Midface Rejuvenation Utilizing Endoscopic Subperiosteal Dissection and Pre-periosteal Fixation

Descent of the midface contributes to the aging features of the face. This downward inward descent can be modified with midface resuspension techniques. External incisions in the lower eyelid and lateral canthus have been adapted to employ endoscopic visualization and operative techniques, minimizing postoperative edema that is often encountered with open surgical techniques. This video demonstrates an endoscopic technique for maximizing direct visualization and allowing easy implementation by both the novice and experience surgeon.

Local anesthetic blocks are placed as regional nerve blocks and also for semi tumescent infiltration of the tissue. A more concentrated local solution is injected at the sites of sensory nerve roots, namely the zygomatic facial zygomatic temporal, and the infraorbital concentrated local is also injected at the sites of the incisions in the temple and the buccal gingival sulcus. 10 to 20 ccs are injected at each site. A more dilute solution of the local anesthetic is injected into the soft tissues in the areas of surgical dissection. As demonstrated 20 to 30 ccs of the dilute local anesthetic is infiltrated in the temple and cheek regions.

The temple incision is made approximately one centimeter behind and parallel to the temporal hairline. It should be safely lateral to the pathway of the frontal branch of the facial nerve. The incision is made through the skin and continued down through the wispy superficial temporalis fascia. The superficial temporalis fascia is spread with the scissor to facilitate dissection to the desired tissue plane superior to the deep temporalis fascia. Direct visualization is used for the first few centimeters of the dissection, and then digital separation of the tissue out to the lateral orbital rim is accomplished.

Guided by the non-dominant hand, the endoscope provides direct visualization for release of the periosteal tissue along the lateral orbital rim, and to extend the plane of this section over the malar eminence vertical spreading with scissors releases the inferior edge of the conjoin tendon along the superior temporal crest line. In this video, the lateral cantal tendon is not disin inserted, but the lateral orbital rim periosteum is released for creation of a pathway to the midface and to allow upward repositioning of the tissue. When possible, the sentinel vessels are preserved by releasing the surrounding periosteum and soft tissue, but are sometimes transected for access purposes.

Both endoscopic elevators and scissors are used to release tissue release of the periosteum of the anterior surface of the maxilla is accomplished through a buccogingival sulcus incision. The surgeon uses a headlight for illumination and the assistant gently retracts the upper lip. The incision is a made above the first premolar. A one centimeter vertical or a one and a half centimeter horizontal incision creates sufficient access and leaves a small cuff of loose mucosa along the dental ridge.

A freer periosteal elevator is used to elevate the periosteum off the anterior face of the maxilla, respecting and preserving the infraorbital nerve. The superior extent of the dissection goes up to the infraorbital rim. The lateral elevation extends over the malar eminence. Medial dissection can stop at or extend in a U-shape around the infraorbital nerve. For the purposes of this video, an endoscope is inserted to visualize the dissection plane.

This diagram provides a representation of the plane and area of cheek dissection. The temporal and lateral dissection pockets are united by passing an elevator from the more superficial deep temporalis plane down to under the periosteum. At the malar eminence, a long hemostat is passed to make sure that the two pockets are continuous fixation techniques for midface elevation are quite variable.

In this video, we demonstrate using a 3.0 Prolene suture fixed from the pre periosteal tissues to the deep temporalis fascia. The proline is placed through the buccal incision, and then the hemostat is used to bring the suture out through the temporal incision. The vertical repositioning of the tissue is demonstrated when traction is placed on the suture. The Prolene suture is passed with a free needle through the deep temporalis fascia. The assistant diminishes traction on the closure as the surgeon cinch and ties the proline.

The oral mucosa is closed with a five or six oh plain gut suture. An optional resection of the temporal tissue is then performed. The temporal incision is closed in layers. The first layer attaches the subcutaneous tissue of the anterior portion of the temporal incision to the deep temporal fascia in a fashion that also increases elevation of the soft tissues. The scalp incision is then closed with running or interrupted four O Vicryl sutures. The photographs demonstrate the pre and postoperative appearance of the patient. The postoperative photographs were taken six months after surgery.