The endoscopic midface procedure begins with the temporal dissection in zone 1, as outlined in the previous section. Temporal vein no. 2 (sentinel vein), temporal vein no. 3, and, the zygomaticotemporal nerves are preserved when possible. The dissection continues in an anterior and inferior direction, remaining above the intermediate temporal fascia. This continues down to the level of the zygomatic arch. The zygomatic arch is entered immediately at the superior border of the arch. The endoscopic visualization allows precise identification of the intermediate temporal fascia, thus exposing the periosteum of the zygomatic arch. The authors prefer elevation of the anterior two thirds of the zygomatic arch periosteum because it enables greater lifting and redistribution of the midface soft tissues. The periosteum of the entire zygomatic arch is elevated when soft tissues lateral to the cheek need to be elevated. Surgeon comfort with the dissection over the zygomatic arch is associated with a significant learning curve. We have found that communication of the midface and temporal dissections is accelerated with pre-elevation of the zygomatic arch, or at least the superior border of the arch.
The midface dissection at this point continues through an intraoral (upper buccal sulcus) incision. The authors' preferred incision is perpendicular to the alveolar ridge (vertical) at the level of the first premolar. We find that the vertically oriented incision preserves the mucosal integrity at the alveolar ridge, allowing a rapid, watertight closure that is associated with fewer complications. Under direct visualization, the initial subperiosteal dissection of the maxilla and malar area is performed. The endoscope is used for the upper malar dissection. The use of the endoscope minimizes trauma to the midface structures caused by excessive traction. The endoscope is most useful during periosteal elevation along the lateral half of the zygoma body, its extension underneath the fascia of the masseter muscle, and the anterior two thirds of the zygomatic arch. The upper (medial) portion of the masseter tendon is also elevated from the zygoma. Endoscopic visualization assists in the preservation of the zygomaticofacial nerve.
Dissection continues along the inferior and lateral orbital rim and continues toward the superior border of the zygomatic arch. Skeletonization of the infraorbital nerve is not necessary under most circumstances.
With the initial midface dissection now complete, the endoscope is returned to the temporal area. An assistant elevates the soft tissue of the midface, thus allowing the surgeon to safely connect the temporal and midface dissection pockets under endoscopic control. Gentle elevation during this step protects the frontal branch of the facial nerve from injury. With wide communication of the temporal and midface pockets, the endoscope is returned through the upper buccal sulcus incision.
The inferior orbital rim is dissected further by elevating the inferior arcus marginalis. A 4-0 PDS suture (Ethicon, USA), introduced endoscopically, is used to imbricate the medial suborbicularis oculi fat (SOOF) to the lateral aspect of the inferior arcus marginalis. It is important to check eye globe mobility at this point with a forced duction test because improper placement of this imbricating suture can trap or place traction upon the inferior oblique muscle.
The lateral aspect of the SOOF is then grasped with a 3-0 PDS suture, providing the first of three suspension sutures (Fig. 43.5). Both ends of this suture are then passed through the temporal incision, under endoscopic guidance. We find it helpful to tag the suture ends with a labeled needle driver. This allows
Exposure of Bichat's fat pad follows the placement of the last suspension suture. Bichat's fat pad is approached through the superomedial wall of the buccal space. The periosteum and buccinator muscle are spread with the use of a blunt dissector. This allows Bichat's fat pad to herniate through maintaining an intact capsular fascia (Fig. 43.6). The fat pad should be carefully dissected free from the wall of the buccal space. Bichat's fat pad should be easily movable for repositioning as a pedicle flap. A 4-0 PDS suture is then woven into the fat pad and the suture ends are delivered to the temporal area, similar to the previous suspension sutures. The endoscope should be used to visualize the delivery of the pedicled fat flap over the malar bone. The endoscope can also assess the trajectory of the suspensions sutures. It is important to avoid crisscrossing the suspension sutures as they are passed to the temporal area.
Each of the suspension sutures is then secured to the temporal fascia proper, in ordered fashion. The sutures should be placed in the temporal fascia proper, below the level of the temporal incision. The first suture, the Bichat's pad fat suspension, should be placed most medially. The inferior malar fascia and fat or modiolus suture is placed next, in a more lateral location of the temporal fascia proper. The most lateral suture, the suborbicularis oculi suture, is the last
to be anchored to the temporal fascia proper. This completes the suspension of the midface.
Butterfly drains are placed bilaterally through separate stab incisions in the temporal scalp. Each drain is carefully directed into the midface and secured to the temporal scalp with a suture. The superficial temporal fascia is then anchored to the temporal fascia proper with two 4-0 PDS sutures, while an assistant provides superomedial traction to the advanced scalp. The intraoral incisions are then closed with interrupted 4-0 chromic catgut sutures. The butterfly drains are placed to gentle suction at the completion of the operative procedure. The drains are typically maintained for 48-72 h postoperatively. Figures 43.743.11 provide several patient examples demonstrating the rejuvenative capacity of the volumetric double ogee rhytidectomy technique.
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