Endoscopic brow lift and midface lift

Preoperative assessment

Patient selection is as important as for other facial plastic surgeries. The patient evaluation should begin with a thorough history and physical examination. Anamnestic examination usually reveals complaints of drooping eyelids and a tired appearance. "Angry" lines in the glabella are also a common concern. Botulinum toxin injections are very effective; however, an endoscopic approach with partial resection of the muscles that corrugate supercilii and procerus muscles gives a more lasting result. Periorbital examination reveals brow ptosis, SOOF and cheek fat pad, as well as a scleral strip between the pupil and the lower eyelid margin. The latter is often observed in patients who have undergone highly aggressive lower blepharoplasty. Midface suspension reduces the downward pull of the lower eyelids and effectively elevates them, reducing the scleral strip between their margin and the pupil. This procedure also results in improved buccal-mandibular contour. If this was the patient's only complaint, we would not suggest performing a midface lift instead of a rhytidectomy; however, we have seen significant improvement in buccal-mandibular contour after this procedure.

The ideal candidate for this type of surgery should be in good physical and mental health and have no uncontrolled systemic diseases. Preoperative screening is always performed to identify diseases and conditions that may adversely affect the outcome of the surgery. Patient education, which is a powerful and effective means of reducing anxiety and setting realistic surgical goals, should begin during the initial consultation. Candidates for a midface lift deserve special attention. This procedure is associated with a longer period of postoperative edema (46 weeks) associated with subperiosteal dissection. These patients require more attention before and after surgery to ensure normal healing of the areas of deep dissection.

• Eyebrow assessment

When examining the patient for age-related changes in the upper third of the face, he should stand in front of a mirror. The forehead and eyes are assessed with the patient's head in line with the Frankfurt horizontal plane. The patient closes his eyes and relaxes his forehead for 15-20 s. He then opens his eyes only to look straight ahead without raising the eyebrows. In this way, the level of the eyebrows at rest, without the effect of excessive muscle contraction, can be assessed. The shape and position of the eyebrow in relation to the orbit are then assessed and compared with the classic ones. Typically, with aging of the upper part of the face, the fat pad of the eyebrow, which should serve as a lining for the edge of the orbit, is lowered and, to varying degrees, displaced onto the upper eyelid. This is noticeable in most of these patients even at rest and is an indication of the need to move the eyebrows. A common mistake is to ignore the position of the eyebrow and simply attribute it to dermatochalasis of the upper eyelid. When performing upper blepharoplasty without moving and fixing the eyebrows, the natural spaces between the lateral canthi and the eyelid folds, as well as the eyelid folds and eyebrows, are shortened, sometimes noticeably, creating an irregular appearance. It is important to diagnose brow ptosis if it occurs, as blepharoplasty performed without primary movement and stabilization of the eyebrows can complicate the problem and lead to additional ptosis. A useful guideline is that the distance between the eyebrow and the skin of the upper eyelid furrow should be approximately 1.5 cm.

• Midface assessment

In the middle and late fourth decade of life, the aging process leads to ptosis of the facial tissues. The zygomatic eminences shift downward and medially, leading to exposure of the lateral orbital margins and deepening of the nasolabial and nasal folds. The fat under the orbicularis oculi muscle also descends, revealing the lower orbital margins and orbital fat, which leads to the formation of a double contour. Endoscopic midface suspension effectively repositions these tissues and counteracts the aging process. This procedure reduces sagging of the cheeks and partially eliminates the nasolabial folds, but does not change the contour of the neck.

Surgical technique (forehead and eyebrows)

Once suitable candidates for endoscopic brow and forehead lift have been selected, a useful addition is the injection of botulinum toxin into the central brow and glabella 2 weeks before surgery. This not only provides an excellent aesthetic result, but also returns and re-fixes the periosteum, which has been pulled down by the depressor muscle that moves the eyebrows downwards. Alternatively, a partial resection of the corrugator muscles can be performed during surgery.

The procedure begins in the problem area before the anesthetic is administered. The patient is examined while seated and the position of the eyebrows is assessed. The desired amount of medial brow lift is determined. Despite its name, endoscopic brow lift does not always result in a medial brow lift. The procedure may be useful for patients who require correction of a wrinkled brow and want to maintain the same brow position. To maintain the preoperative average position of the medial brows, the medial incision for endoscopic surgery should be elevated by approximately 8 mm. Therefore, if a 2 or 4 mm mid-brow lift is required, the medial incision will need to be advanced approximately 10 or 12 mm, respectively. The planned vectors of tension are identified and marked on the patient’s forehead and temporal region. In women, they are usually directed more upward and laterally, while in men, the emphasis is on a more lateral vector than an upward direction. Markings are made with the patient in an upright position, where gravity is at its maximum. If concomitant blepharoplasty is planned, the lower border of the blepharoplasty incision corresponding to the existing eyelid crease is marked at the same time. Additional preoperative markings include the superior orbital notches on both sides, the glabella wrinkle lines, and the frontal branches of the facial nerve.

The patient is then transferred to the operating room, where the equipment is prepared. An intravenous analgesic is administered, followed by local infiltration anesthesia. After 15-20 minutes, during which anesthesia and vasospasm occur, two or three vertical incisions of 11.5 cm in length are made approximately 1.5 cm posterior to the anterior hairline, in the midline and paramedially, corresponding to the desired tension vectors. The number of incisions is determined by the tension vectors and the need for central fixation. Incisions are made with a #15 blade through all layers, down to the cranial bone. The periosteum is then carefully elevated in the incision area with a tail elevator, without tearing. Complete continuity of the periosteum around the incision is important, as this will be vital when applying the suspension sutures. The periosteum is then separated bluntly, using endoscopic dissectors, in the subperiosteal plane, downward to a level 1.5 cm above, laterally to the temporal lines, and approximately to the coronal suture line of the skull posteriorly. At this time, a 30-degree endoscope with a sleeve is inserted, and dissection is continued downward under visual control. The visualized optical cavity should be almost bloodless, with excellent contrast between the underlying bone and the overlying periosteum.

Attention is focused on the area of the supraorbital neurovascular bundles. Care must be taken in isolating these bundles, as in 10% of patients these bundles will exit through the true foramina rather than the supraorbital notches. If resection of the corrugator and procerus muscles is performed, the neurovascular bundle can be isolated by blunt dissection with a small pick parallel to the fibers. Temporary percutaneous sutures are placed across the medial brow and held taut by an assistant to facilitate dissection in the pocket. If necessary, the corrugator and procerus muscles are resected and electrocauterized for hemostasis. Myotomy of the orbicularis oculi muscles is then performed by making multiple radial incisions deeper than the brow with a Colorado electrocautery tip, preserving the frontal branches of the facial nerve. In patients with asymmetrical brows, we perform a myotomy of the orbicularis oculi muscle on the side of the drooping brow to increase its elevation. Once the neurovascular bundles have been localized, the dissection is continued medially and laterally and downwards across the orbital rim to separate the periosteum at the marginal arch. Gentle levering movements allow the periosteum to be separated, exposing the fat pad overlying the brow. The periosteum must be separated at the marginal arch, which lies below the brows. The periosteum can be elevated and repositioned as a bipedicular flap only after complete separation at this level. In patients with very heavy brows and powerful corrugators, these can be transected and partially resected. Once the central pocket is complete, the surgeon's attention turns to creating the temporal pockets on both sides. Once separation is complete, these will be connected to the central optic cavity. The temporal recess lies above the temporal muscle and is bounded by the cephalic margin of the zygomatic arch below, the edge of the orbit in front, and the temporal line above.

Access for the temporal pockets is gained through a 1.52 cm incision within the temporal hairline in accordance with the upward and backward tension vectors of the periosteum, tendon helmet, and temporal fasciae. To maintain the correct plane of work, the dissection of the junction of the central and temporal pockets should be performed from the outside inward. After junction of the pockets from above, the dissection is continued downward with separation of the temporal attachments with the beveled edge of the endoscopic elevator. This is done downward to the area of the lateral part of the superior orbital rim where dense connective tissue adhesions with bone are encountered. This connective tendon extension is subperiosteally separated sharply with a dissector, scissors, or endoscopic scalpel. After this dissection is completed, the same is done on the other side. Finally, the entire frontobrow complex is sufficiently mobile and can be moved upward and downward over the bone.

Once the tissue complex has been completely elevated, the temporoparietal fascia is suspended through a temporal incision to the deep temporal fascia with strong absorbable sutures. Maximal fixation must be achieved in this area, as it cannot be overcorrected. Once bilateral suspension is complete, this procedure is continued centrally. There are many approaches to forehead fixation, including microscrews permanently left under the scalp, cortical tunnels for suturing the tendon cap with prolene suture, and external ties through foam pads. The method of fixation reflects the surgeon's preference and should be based on patient comfort, surgical ease, and cost. Complete release of the entire frontobrow complex is more significant than the suspension method. However, recent laboratory studies showing that separated periosteum completely reattaches within a week call into question the need for long-term suspension. In any case, the final adjustment of the eyebrow height and tightening of the sutures is done after the patient is placed in an upright position to create a gravitational force. The incisions are closed with skin staples. Computer analysis of long-term results has been favorable and has shown that this technique has stood the test of time.

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