Endoscopic eyebrow and midface lift

Preoperative evaluation

The selection of patients is as important as for other plastic surgeries on the face. The examination of the patient should begin with a careful collection of anamnesis and physical examination. Anamnesticheski, we usually identify complaints of ovulation and tired appearance. The "angry" folds in the overgrowth also often disturb the patient. At the same time, injections of botulinum toxin are very effective; However, the endoscopic approach with partial resection of the muscles, wrinkling eyebrows, and muscles of the proud gives a more lasting result. When examining the peri-ocular area, it is possible to identify ptosis of the eyebrows, SOOF and the fatty body of the cheek, and a strip of sclera between the pupil and the ciliary edge of the lower eyelid. The latter is often observed in patients undergoing super-aggressive lower blepharoplasty. Suspension of the middle zone of the face reduces the pulling down of the lower eyelids and effectively lifts them, reducing the scleral band between their ciliary edge and the pupil. This manipulation also leads to an improvement in the shape of the buccal-mandibular area. If this was the patient's only complaint, we do not suggest doing a midface facelift instead of rhytidectomy; nevertheless, we observed a significant improvement in the outline of the buccal-mandibular area after such an operation.

The ideal candidate for such an operation should be in good physical and mental condition and not have uncontrolled systemic diseases. Pre-operative selection is always performed for the detection of diseases and conditions that can adversely affect the outcome of surgical treatment. Educating patients, which is a powerful and effective means of reducing anxiety and shaping the real goals of the operation, should begin already during the initial consultation. Candidates for the lifting of the middle zone of the face deserve special attention. This operation is associated with a longer period of postoperative edema (46 weeks), associated with subperiosteal dissection. To ensure the normal healing of the areas of deep dissection, these patients require more attention before and after the operation.

• Eyebrow rating

When examining the patient for changes in the upper third of the face, he must be in front of the mirror. Evaluation of the forehead and eyes is performed when the patient's head is in accordance with the Frankfurt horizontal plane. The patient closes his eyes and relaxes his forehead for 1520 s. Then he opens his eyes only to look straight ahead, not lifting his eyebrows. In this case, the eyebrow level can be assessed at rest, without the effect of excessive muscle contraction. Then, an evaluation and comparison with the classical shape and position of the eyebrow with respect to the orbit is performed. Usually, with aging of the upper part of the face, the fatty body of the eyebrow, which should serve as the lining of the eye socket edge, is omitted and, to varying degrees, displaced on the upper eyelid. This is noticeable in most of these patients, even at rest and is an indicator of the need to move the eyebrows. A common mistake is that the position of the eyebrow is not given importance, and it simply refers to the dermatochalasia of the upper eyelid. When performing the upper blepharoplasty without moving and fixing the eyebrows, the natural spaces between the lateral corners of the eye cracks and the folds of the eyelids, as well as the folds of the eyelids and the eyebrows, are shortened, sometimes noticeably, forming an incorrect appearance. It is important to diagnose eyebrow ptosis if it occurs, since blepharoplasty performed without primary movement and stabilization of the eyebrows can complicate the problem and lead to an additional ptosis. It is useful to be guided by the fact that the distance between the eyebrow and the skin of the fold of the furrow of the upper eyelid is approximately 1.5 cm.

• Assessment of the middle zone of the face

In the middle and the end of the fourth decade of life, aging processes lead to ptosis of the facial tissues. The skull protuberances move downward and medially, leading to the exposure of the lateral edges of the orbit and the deepening of nasolabial furrows and furrows of the wings of the nose. Fat under the circular eye muscle also descends, opening the lower edges of the eye sockets and orbital fat, which leads to the formation of a double contour. Endoscopic suspension of the middle zone of the face effectively moves these tissues and resists aging processes. This operation reduces the sagging of the cheeks and partially eliminates nasolabial fissures, but does not change the contour of the neck.

Surgical technique (forehead and eyebrows)

After selecting the appropriate candidates for an endoscopic eyebrow and forehead lift, a useful addition is the injection of botulinum toxin into the central eyebrows and nadiprese 2 weeks before surgery. This gives not only a wonderful aesthetic result, but also returns to the place and again fixes the periosteum, drawn by the action of the lowering muscle, shifting the eyebrows downward. Alternatively, a partial resection of the muscles wrinkling the eyebrows during surgery can be performed.

The operation begins in the problem area before the injection of the anesthetic. The patient is examined when he is sitting and assesses the position of his eyebrows. The desired size of the elevation of their medial sections is determined. Despite its name, an endoscopic eyebrow lift does not always lead to their ascent. The procedure can be useful to patients who need correction of a wrinkled eyebrow, and the position of the eyebrows remains the same. To maintain the middle preoperative position of the middle parts of the eyebrows, the medial incision for endoscopic surgery should be raised by about 8 mm. Therefore, if you want to lift the middle sections of the eyebrows by 2 or 4 mm, the medial incision will require an upward movement of about 10 or 12 mm, respectively. The planned tension vectors are determined and marked on the forehead and temporal region of the patient. In women, they are usually more upward and lateral, whereas in men the emphasis is on the lateral vector than on the upward direction. The labels are applied when the patient is in the vertical position, when the effect of gravity is maximum. If concomitant blepharoplasty is planned, the lower boundary of the incision for blepharoplasty is also noted, corresponding to the existing fold of the eyelid. Additional preoperative markings include upper ophthalmic incisions from both sides, lines of wrinkling of the peri-transference and frontal branches of the facial nerve.

Then the patient is transferred to the operating room, where the equipment is prepared. An intravenous analgesic is administered, followed by local infiltration anesthesia. After 1520 minutes, during anesthesia and vasospasm, approximately two and three vertical incisions of 11.5 cm in length are made approximately 1.5 cm posterior to the front line of hair growth, along the median line and paramedically, according to the desired tension vectors. Quantity The sections determine the tension vectors and the need for central fixation. The incisions are made by the blade No. 15 through all the layers, up to the cranial bone. Then, in the region of the incision with the caudal elevator, the periosteum rises neatly, without tears. The complete continuity of the periosteum around the incision is important, as this will be vital when applying suspension sutures. The periosteum is then bluntly separated, with the help of endoscopic dissectors, in the subperiosteal plane, down to a level 1.5 cm higher, laterally to the temporal lines and approximately to the line of the coronary seam of the skull posteriorly. At this time, a 30 degree endoscope is inserted with the sleeve, and the dissection continues downward under the visual control. The surveyed optical cavity should be almost bloodless, with a perfect contrast between the underlying bone and the periosteum above.

Attention is focused on the area of supraorbital vascular-neural bundles. Selecting these bundles, you need to be careful, as in 10% of patients these beams will go through the true holes, rather than the supraorbital notches. If resection of the wrinkling muscles and the muscles of the pride is performed, the neurovascular bundle can be isolated by blunt dissection with a small peak parallel to the fibers. On the medial part of the eyebrows are superimposed temporary percutaneous sutures, which are stretched by the assistant to facilitate dissection in the pocket. If required, the muscles wrinkling the eyebrows and the muscles of the proud are resected and treated with an electrocoagulant for haemostasis. Then, by applying multiple radial incisions deeper than the eyebrows with an electrocoagulator with a Colorado tip, the myotomy of the circular eye muscles is performed to protect the frontal branches of the facial nerve. In patients with asymmetric eyebrows, we perform a myotomy of the circular muscle from the side of the lowered eyebrow to increase its elevation. After the localization of the neurovascular bundles, the dissection continues medially and laterally, and also downwards, through the edge of the orbit, separating the periosteum near the marginal arch. Accurate lever movements allow you to separate the periosteum, exposing the fat cushion covering the superciliary. It is necessary to separate the periosteum near the marginal arch, which lies below the eyebrows. The nasally can be raised and applied to the place in the form of a flap with two legs, only after full separation at this level. In patients with very heavy eyebrows and powerful wrinkling muscles, they can be crossed and partially resected. After completion of work in the central pocket, the surgeon's attention is shifted to creating temporal pockets on both sides. Once the selection is completed, they will be connected to the central optical cavity. The temporal pocket lies above the temporal muscle and is confined to the cephalic edge of the zygomatic arch from below, the edge of the orbit in front and the temporal line from above.

Access to create temporal pockets is made through a 1.52 cm incision inside the hair growth zone on the temple, respectively, the vectors of tension up and back, periosteum, tendon helmet and temporal fascia. To maintain the correct working plane, the dissection when connecting the central and temporal pockets must be made from the outside to the inside. After the pockets are joined from above, the dissection continues downward with the separation of the temporal attachments by the chamfered edge of the endoscopic elevator. This is done down to the region of the lateral part of the upper edge of the orbit where tight connective tissue fusion with the bone occurs. This connective tendon dilatation is subperiosteally separated by an acute route with a dissector, scissors or endoscopic scalpel. After this dissection is completed, the same is done on the other hand. Finally, the entire lobnobrovny complex becomes mobile enough and can move up and down over the bone.

After the complete lifting of the tissue complex, the temporal parietal fascia is suspended through the temporal incision to the deep temporal fascia by strong resorbable sutures. In this area, maximum fixation should be achieved, since it can not be subjected to excessive correction. When the suspension is completed on both sides, this procedure continues in the center. To fixing the forehead, there are many approaches, including micro-screws permanently left under the scalp, cortical tunnels for sewing a tendon helmet with a suture seam, and external straps through foam pads. The fixation method reflects the surgeon's preferences and should be based on patient comfort, surgical simplicity and cost. Complete liberation of the entire frontal-eyebrow complex is more significant than the method of suspension. However, recent laboratory studies showing that the separated periosteum completely grows back within a week, call into question the need for prolonged suspension. In any case, the final setting of the height of the eyebrows and the tightening of the seams are made after the patient has been transferred to the vertical position in order to create a gravitational force. The incisions are closed with dermal staples. Computer analysis of long-term results proved to be favorable and showed that this technique has passed the test of time.

[1], [2], [3], [4], [5], [6]