Surgical technique of endoscopic braces of the middle part of the face

Endoscopic frontal access for hanging the middle part of the face can be performed with or without lifting the eyebrows. In most patients, during the endoscopic forehead lift and the middle part of the face, it is necessary to tackle the lower eyelids, either by excising the skin or by laser resurfacing. This is done because hanging the middle part of the face raises the cheeks, often leading to folding of the skin under the eyes. If the removal of fat is required under the lower eyelid, this is done through the conjunctiva before suturing the middle part of the face; otherwise the lower eyelid will be too close to the eyeball to access.

First, a side cut is performed. The incision is made taking into account the direction of the hair follicles. It is carried down to the level of the surface of its own temporal fascia. For this dissection, a set of endoscopic instruments is required. To raise the skin, a double hook is used, and a dissector Ramirez No. 4 or a flat dissector is used to create a plane of dissection over its own temporal fascia. Fabrics in this plane can be bluntly separated to the upper side of the ear, and back to the place where the temporal muscle terminates and the dissection becomes subperiosteal. The Aufricht retractor with illumination provides the best visualization. Then the dissection continues downward along the temporal line to the upper edge of the orbit, since work in this subperiosteal plane protects the frontal branch of the facial nerve. To continue the plane of dissection over the front temporal temporal fascia, careful rocking movements of the same dissector are used, using the temporal line as a guide. You need to be careful not to delve into the trans fat, which can lead to trauma and occlusion of the temporal region. Too superficial dissection can cause injury to the frontal nerve.

During dissection, there are many perforating vessels. They denote the location of the frontal branch of the facial nerve. Completely allocate the vessels, and then, under tension, treat the bipolar coagulator with the deep part of the vessel so as not to cause conduction thermal damage to the nerve, which is superficial. Dissection continues down to the upper edge of the orbit with the periosteum raised in its lateral part. To release the marginal arc, a bimanual uplift is applied with the position of one hand over the upper eyelid. Then the zygomatic arch is selected. The intrinsic temporal fascia is split approximately at the level of the supraorbital ridge into the intermediate fascia and the deep temporal fascia with intermediate temporal fat between them. Some surgeons prefer to continue dissection in the middle of the fat pad, but we remain superficial than the deep temporal fascia and raise the intermediate fat pad. This plane of dissection is easier to maintain, moving toward the posterior third of the zygomatic arch with a moderate pressure downward by a flat dissector, since the temporal fascia is thicker and stronger posteriorly. This plane of dissection continues down to the upper edge of the zygomatic arch and along it all the way. Depending on the degree of mobility required in this area, a lateral, approximately one-centimeter width, tissue interlayer is retained at the lateral angle of the eye gap. Dissector or scalpel dissects the periosteum at the upper edge of the zygomatic arch. To raise the periosteum above the arch and release some part of the attachment of the aponeurosis of the chewing muscle to the lower sections of the zygomatic arch, a dissector, curved downwards, is used. Then the selection continues dully subperiosteally over the maxillary bone. A finger is placed on the infraorbital for securing the nerve during the separation of the periosteum below the site of its exit. The finger is also placed on the lower part of the eyeball during dissection along the lower edge of the orbit, immediately above the infraorbital nerve. Dissection goes all the way to the nasal bones and pear-shaped aperture. Bimanual lifting of the cheek by the retractor additionally helps to release the periosteum, which then restricts the infraorbital nerve. In this cavity for hemostasis is placed napkin, and the same is done on the other side.

The middle part of the face / fat behind the circular muscle of the eye is suspended by thick resorbable sutures, passed through the periosteum immediately lateral to the temporo-cirrus orifice and back to its own temporal fascia. It is necessary to try not to tighten this seam too much. The second suture is superimposed proximal to the frontal nerve and back to the deep temporal fascia. Excess skin in the temporal region is smoothed by applying three seams to the superficial temporal fascia at the anterior edge of the skin and attaching it to its own temporal fascia back and forth. Then the skin is sutured with vertical mattress seams to prevent staircase deformation. At first the skin of this incision will be wrinkled, but it will smooth out relatively quickly and no skin excision will be required.

At the eyebrow level, one small active drainage is installed, which is displayed laterally through the scalp. It is removed after 1 day. After operation. To reduce the swelling on the forehead, a paper bandage is applied, over which a pressure bandage is fixed, which is removed the day after the operation. Subperiosteal dissection in the middle part of the face causes a greater edema of the face, and patients need to be prepared for this, as well as to a moderate temporal skew in the region of the lateral corners of the eye cracks. The patients are told that they will look adequately in makeup after 23 weeks, but that the swelling and skewing will not happen after 6 weeks.

Complications

After a forehead tightening, certain complications invariably occur, which are usually resolved within 26 months on the forehead and 912 months on the crown. In the process of restoration of sensitivity, paresthesia and itching are very frequent. If excessive tension is used to suspend tissues, alopecia may develop along the incisions, but hair growth is usually restored within about 3 months. There is a temporary paresis of nerves, which can be associated either with thermal trauma due to electrocoagulation, or with excessive dissection of the temporal pockets. You may notice an incorrect position of the eyebrows, which is first treated with a massage. If this does not give the desired result, the suture may need to be opened. Hematomas are formed on the forehead or scalp; however, their development is minimized by vacuum drainage and / or a pressure bandage.

Recovery after the lift of the middle part of the face takes longer and contains more pitfalls than a forehead lift. It is expected (but not a complication) of soreness in chewing. Relieving the adherence of the masticatory muscles in combination with the application of sutures to the temporal muscles can provoke muscle spasm and simulate the temporomandibular joint syndrome. This is usually resolved within the first week. Patients appear presentable after 3 weeks, but for complete resolution of the edema it takes about 68 weeks. The peripheral edema and chemosis can last more than 6 weeks after the operation. In this regard, photosensitivity and dry eye syndrome can develop. After resolving the edema, the function of the circular muscles of the eyes returns to normal, and the lower eyelid is adjacent to the eyeball. The asymmetry of the shape of the eye slits is always present at the beginning, but usually passes when the massage, combined with strong circular contractions of the circular muscles of the eyes, returns the eyelids to their original position. Revision is not recommended until after 6 months.

[1], [2], [3], [4]