Endoscopic assisted facial rejuvenation: a 35 year personal journey

Aim : Traditional facelift techniques rely on pulling. They approach the superficial or intermediate layers where the facial nerves and muscles are located, increasing the risk of facial nerve injury. They approach the central oval from the periphery and produce unnatural vectors of pull and aesthetic results. Alternative techniques that work on the subperiosteal plane using endoscopic techniques are described. Modern concepts of volume augmentation, beautification and rejuvenation of the facial expression are an inherent part of such techniques, or can be easily integrated. Methods : The central oval is approached via four small scalp incisions and additional intraoral, upper gingivo-buccal


INTRODUCTION
The procedures, concepts and principles described in this article were developed over a 35 year period, beginning during my Plastic Surgery residency at the University of Pittsburgh.The driving force behind the innovations described in this article were the unnatural, in vogue facelift results of that era.
Traditionally, the aging face was approached using techniques that pulled and stretched the facial soft tissues.The face was approached in a superficial plane, tightening the skin and SMAS (superficial muscular aponeurotic system) only [1][2][3] .Over time, face lift techniques beneath the SMAS evolved, including the deep plane facelift or composite facelift [4,5] .Initially, some surgeons considered this technique unsafe, and were hesitant to go deep to SMAS due to the proximity of facial nerve branches [6] .Moreover, the degree of facial edema was considered more marked using intermediate layer techniques.Around the same time, Paul Tessier described and popularized the subperiosteal approach [7][8][9][10][11][12] .I first described my five experience into the subperiosteal technique at the 1989 Biannual Congress of the International Society for Aesthetic Plastic Surgery in Zurich, Switzerland, and the 1990 American Society for Aesthetic Plastic Surgery Annual Congress in Chicago Illinois [13] .Another paradigm shift that influenced my thinking was the endoscopic approach to the forehead pioneered by Luis Vasconez [14] .This was first presented at the 1992 annual meeting of the American Society of Plastic and Reconstructive Surgeons, in Washington DC.I quickly adopted and modified Vasconez's forehead rejuvenation technique [14] .Noticing the advantages of the endoforehead compared to the traditional coronal approach I extended the application of the endoscopic approach to total facial rejuvenation [15][16][17][18] .It became clear that the subperiosteal plane was better suited to endoscopic techniques including secondary rhytidectomies [19] .It also made it safer and easier to add supplementary techniques.Those are described below [20][21][22][23][24] [Figure 1].Along the way Adrien Aiache and I discovered the suborbicularis fat that I coined SOOF (sub-orbicularis oculi fat) [25] .It was an excellent structure for filling the tear trough and to lift and imbricate the cheek.More recent research regarding the innervation of the lower eyelid orbicularis has also been relevant to the endo-midface, and the preservation of function of this muscle was another added benefit of this approach [26] .The most important side effects of introducing these new techniques were that surgeons were compelled to compare these with the older techniques.
In the process we started to focus more critically on the anatomy and aesthetics of the face [27,28] .We began thinking more about the benefits of volume preservation and restoration in contrast to the pulling maneuvers of traditional methods [21][22][23][24]28,29] . This aso created a new landscape for developing new minimally invasive techniques and non-invasive techniques, including the use of fillers and neuromodulators as temporary alternatives to surgical approaches [30,31] .
Following the realization that loss of volume was an important component of the aging process many surgeons and dermatologists started over filling faces creating an unnatural aesthetic [32] .In my opinion we need to swing the pendulum back and treat all features of facial aging in a more balanced approach.Moreover, a comprehensive approach addressing all thirds of the face gives a more natural result than when surgery is performed in a segmental fashion.An endoscopic approach to the face can address the three thirds of the face in a balanced fashion.If the endoscopic approach is insufficient to address all of the components of the aging face, other main or ancillary procedures can be easily integrated without burning any bridges.
The endoscopic subperiosteal approach to the aging face can address the forehead/brow, the midface and the lower face around the mandible, i.e., mentopexy.Soft tissue endoscopic cervicoplasty can also be done in younger patients that do not require excisional approaches.In patients over 50 years of age the endoscopic approach becomes the foundation of the rejuvenation and the excess skin of the upper/ lower eyelids, lower face and neck can be removed using standard access incisions.In this setting standard techniques become complementary procedures for a total facial rejuvenation.Likewise, facial implants, fat grafting and laser resurfacing can be easily integrated in the endoscopic subperiosteal facial rejuvenation.

Endoforehead
Forehead rejuvenation is approached via four scalp incisions, each measuring approximately 1.5-2 cm.Two symmetrical paramedian incisions are also made in the frontal scalp, about 2 cm from the midline.A final 1.5-2 cm incision is made in the temporal scalp, at the end of a line from the alar implantation, passing the lateral canthus, and finishing 2-3 cm inside the temporal hairline.Using triangulation techniques for both the endoscope and the periosteal elevators or endoscopic manipulators, a complete subperiosteal dissection of the frontal bone can be achieved (Ramirez Endoscopic Instruments, Marina Medical.Davie, Florida).This is connected with dissection beneath the tempoparietal fascia.Connection between frontal and temporal areas of dissection is done across the temporal line of fusion, coming from lateral to medial, and not the other way around.The frontal dissection stops when the supraorbital (SON) and supratrochlear (STN) nerves and the associated corrugator muscles are identified.The retaining ligaments of the brow are also elevated off the superolateral orbital rim.Temporal dissection stops at the upper limits of the zygomatic arch.The fat pad that surrounds the temporal nerve are elevated off the deep plane of dissection, ensuring protection of the facial nerve.The sentinel vein and the sensory zygomaticotemporal nerves are preserved.Centrally, 80% of the corrugator muscles are resected using special muscle biters (Marina Medical.Davie, Florida), ensuring preservation of the SON and STN.The procerus is then transected in a horizontal orientation at the level of the nasoglabellar angle.The periosteum of the frontal bone is cut from one tail of the brow to the other about 5-10 mm above the arcus marginalis (a variation of the original technique) using "double curved down" Ramirez's endoscopic scissors (Marina Medical.Davie, Florida).A single small butterfly drain is then placed at the level of the glabella.Fixation of the frontotemporal scalp is done after the midface dissection and fixation is complete.The vector of pull is in the superomedial direction.
The intraoral incision is done vertically at the level of first or second premolar.The subperiosteal dissection of the maxillary and inferior portions of the malar bones was initially done with the Aufricht lighted retractor.The endoscope was introduced to dissect the orbital rim and the rest of the malar bone.Laterally the fascia of the masseter muscle is elevated along the line that continues from the inferior border of the zygoma towards the middle third of the zygomatic arch.This elevates some of the retaining masseteric ligaments and the preparotideal SMAS.Using the temporal and intraoral incisions the pockets created are connected across the zygomatic arch, preserving the infraorbital nerve.The next step is to lift the midface and create volume.Both are accomplished using three structures: (1) Bichat's fat pad; (2) suborbicularis oculi fat (SOOF); and (3) modiolus.Each of these elements is manipulated and suspended using polydioxanone (PDS) 3-0 and 4-0 sutures.Elevation of the Bichat's fat pad elevation over the zygoma augments the convexity of the upper midface, and at the same time creates a concavity of the lower midface.With one maneuver the ogee line of the midface can be recreated [Figures 2 and 3] [29,33] .The SOOF overlaps the deep tissues of the midface and effaced any tear trough deformity [Figure 4] [17][18][19][20][21][22][23][24][25] .The modiolus lifts the corner of the mouth [Figure 5] [22][23][24]33] . The ichat's fat pad suture is piggybacked to the SOOF suture.The SOOF and modiolus sutures, are then anchored to the temporal fascia using the adjustable Peruvian fisherman's knot [35] .This suture controls the proper tension for volume control and desired elevation.A 2 mm butterfly drain is placed in the midface and fixated to the temporal scalp.The temporoparietal fascia is lifted and anchored to the temporal fascia with 3-0 PDS sutures.This provides additional remodeling of the upper cheek and periorbital region.The intraoral incision is closed with 4-0 chromic catgut sutures.The frontal scalp is suspended with two self-stabilizing Ramirez endoforehead screws (Dupuy Synthes.Warsaw, Indiana).These were applied percutaneously in the frontal scalp away from the access incisions.

Upper blepharoplasty
Endoforehead lifts the brow and eliminates a small amount of excess skin from the upper eyelid.Greater skin excess will still require an additional blepharoplasty.However, the amount of skin resection was far less than if this was done in isolation.Ptosis of the brow creates apparent or real excess skin in the upper eyelid area area.The apparent excess is reversed with the endoforehead.This will make the need for upper blepharoplasty less likely.

Lower blepharoplasty
When combined with endomidface, lower blepharoplasty becomes more straight forward procedure.Lateral orbicularis is suspended using a 4-0 nylon suture to the temporal fascia, using a skin only resection.This is done after endomidface fixation.Midface lift has the additional benefit of filling the tear trough, and blending it better with the infraorbital fat.I do not remove any intraorbital fat except under unusual indications, i.e., globular eyes, excessive and protruding lower eyelid fat pads.

Advanced objectives of facial rejuvenation
The steps of endoscopic central oval rejuvenation (endoforehead-endomidface) and blepharoplasty described above were all performed in patients below 50 years of age.This was the cornerstone over which other techniques were added to provide a more comprehensive rejuvenation in the older cohort of patients.The techniques described above may by themselves attained some of the objectives outlined below.However, other techniques are needed to obtain the following objectives:

Volume enhancement
Volume augmentation of the face was obtained using one of the following methods:  (1) Facial implants.In a previous publication I stated that facial beauty is "bone deep" [36] .To enhance the facial skeleton my preferred choice of implant material is the porous polypropylene [Medpor (Stryker.Portage, Michigan) Su-Por (Poriferous.Newman, Georgia)].These implants were found to have a different biological behavior to silicone implants and do not erode bone.The soft tissues grew into the porous channels of the implant providing vascularization and a secondary method of fixation.The in-grow of vessels into the implant makes it less susceptible to infection and in cases where infection did develop, antibiotics were able to penetrate the implant [Figure 7].The implants are less prone to capsule formation, and therefore they do not undergo implant shifting due to contracture.Overall, they behave more like bone than any other implant I have employed in my practice.The porous implants were placed following wide dissection, and although this was initially seen as a disadvantage, one must consider this technique as a soft tissue remodeling and reposition.The porous implants are fixed with screws, which do not allow the implant to migrate or move around.I designed implants for each of the different areas of the face [Figure 8].These implants have given me figuratively and literally an extra dimension to my facial rejuvenation practice.
(2) Imbrication techniques.Subperiosteal dissection is also a great method to lift the composite tissues.Applying sutures to the mid or lower boundaries of the dissected areas they were imbricated and suspended to a higher position.The distance of the lower and higher points of imbrication is decreased while the antero-posterior projection is increased.Examples are browpexy, SOOF lift and mentopexy.
(3) Vascularized fat mobilization.Subperiosteal access also allows manipulation of some of the sagging deep scyssarcosis fat for reshaping.The upper eyelid fat pads are placed over the upper orbital rim augmented brow projection.The lower eyelid fat pads are placed over the lower orbital rim to filled in the tear trough region.The herniated Bichat's fat pad is used to create the Ogee line of the midface.
(4) Fat grafting.With subperiosteal endoscopic techniques there is no associated delamination of the anatomical planes, therefore fat can be injected anywhere from dermis to periosteum.Fat is injected with 1cc Luer-Lock syringes attached to the "Ramirez Super-Luer-Lock micro-cannulas" (Tulip Medical, San Figure 6.Additional methods of volumetric enhancement that can be applied to the pureendoscopic central oval facial rejuvenation or the biplanar technique (First published in study [22] ) Diego CA).Fat grafting corrected residual asymmetries and erased dermal creases particularly in the nasolabial folds and glabellar lines.An average of 30 cc of fat is sufficient for the entire face, however I use more fat for gaunt faces, or when the imbrication of the Bichat's fat pad elevation did not provide enough volume.Lately I have incorporated stem cell-rich fat grafting obtained with the Diode 1210 laser.This fat is devoid of fibers and can be injected into the dermal/subdermal plane with 1 cc syringes and 23-gauge needles without the need for centrifugation or filtration.We call it Picograft TM or Picofat TM [37,38] .This provided an excellent alternative for skin damaged by sun exposure or smoking, improving skin quality on several fronts: pigmentation, elasticity, and fine wrinkles etc. [37,38] .

Beautification
Rejuvenation is also a beautification procedure.The three-dimensional enhancement brings back the curves and projection of a youthful and beautiful face.This is different to the stretched look of traditional facelifts.The creation of the ogees of the face is a powerful maneuver to obtain simultaneous beautification and rejuvenation.Other attributes of a beautiful face are angularity and facets, provided by facial implants, in addition to replacing the bony support lost during aging.

Rejuvenation of facial expression
The subperiosteal repositioning of the point of origin of muscles of facial expression in the entire face gives a generalized happy expression in repose and a gentle smile without effort.These changes arose due to the elevation of the modiolus, lifting of the corner of the mouth.The orbicularis oculi muscles are rotated upwards.The dynamics of the perioral muscles changed when mentopexy or chin implants are integrated during surgery.The origin of the lip depressors and of the lip elevator (Mentalis muscle) are detached and advanced upwards.These steps allow the modiolus to be elevated even further and the lower orbicularis oris to be relaxed, diminishing hypertrophy secondary to orbicularis straining.This allows the lower lip to pout easily.The chin dimples secondary to mentalis straining also disappear creating a youthful, happy look.In my view rejuvenation of facial expression is the ultimate paradigm shift in facial rejuvenation [36,39] .

Repositioning of sagging tissues
Although deflation of tissues has been emphasized as the most important component of aging, sagging of facial tissues is just as important as deflation.The Endotemporo-midface, that includes a periorbitoplasty and a Bichat's fat pad repositioning, elevates most of the sagging structures of the central oval of the face.The effectiveness of midface elevation decreases as the distance from cheek to jawline increased.Therefore, correction of jowls requires additional maneuvers.This is particularly relevant for patients over 50 years of age, who require the addition of traditional cervicofacial lift to remove the excess skin of the lower face and jawline.
My cervicofacial lift includes skin undermining of the neck from side to side across the midline.The platysma with or without a digastric corset is advanced towards the midline and the skin in the opposite direction.Treatment of the submental crease and the marionette lines, requires skin separation from the platysma, allowing unrestricted opposing vectors of pull during repair and closure.I open the deep subplatysmal space in approximately 30% of my patients.This is done to resect deep fat, treat the enlarged digastric muscles and the enlarged salivary glands.Digastric corset, or shaving, is done for thick digastric muscles.Ptotic and or enlarged submaxillary salivary glands are treated with partial resection or suspension [40,41] .
Patients with poor chin and/or mandibular support usually age worse than those that have good support.Moreover, aging produces atrophy of the skeletal support.This is addressed with chin and gonial angle implants.Implants make remodeling of the lower face and neck easier and provide superior aesthetic results.Rejuvenation with implants appear to be more durable.Enhancement of the entire mandible is done using specially designed implants that I named the "Mandibular Matrix Implant System" [Figures 9 and 10] [42] .

Rejuvenation of the skin envelope
A comprehensive approach also requires skin excision.After improving the foundation with volume augmentation, with any or all of the strategies described, skin excision is more a re-draping maneuver followed by a tensionless closure.This avoids tension bands on the face that give a typical windswept look.The dissected tissues are robust, allowing use of laser resurfacing when required.I also use stem cell richfat graft in the intermediate and subdermal plane without fear of vascular compromise of the skin.

Subtractive maneuvers particularly on the neck
Not everything is augmentation in facial rejuvenation.The jowls and the neck require subtraction.Jowl fat and supra-platysma fat are removed using a small liposuction cannula, preferably under direct visualization.The deep subplatysmal fat is removed only under direct vision.The danger of liposuction in the deep compartment is bleeding, nerve injury or salivary fistula.Its fibrous consistency also makes suction difficult.Fat removal is in a planimetric fashion that includes extension around salivary gland.Isolated fat excision in between the digastric muscles is not advisable as it can lead to cobra neck deformity.The digastric muscles are tangentially shaved or advanced medially to reduce bulk.If salivary glands are found to be enlarged excision can be performed.If you add the sub-platysma surgery to the neck, the procedure is called Triplanar Endoscopic Assisted Mask (First published in study [36] ).SOOF: sub-orbicularis oculi fat; BF: Bichat's fat; STF: superficial temporal Fascia; TFP: temporal Fascia Proper

RESULTS
I have performed 824 total facial rejuvenation procedures over a 35-year period.In a random sample of 100 of these cases, independent observers and patient's rated the average number of years of rejuvenation to be 18 (range 11-25 years).This group had a minimum of two years follow-up.Patient satisfaction was excellent in 80%, moderate in 18% and substandard in 2%.
Refinements in endoscopic techniques over time have resulted in globally low complication rates.Temporary frontal neuropraxia in endoforehead cases was approximately four percent, with function returning in all cases between one and three months.I have had one case of permanent unilateral frontal nerve injury.This was a secondary case after a previous coronal approach.Likewise, neuropraxia of the zygomatic or buccal nerve branches were uncommon, affecting less than two percent of patients.More common were neuropraxia or musculopraxia of isolated muscles of the face, particularly the levator labii superioris (4%).They were also temporary, recovering by two months on average.Mentopexy, chin and mandibular implants, and deep cervicoplasty all had a combined rate of marginal mandibular neuropraxia of less than three percent.All of these were temporary and likely related to edema or traction.Localized alopecia at the site of scalp access was highly dependent on surgical technique.Silastic port protectors decreased hair follicle damage.Occasionally, patients experienced telogen effluvium, with two cases of near total scalp effluvium that completely resolved after several months.They were related to systemic and localized stresses.Infection was also rare and occurred in less than one percent of cases.
To prevent infection due to bacterial contamination from saliva I use Chlorhexidine gluconate 0.12% oral rinse twice a day pre-operatively.Intra-operatively I clean the intraoral mucosa with Betadine solution and a diluted solution of Betadine was used in the dissection cavity, applied in neurosurgical sponge pads.I also leave a 2 mm drain in the cavity with the drain brought out thru a ministab incision in the temporal scalp.If an abscess occurs post-operatively drainage, irrigation and antibiotics are sufficient to manage this complication.I lost some of the lifting effect following removal of the internal suspension sutures.None required reoperations.
Bleeding complications were rare in this endoscopic cohort.One patient developed a moderate volume post-operative hematoma that required drainage but did not require blood transfusion.A few other cases developed minor localized hematomas that were treated by simple aspiration.The overall hematoma rate is less than 1%.

DISCUSSION
In the last 30 years many advances have been made in the treatment of the aging face.Previously the central oval of the face has been more elusive.The subperiosteal endoscopic approach works beautifully for forehead and midface.The trans-blepharoplasty approach is associated with a high rate of eyelid malposition, but using the endoscopic technique, avoiding eyelid incisions, is almost devoid of this complication [23] .Additionally, rates of neuropraxia are less common than those reported in the intermediate layer techniques.The plane of work in sub-SMAS techniques is where the mimetic muscles and nerves are located.Therefore, neuropraxia is common to all sub-SMAS techniques.The subperiosteal plane is deep to these structures.Nevertheless, there are two areas that are still at particular risk: the frontal nerve as it crosses the zygomatic arch and the zygomatic and buccal nerves as they cross over the masseter tendon.The infraorbital nerves can also be injured by blind dissection or excessive traction.Proper technique can significantly reduce these complications.My personal rate of nerve injury on the midface, forehead and mandible is around 2%, highlighting that this procedure can be performed safely and consistently over time.
Endoscopic rejuvenation of the central oval of the face is the cornerstone of facial rejuvenation at any age (young, old, older).These techniques in isolation can provide the objectives of modern facial rejuvenation previously outlined.The central face approach alone is done in patients between early 20's to late 40's.In the very young group we use the same lifting, imbricating and volumetric approach used in older patients.This is done to correct the congenitally prone sagging of the central oval soft tissues.Because lifting or rejuvenation may have negative connotations in this cohort of patients, we call it "facial beautification", because in principle that is what is accomplished [Figures 13 and 14].One of the advantages of the deeper approach is that you can manipulate the tissues to obtain volume.The brow lift is a remodeling procedure  After pure endoscopic procedures patients can resume work after about 2-3 weeks.The addition of standard facelift or deep subplatysmal cervicoplasty will increase the amount of swelling and extend the recovery period to about 4-6 weeks.Subtle, subclinical swelling can take up to 6 months to subside.Despite this, the degree of rejuvenation that can be obtained (many times as much as 25 years difference) makes the procedure appealing to those patients that are willing to spend the time and resources for long lasting results and paradoxical "very natural results" [Figures 23-29    Patients up to 49 years of age will require only endoscopic techniques.Older patients will require biplanar (BEAM) or Triplanar (TEAM) techniques.Peripheral to the central oval the sagging jowls and excess skin of lower face and neck is approached with a thick-skin rhytidectomy.Problems of the deep neck are approached using a submental incision [40,41] .Methods of three-dimensional enhancement can be incorporated easily into any area of the face with any combination of the techniques described above.Damaged skin can be treated with lasers or stem cell-rich fat grafting [18,20,37,38] .Despite the comprehensive and seemingly aggressive approach the results show few telltale signs of an operated look and has longterm, durable results. .She also had geniomandibularporous polypropylene implant.No upper blepharoplasty was done.Lower -skin onlyblepharoplasty was performed (First published in study [22] )

Figure 1 .
Figure 1.The combination of subperiosteal dissection in the central oval and subcutaneous dissection in the periphery of the face is safest.The intermediate layers where the nerves and the muscles are located are not safe

Figure 5 .
Figure 5.The subperiosteal repositioning of the orbicularis oculi and the origin of the muscles inserted in the modiolus and the specific suture applied to the area near the modiolus will lift the corner of the mouth.All of these will rejuvenate facial expression.SOOF: suborbicularis oculi fat

Figure 7 .Figure 8 .
Figure 7.The ingrowth of tissue in the omni-dimensional porous structure of the porouspolypropylene implants Assisted Mask) facial rejuvenation [Figure 11].The combination of BEAM facial rejuvenation with Deep Subplatysmal Cervicoplasty is called TEAM (Triplanar Endoscopic Assisted Mask) facial rejuvenation [Figure 12].

Figure 9 .Figure 10 .Figure 11 .
Figure 9.The effect of the Mandibular Matrix System to enhance the lower face, neck and jaw line

Figure 13 .Figure 14 .
Figure 13.The endoscopic approach to the central oval in younger patients is calledFacial Beautification.Frontal view of a 36 years old female patient

Figure 15 .Figure 16 .
Figure 15.Observe the beautification of the periorbital area.Patient had endoforehead, endomidface and concomitant laser resurfacing of the face.No upper or lowerblepharoplasties were required ].In conclusion, endoscopic techniques of the central oval of the face are the cornerstone of rejuvenation for patients of any age.In my view, addressing the central oval of the face is what makes the major difference.

Figure 17 .Figure 18 .Figure 19 .Figure 20 .Figure 21 .
Figure 17.Frontal view of a 48-year-old patient with prior standard facelift three years earlier.Still looks sad, the cheeks are sagging, there is hyperactivity of the forehead, and eyelidptosis (left picture).The post-operative view on the right are two years later observe the rejuvenation of "facial expression"

Figure 25 .Figure 26 .
Figure 25.Frontal views, before and after of a 56-year-old edentulous patient with two previous standard face lifts and an anterior hairline brow lift

Figure 29 .
Figure 29.Lateral view of the same patient.Before and after