loss of bony projec-
tion of the malar area. This procedure also provides sup-
port to the tarsal component of the orbicularis muscle
and prevents postoperative ectropion that can result
from temporary palsy of the orbicularis caused by edema
or surgical handling (Figure 5).19-23 These lateral sutures
were placed under direct vision if an upper blepharo-
plasty was performed at the same time or could be
placed blindly by use of “back and forward” sutures as
described for the brow suspension.
Laterofacial area. This area is corrected by 2 approach-
es: temporal and transauricular. The temporal approach
was usually a 3- to 4-cm-long incision, running vertically
above the ear. The temporal area was then dissected blunt-
ly between the parietotemporal fascia and the deep tempo-
ral fascia up to the superior temporal line, where the plane
communicates with the subperiosteal dissection performed
previously in the forehead. Dissection also continued
below down to the upper edge of the zygomatic arch.
The parietotemporal fascia, superficial muscu-
loaponeurotic system (SMAS), and platysma comprise
Update on Minimally Invasive Face Lift Technique
Figure 6. Blunt dissection between the SMAS and the masseter
muscle, performed with a blunt, oval-ended dissector.
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one continual anatomic layer. The best way to shift
this layer in continuity is to free these structures from
their insertion on the zygomatic arch. This was
accomplished through the supraauricular incision, the
lower blepharoplasty incision, a vestibular approach,
or a transauricular approach, depending on the sur-
geon’s preference. The dissection was directed to
reach the zygomatic arch, where the periosteum was
opened with a sharp curved elevator. Dissection of the
zygomatic arch was continued, first over its anterior
surface as far as the malar area, which was partially
dissected, taking care not to damage the infraorbital
nerve by protecting it through application of a finger-
tip of the other hand percutaneously on top. At this
point, the dissection could meet the supraperiosteal
dissection performed on the centrofacial area.
Dissection then continued, obliquely downward and
deeper to reach the upper edge of the zygomatic arch,
where the periosteum was opened along the inferior
border of the arch to reach the posterior surface of the
SMAS, and then using a blunt, oval-ended dissector,
downward between the SMAS and the masseter mus-
cle (Figure 6). The SMAS was freed from the deeper
tissues across the cheek, although the degree of dis-
section was tailored according to the requirements of
the individual patient.
The subperiosteal dissection of the arch was complet-
ed by dissecting along the superior edge of the arch
where this dissection communicates with the previous
dissection done from above in the temporal region.
Because of the proximity of the frontotemporal branch of
the facial nerve, this dissection was performed upward
and was carefully controlled by percutaneous palpation
or with a fingertip through the temporal incision.
Once the periosteum was freed from the zygomatic
arch, it was easy to elevate the SMAS across the cheek.
To achieve the maximum mobilization of the SMAS (and
indirectly of the overlying cheek skin, which was neces-
sary in patients with severe aging changes classified as
grades III and IV rhytidosis), the preauricular SMAS was
Volume 28 • Number 1 • January/February 2008 • 55
Figure 7. Preauricular SMAS vertical section through the extended
temporal approach.
dissected from above through the temporal incision in
two planes, making a subcutaneous and a sub-SMAS
tunnel, and taking care not to damage the temporal ves-
sels. Holding the scissors with one blade deep and one
superficial to the SMAS, the SMAS was divided vertical-
ly, about 2 cm in front of the ear, stopping at the level of
the tragus to avoid injury to the facial nerve (Figure 7).
This freed the lateral attachments of the SMAS and
allowed a larger displacement of this structure.
Dissection of and traction to this layer had to be sym-
metrical on both sides of the face.
In some cases of extreme rhytidosis, the subperiosteal
dissection in the medial third of the face and malar area
was carried out through an additional vestibular upper
sulcus intraoral incision, which provides quick, direct,
and safe access but produces considerable postoperative
edema. If it was necessary to apply tension to the lateral
canthal area to correct the “crow’s feet,” the temporal
incision was extended from its superior end with an inci-
sion directed diagonally toward the tail/lateral eyebrow,
keeping it within the hair of the temple.
The suspension began with two or three SMAS
sutures placed in the preauricular area directed in an
oblique direction forward and upward, anchoring them
to the deep temporal fascia, allowing the preauricular
skin to be redistributed without bunching in the imme-
diate preauricular area, which would have required
excision through a preauricular incision. The tem-
poroparietalis fascia was suspended vertically from
above and sutured to the deep temporal fascia in a
stepwise fashion with 2 or 3 sutures at 3 different lev-
els to disperse the tension and so prevent ischemia and
dehiscence of the supporting tissues (Figure 8). Care
was taken to place these sutures at either side of the
path of the frontal branch of the facial nerve to avoid
catching the nerve with a suture. Some stitches were
applied to pull and fix the parietotemporal fascia of the
temporal skin flap to the temporal aponeurosis. There
was usually no skin excess in the temporal region, and
the incision was simply closed directly.
56 • Volume 28 • Number 1 • January/February 2008
Figure 8. Temporoparietalis fascia attached to the temporal skin flap
is pulled up and fixed to the temporal aponeurosis also.
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ADJUVANT PROCEDURES
In many patients, we performed other procedures at the
same time, such as platysmaplasty, autologous fat injec-
tion in some areas of the face, lateral canthopexy, correc-
tion of senile ptosis, ear lobule reduction, chemical or
laser peels, dermabrasion, rhinoplasty, genioplasty, lip
augmentation, and, in patients who had a previous
rhytidectomy elsewhere, revision of scars or even hair
transplantation to areas of alopecia.
POSTOPERATIVE TREATMENT
The ends of the sutures were fixed with Micropore tape,
and all the sutured incisions were covered with the same
tape. Strips of Micropore were also used to cover the fore-
head, the cheeks, and the neck. The strips were placed
horizontally in the forehead, diagonally in the cheek, and
transversely from one side of the neck to the other from
the submental crease as far as the vertical part of the neck
at the level of the hyoid bone. The intention was to con-
tain any possible distention of the soft tissues caused by
edema that might break the internal sutures. Of interest,
we have observed that in those areas where Micropore
tape was used, bruising was substantially reduced.
In those cases where we considered it necessary to
use a suction drain in the cheek regions, we padded this
area with gauze, cotton wool, and a soft bandage around
the head. By contrast, in patients without drains, the
cheek areas were not bandaged, and we prescribed the
continual use of cold compresses to encourage local
vasoconstriction and thus reduce any possible bleeding.
Because our skin sutures are made of resorbent
material and were placed in a subcuticular fashion, the
knots were trimmed at 4 to 5 days after surgery, and
the wounds were covered with narrow strips of Micropore
for 8 more days. About 15 to 20 days later, by which time
most of the edema had subsided, any prominent or undis-
solved suture ends were checked. This approach was very
convenient for those patients from other cities or countries
or with busy schedules who would have found it incon-
venient to return more frequently.
Aesthetic Surgery Journal
RESULTS
We have been performing minimally invasive face lift
procedures for more than 15 years. Since 1998, we have
carried out the described procedures or combinations of
them, depending on individual patient requirements, on
a total of 539 patients—436 women and 103 men.
Typical results are shown in Figures 9 to 11. We have
been able to avoid preauricular incisions in 83% of cas-
es, including all the patients with grades I and II rhytido-
sis and almost all those with grade III changes.
Preauricular incisions were necessary in only a few
patients with grade III changes and in all the grade IV
cases. There was almost no ecchymosis. The swelling is
from light to medium and disappears in 15 days to 1
month, and at 3 months after surgery the patients
demonstrate very natural-looking results.
Complications were minimal, such as temporary
hypoesthesia of the forehead or the cheek in 79 patients
(15% of cases) or cheeks in 27 patients (5% of cases), as
well as an occasional temporary palsy of the frontotem-
poral branch of the facial nerve lasting between 2 and 4
weeks. All these manifestations resolved spontaneously.
After we introduced the preoperative local application
of botulinum toxin to the occipitofrontalis and depressor
muscles, no evidence of postoperative facial palsy was
observed, so if any nerve was accidentally stretched dur-
ing surgery, causing temporary palsy, it resolved before
the effect of the botulinum toxin dissipated. Given that
the areas where skin was undermined were minimal and
limited to specific cases, we have had very few problems
with hematomas (3% of cases). In one case it was neces-
sary to check the hemostasis in the operating room, but
the other cases did not require any operative intervention
other than a minor office drainage procedure.
In this minimally invasive face lift, the deep soft
tissues are pulled up and relocated, but the skin is not
stretched surgically, respecting its consistency and
elasticity. These factors help us to achieve more natural
results. In addition, because the skin is not pulled
down by the deep soft tissues any more, it stretches
spontaneously and progressively, improving the results.
Patient satisfaction is high, because patients perceive
that improvement continues even 2 or 3 years after
the surgery.
DISCUSSION
The vertical suspension of the deep soft tissues is an
important component of the contemporary face lift. In
the cheek, the vertical suspension corrects the nasolabial
fold and the tear trough, gives excellent definition to the
lower lid contours, and eliminates the tractioning effect
of the descending soft tissues on the orbital septum.
Elevation of these tissues allows the fat pads to return to
their original position within the orbit, restoring the orig-
inal relationship of the orbital contents, moving the eye-
ball forward and slightly elevating the upper lid,
providing a more open eyelid fissure that allows light to
reflect fully on the eye, giving it a youthful sparkle. The
Update on Minimally Invasive Face Lift Technique
dissection of the centrofacial area could be performed in
a subperiosteal or supraperiosteal plane, depending on
the surgeon’s preference; both approaches will produce
the same effect in most cases.
The aging process affects the volume, structure, and
consistency of the neck tissues; platysma and skin are
displaced inferiorly, giving the neck a convex profile.
The vertical displacement of the parietotemporal fascia
in continuity with the SMAS and platysma muscle also
improve alterations of the neck caused by age, so we
treat the neck after the face lift and rarely perform isolat-
ed neck corrections.
The eyelids are also rarely addressed in isolation,
because the upper lid is intimately related to the eye-
brows and the forehead. This whole area should be
treated as one unit. The lower lid is usually treated as
part of the midface region. This concept was the origin
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of our term “centrofacial lifting,”16 which consists of cor-
recting brow position, improving the cheek and the
nasolabial fold, and performing blepharoplasty, all
through a conventional blepharoplasty approach.
We do not use permanent sutures, which may be pal-
pable later on. In our experience, mechanically speaking,
sutures do not need to last more than 3 weeks, which is
why we prefer to use only long-term resorbable sutures.
So far, these minimally invasive techniques have pro-
duced excellent and natural results in our hands. In
patients with grade IV deformity and some patients with
grade III deformity with obvious skin redundancy, it is
necessary to combine these procedures with a traditional
subcutaneous face lift in the lateral cheek region via
preauricular incisions. In such cases, it is not necessary
to make a subcutaneous dissection more than 3 cm to 5
cm wide. Redundant skin is trimmed conservatively to
allow its redistribution over the new facial contour with-
out tension. With aging, skin loses its elasticity, and it is
necessary to preserve whatever elasticity remains by
avoiding tension. In these cases, we have observed that
dissection and tightening of the SMAS, having tightened
the parietotemporal fascia vertically from above, results
in only minimal changes that, in fact, do not justify
dissecting it.
CONCLUSION
The elevation of the deep soft tissues of the face pro-
duces a volume augmentation of key facial prominences,
resulting in a natural, youthful effect. These procedures
are relatively simple and easy to carry out and produce
notable changes. However, they do entail somewhat of a
learning curve to achieve the best results.
One of the great benefits of this method is that it can
restore the structure of the face, augment cheekbone
prominences, redistribute lax skin, and tighten the skin
in a more natural manner than can be achieved with tra-
ditional methods. We believe that results are more
durable because this technique removes the weight that
the descent of the deep tissues exerts on the skin, allow-
ing the skin to recover some of its diminishing elasticity.
Volume 28 • Number 1 • January/February 2008 • 57
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E F
Figure 9. A, C, E, Preoperative view of a 42-year-old woman with rhytidosis, grade I. B, D, F, Postoperative view 22 months after endoscopic fore-
head and minimally invasive face lift (upper blepharoplasty, centrofacial lifting through lower blepharoplasty approach, cheek correction through
temporal approach).

58 • Volume 28 • Number 1 • January/February 2008 Aesthetic Surgery Journal

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Figure 10. A, C, E, Preoperative views of a 53-year-old woman, with rhytidosis grade III. B, D, F, Postoperative views 18 months after minimally
invasive face lift (transpalpebral endoscopic forehead lift), upper blepharoplasty, centrofacial lifting through a lower blepharoplasty approach,
cheek correction through a temporal approach, earlobe reduction, and hammock platysmaplasty (no preauricular incisions).

Update on Minimally Invasive Face Lift Technique Volume 28 • Number 1 • January/February 2008 • 59
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Figure 11. A, C, E, Preoperative views of a 57-year-old woman with, rhytidosis, grade III–IV. B, D, F, Postoperative views 13 months after endo-
scopic forehead lift and minimally invasive face lift (upper and lower blepharoplasty, centrofacial lifting, cheek lift through a temporal approach),
deep and superficial lipoinjection, and limited preauricular skin resection. With the patient looking downward, the support obtained for the soft
tissues is evident.

60 • Volume 28 • Number 1 • January/February 2008 Aesthetic Surgery Journal

These procedures are very safe—safer, we believe, than
other deep plane face lift techniques.
The application of botulinum toxin before surgery to
the frontalis, corrugator, and orbicularis muscles allows
the muscles to relax, so that they will not counteract the
displacement of the soft tissues. In addition, in case of
any possible frontal nerve palsy, it provides a 6-month
window to achieve a complete nerve recovery.
The minimally invasive face lift enables the surgeon
to avoid long incisions and the alopecia associated with
traditional coronal scars, entails minimal blood loss,
causes less altered sensation in hair-bearing skin, avoids
unnecessary elevation of the hairline, and causes less
edema because of the preservation of veins and lym-
phatic drainage pathways, thus accelerating recovery.
The minimally invasive face lift that we describe here
is a technique that is applicable to virtually all cases and
16. Fuente del Campo A. Centro facial lifting. Perspect Plast Surg
1993;7:87–99.
17. Hagerty RC. Central suspension technique of the midface. Plast
Reconstr Surg 1995;96:728–730.
18. Fuente del Campo A. The subperiosteal rhytidectomy and the lower lid
incision approach to the nasolabial fold. In: Bernard RW, editor.
Surgical Restoration of the Aging Face. Butterworth-Heinemann; 1996.
p. 169–194.
19. McCord CD. Redraping the inferior orbicularis arc. Plast Reconstr Surg
1998;102:2471–2479.
20. Hobar PC, Flood J. Subperiosteal rejuvenation of the midface and
periorbital area: a simplified approach. Plast Reconstr Surg
1999;104:842–851.
21. Moelleken B. the superficial subciliary check lift, a technique for
rejuvenating the infraorbital region and nasojugal groove: a clinical
series of 71 patients. Plast Reconstr Surg 1999;104:1863–1874.
22. Hester RT, Vodner MA, McCord CD. The centrofacial approach for
correction of facial aging using the transblepharoplasty subperiosteal
cheek lift. Aesthetic Surg J 1999;16:51–58.
23. Gunter JR. A simplified transblepharoplasty subperiosteal cheek lift.

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Plast Reconstr Surg 2000;103:2029–2036.
has radically changed our approach to the restoration of
the soft tissue contours of the face by reducing morbidi- Accepted for publication June 15, 2007.
ty, achieving more durable results and providing a Reprint requests: Antonio Fuento del Campo, MD, CAP. Interlomas #26,
greater degree of satisfaction to our patients. ◗ Mexico 52786, D.F. Mexico.
Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
DISCLOSURES 1090-820X/$34.00
doi:10.1016.j.asj.2007.06.006
The author has no disclosures wiith respect to this article.

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