Fig. 43.24 Suspension point of the orbicular muscle to periosteum, immediately above the eyebrow. The arrows indicate the ends of the suture (Photo courtesy Dr. Jaime Ramirez)

43.8.5 Endoscopic

At the moment, it is the technique more used, in spite of requiring a curve of learning in the manipulation and exploitation of the specific instrumentation. It is a favorable technique as much for the patient because

it diminishes the sequels of the opened approach as for the surgeon, when magnifying the structures allowing a more precise and conservative work of them. The applied anatomy of the area, referred in general to the beginning of this chapter, has repairs in the endoscopic approach that are important as much for the novel surgeon as for the more experienced surgeon:

Dissection Planes: (a) In the previous frontal region: subperiosteum plane (Fig. 43.29). (b) In the temporary region: interfascial plane (between fascia temporoparietal, superiorly and temporary deep fascia in the inferior part) (Fig. 43.30). (c) In the parietoccipital fissure the subgaleal plane.

Repair Points:

ssTemporal Line: Zone that delimits the interphase between the previous subperiosteal plane and the interfacial plane laterally, constituted by fiber connective tissue or joint sinew (Fig. 43.31)

Orbital Ligament: It extends from the external part of the orbital rim to the orbicular muscle of the eyelids and the dermis.

Sentinel Vein (v. zigomaticotemporal): Located 1 cm approximately to the superior and lateral part of the lateral orbital rim (Fig. 43.32).

Fig. 43.26 (a) Preoperative for eyebrow lift. (b) Two years postoperative after eyebrow lift with correction of the asymmetry of the left eyebrow without any notorious scar (Photo courtesy Dr. Jaime Ramirez)

ssFacial Nerve. Frontal branch. Attending closely near the superior portion of the sentinel vein, throughout the temporoparietal fascia. It ascends from the posterior to the anterior to 1.5 cm of the

eyebrow tail approximately.

ssSupraorbital Package: Artery, vein, and fascia emerging from the orbit throughout the same notch that is easily palpable in the middle portion of the superior orbital rim for its identification and protection.

Preparation: The marking is performed in the skin of the forehead of the temporal, midforehead, and paramedian lines, these last ones coinciding with an imaginary line between the extern canthus and the lateral limb (Fig. 43.33). Later on and limited by portions of hair previously isolated, they are demarcated in the scalp using five incisions of approximately 2 cm in length and 1.5 cm behind the hairline. Three out of these incisions become sagittal, corresponding in the scalp thus: one

Fig. 43.27 Presurgical and postsurgical image of direct eyebrow lift using as a way of approach a preexisting scar in the superior edge of the right eyebrow. Two years postoperative. The old scars are indicated with arrows (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.28 Immediately postoperative showing suspension with direct eyebrow lift used as a way of approach with a preexisting scar (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.29 Endoscopic view of subperiosteum plane. The arrow indicates the dissected periosteum (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.30 Endoscopic view of interfacial dissection in the temporary region. The temporary deep fascia (DF) and the temporoparietal fascia. (TPF) are observed (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.32 Endoscopic view of sentinel vein (SV) (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.33 Frontal lines for the preparation of the endoscopic approach (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.31 Corpse dissection. Endoscopic image, the arrows indicate the frontal bone (FB), the periosteum (PE), and the conjoin sinew (CS) (Photo courtesy Dr. Jaime Ramirez)

with the midforehead line and the other two with paramedian lines. The lateral incisions, in the scalp, become parallel with an imaginary line that goes along the prolongation of the line of the external orbital rim to the implantation line of the sideboards (Fig. 43.34). The zone of the glabellar musculature is also marked making the patient to pucker the frown. If the presurgical analysis shows the necessity of complementary eyelid lift (blepharoplasty), in the same operating act, it is carried out before the forehead lifting, to avoid a consecutive edema in the eyelids.

After infiltrating the marks with 1% lidocaine with 1:100,000epinephrine the described incisions are realized. The sagittal ones extend to the bone to previously make a subperíosteal plane that can be dissected up to 1.5 cm over the orbital rim and toward the

Fig. 43.34 Lateral lines for the preparation of the endoscopic approach (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.37 Endoscopic bipolar (BP) cauterization of the sentinel vein (SV) at its base (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.35 Transverse and sagittal incisions for the endoscopic approach (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.36 Sagittal incisions for the endoscopic approach (Photo courtesy Dr. Jaime Ramirez)

parietoccipital region a subglaleal plane rises. The transverse incisions are deepened to the temporary fascia to identify and to raise endosmotically the temporoparietal fascia (Figs. 43.35 and 43.36).Once there,

from lateral to medial, to prevent any injury of the frontal branch of the facial nerve, a cut of the joint fascia is done communicating the interfacial and subperiosteal planes. In the inferior part of this incision the orbital ligament is released and the sentry vein laterally must be repaired and if not possible, can be inferiorly dissected and cauterized with bipolar in its base, not in the superior part, because of the risk of injuring the frontal branch of the facial nerve (Fig. 43.37). After repairing and cutting the vein, the subperiosteal dissection of the lateral orbital rim and the anterior zygoma is continued, until finishing in the superior orbital edge, which can be identified, guiding externally with a nondominant finger of the surgeon or the assistant. Next, the periosteum is cut with microscissors from lateral to medial, until getting at the repairs of the supraorbital package. In this area, the periosteum is weaker and usually it is necessary to carefully incise with a curved, thin, and blunt dissector. The cut of periosteum is then completed toward the middle line, where the glabellar musculature is found (Fig. 43.38). The cut of periosteum is realized in the same way in the contralateral side. The superior flap of the periosteum is discreetly elevated to expose the musculature.

The superciliary corrugator muscle and procerus muscle are incised and partially dried out making use of microforceps, respecting the supratrochlear innervations. Besides the myotomies of the procerus and corrugator, a resection of a small rectangular segment of the superior portion of the orbicular muscle, lateral to the supraorbital package, can be realized to complete the lysis of the depressant function.

Fig. 43.38 Endoscopic periosteum dissection (PE), being careful with the supraorbital package, frontal bone (FB) (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.39 Endoscopic suspension point (arrow) of the bottom edge of periosteum (PE) to the galea point (Photo courtesy Dr. James Ramirez)

Suspension technique: It is realized beginning with the more lateral suspension, corresponding with the correction vectors of each patient. The points of suspension are placed with Ethibond 3–0, generally three in the temporal area from temporoparietal fascia to deep fascia; two paramedium from periosteum to galea (Fig. 43.39), and a central one from periosteum to galea.

The point of central suspension is indicated if there is medial ptosis of the eyebrow. The suspension points in the temporary region must avoid getting close to the temporoparietal fascia, to prevent injury of the frontal branch of the facial nerve. It is more important that the dissection completely liberates the supraorbital periosteum than the suspension with sutures. Hemovac type drains are left, throughout the more lateral portion but lateral of the fixed transverse incisions to the scalp and the incisions with instruments holding the wound.

Advantages: Well-hidden scars, less invasive approach, amplification of the operative field. Selective manipulation of the glabellar muscles and less bleeding (Figs. 43.40 and 43.41).

Disadvantages: Elevation of the hair line, variable results, requires learning and familiarization with special instrumentation.

Contraindications to this technique include severe ptosis of the brow, thick sebaceous skin, and high frontal hairline [36].

Ideal in young and middle-aged patients, with a normal or low hair line.