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Introduction: The 4-dimensional facelift is an advanced rhytidectomy technique using a combination of the subperiosteal and multiplanar/multivector facelift techniques simultaneously with CO2 and erbium:YAG laser resurfacing for maximal facial rejuvenation. The combination of these procedures produces a rejuvenation that has synergistic benefits. The facelift alone does not rejuvenate fine rhytids around the mouth and infraorbital regions. In addition, laser resurfacing does not address the rhytids caused by deeper ptotic anatomic structures, nor lines of animation. The 4-dimensional rhytidoplasty provides the ultimate in subtle release of the anatomic facial planes. This concentric release of the various anatomic planes reduces unnecessary tension and unnecessary vascular compromise on any particular layer. This results in increased safety of the technique, allows for simultaneous laser resurfacing, and gives a more natural and improved facial rejuvenation. Materials and Methods: Thirty-two patients (4 males and 28 females) underwent the 4-dimensional facelift between November 1998 and December 1999. This includes simultaneous laser resurfacing and a deep-plane multivector facelift, including an extended subperiosteal release. After all adjunctive procedures had been performed and the superficial musculoaponeurotic system had been stabilized, the redundant preauricular skin was lasered, keeping the energy densities the same, but altering the number of passes. The edges were then trimmed and submitted for histologic examination. Conclusions: The authors are not aware of any previous publications combining all the anatomic planes of the face into a single operation. It has also been the accepted dictum by various experts in the field that laser resurfacing over the undermined flap was a contraindication. However, on the basis of our experiences and results, it is our opinion that this can be done and that the clinical endpoint is safely achieved, resulting in a superior cosmetic result and an assumed increased longevity.

Introduction: Since the introduction of the endoscopic browlift, several techniques have been advocated to improve long-term stability and results. These include extensive undermining of the flap, muscle plication, and a variety of fixation techniques. At our institution, intraoral subperiosteal dissection is used in combination with the laser-assisted endoscopic browlift. No clinical studies have compared flap tension using the different methods of periosteal release. The purpose of this study was to compare scalp tension when the flap was pulled posteriorly 10 mm and 15 mm with and without intraoral subperiosteal release of the midface. Materials and Methods: This study included 37 patients and consisted of 4 men and 33 women. They underwent a laser-assisted endoscopic browlift with general anesthesia or intravenous sedation. Scalp tension was measured with a spring scale. Scalp tension was measured at 6 locations (the incisions over the right and left medial brows, brow heights, and temporal regions). After the laser-assisted endoscopic browlift, measurement of scalp tension at each location was recorded while the scalp was pulled posteriorly 10 mm and then 15 mm. Tensions were measured prior to and after intraoral subperiosteal release of the midface. Tensions at each incision site before and after subperiosteal release were compared using paired t tests. Tensions between the medial brow, brow height and temporal flaps for each side were also compared using paired t tests. Results: Subperiosteal release of the midface significantly reduced tension at every incision site by more than 200 g. The average amount of tension reduction gradually increased from the midline sites to the temporal sites prior to subperiosteal release of the midface. Tension was reduced by more than 300 g at the temporal sites after subperiosteal release of the midface. Conclusions: This study demonstrates that by including intraoral broad subperiosteal detachment of the midface, there is less tension on the flap at all incision sites. Reduced tension and more equally distributed tension would be expected to contribute to better would healing, improved predictability, and assumed longevity of results.