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Endoscope simplifies midface, browlifts

Article-Endoscope simplifies midface, browlifts

Colorado Springs, Colo. — Endoscopic surgery provides a minimally invasive alternative for lifts of the midface, brow and other facial areas, provided doctors adequately address the potential for asymmetry in their results.

"The midface is the hot topic right now in aesthetic facial surgery," says Renato Saltz, M.D., a plastic surgeon in private practice in Salt Lake City and associate clinical professor, University of Utah.

Dr. Saltz
"The midface has always been a challenging area for which many different techniques have been developed. Since the mid-1990s, most of us have been trying to find the ideal way to rejuvenate the midface. Some have called the midface the heart of the face, because as we age, you have the brows, midface, lower face, cheek and neck descending. The midface has always been the tricky part," he says. Dr. Saltz favors the approach involving only endoscopic incisions.

"I come in through an incision in the temporal area of the scalp, and subperiosteally, I dissect down into the cheek area. Then I use needles and sutures to suspend that area, elevating in a superior medial direction to provide a midface lift. When you combine this with a brow lift and lower face lift, it really rejuvenates the entire face," Dr. Saltz says.

Dr. Saltz and his colleagues treated a series of 50 patients with endoscopic lifting and direct needle fixation. The doctors achieved safe and aesthetically pleasing results, with a high level of patient satisfaction continuing three years after surgery (Aesthetic Surg J. 2000;20(5):361-367). In this study, researchers found that subperiosteal lifting with direct needle fixation allows the inferior, periorbital and frontal regions to be more precisely repositioned. The technique, furthermore, eliminated the need for midface intraoral and/or infraciliary incisions for 30 patients who underwent additional treatment of the midface.

The doctors used detailed, preoperative markings to map the location of key anatomical structures and nerve pathways. For patients undergoing extended frontal lifting, Dr. Saltz and his colleagues limited their endoscopic entry points to two temporal incisions placed 2 cm behind the hairline, plus two paramedian incisions at the hairline and at the pupillary axis, and a midline vertical incision. They began dissection in a lateral direction above the deep temporal fascia through the temporal incisions. The dissection proceeded medially along the superior and lateral orbital rim in a subperiosteal plane to provide temporal release. The doctors then dissected the frontal region in a subperiosteal plane and linked both areas through complete release of the temporal crest fascial fusion zone.

Additional steps included releasing the brow and carefully dissecting the glabellar musculature. In the midface area, surgeons ultimately released the insertion of the masseter muscle on the malar bone.

To perform direct needle fixation, the doctors relied on endoscopic visualization for direct observation of their handiwork. Video endoscopy minimizes incisions and bleeding while magnifying images to allow for safer, more precise manipulation of the soft tissues.

The use of tissue glues and early postoperative lymphatic drainage massage appears to reduce swelling and bruising, and minimizes dead space present after subperiosteal release of the midface. The combination of minimally invasive endoscopic surgery and these two additional treatments (glues and early massage) speeds recovery, enhances early postoperative results and, therefore, increases patient satisfaction.

The tissue glue acts in two ways: filling lymphatic channels and reducing bleeding. For such applications, Dr. Saltz prefers fibrin glue and Tisseel (Baxter Healthcare, Deerfield, Ill.). For surgical closures, he usually uses Dermabond (Johnson & Johnson, Piscataway, N.J.). Since this study was published, Dr. Saltz says, the most common adverse outcome he sees is not a complication but a small incidence of early asymmetry that improves over time.

Dr. Saltz has used the endoscopic method for browlifts since 1992.

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