Three-Dimensional Endoscopic Midface Enhancement: A Personal Quest for the Ideal Cheek Rejuvenation

Transcription

1 Techniques in Cosmetic Surgery Three-Dimensional Endoscopic Midface Enhancement: A Personal Quest for the Ideal Cheek Rejuvenation Oscar M. Ramirez, M.D. Baltimore, Md. Standard face-lift techniques are excellent for the treatment of the jawline and neck. Treatment of the area between the lower eyelid and the corner of the mouth required the development of techniques in the intermediate lamella of the face. Alternative techniques of subperiosteal dissection by means of lower eyelid incisions were described with good aesthetic results but at the expense of increased morbidity and complications. All these techniques were also two-dimensional manipulations of the soft tissues of the face. The author presents a different approach that he believes is close to the ideal in terms of safety, morbidity, and complications. Although midface rejuvenation may be performed alone, it is more commonly done as a component of total facial rejuvenation. The midface is approached by means of a combination of a temporal slit incision and an upper oral sulcus incision; no eyelid access is used. Fifty percent of the midface dissection is performed under direct visualization, and 50 percent is performed under endoscopic control. Dissection of the temporal area is done under the temporoparietal fascia down to the zygomatic arch. The anterior two-thirds of the zygomatic arch periosteum is elevated along with a few millimeters of the intermediate temporal fascia and the fascia of the masseter muscle. The subperiosteal dissection of the zygoma and maxilla is completed with the medial extension of the dissection just medial to the infraorbital nerve. The orbital fat pads are released by means of intraoral route, and the lateral and middle fat pads are advanced over the orbital rim and fixed to the masseter tendon and the periosteum of the maxillary shelf at the intraoral incision. Three suspension points are typically used on the midface, each one with a different action. All are anchored to the temporal fascia proper. The vascularized Bichat s fat pad is mobilized and fixed with 4-0 polydioxanone sutures. This provides a volumetric cheek augmentation and improvement of the jowl. The inferior malar periosteum and fascia is used for malar imbrication with 4-0 polydioxanone sutures. This provides an anterior projection of the cheek and elevates the corner of the mouth. The suborbicularis oculi fat is used for en bloc vertical suspension of the cheek. This also improves the infraorbital V deformity. This technique has been used in close to 200 patients over the last 5 years. The complications have been minimal: two cases of temporary paresis of the levator of the upper lip, one case of paresis of the orbicularis oris (unilateral), one case of buccinator muscle dysfunction, and two moderate infections that were treated with simple drainage. The degree of facial edema has been minimal compared with the open or the transblepharoplasty approach. Typically, patients can return to work 2 weeks after surgery. The three-dimensional endoscopic midface enhancement provides a technique of midface remodeling that provides the missing dimension (volume) to the rejuvenation of the midface. This can be done with a minimal rate of complications, and the aesthetic results surpass by far the results of other midface techniques previously described by the author. (Plast. Reconstr. Surg. 109: 329, 2002.) Standard face-lift techniques were excellent methods for the treatment of the jawline and neck. However, its effectiveness was diminished as the aging process was manifested from the angle of the mouth to the lower eyelid level. Other methods arose that were effective for the treatment of the nasolabial fold and sagging cheek but still not quite effective for the improvement of the difficult area: the V deformity of the eyelid-cheek interface that has become known, although not quite properly, as the tear-trough deformity. Treatment of this critical area required the development of newer techniques that evolved almost in a par- From the Plastic Surgery Division of the Johns Hopkins University School of Medicine and the Plastic Surgery Division of the University of Maryland School of Medicine. Received for publication October 17, 2000; revised April 2,

2 330 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2002 allel fashion. The common denominator to these techniques was that dissection took place in the intermediate lamella of the face. A powerful alternative for the treatment of the midface, including the V deformity, was the subperiosteal face lift described by Tessier. 1 The beneficial effect of the subperiosteal face lift was extended to the entire periorbita, producing, in effect, a periorbitoplasty with repositioning of not only the origins of the midface muscle, but also the orbicularis oculi muscle in about a 300-degree circumference. This, along with the periorbitoplasty of Hinderer et al., 2 was the earliest effort to treat this condition. The aim of this paper is to describe my personal view of the ideal midface rejuvenation, my involvement in the evolution of this technique, and how and why I have reached the present methodology: the three-dimensional endoscopic rejuvenation and restoration of facial volume on the midface. The Ideal Midface Rejuvenation From my perspective, the ideal midface rejuvenation should: 1. Provide a volumetric remodeling of the cheek. 2. Allow management of the skeletal foundation by augmentation or reduction without additional incisions or an alternative plane of dissection. 3. Allow the injection of fat grafting without the risk of migration or the need for fixation of alternative grafts. 4. Correct the fat pad herniation of the lower eyelid. 5. Correct the V deformity of the eyelidcheek interface. 6. Lift the corner of the mouth. 7. Have the potential for treating the skin layer in the same operative setting without the risk of skin necrosis or delay in healing. 8. Minimize facial edema. 9. Minimize facial numbness. 10. Minimize facial nerve injury. The ideal midface rejuvenation should not rely on: 1. Canthopexy or canthoplasty to suspend the cheek. 2. Canthopexy or canthoplasty as a primary or secondary procedure to avoid eyelid malposition. 3. Pulling or stretching of the soft tissues that may cause a bunching or banding effect on the malar area. 4. Incisions that traverse the orbicularis oculi muscle. 5. A dissection through the intermediate layers of the face where the muscles and motor nerves of the face are located. Historical Review After the initial description of the subperiosteal face lift by Tessier 1 and subsequently by Psillakis et al. 3, I realized some of the difficulties and shortcomings of the procedure. This was obviously expected for any breakthrough technique. For that reason, after extensive anatomical and clinical work, my colleagues and I published a paper called Extended Subperiosteal Facelift: A Definitive Soft-Tissue Remodeling for Facial Rejuvenation. 4 The difference between this technique versus the Tessier approach was the very extensive dissection of the midface that included the fascia of the masseter muscle, a safe access to the zygomatic arch by means of the intermediate temporal fascia, and a more reliable suspension method, which was a flap based on the temporal fascia. The change from my initial description that used both layers of the temporal fascia to the later one that uses only the intermediate temporal fascia was caused by the observation in some patients of the postoperative development of a depression in the temporal region. 5,6 To optimize cheek elevation, I changed the suspension point to the suborbicularis oculi fat. This was initially described in a paper entitled Endoscopic Full Facelift. 7 In that paper, I described the eyelid incision as one of the access points to dissect the zygomatic arch and the midface. This was the endoscopic version of Fuente del Campo s open lower eyelid approach. 8 Although it was obviously shown in pictures (figure 4 of that article), I did not emphasize that the incision in the eyelid was limited. Because this limited incision required endoscopic techniques for the dissection of the midface, it was not readily accepted by surgeons. Other modifications of the technique were done that converted the procedure back to an open technique. 9 This required a full blepharoplasty incision and a canthopexy for suspension of the midface and for prevention of ectropion and eyelid malposition. Despite the preventive canthopexy, these open methods created complications, particularly in rela-

3 Vol. 109, No. 1 / ENDOSCOPIC MIDFACE ENHANCEMENT 331 tion to eyelid malposition. Hurwitz and Raskin 10 described a 50-percent rate of eyelid malposition for the open method, a much higher rate than for the lower blepharoplasty alone, which has been determined to be about 20 percent. 11 My personal technique was evolving toward smaller incisions rather than larger ones Therefore, to minimize lower eyelid complications, I changed my technique to the so-called orbicularis window midface lift. In this technique, I used a crow s foot type of incision or a cutaneous blepharoplasty, with a blunt separation of the orbicularis oculi making a 1- to 1.5-cm window. This later variation was similar to the one described by Hurwitz and Raskin. 10 In both of my initial endoscopic techniques, the midface was suspended with the sub orbicularis oculi fat. In the majority of the cases, the septum orbitale was preserved and the intraorbital fat resection was done only for severely bulging eyes (10 percent of cases). 12 With the window technique, the incidence of temporary ectropion was approximately 1.5 percent, and no permanent ectropion or eyelid malposition was seen. However, because the incision was a little bit more lateral than the lateral extent of the standard eyelid incision, and because of the trauma of the endoscopic manipulation through a tight incision, redness around the suture line frequently occurred. This took several weeks to resolve. In an effort to eliminate completely the approach through the orbicularis oculi muscle, I went back to the surgical principles of the open approach that required the combination of the intraoral with temporal incisions. 1,3 6 To keep the temporal incision to a minimum ( 2 cm), use of the endoscope was mandatory. The orbicularis oculi muscle was left untouched (no incisions) The vertical lifting of the cheek produced recruitment of excess skin on the lower eyelid. This redundancy of skin was treated either with CO 2 laser resurfacing or with a skin-only blepharoplasty. Most of the patients did not require canthopexy, and if canthopexy was performed, this was only a plication type of canthopexy or orbicularis oculi suspension, to the lateral canthal area or both. However, I did not rely on canthopexy for suspension of the cheeks. This operation became totally endoscopically dependent, and several other features were added to the operation. One of those features was the routine use of another point of suspension in addition to the sub orbicularis oculi fat. This was the inferior malar periosteum or fascia that produced an imbricating effect with subsequent production of an anteroposterior projection of the cheek and elevation of the corner of the mouth. The Bichat s fat pad was used to provide further volumetric augmentation of the cheek and to elevate the area of the commissure and jowl areas in a vertical direction. The latest addition to this endoscopic midface lift is the intraoral repositioning of the intraocular fat pad to diminish the severe pseudoherniation and to concomitantly treat the V deformity of the lower eyelid-cheek interface more effectively. Surgical Technique The midface can be approached independently as a midface rejuvenation alone, in combination with a full endoscopic forehead rejuvenation or with inclusion of only the temporal component of the endoscopic forehead lift. In the majority of cases, the midface is done concomitantly with a full endoscopic forehead lift (Fig. 1). This allowed us to perform concomitantly the repositioning of the orbicularis oculi muscle (periorbitoplasty). However, if the patient does not require a central forehead lift or treatment of the frowning muscles, only the temporal component of the forehead is included with the midface. In younger patients, a pure endomidface lift without the temporal component can be done, but this is the exception more than the rule. 16 The main reason for the more comprehensive approach is to avoid disharmonies that can occur if the midface is rejuvenated while the upper periocular and forehead areas still look old. The inclusion of the temporal component into the dissection in one plane with the midface allows for more reliable and easier anchoring points for the midface sutures and a better redistribution of the redundant tissues that will occur after the midface is lifted in the vertical direction. As mentioned, the usual combinations are endoforehead-endomidface or endotemporoendomidface. In either of those circumstances, dissection starts with the temporal component of the endoforehead. This is dissected under endoscopic control. Temporal vein 2 (sentinel vein) and temporal vein 3 and the zygomaticotemporal nerves are preserved. The zygomatic arch is entered approximately 2 to 3 mm above the superior border of the arch with elevation of the intermediate temporal fascia and, immediately, the periosteum of the zygomatic arch

4 332 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2002 FIG. 1. Typically, treatment of the midface is performed concomitantly with a full endoscopic forehead lift. For patients not requiring treatment of the central portion of the forehead, only the temporal component of the endoforehead is included with the endomidface. The superomedial vector of pull of the endoforehead is transmitted to the periorbital and zygomatic areas. SOOF, sub orbicularis oculi fat; IMI, inferior malar imbrication. (Fig. 2). I prefer to elevate the anterior twothirds of the zygomatic arch for better lifting and redistribution of the midface soft tissues. Occasionally, I elevate the entire zygomatic arch, particularly if I want to lift the area lateral to the cheek. Pre-elevation of the zygomatic arch, or at least its superior border, allows a quicker connection with the temporal pocket when dissection of the midface is accomplished. The midface is dissected through an inverted V upper buccal sulcus incision. The subperiosteal dissection of the maxilla and malar bones are performed, initially, under direct visualization with a fiberoptic-lighted retractor, and when the topography of the midface changes in direction, the endoscope is introduced to facilitate dissection and minimize surgical trauma (e.g., excessive traction of soft tissues). This usually occurs at the tendinous insertion of the masseter muscle and, more superiorly, nearby the orifice of the zygomaticofacial nerve. In other words, the endoscope FIG. 2. The zygomatic arch is entered about 2 to 3 mm above the superior border of the arch. The intermediate temporal fascia is incised and elevated, and immediately, the periosteum of the zygomatic arch is entered. The midface subperiosteal dissection is done through the intraoral incision, and both pockets are connected. ITF, intermediate temporal fascia; STF, superficial temporal fascia. is useful for dissection of the lateral half of the zygoma body and its extension underneath the fascia of the masseter muscle and the anterior two-thirds of the zygomatic arch. The integrity of the zygomaticofacial nerve is preserved. Dissection is continued along the external surface of the inferior and lateral orbital rim, and then it proceeds toward the superior border of the zygomatic arch. The predissection of the superior border of the zygomatic arch, done through the temporal slit incision, allows a quick and safe connection with the temporal pocket. Further extension of the incisions along the lower boundaries of the intermediate temporal fascia near its attachment to the superior border of the zygomatic arch is done with change of the endoscopic view coming from the temporal approach while the assistant is gently elevating the midface soft tissue with a narrow elevator. Using a sharp right angle periosteal dissector (Ramirez Endoscopic Minus Series; Snowden Pencer, Inc., Tucker, Ga.), the inferior arcus marginalis is elevated and the orbital septum is exposed. The orbital septum is opened and the most anteriorly located central fat pad and the lateral fat pad are each grasped with a suture. Appropriate release of these fat pads from their surrounding structures is done to allow

5 Vol. 109, No. 1 / ENDOSCOPIC MIDFACE ENHANCEMENT 333 FIG. 3. The Bichat s fat pad is approached through the superomedial wall of the buccal space with a blunt incision of the periosteum and buccinator muscle. The vascularized fat is mobilized and anchored for transposition to the cheek area. br., branch; v., vein; a., artery. specific traction forces exerted to these and not to other structures, such as the eyelid retractors or intraocular muscles. It is important to check for absence of mobility of the eye globe while you are putting traction on these fat pads. This will ensure that this traction is not being transmitted to the inferior oblique muscle. The medial fat pad is repositioned only in cases of severe medial trough or severe herniation of this fat pad. The traction suture of the medial fat pad is usually passed around and medial to the infraorbital nerve. These sutures (4-0 polydioxanone with an RB 1 needle) are anchored in the following positions: the lateral one to the uppermost portion of the insertion of the masseter tendon, the central one to the maxillary periosteum (in the shelf left at the gingival border), and the medial one to the periosteum of the pyriformis aperture. The central and lateral fat pads are repositioned in about 50 percent of cases. The medial fat pad fixation is done in about one case per every 10 cases of lateral or central fat pad fixation. In 20 percent of cases, fixation of only the lateral or medial fat pads is done. In 10 percent of cases, fat pads are removed transconjunctivally. In 20 percent, these are left undisturbed. The suborbicularis oculi fat is grasped from the intraoral approach with a 3-0 polydioxanone and an RB 1 needle, and both ends of the suture are tunneled toward the temporal area. The next suspension suture is the cheek imbrication, which is done with weaving of the suture into the tenuous periosteal layer, fascia, or fat of the inferior maxillary soft tissue near the upper oral sulcus incision. This suture is also tunneled toward the temporal area. The next step is to continue dissection of the periosteal reflection along the superolateral wall of the maxilla, and the Bichat s fat pad is approached through the superomedial wall of the buccal space. The initial incision spreads the periosteum and buccinator muscle. This is done with blunt scissors, and the Bichat s fat pad is allowed to herniate through. The capsular fascia covering the Bichat s fat pad is maintained intact with the use of blunt instruments, and the attached fascial layer of the wall of the buccal space is dissected off the Bichat s fat pad to avoid traction of the nerve structures that cross the lateral wall of the buccal space (Fig. 3). The Bichat s fat pad should be free and easily movable for repositioning as a pedicle flap. You will usually see vessels on the fascia proper of the Bichat s fat pad. A 4-0 polydioxanone suture with an RB 1 needle is woven into the Bichat s fat pad, and the ends of the suture are tunneled to the temporal area. Fixation of the sutures is done below the level of the temporal slits. It follows this sequence: the first suspension suture is the Bichat s fat pad that is anchored most medially on the temporal fascia proper, the next suture is the inferior malar periosteum, fascia, or fat, and the most posterior suture is the suborbicularis oculi fat, which is also the last to be anchored (Figs. 4 and 5). A percutaneous butterfly drain is brought from the temporal scalp into the midface, and the drain is sutured to FIG. 4. This intraoperative external view shows markings of the position of the frontal branch of the facial nerve in relation to the zygomatic arch and the extent of the subperiosteal dissection along the external orbital rim, zygomatic arch, and the cheek. Striped red lines below the malar bone and zygomatic arch show the extent of the submasseteric fascia dissection; above the zygomatic arch, we see the area of elevation of the intermediate temporal fascia off the deep temporal fascia.

6 334 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2002 the scalp for about 36 to 48 hours. The superficial temporal fascia is anchored to the temporal fascia proper with a couple 4-0 polydioxanone sutures while the assistant is applying gentle traction into the advanced scalp. The axis of traction is usually superomedial rather than strictly vertical. If a complete endoforehead was done, the frontal scalp is fixated after the temporal fixation with percutaneous monocortical posts (Endoscopic Forehead Posts; Synthes Maxillofacial, West Chester, Pa.). The intraoral incision is closed with interrupted 4-0 chromic catgut sutures in a V-Y fashion to accommodate for the elevated soft tissues of the midface that will pull the mucosa in a vertical direction. If excessive lower eyelid skin exists, which might be accentuated by the vertical lift of the cheek, a cutaneous lower blepharoplasty without incisions in the lower eyelid orbicularis oculi muscle is performed. This allows removal of significant amounts of skin. A plication canthopexy or orbicularis suspension can be performed through this skin-only exposure. The lower eyelid orbicularis muscle is not cut. Alternatively, the excess lower eyelid skin can be treated with CO 2 laser resurfacing or trichloroacetic acid peel. Fat grafting by injection is used to treat minor facial asymmetries or contour irregularities. They are also helpful for filling of residual creases such as the nasolabial or marionette lines. Because these represent deep dermal damage, no lifting technique or laser resurfacing can completely erase them. Antibiotics are started before surgery and given for approximately 5 days postoperatively. The forehead and midface are taped with halfinch flesh-colored paper tape, and wellcontoured circumferential head and face dressing is applied. The tape is maintained for about 7 days. I do not give oral steroids postoperatively. FIG. 5. This schematic view shows the structures used for three-dimensional remodeling of the midface. Temporal and midface pockets are in interconnected planes. Sutures from the midface are anchored to the temporal fascia proper (TFP) through the tunnel made along the inferior boundaries of the intermediate temporal fascia. Observe the mechanical action of the imbrication suture that allows an anterior and posterior projection of the cheek soft tissues and the elevation of the corner of the mouth. Observe the usual position of each of the anchoring sutures. These may vary according to the aesthetic goals. SOOF, sub orbicularis oculi fat. RESULTS With the steps previously mentioned, we have avoided disrupting the integrity of the orbicularis oculi muscle. We do not need to open the eyelid either transconjunctivally or transmuscularly to reposition the eyelid fat pad. I will also make a plea not to remove the eyelid fat pad. Eyelid fat removal is reserved for patients with bulging eyes, and in those circumstances, it is done through small windows in the conjunctiva. The entire cheek is elevated with volumetric enhancement provided by the inferior cheek soft-tissue imbrication and by reposition of the Bichat s fat pad. The need for cheek implants is reduced but not eliminated. If the patient has a bone deficit, I would strongly suggest the insertion of an appropriate implant for long-term support of the face. The corner of the mouth usually tends to be elevated, and in general, the patient s expression is gently enhanced. The orbicularis oculi repositioning decreases laxity on the lower eyelid, improving an existing loose or round eyelid. If the patient presents with a significant scleral show or mild ectropion, a plication canthopexy can be added with orbicularis suspension through a minimal crow s foot incision, which allows a more functional repositioning of the lower eyelid structures without much disturbance of these. Severe ectropion might require more conventional maneuvers. The rate of patient satisfaction has been extremely high, and we have not seen a single case of eyelid malposition, scleral show, or ectropion. This compares favorably with the first and second generation endoscopic midface rejuvenation (Table I). The functional and aesthetic results of this operation have surpassed all the previous variations of the midface lift that I have performed in the past by using

7 Vol. 109, No. 1 / ENDOSCOPIC MIDFACE ENHANCEMENT 335 TABLE I Endoscopic Midface Operations Generation No. of Cases Incision Eyelid Malposition (%) Neuropraxia* (%) Infection (%) Limited eyelid (frontal nerve) Crow s foot or orbicularis window (zygomaticus major muscle) Intraoral/temporal 0 2 (two levator labii, one buccinator, one orbicularis oris) 1 * Excluding lower orbicularis dysfunction. 18 either open or endoscopic subperiosteal techniques. Most importantly, the degree of facial edema has been minimized, which has made the operation more appealing to patients and to surgeons attending our regular workshops. The sequela of severe, protracted facial edema has been one of the negative drawbacks of the subperiosteal face lift. With the above modifications, I have eliminated this problem in my patients. DISCUSSION Although the subperiosteal midface lift has gone through an evolution in its technical detail, some of the surgical principles are the same either for the open (pre-endoscopic) or any of the three endoscopic generations. These principles are: (1) wide subperiosteal and subfascial dissection, (2) en bloc mobilization of midface structures, (3) periosteal release in the lower and medial boundaries of the cheek, and (4) a strong suspensory element to maintain the cheek in the elevated positions. All of these maneuvers are safe for the midface neuromuscular structures. This is inherent to the level of dissection. However, going from the open to the first, second, and third generation, there was a progressive increase in neuropraxia of midface nerves. This was very uncommon with the open technique. The rate of neuropraxia was about 2 percent for the third endoscopic generation. I believe that this was related to the execution of the technique rather than to the plane of dissection. During the eyelid approach, there was no significant traction of the midface structure except the lower eyelid orbicularis oculi muscle. Therefore, the neuropraxia rate was minimal. When we changed to the endoscopic intraoral approach, the rate of nerve injury increased considerably to four cases in the first 50 patients (8 percent). I determined that the only possible factor was traction during the endoscopic manipulation. To avoid this, I now prefer to use a 4-mm endoscope with a Cobratip sleeve (very blunt) and a miniature set of instruments for dissection and manipulation. I call this a Minus Series (Ramirez Endoscopic Minus Series, Snowden Pencer, Inc., Tucker, Ga.). Furthermore, we avoid the use of retractors except for very specific maneuvers, and this retractor is a very slender one. Since the introduction of these changes, we have not seen any neuropraxia in the last 144 cases. Obviously, we cannot prevent the occasional difficult case in which neuropraxia can occur from excessive traction. Other causes of neuropraxia include needle stick injury during infiltration of local anesthesia or local edema. To avoid those, we use a No. 27- or No. 25-gauge needle for infiltration, and we routinely use butterfly drains connected to Vacutainer tubes for 34 to 48 hours. In relation to eyelid malposition, this had a different fate. With the open approach (bicoronal and intraoral incisions), eyelid malposition was an anecdotal occurrence related more to the concomitant blepharoplasty than to midface surgery. This complication happened in almost 4 percent of cases using the endo-eyelid incision (first generation endoscopic procedures) and in 50 percent of cases using the open eyelid approach. 10 With the technique presented here (third generation endoscopic procedures), this complication has been almost completely eliminated. The high rate of this complication with the eyelid approach was probably related to the denervation of the pretarsal orbicularis oculi muscle and undue tension on the remaining orbicularis oculi muscle for exposure. 18 One of the technical aspects of the open extended technique using the bicoronal approach was the wide dissection of the zygomatic arch. This was completely eliminated in the approach by Hester et al. and the version by Little During midface elevation, there is a recruitment of full-thickness soft tissue around the lateral upper malar area. Both authors overcome this problem with a long tem-

8 336 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2002 poral incision and scalp excision. This represents a short version of the coronal approach used in the open subperiosteal technique. In my view, one of the advantages of the zygomatic arch dissection and the elevation of the fascia of the masseter muscle was to facilitate unrestricted mobility of the composite tissues of the cheek and redrape the excess soft tissues into the temporal area. This dissection of the zygomatic arch was generous during the preendoscopic era. It was restricted to the anterior one-third on the first and second generation endoscopic approach. Now we include onehalf to two-thirds of the extent of the zygomatic arch. If needed, the entire zygomatic arch is freed without any concerns for nerve injury. This is safe and feasible because this part of the dissection is done under strict endoscopic control. We have not seen neuropraxia of the temporal nerve in the last 300 cases. The two cases of localized abscess on the cheek were probably related to two factors: incision and closure of the intraoral access in a horizontal fashion and the early forceful rinsing of the mouth. Since then, the intraoral incision has been made in an inverted V shape and closure done in a V-Y fashion. This way, closure is done without tension because the upward lifting of the soft tissues requires re-accommodation of the mucosa. We do not recommend rinsing of the mouth, but gentle painting of the incisions with cotton swabs moistened in Betadine several times a day. For tooth cleansing, we recommend a children s dental brush. The extent of the subperiosteal dissection medially on the midface follows a curvilinear line from the projection of the medial punctum to the pyriformis. I do not go more medially, and I do not go across the midline. I have done that many times in my open technique, but I did not see a significant difference in the lifting of the cheek. It only increases the facial edema, the potential dysfunction of the orbicularis oris muscle, and unsightly splaying of the nasal ala. If you release the periosteum at the level where the dissection finishes, the tissues lateral and above it will be mobilized en bloc. This principle is similar to the subperiosteal forehead lift. 20 The position of the imbrication suture I use is slightly lower than the one applied by others. 19 It is placed at the periostealfascial-fat layer of the undersurface of the cheek near the buccal incision. It is placed tangentially with two or three woven sutures. Likewise, the sub orbicularis oculi fat suture that always takes periosteum with it is slightly higher than the point at which Little applies his suspension suture. 7 The technique described herein is used in all cases of facial rejuvenation being totally endoscopic (endotemporo-midface, endoforehead-endomidface, endoforehead-endomidface-anterior approach cervicoplasty), 21 or the endoscopicassisted biplanar face lift (endoforeheadendomidface-modified standard cervicofacial). The biplanar technique includes the excisional type of cervicofacial lift with the anterior incision and excision limited to the roof of the helix. Because the intermediate and superficial layers of the midface are maintained intact, they are suitable for fat grafting by injection in these planes. As mentioned, this is used for treatment of residual creases or minor asymmetries. The average amount of fat injected is 15 cc for the entire face. My preference is not to rely on fat grafting for volumetric enhancement because of the potential for development of cherubic faces when the patient gains weight. Furthermore, the steps described here create enough volume that too much of a good thing may not be appropriate in this case. I concur with Little s experience as related to the perception of volumetric enhancement in the cheek by patients and plastic surgeons. 22 When criticizing the volumetric alterations of the face, many surgeons claim that their patients do not want to look different. My experience is that patients are very satisfied with volumetric enhancement. They usually bring photographs from their youth (usually from college) in which it could be readily appreciated the volumetric features of youth and how much loss of volume has occurred during the aging process. Patients who did not have fuller faces, particularly during their youth, welcome the possibility of aesthetic volumetric enhancement without the need to use alloplastic implants. The patients with poor skeletal support may also find it desirable to normalize those features with alloplastic material, which can be done in the same surgical plane already prepared for the volumetric manipulations. Of all the patients I have operated on, only one patient was unhappy with the volume of her cheek. She required defatting by excision of the mobilized Bichat s fat pad. A few patients may find that the cheek volume is too much early in the postoperative period. When tissues settle down and sensation returns to normal,

9 Vol. 109, No. 1 / ENDOSCOPIC MIDFACE ENHANCEMENT 337 FIG. 6.(Above, right) Preoperative view of a 42-year-old woman with early signs of aging in the central oval of the face. In addition, the patient presented with disproportion of the facial segments, with a small chin, particularly in the vertical and horizontal dimension. Observe ptosis of the brow, eyelid V deformity, sagging of the cheeks, nasolabial creases and folds, perioral creases, and marionette lines. (Above, right) Frontal view of the same patient 14 months after endoforehead, three-dimensional endomidface, anterior approach cervicoplasty, 21 a tridimensional RZ Medpor chin implant with a projection of 3 mm, and 11-cc of fat injections to the glabella, brows, and deep lines around the mouth. Observe the elevation of the brow, correction of the V deformity, and tridimensional cheek remodeling. Also, observe the change in expression of her mouth, with the corner of the mouth being elevated, and the increase in width and vertical dimension of the chin. No cheek implants were used. (Below, left) Preoperative three-quarter view. Observe the frowning lines, ptosis of the brow, V deformity, sagging of the cheek, perioral creases, nasolabial crease, marionette lines, and early jowls. (Below, right) Three-quarter view 14 months after the procedure. Observe the gentle, pleasing rejuvenation of the whole face with brow elevation, correction of the V deformity, tridimensional cheek remodeling, elevation of the corner of the mouth, and the tridimensional volume restoration of the chin.

10 338 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2002 FIG. 7.(Above, left) Preoperative frontal view of a 38-year-old patient with early signs of aging: forehead creases, ptosis of the brows, sagging and flattening of the cheeks, and V deformity. She also had scleral show caused by two previous chemical peels of the lower eyelids. Also observe the hollow eyes. (Above, right) Frontal view of the same patient 2 years after endoforeheadendomidface lift and fat grafting to brow, infrabrow, lips, and glabella (total, 16 cc). No eyelid incisions were done and no canthopexy was performed. Observe the effect of the periorbital repositioning of the orbicularis oculi muscle, with improvement of the laxity and position of the lower eyelid. Also notice improvement of the V deformity and the hollowness of the eyes. Observe the tridimensional volume restoration of the cheek. (Below, left) Three-quarter view of the same patient. Observe the tired look of the patient with brow ptosis, sagging of the cheek, scleral show, hollow eyes, tear-trough deformity, and nasolabial fold. (Below, right) Two-year postoperative, three-quarter view of the same patient with a gentle, pleasing rejuvenation. Observe the brow elevation, the correction of the scleral show, and the tridimensional volume restoration of the cheek. Also, observe the expression of the mouth and the improvement in the hollowness of the eyes.

11 Vol. 109, No. 1 / ENDOSCOPIC MIDFACE ENHANCEMENT 339 FIG. 8.(Above, left) Preoperative frontal view of a 40-year-old woman who presented with early signs of aging. Notice the forehead creases, frowning lines, hooding of the brows, V deformity, and sagging of the cheek. She had a tense and tired expression. (Above, right) Frontal view of the same patient 10 months after a SMILE face lift, 13 which entailed an endoforehead-endomidface lift and immediate full-face laser resurfacing. The patient also had fat grafting to the brows, glabella, lateral cheek areas, and marionette lines, with a total amount of injection of 13 cc. Notice the absence of eyelid incisions. (Below, left) Preoperative three-quarter view of the same patient showing forehead creases, hooding of the brows, glabellar frown lines, tear-trough deformity, sagging of the cheek, and nasolabial creases. (Below, right) Ten-month postoperative, three-quarter view with a gentle, pleasing facial rejuvenation with brow elevation, tridimensional restoration of the cheek, and improvement of the V deformity. Observe the expression of the mouth.

12 340 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2002 they are happy and grateful for the degree of rejuvenation and beautification obtained. The technique presented does not require the additional subcutaneous or superficial musculoaponeurotic system rhytidectomy for further volumetric manipulation or for adjustments of excess skin on the midface. The subcutaneous component of the biplanar technique mentioned is reserved for the treatment of the jawline and neck in patients with advanced aging appearances or those who need remodeling of these areas. The patients whose pictures are shown demonstrate typical results obtained by using endoscopic techniques of facial rejuvenation without excision of preauricular or scalp skin (Figs. 6 through 8) For those not accustomed to the use of the endoscope, some or most of the features of the described technique can be adapted to their individual methods. The main principles of this operation are: (1) absence of orbicularis oculi muscle incision, (2) three-dimensional volumetric cheek enhancement, including the repositioning of the Bichat s fat pad, and (3) orbital fat repositioning. These can be integrated beautifully with the open variant. For this, the intraoral incision needs to be extended, and a good-length temporal scalp incision needs to be made for safe access to the zygomatic arch. This will also require a small fiberoptic light (mounted on an Aufricht type of retractor) and the use of smaller periosteal elevators. However, the absence of visible incisional scars and minimal edema makes the endoscopic alternative most appealing to patients. The techniques described herein meet most, if not all, of the objectives outlined as ideal midface rejuvenation. Of these, three-dimensional remodeling and absence of eyelid incisions seem to be the most appealing. This can be done safely and with minimal or no sequelae. Oscar M. Ramirez, M.D. Esthétique International 2219 York Road, Suite 100 Timonium, Md oscar@ramirezmd.com REFERENCES 1. Tessier, P. Lifting facial subperioste. Ann. Chir. Plast. Esthet. 34: 193, Hinderer, U. T., Urriolagoitia, F., and Vildosola, R. The blepharo-periorbitoplasty: Anatomical basis. Ann. Plast. Surg. 18: 437, Psillakis, J. M., Rumley, T. O., and Camargos, A. Subperiosteal approach as an improved concept for correction of the aging face. Plast. Reconstr. Surg. 82: 383, Ramirez, O. M., Maillard, G. F., and Musolas, A. The extended subperiosteal facelift: A definitive soft-tissue remodeling for facial rejuvenation. Plast. Reconstr. Surg. 88: 227, Ramirez, O. M., and Fuente del Campo, A. Facial rejuvenation: Subperiosteal brow and facelift. In R. S. Rees (Ed.), Plastic Surgery Educational Foundation: Instructional Courses, Vol. 6. St. Louis: Mosby, Ramirez, O. M. Extended subperiosteal facelift. Plast. Surg. Tech. 1: 223, Ramirez, O. M. Endoscopic full facelift. Aesthetic Plast. Surg. 18: 363, Fuente del Campo, A. Centrofacial lifting. Perspect. Plast. Surg. 7: 87, Hester, T. R., Codner, M. A., and McCord, D. D. The centrofacial approach for correction of facial aging using the transblepharoplasty subperiosteal cheek lift. Aesthetic Surg. J. 16: 51, Hurwitz, D. J., and Raskin, E. M. Reducing eyelid retraction following subperiosteal facelift. Aesthetic Surg. J. 17: 149, Zarem, H. A., and Resnick, J. I. Minimizing deformities in lower blepharoplasty: The transconjunctival approach. Clin. Plast. Surg. 20: 317, Ramirez, O. M., and Pozner, J. N. Correction of the infraorbital hollow with direct cheek lift. Plast. Surg. Forum 10: 152: Ramirez, O. M., and Pozner, J. N. Subperiosteal minimally invasive laser endoscopic rhytidectomy: The SMILE facelift. Aesthetic Plast. Surg. 20: 463, Ramirez, O. M. Fourth generation subperiosteal approach to the midface: The tridimensional functional cheek lift. Aesthetic Surg. J. 18: 133, Ramirez, O. M. High tech facelift. Aesthetic Plast. Surg. 22: 318, Ramirez, O. M. Buccal fat pad pedicle flap for midface augmentation. Ann. Plast. Surg. 43: 109, Ramirez, O. M. Subperiosteal endoscopic techniques in facial rejuvenation. In B. M. Achauer (Ed.), Plastic Surgery; Indications, Operations, and Outcomes, Aesthetic Surgery, Vol. 5. St. Louis: Mosby, Ramirez, O. M., and Santamarina, R. Spatial orientation of motor innervation to the lower orbicularis oculi muscle. Aesthetic Surg. J. 20: 107, Little, W. J. Three-dimensional rejuvenation of the midface: Volumetric resculpture by malar imbrication. Plast. Reconstr. Surg. 105: 267, Ramirez, O. M. The anchor subperiosteal forehead lift: From open to endoscopic. Plast. Reconstr. Surg. 107: 868, Ramirez, O. M. Cerivcopplasty: Nonexcisional anterior approach. Plast. Reconstr. Surg. 99: 1576, Little, J. W. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast. Reconstr. Surg. 105: 252, 2000.