The midface subperiosteal approach offers some unique advantages to certain patients. Namely, the elevation of the midface musculature with improvement of nasolabial crease, the more anatomic repositioning of tissue over the malar eminence, correction of "tear trough" (either post bleph or primary) and use in many post lower lid blepharoplasty patients with scleral show.

Unfortunately, the initial enthusiasm for open lower lid subperiosteal procedures has been mollified by the morbidity of the lower lid incision, peculiar problems with the temporal fascia suture fixation in patients with globe to intra-orbital rim negative angles and difficulty in dissecting the area.

An intra oral technique of fixation of the SOOF through an oblique drill hole placed through the lower lateral orbital rim and suture with permanent suture is presented.

This has been used in 108 patients with a one-to-four year follow-up.

Simultaneously, "teasing" the lower lid fat pads or replacing soft tissues over zealously removed to drape over the orbital rim has produced very encouraging results.

Technique is demonstrated with vector analysis which mimics normal anatomy recreating pre-aging/bleph positions and facial muscle relationships in repose and animation.

Results are shown demonstrating use in primary cases, post bleph with scleral show, use with cheek/piriform implants and some hints on local anesthetic use and dissection which make this a procedure that would be very useful and predictable for surgeon's with large and varied cosmetic facial surgery requests.

Swelling and tightness across the upper dental arch has been noticed in a few patients (6/108) and asymmetric movement of upper lip in (8/108) all of which has resolved in under ten (10) weeks.

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