Ruth Graf, Daniele Pace, Luiz Roberto de Araujo
Since the introduction of endoscopic brow lifting in the mid-1990s, videoendoscopic surgery has become widely accepted as a method for rejuvenation of the upper third of the face, mainly to achieve eyebrow and forehead elevation. It has many indications and it is performed to correct eyebrow ptosis and to treat glabellar rhytids created by corrugators, and depressor supercilii and procerus muscles.
Several factors, including natural aging, facial nerve injuries and facial trauma, may cause brow pto-sis, although congenital or hereditary factors may also cause this condition. Eyebrow lifting and/or forehead lifting is not a new concept; however, videoendoscopic technique for these procedures is relatively new.
Videoendoscopic surgery of the forehead and mid-face intends to treat forehead wrinkles, elevate the lateral portion of the brow, release the depressor muscles of the glabella, free periorbital ligaments, elevate soft tissue of the midface and correct asymmetries. To accomplish these goals, one must study the frontal, periorbital and midface anatomy. Advantages include visualization and tissue manipulation through very short incisions with image magnification and treatment of wide areas with short scars.
In the physiology of eyebrow ptosis, the depressor muscles pull down the medial portion and the frontal muscle elevates the medial and central portions of the brows, creating horizontal wrinkles on the forehead. On the other hand, there is soft-tissue ptosis on the temporal area owing to the absence of the frontal muscle lateral to the temporal adhesion zone, with descent of the brow tail.
Recent articles report that videoendoscopic surgery of the forehead and midface shows excellent results. The advantages are significant reduction of the incision length, better camouflage of these incisions and less bleeding and surgical trauma. Besides, it reduces the dysesthesia of the scalp because the deep branch of the supraorbital nerve is injured less.
There are several fixation methods, including ab-sorbable and nonabsorbable screws, sutures, cortical tunnel, Endotine and fibrin glue.
The disadvantages include higher cost related to the sophisticated equipment necessary and the long learning curve to achieve proficiency.
One of the earliest reports concerning the use of en-doscopic techniques in plastic surgery was in 1992 when Core and Vasconez  described the endoscop-ic coronal lift. In the follow-up article published in 1995, they noted that the complication rate in endo-scopic brow lifts was not greater than in the open technique . They reported recurrent ptosis in less than 2% of patients. In addition to using external suture stabilization for 3-5 days, they also excised a triangle of skin just in front of the hairline.
In 1994, Vasconez  published a new article describing endoscopic forehead lifting. He detailed the use of an endoscope to guide the release of supraorbital and glabella soft tissues. Dissection was on the subgaleal plane and procerus and corrugator muscles were severed. The fixation technique was not clearly described and seemed to be variable.
Since the first reports, multiple variations of the technique have been used, mostly regarding different incisions, planes of dissection and methods of fixation.
In 1993, Marchac [16, 17] described the use of an endoscope to elevate forehead, malar and maxillary tissues, through a subperiosteal plane and fibrin glue fixation.
Isse  in 1994 described the subperiosteal endoscopic technique for the forehead, dissection over the deep temporal fascia in the temporal area, supraperi-osteal plane in the midface and lower third, and sub cutaneous cervical dissection. He described tissue elevation with vertical and medial vectors with fixation stitches of the forehead to the galea superiorly, and superficial temporal fascia and superficial musculo-aponeurotic system (SMAS) to the deep temporal fascia in the temporal area [7, 8].
In 1994, Ramirez [24-26] described the use of vid-eoendoscopic surgery for the forehead, midface and lower face. He used the subperiosteal plane for all these areas, affirming the need to release the periosteum of the superior gingival sulcus. He also described the biplanar approach at the level of the zygo-matic arch.
Since 1995, Knize [10-14] has published several articles regarding the frontal and temporal anatomy, where he identified fully in detail all structures and elements that should be well known to facilitate the performance of endoscopic technique in order to avoid neurovascular injuries. He described the depressor muscles of the eyebrows: procerus, corruga-tors (transverse and oblique head) and depressor su-percilii, which should be severed. On the other hand, the transverse head of the corrugator muscle should be left intact to prevent widening of the brows.
Many authors studied fixation techniques in endo-scopic surgery, over a long-term period. McKinney  and Daniel  used central and temporal fixation with screws; however, McKinney uses lateral fixation with galea sutures to the deep temporal fascia and bony fixation in parasagittal incisions. He believes that such maneuvers decrease risks of sagittal sinus and middle meningeal artery damage, alopecia and allow a longer esthetic outcome. Jones  compared the use of cortical tunnel suture fixation with fibrin glue. He found sutures were a better method of fixation. De Cordier  makes three triangular pre-capillary incisions that are sutured in a transverse fashion creating additional elevation besides the temporary sutures in the incisions 5 cm posterior to the hairline, kept in place for 3-5 days. Casagrande  described in 2000 the transcutaneous fixation of the midface with a needle.
In 2000, Little  embraced the idea of volumetric enhancement of the face with special regard to mid-face elevation.
Mendelson et al. [21-23] described in 2000 new anatomic terms for the periorbital and facial areas, which are zones of adhesion (temporal adhesion), septii (superior and inferior temporal septum, periorbital septum) and real ligaments (zygomatic and masseteric).
Matarasso  in 2000 evaluated facial rejuvenation and developed an algorithm for the selection of the appropriate technique, and so in patients with only forehead rhytids with no associated surgery he indicates botulinum toxin injections with a laser; for patients with glabellar creases with no surgery associ ated he indicates endoscopic surgery; and when there is a blepharoplasty he corrects the depressor muscles through the same incision. Finally, in patients with brow ptosis he performs endoscopic surgery and when there is rhytidectomy associated he makes temporal suspension through the temporal aspect of face-lift incision.
Surgical Technique 30.3.1
With the patient under sedation, the skin marks and initiated with the temporal fixation zone, the hair is divided exactly where the incisions will be placed, meaning one central, two paramedial (1.5 cm medial to the temporal line to avoid injury of the deep branch of the supraorbital nerve, which crosses within 1.5 cm medial to this line) and two temporal incisions marked as a continuation of a imaginary line drawn from nasal ala to the corner of the eye, 2 cm behind the hairline (Fig. 30.1). Xylocaine (1%) and marcaine with 1:200,000 epinephrine is injected in the areas to be operated on.
The anatomy of the orbital and frontal area has a mul-tilayered structure, including skin, subcutaneous tissue, muscles (orbicularis oculi laterally, corrugators, depressor supercilii and procerus medially), galea, periosteum and bone.
Incisions of 1.5 cm each (one central and two paramedial) are made in a vertical fashion to avoid nerve injury and are placed just a few millimeters behind the hairline. The temporal incision is 3 cm long and is placed 2 cm behind the hairline, perpendicular to the direction of the vectors.
The undermining on the frontal area is performed at first blindly, with a curved dissector in the subperiosteal plane, down to 2 cm above the superior orbital rim. In the temporal area a blunt round dissector is used, superficial to the deep temporal fascia. Right after this dissection, a 4 mm 30° endoscope is introduced, with a protection sleeve with a curved tip to facilitate undermining and visualization. The sub-periosteal plane is used and the dissection is performed under endoscope vision down to the superior
orbital rim, carefully avoiding supraorbital nerve damage bilaterally. Afterwards, with the endoscope placed in the paramedial incision and face-lift scissors in the temporal incision, the temporal ligament is ruptured down to the lateral orbital rim, including its terminal portion, till the superior orbital septum is visualized. The temporal ligament or temporal fusion line (Knize) or medial temporal septum (Mendelson) is a zone of confluence of superficial temporal fascia and galea, and also deep temporal fascia and frontal bone periosteum. This ligament is present till the lateral portion of the superior orbital rim.
The dissection continues medially by cutting the periosteum and galea in the superior orbital rim (ar-cus marginalis) till the supraorbital nerve is visualized (Fig. 30.2). The arcus marginalis is an area of thickening of the galea in the superior portion of the orbit and acts as an adherence point to the septum orbitalis.
Next, the dissection is completed in the temporal area with visualization of the sentinel vein (medial zygomatic-temporal vein) (Fig. 30.3), which is cauterized to avoid tearing and bleeding of this vessel during endoscope manipulation when working towards the midface.
Lateral to this vein there is the medial zygomatic-temporal nerve that can be preserved or severed (sensitive nerve to the surrounding skin). Medial to the sentinel vein, dissection goes to the lower eyelid, and laterally it goes towards the midface. At that point, the undermining can be subperiosteal or supraperios-teal. Our preference is the supraperiosteal plane, which is the same continuing above the deep temporal fascia with no need to incise the periosteum at the level of the zygomatic arch. The undermining contin-
ues below the orbicularis oculi muscle and supraperi-osteal in the lower eyelid, releasing the inferior periorbital septum (retaining ligament), responsible for the nasojugal crease (Fig. 30.4). The precantal tendon is released to allow rotation of all periorbital elements superior, inferior and also laterally.
Right next to the sentinel vein, lateral to it, dissection goes down to the midface in the supraperiosteal plane, below the suborbicularis oculi fat towards the nasolabial fold, undermining below the SMAS and above the zygomaticus major muscle. The medial limit for the dissection is the infraorbital nerve, and laterally the motor nerves for the zygomaticus major muscle, branches of the facial nerve. A blind maneu-
Fig. 30.3. Sentinel vein and medial zygomatic-temporal nerve ver is made rotating medially and superiorly, to detach the zygomatic ligament laterally. The motor branches of the facial nerve should be preserved during videoendoscopic facial surgery. The temporal branch of the facial nerve runs 1.5 cm above and laterally to the superior orbital rim and should remain in the flap throughout the surgery. The zygomatic branches of the facial nerve run between the orbicu-laris oculi muscle and the zygomaticus major muscle, penetrating the orbicularis oculi muscle through several branches (lateral, medial and inferior).
After the undermining is finished in the midface and temporal area, dissection is completed in the gla-bella. The endoscope is placed in the central incision on the subperiosteal plane, and 1 cm above the gla-bella, the periosteum and galea are ruptured with the curved dissector. As a result, the depressor muscles are visualized, from lateral to medial: corrugators (transverse and oblique portion), depressor supercilii and procerus. With a curved grasper, these muscles
Fig. 30.3. Sentinel vein and medial zygomatic-temporal nerve
Fig. 30.5. a Corrugator muscle. b Supratroclear nerves are divided with gentle maneuvers, beginning from the bony end towards the skin, except for the transverse portion of the corrugator, in order to avoid widening of the brows. During this point of the procedure, the supratrochlear nerves and vessels are identified, and should be preserved (Fig. 30.5).
The nerves observed in videoendoscopic surgery are supraorbital and supratrochlear, which exit from their specific foramen. The correct release of the periosteum in the superior orbital rim and division of procerus muscle, depressor supercilii and corruga-tors, preserving sensitive nerves in the supraorbital area, is one the most critical steps in videoendoscopic surgery. Obviously, avoiding injury of the temporal branch of the facial nerve is also very important for a successful procedure.
Finally, after all the dissection is completed, the flap can be easily mobilized. Fixation is then started with demarcation of three points of reference in the following order: (1) inferior and lateral malar area; (2) cen tral malar area; and (3) lateral cantal tendon. With the endoscope, a Casagrande needle is introduced in the points previously marked (Fig. 30.6). The introduction begins externally and then with the endoscope (to avoid nerve damage), reaching the temporal incision, where 3.0 colorless nylon is placed in position and finally the needle is pulled back to the entry orifice, grasping around 1 cm of the midface flap, going back to the temporal incision, where the suture line is withdrawn from the needle. The third point passes also in the periosteum superiorly, so to fixate the mio-cutaneous orbicular flap in a superior position. These three points are sutured in the deep temporal fascia at the level of the temporal incision. Fixation of the forehead is performed with cortical tunnels in the paramedial incisions, fixating the periosteum to the cortical tunnel (2.0 nylon), with the goal to elevate the forehead, mainly in the lateral portion of the brows (Fig. 30.7).
The last step is scalp sutures without skin resection and no tension. Tape over the area dissected is kept for 1 week to decrease the possibility of hematomas and seroma.
There are good outcomes in a long-term period, with maintenance of brow elevation, reduction of glabellar creases, lateral rotation of periorbital elements and midface elevation (Figs. 30.8-30.10). Swelling is effaced in 30-60 days, persisting rarely for more than
3 months. Relapse and asymmetry may occur, and sometimes surgical revision is necessary. Dysesthesia and paresis may occur owing to nervous compression by the endoscope or surgical manipulation, or even through cauterization. Therefore, only the sentinel vein should be cauterized; further bleeding should be controlled by external compression and cold saline only. If there is a permanent nerve injury, the nerve on the opposite side should be divided as well to achieve balance. Skin burn may happen if cauterization is extensive, so it should be avoided. Hematoma is rarely described. Alopecia may appear owing to overly manipulated tissue or excessive suture tension. Prevention is always the best treatment.
Videoendoscopic surgery of the forehead and midface is less invasive, with short discrete incisions, where treatment is performed under direct vision with the endoscope. It is indicated at any age, as a single procedure or associated with rhytidectomy, blepharoplasty, chemical peeling, laser and facial fillers. The learning curve may be long, as appropriate training with specific surgical instruments is needed. Anatomy study is absolutely mandatory and workshops on the technique as well as observation of experienced peers is very important.
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