As surgeons who rejuvenate the face, our goals are simple: reverse as many of the signals of aging, and do as little harm in the process. When we realize the extent of facial aging, we realize we are faced with an essentially impossible task (Table 1). We cannot return the full, undamaged nature of youthful skin. We can only focally reverse the profound fat atrophy that occurs with age. The successful surgeon will have a variety of techniques to customize a surgical plan for his patient, and will keep in perspective (and advise his patient about) the goals and limitations of facial rejuvenation. Thorough preoperative consultation should determine which of the many signs of facial aging bother the patient the most.

Table 1 describes many features which can now be addressed, such as midfacial aging, orbicularis drooping, brow ptosis with thinning hairlines, fat and periorbital fat atrophy. Essential treatments should now include composite grafting for hollow regions, fat preservation in periorbital surgery, and an understanding of advancements in lower eyelid and midfacial rejuvenation. Through skin care and lighter interventions such as peels and various lasers, we are beginning to improve and restore the quality of skin and reduce fine rhytids and sun damage. In vulnerable patients, customized browlifts avoid hairline disturbances while addressing many of the signs of aging. Botulinum toxin focally addresses rhytids that formerly required invasive surgeries, or surgeries that imperfectly or at great price rejuvenated these areas.

Yet unsolved are problems of aging skin surfaces and fat atrophy, specifically facial and periorbital fat atrophy, atrophy of the temporal fat pad, buccal fat pad and malar fat pad, as well as global fat atrophy in the subcutaneous tissue. New understanding of anatomy has caused a renaissance in rejuvenation of the upper and midface. The understanding of the relationship between the midface and the remainder of the face are still evolving.

Clearly, the day is past when all patients receive the same facelift, coronal browlift, upper and lower blepharoplasty with a perioral phenol peel.

• Downward descent of lateral brow
• Downward descent of central brow
• Hollowness of temporal fat pad
• -Subcutaneous fat loss due to senile fat atrophy
• -Vasodilation and exposure of small forehead veins
• -Sun damage lesions
• -Epidermal and dermal atrophy
• -Weakening of the periorbital septa with fat herniation
• -Periorbital fat atrophy with subcutaneous volume loss
• -Globe hollowness and sinking due to periorbital fat atrophy
• -Superior Orbital Blepharochalasis
• -Inferior Orbital Blepharochalasis
• -Nasojugal groove deepening
• -Midfacial complex ptosis
• -Orbicularis oculi ptosis
• -Horizontal forehead rhytids
• -Glabellar rhytids
• -Perinasal rhytids
• -Crowâs feet
• -Thinning and loss of hair at anterior hairline, temporal hairline, sideburn
• -Lightening (graying) of anterior hairline hair, temporal hairline, sideburn
• -Darkening of the corneal surface
• -Thinning and loss of eyelashes
• -Lateral canthal ligament ptosis
• -Ptosis or rupture of the levator mechanism of the upper eyelid
• -Nasolabial fold heaviness and folds
• -Buccal fat pad atrophy
• -Malar fat pad atrophy
• -Lip atrophy
• -Upper lip lengthening
• -Platysmal ptosis and banding
• -Facial skin and fat descent

The recent history of facial rejuvenation can be viewed as a series of trends. These tend to be hairline preservation, avoidance of overresection, periorbital fat preservation, elevation of the midface with the lateral and lower face, customized browlifting procedures, and use of fat and composite grafts to replace tissues lost to fat atrophy. It is now entirely possible to rejuvenate the brow by selectively reducing muscle activity in specific areas without lifting anything. Hence the coronal browlift as a sole option in rejuvenating the brow is superceded by several smaller and more targeted operations.

The decision whether to perform a coronal lift, an endoscopic lift, a minimally invasive direct browlift, selective muscle resection, Botox is complex and cannot in this authorâs opinion be predetermined by mathematical algorithms, but rather by a careful discussion with the patient over what the troubling aspects of the patientâs appearance are, and what the downsides and expected outcome is.[1]

The deep temporal fascia is the covering in the temple of the temporalis muscle. Above it, containing the superficial temporal vessels, is the superficial temporal fascia (STF). The intermediate temporal fascia (ITF) and deep temporal fascias (DTF) surround the temporal fat pad, while the superficial temporal fascia (which continues below the zygoma as the SMAS) is superficial to the ITF. The ITF and the DTF then insert onto the zygomatic periosteum from above. The tissue above the zygomatic periosteum contains the frontal branch of the facial nerve, origination at the tragus of the ear and coursing 1 cm lateral to the lateral brow into the forehead musculature. There is no natural plane from above into the zygomatic subperiosteal space. This is of relevance since this is the anatomic layer where one must be in subperiosteal upper and midfacial procedures; therefore, careful dissection must be undertaken. The surgeon must break through the ITF into the temporal fat pad space, and from there go into the zygomatic subperiosteal space.

The exact anatomy is quite complex and controversial in the temple area, probably because the layers are so thin, and changes over the course of the zygoma. Dispute has been particularly contentious over what exactly happens between the temporal fat pad and the zygoma, and whether this changes over the course of the zygoma from anterior to posterior[2],[3],[4],[5]. Certain aspects of anatomy are undisputed. These are that the deep temporal fascia forms the floor for the temporal fat pad, a discrete entity (Figure 1). The intermediate temporal fascia forms the roof and is separate (and deep to) the SMAS/superficial temporal fascia. The deep and intermediate temporal fascial layers coalesce on the zygoma. Most likely, the two leaflets of the temporal aponeurosis (deep temporal fascia and intermediate temporal fascia) fuse above the zygoma, while in the central zygoma, the fat pad inserts directly onto the zygoma, with no fusion of the layers. The frontal branch becomes more superficial as it heads posteriorly along the zygoma. [6] Masseteric and zygomatic ligaments may hinder upward mobilization of the flap (Figure 2).

Figure 1. The zygomatic anatomy is particularly important as it relates to endoscopic browlifts. Note that the insertion of the temporal fascia varies depending on the location on the zygoma[7]. Note the deep temporal fascia (DTF) and intermediate temporal fascia (ITF) coalesce into the periosteum of the zygoma at the anterior and posterior 1/3 of the zygoma only. In the central zygoma, the insertion of the IFT and the DTF is directly onto the zygoma. In the endoscopic browlift, the plane of dissection is superficial to the intermediate temporal fascia until just before the insertion of the ITF onto the zygoma. Then, the dissection requires division of the ITF, gaining access into the space occupied by the temporal fat pad, and from there, subperiosteal on the zygoma.

Figure 2. The zygomatic and masseteric ligaments limit upward pull of the temple-midfacial flap. The temporal muscle is bounded by the inferior and superior temporal septa, which coalesce anteriorly at the temporal adhesion.[8]

The area surrounding the lower eyelid and midface is germane to rejuvenation of the upper and mid thirds of the face. Periorbital fat, which cushions the globe and is retained by the orbital septum below and above the globe. With age (and sometimes congenitally), the periorbital fat ãherniatesä against the orbital septum, weakening it. Most likely, this occurs as a result of fluid fluxes into and out of the periorbital fat on a daily basis, resulting in a weakening of an indistensible layer, the orbital septum. As all subcutaneous fat in the face atrophies with age, this bulge can assume more prominence because it is accompanied by loss of fat elsewhere in the face. It is believed that the orbicularis oculi muscle becomes ptotic with age and droops. The pretarsal orbicularis muscle gives tonicity to the lower eyelid. Squinting with the eyes tightens this muscle. It is best with any midfacial procedure to leave a cuff of pretarsal orbicularis behind so the lower eyelid does not lose tone and cause a temporary or permanent ectropion. (Figure 3) The lower canthal ligament is important to assess preoperatively as its tonicity will alter which procedure is done to rejuvenate the face. A horizontally or vertical lax lower eyelid may warrant a canthopexy or canthoplasty, and certainly move the surgeon toward caution when performing midfacial or combined mid-upper facial rejuvenation procedures.

The orbital septum inserts into the inferior orbital rim. The arcus marginalis procedure involves separating the orbital septum from the orbital rim from the septum and spilling the periorbital fat into the infraorbital hollow region. Undue tightening or scarring within the orbital septum can lead to middle lamellar scarring, a proven cause of severe ectropion. Caution must be used in performing orbital septal resecting or tightening procedures.

Orbicularis oculi muscle innervation is primarily from inferiorly and laterally through the facial nerve. Therefore, one must be cautious in performing lower eyelid procedures on patients who have had recent Botox injections in the crowâs feet region. Likewise, during any dissection, minimal undermining and cautery should be performed at the lateral suborbicularis region.

Figure 3. Note the many functions of the orbicularis oculi muscle. Preatarsal orbicularis above the upper eyelid helps with eye closure function, while orbital portion impacts on brow furrow formation in combination with the corrugators and procerus muscles. Note the role of the orbicularis on lower eyelid function with pretarsal orbicularis largely responsible for lower eyelid tonicity (Figure 3). The orbital septum inserts on the inferior orbital rim at the arcus marginalis.[9]

The lower eyelids develop laxity of the inferior canthal ligament. There are three infraorbital bulges resulting from laxity of the orbital septum. Periorbital fat atrophies globally around the eye. This results in a sunken appearance to the eyes. There is descent of the cheekpad and malar fat pad. This cheekpad descent has two direct effects: first, the inferior orbital rim becomes apparent as it is ãuncoveredä by the descending cheekpad. Second, the cheekpad falls onto the nasolabial fold, deepening the nasolabial fold and thickening the tissue collecting above the fold.

The mechanics of brow aging have been studied anatomically. The lateral brow ages earlier than the central brow. The descent of the lateral brow is due to the complex interaction of gravity and the corrugator supercilii, the frontalis, the galeal fat pad, the preseptal fat pad, and the subgaleal fat pad glide space all may contribute to descent of the lateral brow.[10]

The projection of the cheekpad anteriorly can be juxtaposed to the projection of the globe. With youthful faces, the cheek projects approximately 1.5 mm anterior to the globe. In older faces, a negative vector develops, with the cheek retropositioned approximately 2.5 mm behind the position of the globe. This largely reflects ptosis of the cheekpad complex and subcutaneous fat atrophy. [11]

In Caucasian women, the median height of the eyebrow at the midpupillary level is 23 mm. The distance between the infraorbital sulcus and the lower eyelid margin is 12 mm.[12] The medial end of the brow ends ideally on a vertical line from the medial canthus and the lateral border of the nasal ala. The lateral brow should terminate in an oblique line drawn from the ala of the nose through the lateral canthus. Eye shape in youth resembles more an apex lateral slant; the lateral canthus is approximately 4 degrees higher laterally than the medial canthus (Figure 4). The lateral to medial canthal distance is typically 31 mm. With age, the lateral canthal ligaments weaken and droop, causing increased scleral show as the lower eyelid droops down.

Figure 4. There is a 4 degree upward slant medial to lateral in young Caucasian women[13]

Excessive elevation of the medial brow causes a startled, surprised expression and is to be avoided. There is an alarming trend in the literature to measure success by the degree of elevation of different brow points. Excessive elevation of the lateral brow also results in an overly animated, artificial appearing facial expression. A lateral brow with a horizontal aspect to the medial brow in men or a slightly elevated aspect in women is aesthetically desirable.

Aesthetically, the medial brow position should be lower or at most at the level of the supraorbital rim. The eyebrow shape should have an arched appearance, or an apex lateral slant.[14] The most common postsurgical configuration of the post-surgical browlift is one of excessive elevation of the medial brow past the supraorbital rim.

Treating and avoiding postblepharoplasty syndromes is imperative. Midfacial-lateral brow procedures have been modified to treat midfacial retraction caused by aggressive blepharoplasty. Classically, an accurate diagnosis is made between the three lamellae and their contribution to the lower eyelid problem. Also, the degree of horizontal or vertical shortening or laxity is determined to see how the reconstruction is to proceed. The most frequent postblepharoplasty problem is retraction of the anterior (skin and orbicularis muscle) and middle lamella (orbital septum). Surgeons with an interest in the midface have long recognized that correction of the lower eyelid deformity must simultaneously involve midface elevation. It is no longer acceptable to perform a traditional blepharoplasty and cause such deformities. It is also no longer acceptable to transfer our complications to the oculoplastic surgeon for correction when they are so easily preventable (Figure 5).

It is also becoming common for surgeons to offer midfacial rejuvenation in their practices. It is difficult to rationalize not offering such techniques when a thorough knowledge of midfacial and lateral brow anatomy, and a familiarity of various midfacial rejuvenation techniques can enhance our ability to rejuvenate the face more harmoniously. It is critical that surgeons performing complex lower blepharoplasties, including revisions, forward set globes, cases with lower eyelid laxity, are familiar with midfacial procedures and ectropion repair and reconstruction.

There is an increasing incidence of lower eyelid problems such as ectropion, lateral canthal dystopia and excessive scleral show resulting from the widening use of midfacial procedures.[15] Schorr described the Madame butterfly procedure [16] as an operation to treat post lower blepharoplasty ectropion and excessive scleral show. The dissection involves 1) lysis of middle lamellar tethering cicatrix, 2) a complete canthotomy of the two limbs of the lateral canthus, and 3) a lateral and inferomedial undermining of cheek tissue at the supraperiosteal level, and 4) anchoring SOOF tissue to the periosteum of the orbital rim at the arcus marginalis.

Figure 5. Palatal mucosal graft inserted into lower eyelid conjunctival surface to replace scarred or missing middle and posterior lamellar tissues[17] This operation can be avoided by meticulous attention to not overresecting lower eyelid skin, not causing undue scarring in the orbital septum (middle lamella), and by properly supporting the lower eyelid during any surgery (i.e. midfacial elevation, canthopexy, canthoplasty). Midfacial procedures performed in a subperiosteal plane may be associated with a higher incidence of ectropion that with a suborbicularis dissection for midfacial elevation.

Preservation of the temporal, anterior and sideburn hairline in females and the temporal and anterior hairline in males is crucial. Performing a coronal lift in all patients is not acceptable because of the hairline destruction in many patients with high or receding hairlines.

Sideburn preservation in women is important. It can no longer be elevated with impunity during a coronal lift, as this leaves the patient with an extended preauricular bald spot which is difficult to conceal and will never regrow. Many secondary techniques aim to reverse this deforming technique, with variable success. The deformity can be avoided by excising a triangle at the base of the sideburn during a facelift procedure. In some patients with a high hairline an anterior hairline technique or an endoscopic technique with fixation to the deep temporal fascia may be needed.

The temporal hairline should not be excessively mobilized posteriorly. This creates a vast hairless expanse and contributes greatly to the ãwindsweptä look (Figure 6). It may be necessary to balance a temporal lift (subcutaneous or subgaleal) with an upper lid blepharoplasty to achieve relief of upper lid blepharochalasis with lateral brow ptosis, or to perform an anterior hairline procedure.

The surgeon should consider the height of the forehead. Already high foreheads should not be further elevated with a coronal lift. This creates a large, unattractive hairless forehead. It may be necessary to balance the degree of skin resection in the performance of a coronal lift with procedures targeted to the procerus, corrugator, superior orbicularis oculi fibers, and frontalis fibers. In patients with high frontal hairlines, an anterior hairline procedure or endoscopic procedure targeted to specific muscle groups is more appropriate. In the properly selected patient, botulinum toxin treatments are now a viable alternative to direct or indirect brow procedures.

Figure 6. Patient with excessive elevation of the temporal hairline and sideburn after conventional coronal browlift and facelift without a hairline sparing incision. This is a frequent sequela of conventional facelift and coronal browlift surgery.

If further brow ptosis occurs in a patient who has excessive elevation of the anterior hairline, it may be advisable to perform a subcutaneous temporal browlift. This procedure predictably restores some anterior hairline; however, it does create an anterior hairline incision. This incision can be minimized if the randomness of the anterior hairline is followed with the incision. Selected temporal lifts in the widowâs peak are very effective at elevating the lateral brow with minimal scarring and no further destruction of the hairline. Subcutaneous or subgaleal anterior hairline browlifts can selectively elevate the lateral brow without undesirable excessive central brow elevation.

Excision of a triangle underneath the sideburn in the performance of a revisional facelift restores to some extent the sideburn. It may be necessary to perform Z-plasties or transposition of hair-bearing skin to correct a severely disturbed hairline. Occasionally, hair transplantation with micrografts is necessary when previous excessively aggressive coronal lifts have been performed.[18] Various hair-bearing flaps can transpose hair-bearing skin into iatrogenic alopecic defects.[19]

When performing a browlift within the hairline, there has been some debate over the best direction of incision. Incisions perpendicular to the direction of exit of hair follicles may result in improved scarring, although conventional wisdom, and the authorâs experience, indicates the incision should be exactly parallel to the exiting direction of the hair shafts, preserving the delicate hair bulbs.[20] Certainly, careful handling of the tissues, exact coaptation of the edges, judicious use of electrocautery around hair follicles, and care not to cut through the hair bulbs all contribute to finer scars.

It may be preferable in all women except those with the lowest sideburns to preserve the sideburn by creating an incision at the base of the sideburn rather than elevating the hairline superiorly. The incision should approximate closely the anterior ear. The tragus should redrape easily and have a slight anterior hollow and not be pulled forward. The earlobe should be anchored in such a fashion as not to create a pulled, or ãpixieä ear deformity. Posterior auricular incisions are best made into, and not along the hairline. The posterior hairline should match after elevation of the neck flap without a surgically created step-off.

Patients with upper lid blepharochalasis and brow ptosis represent a challenge. It is often best to perform the brow elevation technique first. This will allow the surgeon to avoid an unexpected lagophthalmos when the blepharoplasty is then performed. Dry eye syndrome and excessive corneal exposure can occur if excessive resection from a blepharoplasty is exacerbated by simultaneous brow elevation. Although this practice has been largely abandoned, some surgeons advocate having patients awake during the performance of these procedures. Others advise staging brow and upper eyelid rejuvenation.[21] Upper blepharoplasty does not appear to change brow position.[22]

The effect of brow-midface techniques on the lateral canthus must be anticipated. Hairline endoscopic techniques which raise the midface may raise the lateral canthus. This canthal elevation can at times be desirable, i.e. when a post-blepharoplasty round eye deformity or a depressed lateral canthus is present. However, the effect on the canthus should be anticipated preoperatively. Tension that raises the midface must traverse as a midpoint the lateral canthal region and exert an upward vector on this area. If the lateral canthus is in the correct position, a combined brow-midface technique may have an undesirable effect on the lateral brow, creating the artifact of an overly high lateral canthus.

Techniques aimed solely at elevation of the lateral brow (coronal browlift, pretrichial lifts, temporal lifts) do not generally impact the position of the lateral canthus. Such brow elevation techniques performed in a subperiosteal, subgaleal and subcutaneous level generally do not impact the position of the lateral canthus.

There are many components to midfacial aging. Lower eyelid fat herniations develop. A prominent nasojugal groove and infraorbital hollow develops as the cheekpad complex descends (Figure 7). Laxity of the lateral canthal ligament results in horizontal lid laxity. Orbicularis droop with relaxation of the orbicularis oculi muscle can contribute to festoon formation and descent of the cheekpad complex. Subcutaneous fat atrophy causes facial volume loss. Upper eyelid blepharochalasis and lateral brow hooding develop. Nasolabial fold depth and heaviness above nasolabial fold result from midfacial droop and midfacial fat atrophy.

Figure 7. Ptosis of the orbicularis muscle, the cheekpad complex and the malar fat pad deepen the nasolabial fold. Descent of the malar fat pad leaves the infraorbital rim exposed.

This innovative technique allows for distribution of unwanted fat herniation from infraorbital fat bulges down into the infraorbital hollow (Figure 8). The effect is reduction of infraorbital hollowness. This camouflage technique is useful not only as a primary technique, but also as an adjunct for midfacial advancement techniques. In many patients with thin skin the lower eyelid bulge does not seem to be effectively effaced. In such patients, it may be preferable to remove the fat completely from underneath the orbital septum and replace it as a free (untraumatized) fat graft into the nasojugal groove and infraorbital hollow.

Figure 8. The insertion of the orbital septum onto the inferior orbital rim is the arcus marginalis.[23]

Nevertheless, this technique was critical in the evolution of the concept of fat preservation rather than fat removal from the periorbital area.

Owsley advocated elevating in a supero-lateral vector the malar fat pad during a facelift (Figure 9).[24] Nicoletis also recognized the necessity of elevation of the midface as well as the side and lower portions of the face. [25] Both surgeons recognized the role of the malar fat pad in midfacial aging and heaviness of the nasolabial fold.

Figure 9. Direct elevation of the malar fad pad during a facelift[26]

To treat lower lid ectropion or to produce midfacial smoothening, McCord, Codner and Hester (Figure 10, Figure 11)) described redraping the orbicularis arc with a lateral canthoplasty and bony fixation. The procedure involves drill hole fixation through the supero-lateral orbital bony rim to anchor the lateral canthus. This can be combined with spacer implants for middle lamellar deficiencies.[27] Other orbicularis redraping operations have been proposed by Fogli[28], Hinderer[29] and Trepsat[30].

Figure 10. Redraping of the orbicularis arc. An early paper recognizing the key role of the orbicularis muscle in midfacial elevation, the suborbicularis dissection, and lateral canthal support.[31]

Figure 11. Lateral canthal support for a patient with lower eyelid laxity[32]

Cervicofacial Hike Procedure

Figure 12. The cervicofacial hike is a reconstructive procedure for reconstruction of cheek defects. It involves elevation and fixation of mid and upper facial tissues.[33]

The cervicofacial hike and similar procedures were innovative operations for reconstruction of large extirpative defects in the infraorbital region (Figure 12). This procedure incorporated elements that would be subsequently be used for cosmetic purposes in temporal and midfacial advancement procedures. [34],[35]

The subperiosteal approach to a facelift may have special merit in younger patients or patients with preferential upper face and midface ptosis with minimal neck ptosis. With the exception of the transition from the temple to the zygomatic periosteum, the dissection is straightforward. There may be advantages to endoscopic techniques since they do not disrupt blood supply to the extent that an extended subcutaneous dissection can. Therefore, there may be a greater margin of safety in combining full face laser resurfacing with endoscopic temple and facelifts than with conventional facelifts. [36]

The Achillesâ heel of the subperiosteal facelift has always been injury to the frontal branch of the facial nerve and significant postoperative swelling.

A temporal incision, either through endoscopic stab incisions or a longer non-endoscopic temporal incision is made. A second incision is then made through the gingivobuccal sulcus or a subciliary incision. Mobilization of the tissues at the subperiosteal level occurs, with care taken around the zygoma to avoid frontal branch injury.[37] A posterior approach to the zygoma at the level of the tragus may reduce the risk of frontal branch injury when mobilizing soft tissues off the zygoma. A posterior approach to the zygoma may lessen the incidence of nerve injury in an area with considerable anatomic transition. However, with experience, most practitioners find the subperiosteal technique to have a very low incidence of temporary or permanent nerve injury.[38] The maxilla, periorbital areas and zygomatic areas are dissected at a subperiosteal layer, generally through a gingivo-buccal sulcus incision or a subciliary incision. A Cottle elevator is used to sweep superiorly and inferiorly, and then completing the anterior and posterior dissections completes the arch dissection.[39] Extensive release of the upper midface ligamentous structures has been advocated to facilitate upward rotation of the flap. Wide undermining of the orbicularis oculi muscle fibers may also assist in upward elevation. Cheekpad elevation in a superior-lateral vector can generally be achieved.[40]

There is a problem area in the subperiosteal dissection involving a transition from the temple to the zygoma. The easily accessible intermediate temporal fascial space and the easily accessible subperiosteal space of the midface must be connected in order to allow upward mobilization of the flap. The intermediate temporal fascia above the temporal fat pad must be incised to allow the transition onto the zygomatic periosteum. Undue traction on the frontal branch of the facial nerve can cause a temporary or permanent injury and hemiparesis.

If the neck is to be rejuvenated, this approach can be combined with a periauricular incision.

Advantages of a purely subperiosteal upper and midfacelift with combined temporal and buccal sulcus incisions include ease of implementation, no necessity of infraorbital incision, and minimal risk of ectropion. The purely endoscopic upper and midfacelift technique is especially useful if modest elevation of the midface with no treatment of the orbicularis oculi muscle is necessary.

The lateral canthus may rotate upward in a pure subperiosteal dissection in the lateral brow and midfacial region. This can produce a ãcat-likeä appearance if pull is excessive or if the patient has preexisting superiorly positioned lateral canthus. Care must be taken when performing any surgery that elevates midfacial tissue in a superior-lateral direction that the interzygomatic (intermalar) distance not become excessively wide, or a ãpraying mantisä deformity may result. One must avoid increasing intermalar distance in any midfacial or temporal-midfacial procedure when the vector of pull of the malar fat pad is superiorly and laterally.

There is a growing trend away from the purely subperiosteal facelift toward a combined approach÷a midfacial technique encompassing a subperiosteal dissection with a separate lateral brow technique. The frontal branch is thereby taken out of harmâs way.

Differentiation between the subperiosteal facelift and the endoscopic facelift-browlift-midfacelift is becoming blurred. Hybrid procedures combining minimal temporal incisions vs. endoscopic incisions make the distinction between endoscopic and subperiosteal facial and brow rejuvenation procedures fluid.

This upper face-midfacial rejuvenation technique involves elevation of the entire face through conventional facelift incisions and a subciliary incision, with complete detachment of the pretarsal orbicularis oculi muscle and a suborbicularis plane of dissection. As described, this technique results in a significant elevation of the lateral sideburn, often to a position above the ear. In addition, lateral canthal elevation may occur when the composite flap is elevated superiorly. This technique is important in that it introduced simultaneous midface, lower, upper and lateral face elevation. Combining midfacial elevation with more conventional upper and lateral facial elevation will reduce the lateral sweep deformity.[41]

Hamra described repositioning of the orbicularis muscle to the orbital rim periosteum as a component of a composite rhytidectomy.[42] This technique can be combined with a zygorbicular dissection and midface elevation.[43] This operation involves separation of the pretarsal orbicularis muscle and inclusion in the flap, with subsequent dissection inferiorly and eventually below the zygomaticus muscle. This flap is then combined with a subcutaneous facelift dissection from below, above the level of the zygomaticus major muscles.

The necessity of midfacial rejuvenation is growing. The lateral sweep appearance of the face is avoided by lifting the midface as well as the side and bottom of the face and neck. Camouflage techniques such as a conventional lower blepharoplasty or arcus marginalis blepharoplasty will not suffice to achieve midfacial rejuvenation in many patients with significant cheek ptosis (Figure 13 A-D).

A harmoniously rejuvenated face should include as many important youthful features with as few telltale signs and distortion of normal anatomy (Figure 14 A, B).

Figure 13 A

Figure 13 B

Figure 13 C

Figure 13 D

Figure 13 A, C. Preoperative view of a patient with previous facelift with no midface rejuvenation

Figure 13 B, D. Postoperative views after elevation of the midfacial tissues with reduction of the ãlateral sweepä phenomenon

Figure 14 A

Figure 14 B

Figure 14 A. Preoperative patient with previous facelift with midfacial sagging despite upper and lateral facial tightness

Figure 14 B. Postoperative view of patient after a midfacial elevation (superficial cheeklift) along with a revisional facelift

The role of midfacial rejuvenation in the unhappy postblepharoplasty patient is also growing. As a component of lower blepharoplasty, lower eyelid skin excision has been performed for decades. Many patients have developed lower eyelid retraction, lateral canthal dystopia, increased scleral show, round eye deformity, and often frank ectropion. Correction requires elevation of the midfacial tissues to efface the nasojugal groove and infraorbital hollowness, plus grafting into the hollow region (Figure 15 A, B).[44]

Figure 15 A

Figure 15 B

Figure 15 C

Figure 15 D

Figure 15 A, C. Preoperative patient with postblepharoplasty hollowness

Figure 15 B, D. Postoperative view after midfacial rejuvenation and arcus marginalis release with transposition of fat into infraorbital hollow. In patients such as this, dermal-fat-fascial grafts are now inserted into the infraorbital and nasojugal hollows.

One effective technique for mild postblepharoplasty syndrome is lateral canthal elevation with mild undermining of the orbicularis muscle, leaving a cuff of orbicularis muscle (Figure 16). As described, this technique uses an optional canthotomy and drill fixation of the suspension suture. More aggressive techniques may necessitate wider midfacial elevation. Another approach is to combine midfacial elevation with lateral canthopexy (Figure 17).

Figure 16: A technique for isolated lateral canthopexy for downward lateral cant to the lower lateral eyelid. As described, a formal canthotomy with division of the canthal ligament and drill fixation to the orbital rim is generally performed with this procedure. [45]

Figure 17 A

Figure 17 B

Figure 17 A. Preoperative view of a patient with downward cant of the lateral canthus.

Figure 17 B. Postoperative view after selective elevation of the lateral canthus plus midfacial elevation.

Crowâs feet (lateral periorbicular wrinkles) are a stubborn problem with many suggested solutions. The etiology is muscular hyperactivity combined with senile degeneration of the overlying skin and the formation of rhytids. With the advent of botulinum toxin, the appearance of dynamic crowâs feet can be reduced on a temporary basis. Sectioning operations may result in recurrence of the lateral orbicularis oculi activity once microscopic nerve fibers regenerate into the healed muscle fibers. Simultaneous elevation and sectioning of the orbicularis has also been proposed.[46] Deep established rhytids may require laser resurfacing in addition to treatment of the underlying orbicularis muscle.

Elevation of the midface and lateral face can be accomplished in subcutaneous plane, a suborbicularis plane, or a subperiosteal plane (Figure 18). Elevation at the subcutaneous plane may neglect many of the deeper signs of aging, such as ptotic orbicularis muscle, infraorbital fat against the orbital septum, and ptotic malar fat pad. Advantages of accessing the upper and midface in a suborbicularis plane are ease of performance, ability to tailor the orbicularis oculi muscle, avoidance of subperiosteal associated swelling, recovery time, and postoperative ectropion. In a suborbicularis plane, it is possible to perform simultaneous lower blepharoplasty with treatment of fat herniation and orbicularis descent. An inherent advantage of a suborbicularis technique is the ability to correct a ptotic orbicularis muscle, and an ability to move tissues otherwise tethered by an unyielding periosteum. This technique is especially suited when lower eyelid rejuvenation or microadjustment are necessary. Risk to the frontal branch of the facial nerve is remote. If a 4-5 mm cuff of pretarsal orbicularis oculi muscle is maintained, orbicularis hypotonicity is very rare. As a cautionary note, the patient should not have Botulinum toxin injections in the lateral periorbital region during the immediate preoperative period, since hypotonicity can manifest postoperatively after upper or midfacial elevation procedures.

The zygorbicular plane of midfacial elevation is basically a suborbicularis approach to the midface. It also uses a second plane, underneath the medial portions of the zygomaticus major and minor. This technique is combined with a composite facelift, in which a composite face lift flap is created and rotated upward. However, a component of the composite lift may be an extreme elevation of the sideburn. Implications of this sideburn loss should be discussed preoperatively with the patient, and may not be appropriate for patients with an already high sideburn. In development of the composite flap, the pretarsal orbicularis oculi muscle is taken from its lower eyelid attachments with no cuff remaining on the lower eyelid.[47] When no cuff of pretarsal orbicularis muscle is left behind to support the lower eyelid, there is elevated potential for dystonia of the lower lid, ectropion or lid retraction. Dissection at the suborbicularis level has inherently less swelling than when the subperiosteal space is entered.

Many hybrid techniques are emerging combining aspects of isolated techniques (Figure 19). In one such technique, a subperiosteal dissection is combined with a lateral temporal incision. Malar fat pad is elevated supero-laterally and fixated to the deep temporal fascia.

Figure 18. This technique incorporates a suborbicularis dissection from a subciliary incision with a subcutaneous dissection from a standard rhytidectomy incision. Note that no pretarsal orbicularis cuff remains behind on the lower eyelid. [48]

Figure 19. A technique for midfacial complex elevation with direct sutures from the malar fat pad to the deep temporal fascia in combination with a subperiosteal dissection. [49]

With the superficial cheeklift by Moelleken,[50] rejuvenation of the midface and lateral periorbital region can effectively be achieved by a midfacial and lateral periorbital lift through a subciliary incision. The dissection is carried down through the orbicularis muscle, preserving a 4-5 mm cuff of pretarsal orbicularis muscle (Figures 20- Figure 23). A suborbicularis dissection is then undertaken to free the malar fat pad and midface from its midfacial attachments. The entire midfacial complex is advanced superiorly and the cuff of cheek orbicularis is anchored to the so-called intermediate temporal fascia. This has resulted in predictable rejuvenation of the midfacial and lateral periorbital region. The extended healing time of the subperiosteal approach is avoided. The morbidity of a canthotomy is also avoided. Microadjustment of the orbicularis oculi muscle is possible prior to closure of the subciliary incision. Although the published series of this procedure has a zero incidence of ectropion, the superficial cheeklift does require familiarity with the midface and lower eyelid, and may be technically more difficult than midfacial techniques not performed through a subciliary incision. Its reward has been a negligible incidence of ectropion.

Complications have been minor and include palpable fixation sutures, subtle facet formation at the lateral inferior periorbital region, postoperative lateral periorbital incisionsal swelling, and visible scars requiring minor scar revisions. Using very short lateral periorbital incisions, carefully adjusting tension on the cheeklift flap, and taping of the lateral periorbital area for a period of three days postoperatively, can minimize these complications.

In keeping with the trend for more comprehensive rejuvenation, dermis-fat or SMAS grafts can be placed in regions of excessive hollowness at the same time as midfacial elevation is performed (Figure 24).

This operation provides predictable elevation of midfacial tissues with effacement of the infraorbital hollow region in a technically straightforward plane of dissection (Figure 25 A, B).

Figure 20. Lateral view of the upper cheek anatomy. Note role of orbicularis oculi muscle (distal fibers) with malar fat pad. The SOOF layer, located deep to the orbicularis oculi muscle, is simply a gliding layer for the orbicularis muscle to function properly, in the opinion of the author. The SOOF is by itself not a structural layer capable of elevating and fixating the midfacial tissues.[51]

Figure 21. Superficial cheeklift dissection with suborbicularis dissecting, preserving a pretarsal orbicularis cuff and avoiding lateral sub-orbicular dissection. These two cautionary steps will avoid temporary or permanent denervation of the orbicularis with postoperative ectropion.[52]

Figure 22. Securing of the elevated midfacial cheekpad complex to the ITF (intermediate temporal fascia) via the orbicularis muscle and its attachments to the malar fat pad. [53]

Figure 23. Anatomic cutaway of the superficial cheeklift operation to demonstrate level of dissection. Level of dissection of the superficial cheeklift is suborbicularis, leaving the zygomaticus muscles behind.[54]

Figure 24 A

Figure 24 B

Figure 24 A. Intraoperative photograph showing SMAS grafts prior to placement in a region of infraorbital hollowness.

Figure 24 B. Intraoperative photograph shows both infraorbital regions after placement of the SMAS grafts. Midfacial elevation of left side completed; prior to elevation of right side. Direct placement of living autologous grafts will have higher reliability than aspirated and transplanted fat grafts.

Figure 25 A

Figure 25 B

Figure 25 A. Preoperative view of a woman with infraorbital hollowness and cheekpad complex ptosis.

Figure 25 B. Postoperative view after a superficial cheeklift in combination with a face and necklift, resulting in rejuvenation of the upper, mid and lower face.

There was a disturbing trend to maximize the amount of midfacial elevation during the performance of midfacial or upper facial-midfacial tissues. The amount of available tissue for elevation is very limited. In the authorâs experience, there are fewer than 50 square cm. of tissue total from the lower eyelid to the upper lip. Only approximately 1 - 4 square cm. of tissue are available for resection and elevation. More tissue can be resected when solid canthal reconstruction with midfacial tissue support can be established, and only in patients with very lax cheek skin. In patients with previous blepharoplasty, there is typically no tissue that can be resected. Rather, all elevated midfacial tissues will be required to allow for middle lamellar scarring, downward pull due to incisional tightening, and lateral canthal reconstruction. Surgeons experienced with the midface do not attempt aggressive midfacial lifts.

Excessive elevation of midfacial tissues can result in ectropion, round eye deformity, and orbital exposure with keratopathy. In patients who have had aggressive midfacial elevation procedures, early signs of tightness in the midface are a downward lower eyelid pull when the patient opens their mouth and forces the upper lip over the front teeth.

Subperiosteal subciliary procedures

Many subperiosteal subciliary techniques are described with canthotomy and a subperiosteal dissection. Complications can be significant and include prolonged swelling associated with the subperiosteal dissection and lateral canthal distortion associated with a canthotomy. This technique and all midfacial techniques require considerable experience with the midface and lower eyelid. More recently, advocates of this technique have abandoned the canthotomy[55].

The subperiosteal cheeklift, despite its difficulty and potential complications, can produce excellent midface elevation when performed by surgeons with expertise in midfacial procedures. It is important to avoid a long lateral periorbital incision, and whenever possible to avoid a canthotomy. Since the periosteum is an unyielding layer, upward rotation of the flap may necessitate scoring from below of the periosteum during flap elevation.

The transmalar subperiosteal midfacelift is a subperiosteal technique which anchors the zygomaticus muscle origins to the deep temporal fascia and is accomplished with a blind dissection through the skin on the zygoma with minimal skin and SMAS undermining. [56] A theoretical disadvantage of this technique may be the concentration of the entire vector of the lift in a single suture. Temple and gingival sulcus incisions are the most common locations of these incisions for these types of procedures.[57]

Endoscopic techniques performed at a subperiosteal level excel at rejuvenating the upper and middle of the face. They share mobilization of the midface at a subperiosteal level, a careful dissection over the zygoma where the frontal branch of the facial nerve runs, and anchoring of the elevated flap to higher tissues, usually the deep temporal fascia. These techniques are frequently combined with separate incisions for a necklift or upper or lower blepharoplasty.[58]

Endoscopic, subperiosteal elevation is accomplished with anchoring of the midfacial tissues to the deep temporal fascia with suspension sutures.[59] This may accomplish an elevation of midfacial tissues with suspension to the deep temporal fascia. It does not involve a subciliary incision, so concomitant blepharoplasty will require a separate incision.

Selective brow analysis should lead the surgeon to perform tailored operations combining a number of accepted techniques in a customized fashion.

Endoscopic or direct myomectomy can be performed in patients who do not wish to have repeated Botulinum toxin injections. This procedure, involving a debulking or complete removal of glabellar musculature, can be performed through an endoscope with hairline entry incisions. Alternatively, the same procedure can be performed through an upper blepharoplasty incision or stab incision in or just below the medial brow. The muscles targeted are the procerus, corrugator, frontalis and medial fibers of the orbicularis oculi muscle. The extent of dissection is generally a region 1.5 cm laterally to the midline, onto the radix, and upward by 2 cm. This avoids the neurovascular bundle and main branches of the supratrochlear nerves.

The effect of this procedure can be predicted by remembering the functions of the individual forehead muscles. The corrugator depresses the brow and brings it centrally, as do orbital fibers of the orbicularis oculi. Procerus fibers depress the central brow. Therefore, after the procedure the interbrow distance increases and some central elevation of the brow is noted. Glabellar and procerus furrows are reduced. Frowning is not eliminated, as a frown can still be generated from frontalis and orbicularis fibers above the medial and lateral brow.

Techniques that involve division of forehead muscles usually work only temporarily. Generally, muscle function returns as small nerve fibers and muscle regenerate. This includes division of glabellar musculature, and superselective ablation of frontal nerve branches destined for the glabellar musculature. Most clinicians have found that transsection alone of corrugators is at best a temporary solution.

A similar situation for end-nerve ablation techniques exists. Nerves to the corrugators can be ablated selectively in a transcutaneous procedure where external nerurostimulators isolate the locus of the end nerve. In this way, individual nerves to the corrugators or orbital portion of the orbicularis muscle causing frown lines or glabellar furrowing can be ablated. Absolute alcohol is then injected into this locus.

Because end nerves regenerate, this technique seems also to be short-lived. Perhaps the neurostimulator is detecting muscle activity rather than end nerves, and that the damaged muscle fibers from the absolute alcohol regenerate or heal.

One hallmark of all standard techniques is that undermining is done in a relatively wide plane of the tissues to be elevated. Historically, there have been single stitch techniques (i.e. The ãMarionetteä stitch) described which purport to elevate tissues based on a single suspension type stitch with minimal or no undermining. These techniques have not gained wide acceptance and may suffer from two potential problems. First, the stitch may break or pull loose, rendering the operation ineffective. Second, the tension may be directed to a very small segment of tissue, and the pull may not elevate the adjacent tissues, resulting in visible lines of pull. If the stigmata of aging in a patient were isolated to a single locus, a single stitch might remedy this focal aging. Most patients, however, age over a broad plane and benefit from the broad undermining and elevation, a concept which all current tissue elevation techniques espouse.

Augmentation of underlying bony structures in the supraorbital-temporal ridge area and malar-midface areas may counteract the effects of aging by filling in tissues lost to senile subcutaneous atrophy.[60],[61],[62]

The placement of cheek implants or submalar implants may successfully replace soft tissue loss due to subcutaneous tissue atrophy. Careful analysis of the facial zones and tissue deficits is essential. There is a tendency away from the older style ãbutton implantsä placed on top of the lateral zygoma, as these are often visible and unattractive. Increased intermalar distance, the ãpraying mantis effectä should be avoided in placement of any midfacial implants.

When profound midfacial wasting is present (as with HIV patients who are taking multiple antiviral medications), large pyriform aperture-midfacial implants can be fashioned based on a CT-scan computer generated moulage. The implants are then customized preoperatively and minor revisions performed in the operating room. Generally, an upper buccal sulcus incision is sufficient to place even very large custom implants in the midface and pyriform area.

There is an increasing trend toward subcutaneous fat injection under rhytidectomy flaps prior to closure to combat the facial fat atrophy in the subcutaneous layers.[63] Repeated injections may be necessary, due to the inherent low survival of fat subjected to the trauma of liposuction, purification and injection (20-25% in most series at best). Nevertheless, injected fat may provide a means of augmenting a large tissue plane with fat and combating facial fat atrophy. Autologous grafts of dermis-fat survive more predictably than aspirated fat grafts (Figure 26).

Practitioners who have considerable experience with fat injection stress the necessity of handling the fat gently, and harvesting and transferring small allotments of fat. A blunt canula may minimize trauma to the fat cells. The limiting factor in fat injection is the survival of the grafted tissue. Survival reports vary, but it seems that most fat transplantation has minimal permanent survival, with one study reporting a 3-4% 14-month survival after the last transplantation session,[64] while others report successful long-term survival in grafted patients, even with Rombergâs syndrome.[65] There may be some utility to deep frozen autologous fat as a filler.[66] One emerging theme is that if fat injection is used as a significant volume filler, repeated injections are necessary over time, and the longevity of the grafts is yet undetermined.

Figure 26. Rhytidectomy patient prior to placement of harvested SMAS grafts into critical areas (1) supraorbital sunkenness from previous blepharoplasty (2) infraorbital groove hollowness (in combination with a superficial cheeklift) (3) upper and lower lip augmentation (4) glabellar furrow grafts; fat injection of carefully harvested fat is also placed underneath facelift rhytidectomy flaps and into hollow created by temporal fat pad of atrophy.

Care must be taken not to inject fat into areas covered by excessively thin flaps, as the fat may then be visible as a subcutaneous irregularity. This fat presents a particular problem, as fat which does survive injection tends to be very fibrous and firm. One area that seems unsuited for routine fat injection is the infraorbital hollow region in patients with thin skin (Figure 27 A, B). Occasionally, injected fat can form calcific nodules, which require direct excision. In some circumstances, direct placement of SMAS or dermal-fat-fascial grafts into glabellar furrows, nasolabial folds and infraorbital hollow regions may be preferable to fat injection.

Figure 27 A

Figure 27 B

Figure 27 A. Preoperative view of a patient who had previously undergone subcutaneous fat injection, which survived as a lumpy subcutaneous growth. The patient had failed attempts at removal of the fat with liposuction and direct excision and suffered from dry eye syndrome and lateral canthal dystopia.

Figure 27 B. Postoperative view after removal of fat, canthal reconstruction and superficial cheeklift.

Carbon dioxide or erbium-YAG laser resurfacing can be performed in most patients at the same setting as subperiosteal or subgaleal browlifts. It is not recommended to resurface the actual incision in anterior hairline browlifts. Similarly, most midfacial rejuvenation procedures can safely be combined with laser resurfacing, as can midfacial/brow rejuvenation procedures (Figure 28 A ö D).[67] Small series have described simultaneous carbon dioxide laser resurfacing with subperiosteal facelifts for the upper and mid third of the face, caution should be exerted before performing laser resurfacing over undermined flaps.[68] Perhaps there is more safety in performing an endoscopic lift with full-face CO2 laser resurfacing than with a conventional facelift.[69]

Figure 28 A

Figure 28 B

Figure 28 C

Figure 28 D

Figure 28 A, C. Preoperative patient troubled by periorbital aging and lip rhytids patient Figure 28 B, D. Postoperative views after full full-face CO2 laser resurfacing, upper blepharoplasty and midface elevation. Additional brow surgery would have resulted in excessive brow elevation. Patient did not desire neck rejuvenation.

The primary goals in brow rejuvenation surgery are to correct the signs of aging ion the brow, temple and periorbital areas. Infrabrow hooding, decrease in the vertical dimension of the orbital aperture and upper blepharochalasis occur with advancing age. Many signs of aging occur in the periorbital and temple area as well (Table 1).

The efficacy of traditional vs. endoscopic browlifts has been debated. In either case, brow ptosis is likely to recur over a period of years. One year postoperatively, there may be no difference in standard anthropomorphic sites including brow, medial canthus and subnasale. Pretrichial or coronal lifts may relax so that at 5-year follow-up, little residual brow elevation may be present. Some authors have found that there is little longevity of conventional coronal lifts compared with endoscopic subperiosteal lifts.[70]

The facelift incision is extended cephalad approximately 5 cm from the anterior hairline around to the contralateral ear. Dissection proceeds at a subgaleal level until 5 cm above the supraorbital rim, where the dissection then traverses to the subperiosteal plane. This allows for preservation of the supraorbital and supratrochlear nerve bundles. Glabellar musculature and transverse frontalis lines can be dealt with by direct excision. Dissection onto the glabella and release of lateral superior orbital ligaments facilitates upward rotation of the flap. A segment of hair-bearing skin is then removed, tailored to the needed degree of brow elevation desired. The coronal lift will alter the hairline and this change should be projected and weighed against less invasive forehead treatments.

The coronal lift achieves predictable, long-lasting elevation of the brows and significant reduction in glabellar and transverse frontalis rhytids. It is technically easy, provided one avoids the frontal branch in the lateral forehead flaps.

There are several disadvantages to the coronal lift. Dysesthesias with long lasting or permanent numbness can occur around the long coronal incision. If overdone, the coronal lift can produce excessive elevation of the brow, especially the central brow, and lead to a surprised appearance. Often, permanent alterations of the hairline occur. Medial elevation of the brow translates directly to loss of anterior hairline hair and an elevation in the forehead height. The lateral brow elevation translates to a commensurate loss of temporal hairline. If combined with a traditional facelift in which the sideburn is raised, there can be considerable loss of temporal and sideburn hair, potentially leading to a windswept, bald appearance. If excessive hair-bearing skin is resected, and the incision is closed under tension, large areas of alopecia can result.

The frequency of male plastic surgery is increasing. Endoscopic brow surgery may be appropriate for men with male pattern balding. Endoscopic surgical approaches may minimize the incidence of visible scars in patients with receding hairlines, hair transplants or baldness.

Care must be taken not to elevate either the medial or the lateral brow excessively. This may produce an overly feminized appearance. Rather than having an arched lateral brow in men, a flat or mildly descending brow may be more aesthetically appealing. Often, a subcutaneous lateral browlift and an extended upper blepharoplasty will suffice to rejuvenate the periorbital and brow area in men without feminization characteristic of overaggressive browlifts (Figure 29 A ö D).

Figure 29 A

Figure 29 B

Figure 29 C

Figure 29 D

Figure 29 A, C. Preoperative views of a man with aging face, eye, midface and brows. Figure 29 B, D. Postoperative views after facelift, cheeklift, extended upper blepharoplasty and subtle lateral temporal browlift. An extended upper blepharoplasty combined with a lateral browlift results in minimal distortion of the temporal hairline yet offers adequate rejuvenation without feminization associated with excessive browlifting procedures in many male patients.

Especially in men, the effect on forehead or midfacial lifting on the temporal and sideburn hairline must be discussed preoperatively. If a retro-tragal facelift is performed, the sideburn may move laterally, obscuring the normal hairless landmark between the tragus and the beginning of the sideburn. In some patients, the length of the sideburn is limited. Therefore sideburn elevation with lateral brow lifts or the superior portion of the rhytidectomy may obliterate the sideburn. This can be avoided if a Burrowâs triangle is excised below the sideburn during elevation of the facial flap.

Considerable upper facial rejuvenation can be accomplished through an upper blepharoplasty incision alone.[71] Dissection encompasses the superior orbital rim. Soft tissues are elevated. Resection of the procerus and corrugator muscles is accomplished through the blepharoplasty incision. Typically, brow tissues are elevated and secured to temporal fascia and periosteum of the orbital rim. The frontotemporal flap can be anchored with percutaneous screws or contouring tape.

A thorough knowledge of the fascial layers of the temple, the ligamentous attachments of the upper and midface, and a working knowledge of the anatomy of the brow, temple area, and upper face is essential for surgeons performing endoscopic brow and facial surgery (Figures 30 ö 33).

Younger patients who are disinclined to have repeated Botulinum toxin injections or male patients with male pattern baldness are well suited for the endoscopic approach to facial and brow rejuvenation. Patients who already have higher foreheads of relatively high or sparse temporal hair patterns may also be good candidates.[72] In addition, the endoscopic browlift may benefit patients suffering from unilateral frontal branch paresis with ptosis.[73] Patient acceptance of endoscopic forehead lifts may be higher than that for long incision techniques.

Figure 30. Additional releasing of the inferior and superior temporal septa and the temporal adhesion may be necessary to elevate the lateral brow area in endoscopic browlift technique. If midfacial tissue is also elevated, it may be necessary to release the lateral orbital thickening of the septum (LOT) and spare the zygomaticotemporal nerve (ZTN). The sentinel vessel (SV) is located laterally and superiorly at the outer orbital rim.[74]

Figure 31. Anterior view of area to be released in performance of endoscopic lateral browlift, including periorbital septum (PS), lateral brow thickening of periorbital septum (LBT) and the inferior temporal septum (ITF). Cheek elevation may require additional elevation of the lateral orbital region.[75]

Figure 32. Hairline incisions from endoscopic with nerves delineated, lateral view. Note typical location of incisions. Particularly note the course of the frontal branch of the facial nerve.[76]

Figure 33. Nerves to be avoided in the course of subperiosteal undermining for the endoscopic facelift. [77]

Figure 34. Endoscopic dissection in the transition area from the temple to the zygomatic periosteum. The intermediate temporal fascia (ITF) is opened. If this dissection occurs in the mid portion of the zygoma, there will be a direct transition from the temporal fat pad into the zygoma, with no transitional fascial layer. Damage to the temporal fat pad should be avoided to avoid excessive temporal hollowing.[78]

Figure 35. Levels of dissection in the endoscopic upper face/midface lift incorporates a subperiosteal dissection over the midface and zygoma, combining with a dissection on the deep temporal fascia from above. The transition point in this dissection is at the temporal fat pad in the lower temple, just above the zygoma.[79]

Figure 36. Combined subperiosteal technique with a lateral temporal incision is characteristic of the many mixed open-endoscopic techniques.[80]

Coronal lifts are often compared to endoscopic lifts of the forehead. Endoscopic lifts involve elevation at a subperiosteal level of tissue above the zygoma, with elevation of the zygomaticus major and minor muscles, the levator anguli and portions of the orbicularis oris muscles. This dissection is connected with a dissection in the temple area carried out above the deep temporal fascia. The temple area can be accessed through temporal or lateral hairline incisions, or in some cases with a larger incision over the lateral temporal region.

For two reasons, the difficult portion of the dissection is the transition from the ITF to the subperiosteal plane at the zygoma, for two reasons. First, the frontal branch of the facial nerve runs supra-periosteally from the tragus of the ear to a position 1.5 cm lateral to the lateral brow. This can be injured if the dissection is not strictly subperiosteal over the zygoma, or if undue traction is placed in this relatively inflexible layer. Second, the transition from the deep temporal fascia to the zygomatic subperiosteal plane involves transition over the temporal fat pad. If this is injured, a hollow appearance in the temple can result unilaterally or bilaterally.

In this dissection, an intraoral approach is very helpful. Through an upper buccal sulcus incision (avoiding the buccal fat pad), a subperiosteal plane is developed. This is relatively easy up to the level of the zygoma. Many surgeons then transition either from the superior dissection, or through a separate lateral incision over the zygoma itself, where a subperiosteal dissection is easily performed. Then, the lower and upper dissection planes can be connected at the ITF (Figure 34).

Care is taken not to injure the zygomaticotemporal, supraorbital, the zygomaticofacial and the infraorbital nerves (FIG) in the course of the subperiosteal dissection.

Generally, three hairline incisions allow for insertion of the endoscope and instruments (Figure 35, Figure 36). The forehead flap is undermined endoscopically and the glabellar muscles avulsed or cut directly under endoscopic guidance. The lateral superior orbital ligaments are released to allow upward rotation of the forehead flap. Anchoring is performed to the posterior scalp, to biodegradable pins, or to anchor screws placed in the scalp. Temporary posts are removed after sufficient time to allow the periosteum to adhere to its new position. [81] Periosteal adherence is believed to occur within 12 weeks postoperatively. Until that time, depressor mimetic muscle function counteracts the effect of superior advancement of the subperiosteal flap. Depressor muscles include the procerus, medial fibers of the orbicularis muscle, and corrugator fibers. It may be beneficial to use botulinum toxin during the healing phase of an endoscopic browlift to reduce the undesirable depressor function.[82] Midfacial suspension sutures can help anchor the subperiosteal flap in place while elevating midfacial and upper facial tissues (Figure 37, Figure 38).

Figure 37. Lateral view of the anchoring of the mid and upper face. There two common anchoring sites, the inferior orbital rim and the temple, intermediate temporal fascia (ITF) or deep temporal fascia (DTF). Of these sites, the ITF or DTF may provide greater purchase and easier elevation of the facial flap. This technique incorporates a midfacial elevation at the suborbicularis level over the zygomatic muscles using the orbicularis-SOOF-malar fat pad (see also [83],[84])

Figure 38. Elevated subperiosteal flap in mid-upper facial rejuvenation, side view. [85]

Long-term elevation has been noted in these patients. It is often thought that brow position falls more quickly after endoscopic lifts than with traditional skin-excision type browlifts. With more extensive mobilization, and midface and upper facial resuspension, this may no longer be true. Also, hairline preservation is generally superior in endoscopic vs. traditional coronal incisions.

More extensive release of ligamentous structures, plus undermining at a subperiosteal level (below the innervation) of the orbicularis oculi may improve brow tail elevation in the upper midface. This may allow superior elevation of the cheekpad-temple complex.[86]

Once mobilization of the brow and disinsertion of the superior orbital rim attachments has been accomplished, fixation should elevate the brow and hold it in a more superior position. Numerous methods for fixation of the brow have been described, including K-wire fixation transcutaneously, flexible tape on the forehead, absorbable and non absorbable screws, and no fixation at all (allowing unopposed frontalis pull to elevate the brows).

Specific rhytids can be marked externally and resected endoscopically. This can include fibers of procerus, superior orbicularis oculi, corrugator, and frontalis muscles. Predictably, resection of these muscles is as important as considerations of the degree of brow elevation.

Longevity- Endoscopic vs. Coronal Browlifts

Physicians using the endoscopic approach have noted greater elevation of the brow over time. In particular, there was a persistent elevation of 7 mm in the vertical height of the midpupillary brow 1 year after the operation. In one cadaver study, no difference in forehead elevation between differing techniques was noted, including subperiosteal dissection to the superior orbital rim, subperiosteal dissection with release of the periosteum and subgaleal dissection. Rather, all techniques accomplished an elevation off the brow.[87],[88]

The anatomic transitions around the temple and the retaining ligaments of the cheek present unique challenges in endoscopic surgery. In particular, extensive dissection above the zygomaticus major may weaken orbicularis oculi nerve fibers[89]. Patients can have hair growth problems at the canula insertion sites that can be significant and permanent. Care must be taken not to torque the canulas and endoscopic equipment excessively against the insertion sites, lest alopecic or scarred areas develop. Patients should be cautioned that canula insertion sites could be visible either temporarily or permanently. Many surgeons feel that the results of endoscopic brow lifts are more temporary than those of coronal lifts. Bunching of the skin at the hairline can occur. Generally this is temporary and adjusts without any fall in the anterior hairline in the short term. Endoscopic forehead surgery can also lead to a loss of temporal fat pads causing a temporal hollowing.

Lateral brow ptosis can be corrected with a lateral subcutaneous browlift. This can be combined with interbrow muscle resection. A triangular section of balding skin is excised at an anterior hairline location and a subcutaneous dissection performed.[90] This technique can partially correct an excessively raised or high natural hairline at the level of the lateral frontal forehead.

Nerve damage of any sort is very rare. Elevation of the lateral brow is predictable and safe, with the proviso that there will be an anterior hairline incision. This lateral browlift has been combined with a medial corrugator resection. The supraorbital and supratrochlear neurovascular bundle is almost never encountered more medial than 1.6 cm lateral to the midline. Therefore, a blind resection encompassing 1.5 cm lateral to the midline predictably avoids the supratrochlear neurovascular bundle.[91],[92]

These minimally invasive techniques have particular use when previous excessive hairline elevation is present, and in thinning widowâs peak area in older ladies. These so-called trichophytic incisional approaches to the upper brow are a valuable tool in revisional facial rejuvenation surgery.[93]

Patients with iatrogenic excessive lateral or central hairline elevation who now require either correction of their hairline or further brow surgery may benefit from anterior hairline incisions or endoscopic surgery.

The endoscopic approach with midfacial and temporal mobilization may be used to reduce the effects of excessively elevated hairlines from previous coronal brow lifting or over-aggressively elevated endoscopic brow surgeries.[94]

Other techniques have been developed to lower an excessively high forehead. These include recreating the coronal incision and releasing any fixation sutures (from an endoscopic browlift), or from serial galeal scoring with dressing fixation of the forehead in a lower position. Excessive brow elevation caused iatrogenically may result in chronic dry eye syndrome corneal exposure with exposure keratopathy, and a persistent lagophthalmos.

Many Asian patients possess distinct facial contours: typically a brachycephalic skull with a prominent zygoma and mandibular angle. A subperiosteal procedure using upper buccovestibular and subciliary incisions has been used to rejuvenate the temporal and midfacial region of the Asian face in a natural manner, especially when combined with a multivector facelift.[95] Special care must be taken not to increase intermalar distance by upward and lateral vector lifts of the cheekpad complex during midfacial or temple-midfacial procedures.

Botulinum toxin, applied to glabellar musculature, can reduce the downward force of depressor mimetic muscles that can reverse the advancement of the subperiosteal flap in endoscopic brow surgery. The frontalis muscle can then function unopposed to elevate the brow.

Botulinum toxin now deserves a separate section in the discussion of brow rejuvenation. It is important to understand how Botulinum toxin affects the forehead musculature, and the interrelated dynamics of forehead muscle pull of each of the muscle groups. Plastic and reconstructive surgeons are uniquely suited to perform botulinum toxin injection, as they are familiar with individual muscle roles on the forehead as a whole.

The mean elevation midpupillary brow elevation from glabellar Botox injection was 1 mm. The average lateral brow elevation after selective injection of brow depressors laterally was 4.8 mm.[96] These temporary results are comparable to published series of successful browlifting procedures. Botox now assumes a more prominent role as a temporizing treatment for patients not yet ready for surgery, especially younger patients.

The effect of Botulinum toxin can be predicted by remembering the functions of the individual forehead muscles. The corrugator acts to depress the brow and bring it centrally. The frontalis muscle can assist in medial positioning of the brow. Therefore, with glabellar Botox injection, the interbrow distance increases and some central elevation of the brow is noted. Glabellar and procerus furrows are reduced. Frowning is not eliminated, as a frown can still be generated from frontalis and orbicularis fibers above the medial and lateral brow.

Botulinum toxin can be applied selectively to lateral frontalis rhytids. This may produce a brow ptosis in older patients, as the tonic brow elevation of the frontalis muscle is cancelled.

Selective application to the upper orbicularis fibers (which act to depress the brow) results in slight elevation of the lateral brow. Care must be taken not to inject the levator mechanism of the upper eyelid when performing this maneuver.

Presently, it is inadvisable to use botulinum toxin on the crowâs feet region of the orbicularis oculi muscle when a midface lift is undertaken, usually for 3-6 months, depending on the state of the lower eyelid tonicity, as temporary hypotonicity of the lower lid can result.

There is a trend toward customization of aesthetic procedures based on anatomy and surgical findings. We endeavor to correct more signs of aging with fewer stigmata of surgery and more minimal incisions. Advances in understanding of midfacial and temporal anatomy have introduced surgeons to the idea of customizing rejuvenation surgery to individualized patientsâ needs.