Surgical technique of endoscopic midface lift

The endoscopic forehead approach for midface suspension can be performed with or without brow raising. In most patients, the endoscopic forehead and midface lift also require lower eyelid treatment, either through skin excision or laser resurfacing. This is done because midface suspension elevates the cheeks, often causing skin wrinkling under the eyes. If lower eyelid fat removal is required, it is done through the conjunctiva before the midface sutures are placed; otherwise, the lower eyelid will be too close to the globe to allow access.

A lateral incision is made first. The incision is made taking into account the direction of the hair follicles. It is carried down to the level of the surface of the proper temporal fascia. This dissection requires an endoscopic instrumentation kit. A double hook is used to elevate the skin and a #4 Ramirez or flat dissector is used to create a dissection plane over the proper temporal fascia. The tissue in this plane can be bluntly dissected to the superior aspect of the ear and posteriorly to where the temporalis muscle ends and the dissection becomes subperiosteal. An Aufricht retractor with light provides better visualization. The dissection is then continued down along the temporal line to the superior orbital rim since working in this subperiosteal plane protects the frontal branch of the facial nerve. A gentle rocking motion of the same dissector is used to continue the dissection plane over the anterior proper temporal fascia, using the temporal line as a reference. Care must be taken not to penetrate too deeply into the infratemporal fat, which may cause trauma and temporal depression. Too superficial a dissection may cause trauma to the frontal nerve.

During dissection, numerous penetrating vessels are encountered. They mark the location of the frontal branch of the facial nerve. Isolate the vessels completely and then, under tension, treat the deep portion of the vessel with a bipolar cautery so as not to cause conductive thermal injury to the more superficial nerve. Dissection is continued downward to the superior orbital rim, with elevation of the periosteum at its lateral portion. Bimanual elevation with one hand over the upper eyelid is used to release the marginal arch. The zygomatic arch is then isolated. The proper temporal fascia is divided approximately at the level of the supraorbital ridge into the intermediate fascia and the deep temporal fascia with the intermediate temporal fat pad between them. Some surgeons prefer to continue the dissection in the middle of the fat pad, but we remain superficial to the deep temporal fascia and elevate the intermediate fat pad. This plane of dissection is more easily maintained by moving toward the posterior third of the zygomatic arch with moderate downward pressure with a flat dissector, since the temporal fascia is thicker and stronger posteriorly. This plane of dissection is continued downward to the superior margin of the zygomatic arch and along it for its entire length. Depending on the degree of mobility required in this area, a lateral layer of tissue approximately one centimeter wide at the lateral canthus is maintained. The periosteum at the superior margin of the zygomatic arch is incised with a dissector or scalpel. A dissector curved downward is used to elevate the periosteum above the arch and release some of the attachments of the masseter aponeurosis to the inferior portions of the zygomatic arch. Dissection is then continued bluntly subperiosteally over the maxillary bone. A finger is placed on the infraorbital foramen to protect the nerve during dissection of the periosteum below its exit. The finger is also placed on the inferior aspect of the globe during dissection along the inferior orbital margin, just superior to the infraorbital nerve. The dissection extends all the way to the nasal bones and the pyriform aperture. Bimanual elevation of the cheek with a retractor further helps to free the periosteum, which then confines the infraorbital nerve. A drape is placed in this cavity for hemostasis, and the same is done on the other side.

The midface/orbicularis oculi fat is suspended with thick absorbable sutures placed through the periosteum just lateral to the temporozygomatic foramen and posterior to the proper temporal fascia. Care should be taken not to overtighten this suture. A second suture is placed proximal to the frontal nerve and posterior to the deep temporal fascia. The excess skin in the temporal area is smoothed by placing three sutures in the superficial temporal fascia at the anterior edge of the skin and anchoring it to the proper temporal fascia posteriorly and superiorly. The skin is then closed with vertical mattress sutures to prevent scalloping. The skin at this incision will initially be puckered, but it will smooth out relatively quickly and no skin excision is required.

A single small active drain is placed at the brow level and brought out laterally through the scalp. It is removed 1 day after surgery. To reduce swelling, a paper patch is placed on the forehead, over which a standard facelift pressure bandage is fixed, which is removed 1 day after surgery. Subperiosteal dissection in the midface causes more facial swelling, and patients should be prepared for this, as well as for a moderate temporary tilt in the lateral canthi. Patients are told that they will look good with makeup after 23 weeks, but that the swelling and tilt will not go away after 6 weeks.

Complications

Some complications invariably occur after forehead lift, which usually resolve within 26 months on the forehead and 9-12 months on the vertex. Paresthesia and pruritus are very common as sensation returns. Alopecia may develop along the incisions if excessive tension is applied during tissue suspension, but hair growth usually returns within about 3 months. Temporary nerve palsy occurs, which may be due to either thermal injury from electrocautery or excessive dissection of the temporal pockets. Malposition of the eyebrows may occur, which is initially treated with massage. If this does not produce the desired result, suture release may be necessary. Forehead or scalp hematomas may develop; however, their development is minimized by vacuum drainage and/or pressure dressing.

Recovery from a midface lift is longer and has more pitfalls than a forehead lift. Soreness when chewing is expected (but not a complication). Release of the masseter attachments in combination with suturing of the temporal muscles may provoke muscle spasm and simulate temporomandibular joint syndrome. This usually resolves within the first week. Patients look presentable after 3 weeks, but it takes about 68 weeks for the swelling to completely resolve. Periorbital edema and chemosis may persist for more than 6 weeks after surgery. In this regard, photosensitivity and dry eye syndrome may develop. After the edema has resolved, the function of the orbicularis oculi muscles returns to normal, and the lower eyelid is attached to the eyeball. Asymmetry in the shape of the palpebral fissures is always present initially, but usually resolves when massage, combined with strong circular contractions of the orbicularis oculi muscles, returns the eyelids to their original position. Revision is not recommended earlier than after 6 months.

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