History

Endoscopic facial rejuvenation is an approach that was started by the pioneering work on the forehead by Luis Vasconez and associates in the early 1990s.¹ Many of us working independently and almost simultaneously developed our own methods to address the upper face.^2–4 I had the privilege to perform the first ever recorded case of a complete endoscopic facelift that included the forehead, midface and neck,⁵ although a year earlier in April of 1992 at the First International Workshop on Facial Rejuvenation in Baltimore, Maryland, Oscar Ramirez and Robert Oneal telecasted live surgery demonstrations of two cases of endoscopic “assisted” open subperiosteal facelifts at the Johns Hopkins Hospital (video records). In the evolution of my own procedure, I also issued the first paper on the tridimensional approach to midface rejuvenation.⁶ A more extensive report followed in the years 2000 and 2001.^3–8

Physical evaluation

The preoperative evaluation of my prospective patient follows this sequence.

Fig. 16.1 In this volunteer woman, the vector of soft tissue repositioning in facial rejuvenation is demonstrated. The central oval is lifted vertically and the peripheral hemicircle gradually from medially oriented oblique pull in the temple to horizontal in the neck.

Anatomy

For evaluation and surgical purposes, the face is divided into large anatomical and aesthetic zones: the central oval and the peripheral hemicircle. The central oval is confined between the outlines of the “double ogee” lines of the right and left. The peripheral hemicircle is everything posterior and inferior to this line including the submental and submandibular areas.

The central oval is where the ocular, nasal, and oral frames are located. Therefore, they are the most mobile and dynamic parts of the face. These are the areas where the facial mimetic muscles are located. The areas of transition between the central oval and peripheral hemicircle is where the motor branches of the facial nerve are most susceptible to injury. If surgical dissection continues from the superficial layers on the peripheral hemicircle to the intermediate layers of the central oval, more chances of nerve and muscle injury are likely (Fig. 16.2).

Fig. 16.2 Combination of subperiosteal dissection in the central oval with subcutaneous dissection in the peripheral hemicircle is the safest plane. Dissection coming from superficial in the peripheral hemicircle to deeper planes in the central oval poses a high risk of nerve and/or muscle injury.

An important finding of our research is that the lower orbicularis oculi muscle is innervated by branches of the zygomatic and buccal nerves that penetrate the undersurface of this muscle, not from the lateral aspect as originally was presumed, but from the inferior border.¹⁰ Therefore, when cutting or separating the pretarsal portion from the preseptal muscle portions during routine lower blepharoplasty (the McIndoe operation), the pretarsal muscle is denervated (Fig. 16.3). The extent of denervation will depend on how aggressive is the separation medially. Limited separation will preserve some of the innervations. Likewise, lifting the innervated preseptal portion over or close to the denervated pretarsal portion during canthopexy or orbicularis oculi muscle suspension will favor a quicker neurotization.

Fig. 16.3 The bucco-zygo-orbicular plexus innervates the orbicularis oculi muscle and approaches the muscle fibers perpendicular to their orientation. Standard lower eyelid blepharoplasty using the skin–skin/muscle flaps transects the nerves that go to the pretarsal portion of the muscle. The degree of denervation and eventual neurotization will depend on the length of the muscle incision.

Another important anatomical characteristic relevant to my technique is that the orbicularis oculi muscle is attached to the bony orbital rim. Better redraping and upper lifting of this muscle requires the detachment of this bony origin. The suborbicularis oculi fat (SOOF) is a fatty structure deep to the orbicularis oculi muscle. This is in continuity with another fatty structure that I call a “deep orbital malar fat” (DOMF). Both provide deep structural support to the orbit and midface. These fatty structures are rich in fibrous tissue. This fibroadipose character allows application of sutures for support and lifting. These deep fatty structures are not isolated from the more superficial fatty structures located over the mimetic muscles of the face. They are interconnected through the intermuscular spaces forming a network of soft tissue structural support in which the mimetic muscles, motor and sensory nerves, and vessels are located. It seems that atrophy of this deep fat is more important in the aging appearance of the older face. The superficial fat with a less fibrous component is more prone to sagging, forming the ptotic nasolabial folds and jowls that you see with aging.

The eyelid fat pads and the buccal fat pad (Bichat’s) allow the gliding mechanism of the ocular motor muscles and the masticatory muscles respectively. They are also more prone to herniation because of the muscle activity of the related muscles and the lack of external support overlying these fat pads. They are also encased in a thin fascial pouch that allows gliding. This gliding also facilitates their expulsion from their original anatomical locations. This is clinically seen as a pseudo-herniation (Fig. 16.4). The Bichat’s fat pad is an important component of the upper jowl, located lateral to the oral commissure. Here forms the typical bulging of aging. Structurally some young individuals also have fullness in this area. Therefore excision or reposition of this structure helps improve the aesthetics of this portion of the face.

Fig. 16.4 The gliding capacity of the true fat pads makes them prone to pseudo-herniation. Example here is the buccal fat pad.

Another important anatomical and aesthetic configuration of the face is the presence of planes and curves. The face has multifaceting not unlike the faceting of the nose that has been previously described elsewhere. The most important curve of the face is seen in a three-quarter oblique view while both inner canthi are seen in this view. I call this the “reciprocal multicurvilinear line of beauty” or “double ogee” line.⁹ The single ogee of the cheek, also called “sigma,” has been previously described by William Little; however in my view the “double ogee” line is a more complete observation of the outline of the face (Fig. 16.5).

Fig. 16.5 This model from a glamour magazine shows the typical double ogee outline demonstrated in a view. The presence of this line characterizes youth and beauty.