Endoscopic Midface Procedure

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

Medial Suborbicularis Fat
  1. 43.5. The suspension suture locations and vectors of pull generated with the endoscopic midface technique. Note that the three suspension sutures are initially placed transorally through a gingival buccal sulcus incision and are directed individually to the temporal dissection pocket under endoscopic guidance. BF Bichat's fat pad, SOOF suborbicularis oculi fat pad
  2. 43.5. The suspension suture locations and vectors of pull generated with the endoscopic midface technique. Note that the three suspension sutures are initially placed transorally through a gingival buccal sulcus incision and are directed individually to the temporal dissection pocket under endoscopic guidance. BF Bichat's fat pad, SOOF suborbicularis oculi fat pad
Bola Bichat Anatomia
  1. 43.6. Delivery of Bichat's fat pad. a The fat pad herniates through the spread periosteum and buccinator muscle. b Gentle dissection with a blunt dissector mobilizes the fat pad. c The fat pad is then gently teased from the buccal space with forceps. d Continued gentle traction and concomitant blunt dissection will assist the full delivery of the fat pad
  2. 43.6. Delivery of Bichat's fat pad. a The fat pad herniates through the spread periosteum and buccinator muscle. b Gentle dissection with a blunt dissector mobilizes the fat pad. c The fat pad is then gently teased from the buccal space with forceps. d Continued gentle traction and concomitant blunt dissection will assist the full delivery of the fat pad the surgeon to keep track of each suspension suture. The second suspension suture is the cheek imbrication, or "modiolus" suture. This suture is placed into the tenuous fascia and fat of the inferior maxillary soft tissue near the upper buccal sulcus incision. Both ends of this suture are then directed through the temporal incision and tagged, as previously described.

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

Bilateral Upper Anchor Blepharoplasty
  1. 43.7. Preoperative (left) and postoperative (right) views of a 46-year-old female patient exhibiting signs of early facial aging. The preoperative image demonstrates evidence of frontalis muscle hyperfunction in conjunction with "normal" brow position and upper eyelid pseudoptosis. The patient was treated with a full endoscopic forehead and midface double ogee facial rejuvenation, along with bilateral lower lid blepharoplasty. Note the relaxed forehead and improved upper-lid position that results from correction of the true brow ptosis
  2. 43.7. Preoperative (left) and postoperative (right) views of a 46-year-old female patient exhibiting signs of early facial aging. The preoperative image demonstrates evidence of frontalis muscle hyperfunction in conjunction with "normal" brow position and upper eyelid pseudoptosis. The patient was treated with a full endoscopic forehead and midface double ogee facial rejuvenation, along with bilateral lower lid blepharoplasty. Note the relaxed forehead and improved upper-lid position that results from correction of the true brow ptosis
Midface Elevation
  1. 43.8. Preoperative (left) and postoperative (right) oblique or three-quarter views of the 46-year-old patient shown in Fig. 43.7. The preopera-tive view clearly shows the flattened midface associated with facial aging. Restoration of midfacial volume gives the patient a youthful, rejuvenated appearance. The double ogee is clearly defined in the postoperative result
  2. 43.8. Preoperative (left) and postoperative (right) oblique or three-quarter views of the 46-year-old patient shown in Fig. 43.7. The preopera-tive view clearly shows the flattened midface associated with facial aging. Restoration of midfacial volume gives the patient a youthful, rejuvenated appearance. The double ogee is clearly defined in the postoperative result
Fig. 43.9. A youthful photograph of the patient from Fig. 43.7 and 43.88 taken during her early 20s. Compare this view with her postoperative results. Considerable rejuvenation can be achieved with the double ogee technique
Bicht Fat Pad
  1. 43.10. Preoperative (left) and postoperative (right) views of a 42-year-old female patient who underwent endoscopic forehead and midface rejuvenation in conjunction with bilateral upper and lower blepharoplasties. The preoperative view demonstrates subtle flattening of the brows, glabellar frown lines, and moderate midface soft-tissue decent. The postoperative result shows improved brow shape, smoothing of the glabellar rhytids, and improved midface soft-tissue volume
  2. 43.10. Preoperative (left) and postoperative (right) views of a 42-year-old female patient who underwent endoscopic forehead and midface rejuvenation in conjunction with bilateral upper and lower blepharoplasties. The preoperative view demonstrates subtle flattening of the brows, glabellar frown lines, and moderate midface soft-tissue decent. The postoperative result shows improved brow shape, smoothing of the glabellar rhytids, and improved midface soft-tissue volume
Fig. 43.11. Preoperative (left) and postoperative (right) three-quarter views of the 42-year-old patient shown in Fig. 43.10. Moderate brow ptosis with lateral hooding can be seen in this oblique view. Improved brow and cheek soft-tissue position accentuate the double ogee in the postoperative

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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